ALF Nyborg Strand March 2012 Improving conversation in

ALF, Nyborg Strand, March 2012 Improving conversation in acquired language disorders: 
An interactionfocused intervention approach in aphasia therapy Ray Wilkinson Neuroscience and Aphasia Research Unit University of Manchester

Overview of presentation 1. Why focus aphasia assessment therapy on conversation? 2. Conversation analysis methods and areas of investigation in aphasia: a) Data collection, transcription and analysis b) Analysing repair, turns and sequences, topic and how they are affected by aphasia 3. Interaction-Focused Therapy 4. Implementing and evaluating Interaction-Focused Therapy: Two aphasia therapy case studies 5. Current and future research directions and clinical issues

Conversation ² The most prevalent use of spoken language and communication in daily life (Davidson, Worrall and Hickson, 2003) Therefore, conversation important as target for therapy and as place where improvement after therapy should be evident ² ‘conversation is…. . a vehicle through which selves, relationships and situations are talked into being’ (Schiffrin, 1988) Therefore, conversation relevant not only to language and communication, but also psychsocial issues of how personal identity and relationships are constructed and managed

Conversation differs from other types of aphasia language and communicative assessments Utterances in conversation are produced: ² as part of a social interaction: involves at least two people; PWA having to produce utterance in response to what other has just said; having to understand speak at same time ² online and under time pressure: little time for utterance planning or production ² matter: conversation used to produce actions (eg requests, jokes etc. ); errors and delays affect actions and one’s identity We can’t predict conversational problems and abilities from testing (Wilkinson, 1995; Beeke et al. , 2003) To see how PWA copes in conversation, we need to assess conversation

Conversation: An interaction-focused approach in aphasia assessment and therapy Using Conversation Analysis approach (Sidnell, 2010): ² Focus on conversation features eg: § Turns and sequences § Repair § Topic ² Methodological features: § Data collection: naturally-occurring conversational data § Data transcription: capture features of how speakers talk § Data analysis: how do speakers collaborate turn by turn to produce talk which is meaningful for each other? ; how do they show to each other eg (a) how they interpret what an utterance means; (b) that something is problematic for them to understand

Uses of an interaction-focused approach for aphasia ² Assessment and therapy planning: allows insight into how people with aphasia (PWA) and their main significant others (SO) communicate spontaneously and in the home environment; allows insight into how they are adapting to conversation with aphasia; what the problems or limitations are ² Therapy implementation: allows individualised therapy to be carried out with the dyad (PWA & SO) together to change conversational patterns of behaviour; allows therapy to be targeted at real problems or limitations experienced by the dyad in daily life ² Therapy evaluation: allows investigation of whether improvement has occurred in real language use and communication at home in daily life activities

Assessing communication at home: Pedagogic activity you know what I mean I think they’ve joined up you’ve got no id- it’s and now it drives me mad because I- so she said I can go- if I come to (2. 3) San-tander Say it again San tan der San-der San tan Sand (2. 0) San-tan San-don’t it’s driving me mad! ( )

Pedagogics: ‘Mc. Flurry’ no leave it (0. 4) but then (0. 5) I can go (1. 6) what did you have the other day? what? d’you know on F- on eh (1. 7) Thursday yeah Thursday (0. 4) when we drove, I went to- I know what was it I know I-wait a minute (0. 6) we went we ate, we ate? something and I went (0. 9) oh god I went eh wait a minute (. ) I went by myself (1. 1) with the car (. ) and we went and I said (0. 4) oh god (0. 4) Mac. Fru- (7. 2) Mac please could I have you said please could I have (. ) a (1. 6) Mac (16. 1) Fruly its not Fruly (1. 3) Mac. Fruly nearly (1. 3) Mac (1. 2) fu-fu-fu Mac (2. 0) Furry Mac. Furry Mc. Flurry

Pedagogics: ‘Hamburger’ Mc. Flur- Mc. Flurry. yeah and one (. ) hambur- hambe- ham han (1. 1) ha m ham-bury bu r bu- (1. 8) hamburgy, burger. hamburger ham burger but what did you get the Mc. Flurry (. ) which one did you get with smarties yeah ((both laugh)) smarties! ((laughs)) yeah no I had it it was good cos before you used to say ‘the dots’ dots! ((both laugh))

