The seven habits of highly effective aphasia therapists: The perspective of people living with aphasia

Poststroke Communication Ability Predicts Patient-Informant Discrepancies in Reported Activities and Participation

BACKGROUND

Participation in life situations has been identified by people with aphasia (PWA) as an ultimate outcome of rehabilitation and is often measured with patient-reported outcome measures (PROMs) or informant-reported measures. It is known that PWA and informants do not always produce similar scores on measures of activities and participation. However, systematic differences between PWA and informants and the causes of these differences are not well understood. Here, we investigated these differences as a function of language impairment, perceived level of activity and participation success, and depressive symptoms.

METHOD

Participants were 29 PWA-informant dyads who completed a performance-based language assessment and three measures related to different aspects of activities and participation. Outcome variables were PWA-informant difference scores in the activities and participation measures.

RESULTS

PWA ratings of activities and participation were not statistically significantly associated with performance-based language severity. Hierarchical regression models with both language impairment and informant-reported scores as predictor variables explained 53%-71% of the variance in PWA-informant difference scores (all p < .05). In particular, mild communication challenges were associated with the PWA reporting significantly worse participation than the informant perceived. In contrast, more severe communication challenges were associated with the PWA reporting significantly better participation than the informant perceived.

DISCUSSION

These findings highlight the importance of measuring participation by PROM. The PWA's experience of participation is not related to their level of language impairment and is predictably different from their care partners' perspective. As others have also reported, "mild" aphasia is not so mild to the PWA. Similarly, "severe" may not be so severe to the PWA. Further research is needed to connect these findings with counseling and caregiver education. Research on response processes (e.g., response shift) is also warranted.

Elizabeth Usher memorial lecture. Models, mind maps, and metacognition: How theory is the true hero

Within the educational context of identifying the critical ingredients of an effective speech-language pathologist, this paper highlights the centrality of theory in underpinning every level of our practice. A spotlight is placed on us knowing how language and communication work, what makes our interventions work, how we can make the most difference through our choices in therapy, and what makes both us and our clients respond. So, what are the critical ingredients of an effective speech-language pathologist, of an effective therapy, of an effective therapeutic alliance, and why is this so important? While there are many foundational and guiding habits upon which new graduates, early career, and experienced clinicians shape their practice, no one habit is regarded as more important than us exploring the theoretical underpinnings of what we are doing and why. To underscore the role of theory in our everyday practice, a discourse level intervention for people with aphasia is used as an exemplar to track the complex contribution of different theories to a single intervention. Discourse level interventions are relatively new on the scene in the area of acquired language disorders. Child language interventions, on the other hand, have frequently revolved around the story, aiming to bridge the oral-literate divide through the development of narrative structure. This paper will aim to weave its own story around discourse level interventions, combining the narrative genre with the everyday genres used by adults in conversation. I will highlight how this approach taps into lexical theories, sentence processing theories, discourse organisation, and the cognitive underpinnings of language, and closely examine how this multilayering of language in context may hold some of the answers to questions around generalisation, impact, and making the greatest difference to individuals.

Qualitative Exploration of Speech Pathologists' Experiences and Priorities for Aphasia Service Design: Initial Stage of an Experience-Based Co-Design Project to Improve Aphasia Services

INTRODUCTION AND AIMS

Stroke survivors with aphasia (impaired language/communication) have poor outcomes and gaps in the clinical implementation of best practice contribute to this. Little is known, however, about speech pathologist perspectives on the touchpoints (key moments shaping experiences) in the clinical care pathway that have the greatest impact on service delivery nor how this varies by geographical location. We explored the experiences of speech pathologists who provide aphasia services to establish priorities for improvement and design.

METHODS AND ANALYSIS

This is the initial experience gathering and priority identification stage of an experience-based co-design (EBCD) project. Speech pathologists were recruited from 21 geographically diverse Hospital and Health Services in Queensland, Australia. Speech pathologists working in acute, rehabilitation and community services shared positive and negative experiences of delivering aphasia care in interviews and focus groups. Experiential data were analysed using qualitative thematic analysis to determine touchpoints. Priorities for service design were identified using an adapted nominal group technique.

RESULTS

Speech pathologists (n = 62) participated in 16 focus groups and nine interviews and shared 132 experiences of delivering aphasia care. Providing care in teams with poor awareness of the impacts of aphasia was identified as a key challenge, as poor patient-provider communication was perceived to increase risk of adverse outcomes for patients. Speech pathologists identified areas for improvement related to their own professional needs (e.g., greater access to clinical supervision); collaborative health care (e.g., better coordination and interdisciplinary care to increase therapy time); and the service context and environment (e.g., psychological services able to support diverse communication needs).

