Exposed and embedded corrections in aphasia therapy: issues of voice and identity

Online Aphasia Groups: Navigating Issues of Voice and Identity

PURPOSE

Participation in aphasia groups is associated with increased communication, reduced feelings of social isolation, and increased quality of life. Despite the growing popularity of online aphasia groups, little is known about how to manage conversation in this format. We examined online aphasia book club sessions to examine how the facilitator supported group members' participation in conversation.

METHOD

Interactional sociolinguistic discourse analysis was used to analyze the behaviors and actions of the facilitator and group members. Qualitative data for this study were drawn from four recorded online aphasia book club sessions held through a university's free aphasia clinic on the Zoom web-conferencing platform.

RESULTS

Sociolinguistic discourse analysis revealed strategic facilitator behaviors that served to (a) give members with varying levels of verbal language abilities voice, (b) foreground or background aspects of voice, and (c) minimize her own voice to promote interactional symmetry between herself and group members.

CONCLUSIONS

Identity formed the backdrop for facilitators' actions when leading online groups, guiding decisions about who got to talk, when, for how long, through what modality, and about what topics. A better understanding of the interactions that occur online, such as how to develop and protect the identities of group members, could equip facilitators with the tools necessary for facilitating positive, engaging aphasia therapy groups online.

Looking at gesture: The reciprocal influence between gesture and conversation

INTRODUCTION

There is limited research in group communication treatment for people with aphasia but existing studies report benefits of gesture to support conversation. Gesture supports conversation through recipient design features and reducing linguistic demands of lexical retrieval and formulation. Additionally, gesture serves an affiliative function. However, the relationship between gesture use and gestural capacity has not been widely examined. As part of a larger study on group cohesiveness and conversation, this investigation examined the patterns of co-speech gesture within authentic conversations among persons with aphasia to discern the functions of gesture use for the participants, changes in the use of gesture over time, and the relationship between gesture use and gesture ability.

METHODS

Conversation Analysis (CA) was applied in an embedded case-study design. Three participants received an academic semester of group and individual conversation-based treatment according to Facilitating Authentic Conversation (Damico et al., 2015). Four conversations from the treatment were selected and transcribed for multi-modality communication with CA conventions applied, and then cyclically analysed for patterns of gesture.

RESULTS

Participants demonstrated gesture that served social and linguistic functions: ratifying clinicians' proxy turns, turn-allocation, turn repair, relaying novel visual information, emphasizing content, demonstrating affiliation with the prior speaker, demonstrating their assessment others' talk, and demonstrating humor. All three participants showed an increased rate of gesture per turn and increasingly used gesture to repair conversation breakdown. Increased gesture use over the course of the semester coincided with increased scores for pantomime on the Porch Index of Communicative Ability (Porch, 1981, PICA).

CONCLUSION

Individuals with aphasia demonstrated increased use of gesture for varied purposes and improved gestural processing following a semester of conversation-based treatment. This is significant because gesture is an effective support for the repair of conversation breakdown typical of persons with aphasia.

Conversation Analysis of Texting Exchanges in Aphasia

PURPOSE

Conversation analysis (CA) is an established method that has been used to understand how aphasia impacts the conversational success of individuals with aphasia (IWAs) and their conversation partners. This article demonstrates CA as a valuable analytic tool for studying text messaging in aphasia to better understand the specific co-constructed actions of IWAs and their partners as they engage in this communication modality.

METHOD

CA was applied to transcribed text message data from eight IWAs. Conversational structures present in face-to-face interactions were identified, segmented, and explicated with a focus on how IWAs and their partners negotiate interaction in this medium.

RESULTS

Three key elements of CA, namely, sequential organization, repair, and topic negotiation, were identified within the texting exchanges of participants and their texting partners and compared with existing CA studies on electronic messaging in adults without brain injury.

CONCLUSIONS

Findings suggest a multitude of strategies that IWAs and their partners used to meet both transactional and interactional goals of communication. Understanding gained from applying CA to texting in aphasia can inform the development of interventions that improve access to digital communication for IWAs.