Pedagogic behaviour: a common feature of aphasic conversation (Wilkinson et al. , 1998; Booth & Perkins, 1999; Lindsay & Wilkinson, 1999; Turner & Whitworth, 2006) Also found in German aphasic conversation (Bauer & Kulke, 2004) and Dutch aphasic conversation (Wielart & Wilkinson, 2012) Pedagogic behaviour - aims to help aphasic speaker learn/practise language; but also has social costs: ² Focuses attention on aphasic speaker’s incompetence ² Takes over as the topic and slows conversation down ² Often, but not always, creates negative emotion in aphasic speaker eg embarrassment, emotional upset

Pedagogic behaviour in this dyad’s talk: ² Engaged in relatively frequently ² Appears generally emotionally unproblematic for them/for PWA – in fact often a source of humour/laughter ² PWA sometimes initiates the pedagogic activity ² the SO temporarily takes on role of teacher/trainer but this shift in social roles seems unproblematic This is not always the case and can often be a target for therapy

Pedagogic behaviour as problematic: Connie & Sam did you paint that thing today? (1. 0) yes (0. 4) uhm (0. 3) wheel barrow yeah uhm (. ) I can't (0. 3) paint it why's that? eh lef hands. what hand? lef hands. lef: T lef –t hand you're saying- you're saying lef: you're not putting the ‘t’ at the end (0. 2) left. lef: -t you're missing the ‘t’ (0. 3) left lef (. ) hands (0. 3) I can't (hear) it ((sounds and looks upset)) yes but you tried didn't you? you try. mm ((laughs)) (1. 5)

Connie and Sam: pedagogic behaviour as maladaptive form of repair behaviour and as target for therapy (Lock, Wilkinson &Bryan, 2001; see also Booth & Perkins, 1999: Turner & Whitworth, 2006) Couple report they engage in these behaviors regularly – to give Connie practice at saying words Conversation analysis research on repair in normal conversation But as seen in example: ² Preference for self completion of repair ² Leads to negative emotions (eg upset) on occasion ² Takes over as topic – slows down conversation ² Prolonged focus on Connie’s inability to say ‘simple’ word (Schegloff, 2000): ² Preference for repair to be short ² Issues of competence and ‘face’

Adaptation by dyads in turns and sequences: Test Questions (Lock et al. , 2001; Bauer & Kulke 2004) what jobs was you doing? . . what did you do in oil? . . what do I do for a living? . . . what do I do on a computer? i. e. method of having a ‘conversation’, especially with people with severe aphasia but not a real exchange of information; highlights inability; limited and controlling form of talk

Targeting improved aphasic conversation: Four approaches (Wilkinson, 2010) Intervention Approach Data collection Data analysis pre/post Tx Focus of conversation -related Tx

Targeting improved aphasic conversation: Four approaches (Wilkinson, 2010) Intervention Approach Data collection Data analysis pre/post Tx Impairment-focused (Hickin et al. 06) Conversation between Word retrieval within PWA and SO or conversation professional Focus of conversation -related Tx Impairment-word finding difficulties

Targeting improved aphasic conversation: Four approaches (Wilkinson, 2010) Intervention Approach Data collection Data analysis pre/post Tx Focus of conversation -related Tx Impairment-focused (Hickin et al. 06) Conversation between PWA and SO or professional Word retrieval within conversation Impairment-word finding difficulties Communicationfocused (Conversational Coaching: Holland et al, 02) Communication task with PWA and SO Main concepts of a story communicated during task Verbal and non-verbal communication strategies used by PWA and SO

Targeting improved aphasic conversation: Four approaches (Wilkinson, 2010) Intervention Approach Data collection Data analysis pre/post Tx Focus of conversation -related Tx Impairment-focused (Hickin et al. 06) Conversation between PWA and SO or professional Word retrieval within conversation Impairment-word finding difficulties Communicationfocused (Conversational Coaching: Holland et al, 02) Communication task with PWA and SO Main concepts of a story communicated during task Verbal and non-verbal communication strategies used by PWA and SO Psychosocial-focused (Supported Conversation: Kagan et al. 01) Interview between PWA and a volunteer Message exchange and social interactive skills of participants using (M)SCA and (M)PCA Volunteer’s skills in acknowledging and revealing the competence of PWA