CONCLUSIONS

Speech pathologist delivery of aphasia services could be improved through increased access to clinical supervision, opportunities for peer debriefing and interdisciplinary care. Priorities for service design varied by geographical location and included: education to support care transitions (remote areas), improved referral pathways and service linkage (regional areas) and dedicated aphasia staffing (metropolitan areas).

PATIENT OR PUBLIC CONTRIBUTION

A consumer advisory committee comprising people with aphasia (n = 3, authors K.M., K.D. and B.A.), their significant others (n = 2, authors J.D. and P.M.), and a Cultural Capability Officer (author G.B.) guided this research. The team: (1) reviewed participant information; (2) co-designed surveys and workshop resources; (3) copresented research outcomes and contributed to publications. Research questions and study design (e.g., analysis methods and assessment measures) were developed by the research team (authors L.A., V.J.P., D.A.C. and S.J.W.).

Therapeutic relationships in speech-language pathology: A scoping review of empirical studies

PURPOSE

This scoping review provides an overview of empirical studies investigating therapeutic relationships between speech-language pathologists (SLPs), clients, and caregivers across all ages and clinical areas, and identifies areas of future research.

METHOD

The Joanna Briggs Institute's (JBI) scoping review method was employed. Systematic searches were conducted across seven databases and four grey literature databases. Research published in English and German until 3 August 2020 was included. Data were extracted for the primary aim, terminology and theoretical foundations, research design, and focus. Central findings concerning the input-, process-, outcome-, and output-level of speech-language pathology were categorised.

RESULT

Of 5479 articles, 44 articles were included in the analysis. Psychotherapy was the leading discipline for the theoretical foundation and measurement of relationship quality. Most findings focused on therapeutic attitudes, qualities, and relational actions to build the basis of a positive therapeutic relationship. A small number of studies indicated connections between clinical outcomes and the quality of the relationships.

CONCLUSION

Future research needs to address precision of terminology, expansion of qualitative and quantitative research methods, development and psychometric examination of measuring instruments specific to SLPs and the development and evaluation of concepts to support professional relationship building in speech-language pathology training and everyday work.

Developing consensus-based clinical competencies to guide stroke clinicians in the implementation of psychological care in aphasia rehabilitation

Background People with aphasia experience depression and anxiety associated with negative outcomes across a range of time post-stroke. Stroke clinicians are well-positioned to facilitate low-intensity psychotherapeutic interventions after aphasia (e.g. mood screening, behavioural activation, problem-solving therapy, relaxation therapy); however, they self-report a lack of knowledge, skills and confidence to do so. The Theoretical Domains Framework (TDF) provides a lens through which to view and target clinician behaviours and training needs in this area of practice. The aim of this study was to develop and gain consensus on items for a rating scale of clinical competencies in facilitating individual-based, low-intensity psychotherapeutic interventions for people with aphasia. Methods An e-Delphi methodology using focus groups and survey rounds was used to gain consensus on clinical competencies considered important. Results Eight stroke clinicians (speech pathologists and psychologists), two people with aphasia and three family members participated in one of four focus groups. Four themes were derived from the data: (1) Communication support, (2) Assessment and therapy structure, (3) Interpersonal skills, and (4) Needs of the significant other (family or friend). Themes informed an initial list of 23 self-rated and observer-rated competency items. Following two rounds of e-Delphi surveys, 11 stroke clinicians (six speech pathologists and five psychologists) reached consensus (80-100%) for 19 competencies. Conclusions The Psychological Care in Aphasia Rehabilitation Competency scale offers a preliminary list of items to guide and train clinicians to implement low-intensity psychotherapeutic interventions for people with aphasia.

Muddles and puzzles: Metaphor use associated with disease progression in Primary Progressive Aphasia

Background

Primary Progressive Aphasia describes a language-led dementia and its variants. There is little research exploring the experiences of living with this disease. Metaphor, words that represent something else, have been studied extensively in health-related narratives to gain a more intimate insight into health experiences.

Aims

This study explored the metaphors used spontaneously by people with PPA, their care partners (family), and speech and language therapists/pathologists (SLT/Ps) providing support along the continuum of care.

Methods & Procedures

This study examined two previously collected data sets comprising naturalistic talk where metaphors were not the specific focus, the first from focus groups conducted with people with PPA and their families and the second from focus groups conducted with SLT/Ps working with people with PPA. Transcribed data were analysed for metaphor use through an iterative narrative approach.

Outcomes & Results

In all, 237 examples of metaphorical language were identified in the data, with 14 metaphors from people with PPA, 116 from the families and 106 from SLT/Ps. Different metaphors were used by participants to describe their experiences depending on which variant of PPA they were living with, and people also described their disease differently over time. SLT/Ps also used metaphors, however, their language reflected the structured, professional perspective of delivering speech and language therapy services.