Characteristics and impacts of community aphasia group facilitation: a systematic scoping review

PURPOSE

Community aphasia groups (CAGs) can provide a range of benefits to people with aphasia and support long-term psychosocial wellbeing. However, the dominant speech-pathologist-led service delivery model is inherently limited in scope. Peer-led groups hold potential as a sustainable and empowering extension of this traditional model. The implementation of peer-led models likely requires targeted training and support, however little is known about the characteristics and impacts of CAG facilitation. This study reviews the literature on CAGs and their facilitation.

MATERIALS AND METHODS

We conducted a scoping review on this topic.

RESULTS

One hundred and seventy-seven texts were included, reporting on a heterogeneous range of activities. Most texts reported on speech-pathologist-led groups, however, a range of alternative models were also represented. While no studies directly compared the impacts of different facilitation models, some comparative benefits could be drawn from the literature. Facilitation was perceived as complex and challenging, and significant gaps were identified in the training of facilitators. Ten qualitative studies investigated characteristics and impacts of facilitator behaviours, providing a useful foundation for future development of training and evaluation tools.

CONCLUSIONS

Further investigation into alternative facilitation models and facilitator training needs will likely support the proliferation of high-quality CAGs.Implications for RehabilitationCommunity aphasia groups (CAGs) play an important role in supporting identity and wellbeing for individuals with chronic aphasia.The traditional speech-pathology led model of group service delivery is limited in scope; the addition of peer- and volunteer-led CAGs may facilitate access to groups and meet a range of different needs for individuals with aphasia.CAG facilitation is a complex and challenging task, likely requiring specialised training, however, this has not been widely available to facilitators.The development of specialised facilitator training will likely support the proliferation of sustainable and high-quality CAGs.

"If You Just Stay With Me and Wait…You'll Get an Idea of What I'm Saying": The Communicative Benefits of Time for Conversational Self-Repair for People With Aphasia

PURPOSE

This study investigated the communicative benefits of self-repair during conversation for persons with aphasia (PWAs). Self-repair of trouble sources is an interactional priority that emphasizes autonomy and competence. Of equal importance, conversationalists desire to minimize silences and work together to ensure forward movement (progressivity) of conversation. Simultaneously achieving progressivity and self-repair is challenging in aphasia, and PWAs and their partners often make trade-off decisions between these two activities. Conversation-level aphasia interventions usually focus on supportive techniques that promote participation while maintaining progressivity, effectively favoring progressivity over self-repair. This study evaluates the benefits of an alternative approach that shifts the emphasis to self-repair, thereby highlighting potential trade-off costs of routinely forgoing self-repair to achieve progressivity.

METHOD

Ten people with mild-to-moderate aphasia each held two conversations with two different partners. When trouble sources characterized by silent and/or filled pauses occurred, partners maintained a supportive and engaged stance, allowing PWAs time to self-repair. We analyzed language produced during these "edited turns" using three paradigms considering form, content, and use.

RESULTS

The data yielded 311 edited turns. For form, on average, each edited turn resulted in 3.72 words; for content, most edited turns contained autobiographical information; for use, approximately 40% of edited turns introduced new information, and 40% added to the ongoing topic. The remainder were either ambiguous or comments such as, "I can't think of it."

CONCLUSIONS

When given engaged support and time to self-repair, PWAs contributed meaningful personal information to conversations for approximately 80% of edited turns. Importantly, self-repair often resulted in self-expression that directed the conversation, which is a communicative role critical for empowering agency and identity. This research opens a dialogue about benefits and limitations of approaches that prioritize either progressivity or self-repair and how to balance the two to optimize therapeutic benefits for each individual.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19379738.