Targeting improved aphasic conversation: Four approaches (Wilkinson, 2010) Intervention Approach Data collection Data analysis pre/post Tx Focus of conversation -related Tx Impairment-focused (Hickin et al. 06) Conversation between PWA and SO or professional Word retrieval within conversation Impairment-word finding difficulties Communicationfocused (Conversational Coaching: Holland et al, 02) Communication task with PWA and SO Main concepts of a story communicated during task Verbal and non-verbal communication strategies used by PWA and SO Psychosocial-focused (Supported Conversation: Kagan et al. 01) Interview between PWA and a volunteer Message exchange and social interactive skills of participants using (M)SCA and (M)PCA Volunteer’s skills in acknowledging and revealing the competence of PWA Interaction-focused SPPARC: Lock et al, 01) Conversation between PWA and SO Impact of aphasic impairments on conversation (eg repair, turns etc) and how PWA and SO adapt in conversation Behaviours used by the PWA and SO to deal with aphasic impairments in conversation (turms, repair etc)

Therapy Case Study 1: Dealing with limited choice of actions within turns and sequences (Wilkinson, Bryan, Lock & Sage, 2010, Aphasiology) Len Jane (wife) Age: 66; left CVA 18 months Retired teacher prior Broca’s type aphasia and verbal apraxia Hemiplegia: able to walk with care, write with non-preferred hand Retired head teacher

Comprehensive Aphasia Test: Cognition Pre treatment Ravens CPM 8/12 Pyramids & Palm Trees Verbal fluency 6/10 Verbal recognition 10/10 Ideomotor apraxia 7/12 Picture description 5/10 Arithmetic 5/6 4

Comprehensive Aphasia Test: Cognition Pre treatment Post treatment Ravens CPM 8/12 Pyramids & Palm Trees Verbal fluency 6/10 8/10 4 5 Verbal recognition 10/10 Ideomotor apraxia 7/12 6/12 Picture description 5/10 6/10 Arithmetic 5/6 4/6

Language Comprehensive Aphasia Test: Language Pre treatment Auditory comprehension (SW) 24/30 Written comprehension (SW) 26/30 Auditory comprehension (S) 11/16 Written comprehension (S) 10/16 Repetition (SW) 8/32 Noun naming 9/48 Reading (SW) 7/48

Language Comprehensive Aphasia Test: Language Pre treatment Post treatment Auditory comprehension (SW) 24/30 22/40 Written comprehension (SW) 26/30 24/30 Auditory comprehension (S) 11/16 13/16 Written comprehension (S) 10/16 15/16 Repetition (SW) 8/32 6/32 Noun naming 9/48 10/48 Reading (SW) 7/48 4/48

Pre-intervention CAT Picture Description `a man asleep and the (ray) is…it. . ah cup (dik, cots, frot) cat goin in the (blefa) the gates are falling and recorder it on. . a plant'.

Conversation Analysis Profile for People with Aphasia (CAPPA: Whitworth, Perkins & Lesser, 1997) Changes in couple’s report of regained premorbid patterns:

Len and Jane: Assessment and Intervention Assessment 1 Conversation recorded (15 mins) Language assessments CAPPA interview 8 weeks rest Assessment 2 Conversation recorded (9 mins) CAPPA interview 8 weeks intervention (1 -2 hrs, 1 per week) Assessment 3 Conversation recorded (37 mins) Language assessments CAPPA interview

Question-answer sequences: Research from normal conversation (Schegloff, 2007) Questions constrain next speaker Questions are first-pair parts (FPPs): normative expectation that an answer will be produced and be in line with the question asked Questioner temporarily controls the conversation and the Q-A sequence - unless answerer does something extra, questioner can speak again (and maybe start a new sequence)

Yes-no questions (Raymond, 2003) Y-N questions particularly constrain the answerer An expectation that an answer will contain a ‘yes’ or a ‘no’ (this may end up being answers full contribution) Answerer may not answer with a ‘yes’ or a ‘no’ but this will be noticeable (why avoiding it? ) and may entail more linguistic work Example of ‘positionally sensitive grammar’ (Schegloff 1996) ie where an utterance comes in conversation can affect its form

Conversation: Pre-intervention 1 did you have a good walk? (4. 5) did you enjoy your walk? yes was it very hot? yes. did you see anybody? (0. 5) uh: no. yeah, (1. 9) man with a dog. you saw the man with the dog uhm (. ) whats his name. not Bob. cant remember what his name is. right. was he going for a walk with the dog? no oh right he’s coming back. he was coming down, right. yeah and uhm you didn’t see Gwyn or Edna? (0. 2) y: es,