Conclusions & Implications

SLT/Ps should listen for and recognise the metaphorical language used by people with PPA and their families to ensure therapeutic alignment, see beyond the PPA to recognise the individual's needs, and provide person-centred and empathic support.

Principles and philosophies for speech and language therapists working with people with primary progressive aphasia: an international expert consensus

PURPOSE

Primary progressive aphasia (PPA) is a language-led dementia associated with Alzheimer's pathology and fronto-temporal lobar degeneration. Multiple tailored speech and language interventions have been developed for people with PPA. Speech and language therapists/speech-language pathologists (SLT/Ps) report lacking confidence in identifying the most pertinent interventions options relevant to their clients living with PPA during their illness trajectory.

MATERIALS AND METHODS

The aim of this study was to establish a consensus amongst 15 clinical-academic SLT/Ps on best practice in selection and delivery of speech and language therapy interventions for people with PPA. An online nominal group technique (NGT) and consequent focus group session were held. NGT rankings were aggregated and focus groups video recorded, transcribed, and reflexive thematic analysis undertaken.

RESULTS

The results of the NGT identified 17 items. Two main themes and seven further subthemes were identified in the focus groups. The main themes comprised (1) philosophy of person-centredness and (2) complexity. The seven subthemes were knowing people deeply, preventing disasters, practical issues, professional development, connectedness, barriers and limitations, and peer support and mentoring towards a shared understanding.

CONCLUSIONS

This study describes the philosophy of expert practice and outlines a set of best practice principles when working with people with PPA.Implications for rehabilitationPrimary progressive aphasia (PPA) describes a group of language led dementias which deteriorate inexorably over time.Providing speech and language therapy for people with PPA is complex and must be person centred and bespoke.This study describes the philosophy of expert practice and outlines a set of best practice principles for speech and language therapists/pathologists working with people with people with PPA.

'Emotion is of the essence. … Number one priority': A nested qualitative study exploring psychosocial adjustment to stroke and aphasia

BACKGROUND

Stroke and aphasia can have a profound impact on people's lives, and depression is a common, frequently persistent consequence. Social networks also suffer, with poor social support associated with worse recovery. It is essential to support psychosocial well-being post-stroke, and examine which factors facilitate successful adjustment to living with aphasia.

AIMS

In the context of a feasibility randomized controlled trial of peer-befriending (SUPERB), this qualitative study explores adjustment for people with aphasia in the post-acute phase of recovery, a phase often neglected in previous research.

METHODS & PROCEDURES

Semi-structured interviews were conducted with 20 people with aphasia and 10 significant others, who were purposively sampled from the wider group of 56 people with aphasia and 48 significant others. Interviews took place in participants' homes; they were analysed using framework analysis.

OUTCOMES & RESULTS

Participants with aphasia were 10 women and 10 men; their median (interquartile range-IQR) age was 70 (57.5-77.0) years. Twelve participants had mild aphasia, eight moderate-severe aphasia. Significant others were six women and four men with a median (IQR) age of 70.5 (43-79) years. They identified a range of factors that influenced adjustment to aphasia post-stroke. Some were personal resources, including mood and emotions; identity/sense of self; attitude and outlook; faith and spirituality; and moving forward. Significant others also talked about the impact of becoming carers. Other factors were external sources of support, including familial and other relationships; doctors, nurses and hospital communication; life on the ward; therapies and therapists; psychological support, stroke groups; and community and socializing.

CONCLUSIONS & IMPLICATIONS

To promote adjustment in the acute phase, hospital staff should prioritize the humanizing aspects of care provision. In the post-acute phase, clinicians play an integral role in supporting adjustment and can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy. What this paper adds What is already known on the subject Anxiety and depression are common consequences of stroke, with depression rates high at 33% at 1 year post-onset. There is evidence that the psychological needs of people with aphasia are even greater than those of the general stroke population. Social support and social networks are also negatively impacted. Few studies have examined adjustment when people are still in hospital or in the early stages of post-stroke life in the community (< 6 months). Further, many stroke studies exclude people with aphasia. What this paper adds to existing knowledge Adjustment to living with stroke and aphasia begins in the early stages of recovery. While this partly depends on personal resources, many factors depend on external sources of help and support. These include doctors, nurses and hospital communication, their experience of life on the ward, and their therapists' person-centred care. What are the potential or actual clinical implications of this work? Clinicians play an integral role in facilitating people with aphasia to utilize their personal resources and support systems to adjust to life after stroke. They can help by focusing on relationship-centred care, monitoring mental health, promoting quality improvement across the continuum of care and supporting advocacy.