Toward Empowering Conversational Agency in Aphasia: Understanding Mechanisms of Topic Initiation in People With and Without Aphasia

PURPOSE

This study examined topic initiation (TI) in conversations involving people with aphasia (PWA), matched people without aphasia (M-PWoA), and speech-language pathologists who were their conversation partners (SLP-Ps). For each speaker type, we analyzed patterns of distribution of typical mechanisms of TI and patterns of simultaneous use of multiple TI mechanisms. Lastly, we examined associations between use of simultaneous TI mechanisms and communicative success.

METHOD

Twenty PWA and 20 M-PWoA each participated in two conversations with SLP-Ps. Conversation samples were analyzed for TI locations and mechanisms, with results tallied for each speaker type following a published typology. A measure of communicative success was applied to TI utterances. Rank-order correlations were conducted to evaluate the patterns of distribution of the TI mechanisms between speaker types and the patterns of multiple mechanism usage between speaker types. Descriptive analysis was conducted to provide additional insight to the TI behaviors of each speaker type and to evaluate the relationship between multiple TI mechanisms and communicative success.

RESULTS

All speaker types used cohesion most often to achieve TI. PWA used an abrupt method of TI (noncoherent TI) more often than other speaker types. A single mechanism of TI was used most often by all speaker types, except for SLP-Ps when they were in conversations with PWA. In this case, SLP-Ps most often used two or more layered mechanisms of TI. SLP-Ps also used a highly salient TI mechanism with greater frequency when speaking with PWA than observed between other speaker types. When PWA layered mechanisms of TI, they appeared to be more likely to achieve better communicative success.

CONCLUSIONS

Specific, teachable behaviors such as favoring certain TI mechanisms and using multiple TI mechanisms may improve communicative success during TI for PWA. Furthermore, findings suggest that SLP-Ps modify their TI behaviors when speaking to PWA.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.17699423.

Assessing Language in Unstructured Conversation in People With Aphasia: Methods, Psychometric Integrity, Normative Data, and Comparison to a Structured Narrative Task

Purpose This study evaluated interrater reliability (IRR) and test-retest stability (TRTS) of seven linguistic measures (percent correct information units, relevance, subject-verb-[object], complete utterance, grammaticality, referential cohesion, global coherence), and communicative success in unstructured conversation and in a story narrative monologue (SNM) in persons with aphasia (PWAs) and matched participants without aphasia (M-PWoAs). Furthermore, the relationship of language in unstructured conversation and SNM was investigated for these measures. Methods Twenty PWAs and 20 M-PWoAs participated in two unstructured conversations on different days with different speech-language pathologists trained as social conversation partners. An 8- to 12-min segment of each conversation was analyzed. Additionally, a wordless picture book was used to elicit an SNM sample at each visit. Correlational analyses were conducted to address the primary research questions. Normative range and minimal detectable change data were also calculated for the measures in both conditions. Results IRR and TRTS were moderate to good for parametric measures and moderate to excellent for nonparametric measures for both groups, except for TRTS for referential cohesion for the PWAs in conversation. Furthermore, in PWAs, a strong correlation was demonstrated for three of eight measures across conditions. Moderate or weaker correlations were demonstrated for three of eight measures, and correlations for two of eight measures were not significant. An ancillary finding was no significant differences occurred for sample-to-sample variability between the two conditions for any measure. Conclusions This study replicates previous research demonstrating the feasibility to reliably measure language in unstructured conversation in PWAs. Furthermore, this study provides preliminary evidence that language production varies for some measures between unstructured conversation and SNM, contributing to a literature base that demonstrates language variation between different types of monologue. Thus, these findings suggest that inclusion of the specific types of discourse of interest to the PWA may be important for comprehensive assessment of aphasia. Supplemental Material https://doi.org/10.23641/asha.16569360.