Sequences in Len and Jane’s conversation: Pre-intervention

Sequences in Len and Jane’s conversation: Pre-intervention Turn 1 by Jane Typically produces questions in the form of: 1) yes-no questions (eg ‘did you have a good walk’? ) 2) 2) ‘closed’ questions which demanded specific answers (eg ‘who did you see? ’)

Sequences in Len and Jane’s conversation: Pre-intervention Turn 1 by Jane Turn 2 by Len Typically produces questions in the form of: 1) yes-no questions (eg ‘did you have a good walk’? ) 2) 2) ‘closed’ questions which demanded specific answers (eg ‘who did you see? ’) Typically uses the minimum form to answer the question: -answers Y-N questions with a ‘yes’ or ‘no’ -answers closed/’wh-’ questions with minimal information required (‘two’) Very few sentences/attempted sentences, despite their use in tests (here only ‘he’s coming back’)

Sequences in Len and Jane’s conversation: Pre-intervention Turn 1 by Jane Turn 2 by Len Typically produces questions in the form of: 1) yes-no questions (eg ‘did you have a good walk’? ) 2) 2) ‘closed’ questions which demanded specific answers (eg ‘who did you see? ’) Typically uses the minimum form to answer the question: -answers Y-N questions with a ‘yes’ or ‘no’ -answers closed/’wh-’ questions with minimal information required (‘two’) Very few sentences/attempted sentences, despite their use in tests (here only ‘he’s coming back’) Turn 3 by Jane’s responses typically take the form of another question, launching a new sequence

Example 2: the ‘best’ section in the pre-intervention conversation as chosen unanimously by three blind raters More sentence forms by Len, but still the general patterns of sequence and topic seen in Extract 1:

Pre-intervention Ex 2 a so when I went ehm (0. 4) to the hospital with Nana this morning (0. 8) what did you do I went eh (0. 4) wa ge gu walk you went for a walk (0. 4) ehm (0. 4) what time did you get up (6. 0) eh (se woo) (1. 3) wah (0. 6) t-t- tu before eight o’clock? (0. 7) yes ((nods)) got up before eight o’clock (0. 8) right and em (0. 4) did you do your breakfast or did Anthony do it for you ooh I did it you did it right did you make yourself a cup of tea ye: s ((nods)) good ooh (. ) and I made (. ) Anthony (. ) cup of (. ) tea

Pre-intervention 2 a cont. you made Anthony a cup of tea heh (. ) did you take it up no heh heh okay so he came down for his cup of tea yeah (0. 5) so (. ) what did you do then (1. 4) went out for a walk you went out for a walk (0. 4) ehm (. ) where did you go ooh (. ) I-I (0. 8) I: (0. 6) went (. ) to: (. ) the: (0. 7) right did you go up as far as Sou thgate? y-ah! ((points)) y-no you went to the end of Blag don’s Lane? ye: s ((nods)) ye: s right okay you went to the end of Blagdon’s Lane yeah (0. 4) and I came back> and you came back

Len and Jane pre-intervention: Sequence and topic ² Len is almost constantly in the role of ‘answerer’ ² Len is interactionally passive and responsive. His role in relation to determining the content, direction, and topical development of these two conversations is a minimal one ² It is Jane who constantly takes the initiating actions - asking questions, initiating and developing the topics of talk

Intervention Aims: Discussed and worked with the couple (a) Jane: make greater use of other forms to initiate sequences rather than yes/no and closed questions (b) Jane: respond to some of Len’s answers with a repeat or paraphrase of his turn, or with a minimal agreement (such as ‘mm hm’) rather than with another question (c) Len: use the extra opportunities for talk that Jane’s changes in behaviour provide in order to contribute more to the conversation

Interaction-focused intervention process 1. Raise participants’ awareness of a conversational behaviour in general Using handouts adapted from those used in the SPPARC, Jane introduced to findings about turns and sequences (such as questions and answers) ² different types of questions ² the constraining effects of questions on the recipient

Interaction-focused intervention process 2. Raise participants’ awareness of own patterns of conversation Jane shown video clips of her question behaviours with Len and this discussed with her Jane given handouts which included examples of her different types of questions and their effect on Len’s responses

Interaction-focused intervention process 3. Strategies for change Jane asked to read written versions of a range of questions she had used and decide which type of question each was (i. e. yes/no question etc. ) Jane encouraged to use different types of turns at home to initiate sequences (i. e. , different types of questions, statement forms instead of questions etc) and to respond with paraphrases and minimal turns In forms of: role plays, homework tasks to monitor herself and elicit her feelings about changes