Experiences of Social Distancing During Coronavirus Disease 2019 as a Catalyst for Changing Long-Term Care Culture

Purpose In this article, we draw a parallel between the experience of social isolation that occurred throughout the world during the Coronavirus Disease 2019 pandemic and similar experiences occurring in everyday life for people with communication disorders living in long-term care (LTC) facilities. We propose that speech-language pathologists can use the widespread experience of social isolation as a learning catalyst in the effort to shift the LTC culture to one that more highly values a communicative environment that is accessible to all, thereby reducing risk of social isolation for those with communication disorders. Conclusions Many training paradigms for promoting an accessible communicative environment are available in the speech-language pathology literature, yet institutional barriers exist for their widespread implementation. Overcoming these barriers is a challenge that requires awareness and learning on the part of staff and administration regarding the impact of an unfriendly communicative environment on social isolation, and the resulting psychosocial consequences. Learning theory indicates that new learning in adults is motivated by connections between personal experiences and the material to be learned. Explicitly infusing established training programs with the experience of social isolation brought on by the Coronavirus Disease 2019 pandemic may be the key needed for changing the communicative environment in LTC.

Information, communication, advocacy, and complaint: how the spouse of a man with aphasia managed his discharge from hospital

Background: The impact of stroke and aphasia has been recognised as a family problem for many years with studies highlighting spouses' need for information at different times along the recovery journey, for practical and emotional support, recognition, and respite. In particular, the decision-making around discharge from hospital, or planning for rehabilitation, is not always collaborative even though family involvement assists family members to plan and adjust to their new caring role. Aims: This study aims to explore how the wife of a man with aphasia managed his discharge from hospital in the acute phase post-stroke. It provides an opportunity for health professional learning and sensitisation through the detailed analysis of a de-identified but a real case that happened to reflect key issues reported by families in previous research: lack of information, poor communication with healthcare professionals, and the need for advocacy. Methods and procedures: The data for this paper are drawn from two sources: a single in-depth interview with the wife collected as part of an earlier large multi-site study that included interviews with 48 family members of people with aphasia after stroke; and two complaint letters she wrote to the hospital and two letters received back. This study uses a narrative analysis of the interview, and a systemic functional linguistics (SFL) analysis of the letters in order to shed light on the key issues of information, communication, and advocacy. Outcomes and results: The narrative analysis of the interview and the SFL analysis of the letters together help to unpack the reasons why the wife felt motivated to write a complaint letter to the hospital where her husband had been admitted post-stroke. The letters themselves demonstrate careful choices of language for both parties, with the hospital discounting the wife's concerns and closing down the exchange. They also reflect a profound misunderstanding by the hospital about the functional consequences of aphasia and its impact on the family. Conclusions: It is important that family members, taking on a caring role for people with aphasia after stroke, are supported with clear information and good communication in acute settings. This may enable them to be engaged in the recovery process as partners with healthcare teams and more effectively support adjustments to post-stroke life in the longer term.

Spotlight on the Clinician in the Life Participation Approach to Aphasia: Balancing Relationship-Centered Care and Professionalism

Background

Speech-language pathologists make clinical decisions informed by evidence-based theory and “beliefs, values and emotional experiences” ( Hinckley, 2005 , p. 265). These subjective processes, while not extensively studied, underlie the workings of the therapeutic relationship and contribute to treatment outcomes. While speech-language pathologists do not routinely pay attention to subjective experiences of the therapeutic encounter, social workers do. Thus, the field of social work makes an invaluable contribution to the knowledge and skills of speech-language pathologists.

Purpose

This clinical focus article focuses on the clinician's contribution to the therapeutic relationship by surfacing elements of the underlying subjective processes.

Method

Vignettes were gathered from clinicians in two community aphasia programs informed by the principles of the Life Participation Approach to Aphasia.

Results and Discussion

By reflecting on and sharing aspects of clinical encounters, clinicians reveal subjective processing occurring beneath the surface. The vignettes shed light on the following clinical behaviors: listening to the client's “whole self,” having considerations around self-disclosure, dealing with biases, recognizing and surfacing clients' identities, and fostering hope. Speech-language pathologists are given little instruction on the importance of the therapeutic relationship, how to conceptualize this relationship, and how to balance this relationship with professionalism. Interprofessional collaboration with social workers provides a rich opportunity to learn ways to form and utilize the benefits of a strong therapeutic relationship while maintaining high standards of ethical behavior.

Conclusion

This clinical focus article provides speech-language pathologists with the “nuts and bolts” for considering elements of the therapeutic relationship. This is an area that is gaining traction in the field of speech-language pathology and warrants further investigation.