Patterns of Conversation Trouble Source and Repair as Indices of Improved Conversation in Aphasia: A Multiple-Case Study Using Conversation Analysis

Purpose Social approaches to intervention for aphasia are being increasingly employed to address the functional communication barriers experienced by persons with aphasia. One specific approach is the use of conversation-based treatment in both group and two-person dyads. Although there are several methods to measure improvement for stimulation and cognitive neurolinguistic approaches, researchers have consistently indicated a need for outcome measures that can objectively demonstrate improved communication following conversation treatment. This study aims to demonstrate the utility for examining the patterns of conversation trouble source and repair as indices for improved communication as a positive response to intervention. Method The conversations of 20 consecutive participants, before and after 3 months, or 40 hr, of group and individual conversation-based treatment, were transcribed using conventions of conversation analysis, and sociolinguistic discourse analysis was applied. Measures of trouble source and repair were aggregated and subjected to statistical analysis. Results Persons with aphasia demonstrated statistically significant improvement in patterns of conversation trouble source and repair posttreatment for the rate of conversation trouble source and the length of repair. However, measures of self-initiation and self-completion of repair did not reach significance. Conclusion The study indicates that, following conversation-based treatment, the conversations of persons with aphasias were more efficient, experiencing fewer trouble sources and shorter repair sequences. These findings suggest that measures of conversation for the rate of trouble source and length of the repair sequence are valid indices of improved conversation.

Correction and repair: a comparative analysis of a boy with ASD interacting with a parent and with an ABA trainer

Applied Behaviour Analysis (ABA) is a widely used therapeutic intervention for children with autism spectrum disorder (ASD) yet there has been little research into the interactional organization of ABA sessions. We report a comparative case study of two interactions in which the same child, a 12-year-old boy with ASD, interacts with his father and interacts with an Applied Behaviour Analysis (ABA) trainer. Both interactions occur at home and are drawn from a small corpus (2 h) of children with ASD in domestic settings. Drawing on CA to delineate the sequential relationships between the actions of the adult participant and the child, we present a quantitative and microstructural analysis of 156 directive sequences in order to examine the similarities and differences between the two interactions. We first show that the rate of the production of directives is higher in the ABA session. The analysis then demonstrates the applicability of Schegloff, Jefferson and Sacks' (1977) treatment of repair in conversation to some problems that occur in how the child responses to adults' directives. However, we show that whilst some correction-initiations target problems with hearing, speaking, and understanding, some target substantive problems. We identify a practice, explicating an error, whereby correction-initiations are expanded to point out the nature of the error. This practice can show that the correction-target is being construed as a substantive error. In such cases, the correction-initiation is not a subtype of repair-initiation in the sense of Schegloff, Jefferson and Sacks' (1977) analysis of repair.

Correction and turn completion as collaborative repair strategies in conversations following Wernicke's aphasia

This study explores repair practices deployed by the interlocutor of a speaker with Wernicke's aphasia, their relationship to types of aphasic difficulty, and how mutual understanding and the progression of talk is maintained. A 75-year-old woman with Wernicke's aphasia of 16 months duration and her friend video recorded 36 minutes of conversation at home. Using conversation analytic methods two patterns of other-repair by the non-aphasic interlocutor were identified. The first practice was turn completion, which occurred in the context of self-initiated word search by the person with aphasia. The second was correction in the context of trouble with reference to person or place, manifested as an erroneous word, mis-selection of a gendered pronoun, or use of a pronoun where a person's name was expected. This correction was mainly overt, completed via a short side sequence dealing with the repair, although a few examples were embedded, where a word or phrase was replaced with a corrected form without overtly drawing attention to the correction. None of the examples included an account for the error. Unlike in typical talk, the person with aphasia did not repeat or use the corrected form in subsequent talk. For this dyad, correction and completion function as interactionally acceptable collaborative repair strategies, maintaining progressivity and a focus on topic development rather than on repair itself. There is no evidence that other-correction is dispreferred, which accords with recent findings for typical interaction but differs from other studies of aphasic talk. Correction should not be dismissed out of hand as a negative interactional practice when talking to someone with Wernicke's aphasia.