Post-intervention tell me about your walk. (2. 0) I eh (1. 9) I’ve eh (4. 7) I (0. 7) eh walked past the (0. 5) cemetery (1. 1) I saw Gwyn (1. 1) you walked (. ) past the cemetery (. ) you s aw Gwyn saw Gwyn (0. 5) and he (was) (0. 7) coming down he had a bag with him right? Gwyn was coming down. ye: s (1. 2) and he was yeah. (0. 5) and he have (2. 1) going out (0. 5) t-to, (2. 2) to bwocks with him (0. 9) a with eh, (2. 6) ) oh anyone oski the (0. 3) eh- (0. 4) him (1. 0) eh eh (0. 5) kower but eh lays and hehe had a box with him and (0. 5) he was (0. 7) eh s: saying NO: : : a bag. (0. 6) eh par eh ooh

Post-intervention cont. (0. 9) at eh (1. 1) ooh (1. 5) eh he had a bag with him was he going shopping? no coming home from the shops. no he was (0. 9) he (wa) (ts) (0. 9) and he (wat) (. ) talked to me about the Wales? he talked to you yeah he talked to you about Wales (. ) right?

Sequences in Len and Jane’s conversation: Post-intervention

Sequences in Len and Jane’s conversation: Post-intervention Turn 1 by Jane Now initiating sequences with forms other thn questions eg a topic-eliciting statement (‘tell me about your walk’)

Sequences in Len and Jane’s conversation: Post-intervention Turn 1 by Jane Now initiating sequences with forms other thn questions eg a topic-eliciting statement (‘tell me about your walk’) Regularly consisting of sentences or attempted sentences – sometimes 2 or more sentences in a turn Turn 2 by Len Taking active role in conversation: -actively developing, and in charge of, topic -correcting Jane

Sequences in Len and Jane’s conversation: Post-intervention Turn 1 by Jane Now initiating sequences with forms other thn questions eg a topic-eliciting statement (‘tell me about your walk’) Regularly consisting of sentences or attempted sentences – sometimes 2 or more sentences in a turn Turn 2 by Len Taking active role in conversation: -actively developing, and in charge of, topic -correcting Jane Turn 3 by Jane Responses regularly take non-question forms esp. repeats and paraphrases Generally very ‘other-oriented’ ie oriented to Len’s talk

Sequences in Len and Jane’s conversation: Post-intervention Turn 1 by Jane Now initiating sequences with forms other than questions eg a topic-eliciting statement (‘tell me about your walk’) Regularly consisting of sentences or attempted sentences – sometimes 2 or more sentences in a turn Turn 2 by Len Taking active role in conversation: -actively developing, and in charge of, topic -correcting Jane Turn 3 by Jane Responses regularly take non-question forms esp. repeats and paraphrases Generally very ‘other-oriented’ ie oriented to Len’s talk Produces another turn developing his topic Turn 4 by Len

Quantitative comparisons of samples pre-intervention

Quantitative comparisons of samples pre and postintervention

Conversation post-intervention: Speech and language therapists’ ratings Could the changes we had identified using Conversation Analysis be identified by others who had not undertaken the close analysis? 1. Could 15 naive SLTs select from two samples of conversation which sample is taken from the pre. Intervention video and which is from the post-. 2. Was there a difference between the two samples on the behaviours identified.

Method: Take sample of post-intervention conversation showing changes Select best section from pre-intervention conversations for comparison (chosen unanimously by three naïve raters) 15 SLTs took part in ratings Average time since qualification: 11. 2 years Average number of years working with aphasia: 9. 6 years

Task 1: which sample is pre-intervention and which post-intervention? ² Extracts presented as ‘green’ and ‘harlequin’ ² SLTs shown the two extracts twice (g; h; g; h) ² Make decision on which extract is pre, which post and comment why

Task 2: Observations of specific behaviours ² Treatment described to SLTs ² SLTs given written transcripts of the extracts ² Given description of behaviours with codes ² Watched extracts twice (h; h; g; g) and marked down when behaviours evident

Results: Task 1 - which sample is pre-treatment and which post-treatment? 14 out of the 15 SLPs correctly identified green extract as occurring post-treatment

Task 2: Proportion behaviours observed pre-intervention

Task 2: Proportion behaviours observed postintervention

Conversation post-treatment: Jane’s perception ‘The main difference in Len’s conversation since last June is that he now uses sentences daily instead of one word requests or answers. Len speaks to our son and my mother and his weekly telephone call to his brother is much less of a chore for Len. He attempts more conversation with friends. When Sarah first set up the recorder and stated that she wanted us to record our conversation my heart dropped. We had no conversation as I understood it. I would talk to Len constantly and apart from making sure that he understood me, I was content to leave it at that.