Facilitator Behaviors Leading to Engagement and Disengagement in Aphasia Conversation Groups

Purpose Researchers have identified features of successful aphasia conversation groups and clinician behaviors leading to engagement and group cohesion. There has been less focus in the literature on facilitator behaviors that hinder participation or result in disengagement. This study aims to explore the behaviors of graduate student facilitators that contribute to and detract from engagement in aphasia conversation groups. Method Data were drawn from 4 conversation group sessions from 2 different university settings. Groups included 1 graduate student facilitator and 3 or more persons with aphasia. Sociolinguistic discourse analysis was applied to transcripts of group sessions. Results Three broad patterns detailing facilitator behaviors were identified. Several facilitator actions contributing to engagement were noted, including strategic use of topic elicitors, multimodal communication supports, and techniques to avoid interactional asymmetry. Behaviors associated with participant disengagement were also noted across sessions, including restricted discourse behaviors and difficulty managing the competing needs of participants. Engagement and disengagement were the product of several coordinating actions of the facilitator and group members that together influenced participation in conversation. Conclusion Results suggest that novice facilitators exhibit behaviors that contribute to and detract from participant engagement in aphasia conversation groups. Findings, discussed within the context of the literature on well-managed groups, highlight the skill required in managing the needs of participants with aphasia and knowing how and when to employ clinician-led strategies.

Humour in clinical-educational interactions between graduate student clinicians and people with aphasia

BACKGROUND

During clinical interactions, clinicians and people with aphasia (PWA) use humour and laughter for a range of purposes, most of which contribute to friendly interactions in which the participants appear to develop a positive regard for one another. Moreover, humour is a vital component of facework, or the processes interactants engage in to protect their own and one another's well-respected, public personas.

AIMS

To examine the ways in which speech-language pathology graduate student clinicians enlist humour during one-on-one therapy sessions for PWA.

METHODS & PROCEDURES

Three dyads composed of one graduate student clinician and one person with aphasia acted as participants. We recorded six routine individual aphasia therapy sessions that were each about 60 min in length. All sessions were orthographically transcribed by a trained research assistant. Transcriptions included verbal and non-speech communication (e.g., facial expressions, gestures, writing). For analysis, we employed an ethnographic microanalysis framework. First, by focusing on laughter produced by the interactants, we identified segments in the data that involved clinician-led humour. Next, we sought to understand patterns that represented potential functions of humour. We consciously sought out instances that did not appear consistent with our developing understanding of the functions of humour. Such negative cases were used to refine our description of how graduate student clinicians use humour. Other verification procedures included member checking and peer debriefing.

OUTCOMES & RESULTS

The findings illustrate that graduate student clinicians use laughter and humour for a range of interactional purposes when interacting with clients with aphasia. Humour was used as a means of (1) softening exposure to client's errors, (2) equalizing interactional power, (3) mitigating errors made by graduate student clinicians, (4) supporting own narrative production and (5) demonstrating affiliation.

CONCLUSIONS & IMPLICATIONS

The current study demonstrates that graduate student clinicians we observed, like the clinicians studied in previous investigations of humour in therapeutic encounters, possess the humour and laughter-related skills that help to foster positive interactions with PWA. Future investigations of the source of these skills should determine if students are adept because of natural abilities or if students can be taught to be better interactants via instruction. Findings emanating from these studies can be used to inform curriculum design, which will in turn help our field better meet the needs of clients.

Speech-language pathologists' preferences for patient-centeredness

PURPOSE

Preferences for patient-centeredness is an important indicator in healthcare service delivery. However, it remains largely unexplored in the field of communication science and disorders. This study investigated speech-language pathologists' (SLPs) preferences for patient-centeredness METHOD: The study involved a cross-sectional survey design. SLPs (n = 102) fully completed the modified Patient-Practitioner Orientation Scale (PPOS; Krupat et al, 2000) and also provided demographic details. Data were analyzed using descriptive statistics, correlation, and linear regression methods.

RESULTS

Mean PPOS scores indicated that SLPs value patient-centeredness. There was a strong positive correlation among sharing and caring subscales with the full-scale. Results from the linear regression modeling suggested no relationship between demographic factors and preferences for patient-centeredness.

CONCLUSIONS

SLPs value patient-centeredness, although there may be regional and cultural variations. Qualitative investigations may help uncover dimensions of patient-centeredness that were not captured in the PPOS scale. In addition, further research should explore congruence in preferences for patient-centeredness among SLPs and patients.

'Communicative competence' in the field of augmentative and alternative communication: a review and critique

BACKGROUND

Understandings of 'communicative competency' (CC) have an important influence on the ways that researchers and practitioners in augmentative and alternative communication (AAC) work toward achieving positive outcomes with AAC users. Yet, very little literature has critically examined conceptualizations of CC in AAC. Following an overview of the emergence of the concept of CC and of the field of AAC, we review seven conceptualizations of CC identified in the literature.

AIMS

To consider the contributions and potential shortcomings of conceptualizations of CC in AAC.

METHODS & PROCEDURES

We use a critical theoretical approach to review, critique and synthesize conceptualizations of CC in AAC, with a particular focus on uncovering 'taken for granted' assumptions. By historically situating the reviewed literature, we examine the shifting boundaries and tensions among theoretical conceptualizations of CC in AAC and their potential impacts on practice.

MAIN CONTRIBUTIONS

We suggest ways that revisiting past scholarly work, alongside emergent, innovative conceptualizations of CC might shift ways of thinking about CC in AAC which tend to focus on the individual who communicates differently, toward (re)location of CC as a shared, socially incorporated and performed communication construct.

CONCLUSION & IMPLICATIONS

We propose that emerging critical perspectives drawn from AAC and other interdisciplinary literatures offer innovative ways of theorizing communication difference, which might inform evolving conceptualizations of CC in AAC.

Communicative empowerment of people with intellectual disability

BACKGROUND

Personal narratives are conditional for victims of sexual abuse to overcome their trauma. Counsellors can help victims with intellectual disability to take an active position in conversations about sexuality and to co-construct a personal narrative.

METHOD

Using discourse and conversational analysis, we studied 4 conversations between a counsellor and a woman with autism and mild intellectual disability.

RESULTS

In conversation with a counsellor the participant was able to express her inner emotions and understanding about sexual issues and other sensitive topics. She was able also to express disagreement and lack of understanding.

CONCLUSION

In spite of communication limitations, clients with an intellectual disability can participate actively in conversations with counsellors. Although a helping or encouraging professional approach may also be suggestive and affect the authenticity of the client's narrative, it is the counsellor's duty to prevent distressing effects within the interview.

A controlled study of changes in conversation following aphasia therapy for anomia

This paper investigates the relationship between change in picture naming with anomia therapy and changes in word retrieval in conversations between adults with aphasia and a regular conversational partner. We present data from two therapy projects (Hickin et al. [ 1 ] and Best et al. [ 2 ]). In each study, therapy involved cueing with the aim of improving retrieval of a set of nouns. Naming of the experimental items was assessed twice prior to therapy and again immediately afterwards. There was a significant change in word finding, as measured by picture naming, for the group and for 11 of the 13 participants. At the same time points, we collected conversations between the person with aphasia and a regular conversational partner. We analysed these using Profile of Word Errors and Retrieval in Speech (Herbert et al. [ 3 ]) and investigated a set of conversational variables predicted to change with therapy. Unsurprisingly, the conversation data is not straightforward. There is no significant change on the conversation measures for the group but some changes for individuals. We predicted change in word retrieval after therapy would relate to change in everyday conversations and tested this by correlating the change (post-therapy minus mean pre-therapy) in picture naming with the change in conversation variables. There was a significant positive relationship between the change in picture naming and change in some conversation measures including the number of nouns produced in 5 min of conversation (r = 0.50, p < 0.05, one-tailed) and the number of nouns produced per substantive turn (r = 0.55, p < 0.05, one-tailed). The findings suggest changes in word finding following therapy for aphasia can be reflected in changes in conversation. The clinical implications of the complex results are explored.