When Len needed to tell me something we played ‘twenty questions’ until I understood his needs. When we studied the tape we were both very surprised to see that Len was able to answer some questions. He gained in confidence through this experience and has gone from strength to strength. The initial sounds are sometimes wrong but Len is forming complete sentences, in his head, and attempts to talk in complete sentences. Len finds it easier to initiate a conversation relating to his needs…. . ’

In this study…. ² Couple had mutually adapted in a way which ‘worked’ for them to some extent: - Jane gets Len to talk by asking easy questions where the form is easy for him eg Y-N questions - Len’s linguistic limitations are not exposed ie little delay /errors/repair But this adaptation was at a large cost: - Len very passive in conversation and contributing only minimally to topic development The intervention provided them with choices ie can do other actions in conversation except very restricted Q-A-Q-A Notably, Len’s language output changed (was encouraged to be used) in conversation, even though it was Jane who was most targeted in intervention (cf. Simmons-Mackie et al. , 2005)

Therapy case study 2: Improving PWA’s ability to produce successful topic initiations (Wilkinson, Lock, Bryan & Sage, 2011, IJSLP) Connie 36 Left CVA 14 months previously Agrammatic Phonemic and semantic paraphasias Mild dysarthria Good comprehension Profession: ex-catering manager Sam (spouse) 38 Profession: manager in a service industry

Interaction-focused therapy for Connie & Sam 1. Collect recordings of couple at home and carry out tests 2. Conversation assessment: pre-and post intervention and plan intervention u Repair u Topic u Turns and sequences 10 minutes transcribed analysed 1. Interaction-focused intervention: four 2 -hour sessions with the couple together at home

Comprehensive Aphasia Test: Disability Questionnaire for Connie Key: lower the score, lower the perceived disability

Topic initiation in normal conversation Can occur almost imperceptibly within turns. But other topic initiations are ‘boundaried’ ie marked to be heard as disjunctive to what has just been talked about Successful topic change is a collaborative and mutual phenomenon eg: -one speaker announces some news (‘oh I saw John last night’) -other speaker aligns with this news/new topic (‘oh really? ’) It is important that topic initiating turns are recognizable as such -often using ‘prefatory discontinuity markers’ eg ‘anyway’, ‘ well’ etc -separates off the new topic from the old ie makes it disjunctive Also speakers mark when current topic winding down (eg by repeating/returning to words used at the start of the topic) -ie current topic is marked as winding down, new one may be expected Collaborative work between two speakers

Topic initiations by Connie: Pre-intervention Connie initiates topic three times in the pre-intervention conversation data But each time the topic initiation is problematic eg Sam has difficulty in understanding Connie’s topic initiating turns

Pre-intervention Ex. 1 stop off in California (0. 8) on the way there- in (. ) New York on the way there. . hhh ehm (1. 4) eh feberi February. no: : ! (0. 6) fareri family. yeah. (1. 2) family. fabi, fa: mi: ly. that’s it. (0. 3) family. your family in A-America. (0. 5) we’ll see them. no: : : ! family? sorry (. ) I’m (. ) mistaken fabawi (1. 3) fa: mi: ly. =yeah, Jimmy yeah. (0. 7) and they’re going. no: : ((looks frustrated)) go on< go on sorry go on eh Jimmy. . . Mary…

Pre-intervention Ex. 2 and it's ten past eleven (2. 0) and I just feel tired (. ) I'll have a shower now (. ) (scuse) I just keep yawning ((yawns)) have a shower (. ) go to bed and get up again. ehm rea: d my: boo: ks: (1. 5) sorry ( ) rea: d my: boo: ks: read your book? mm where's your book? ((C picks up homework book))

Summary of Connie’s topic initiations preintervention All three topic initiations were initially unsuccessful Problem for Sam in understanding/hearing them: - not only dysarthric/agrammatic problems but some evidence he does not always recognize them AS topic initiating turns Psychosocial consequences: Sam’s difficulties in understanding Connie are evident, often over several turns/tries Factor: Connie’s design of these turns, and not marking them clearly enough as topic initiations – not getting Sam’s attention eg no use of ‘prefatory discontinuity markers’

Intervention for topic initiation difficulties 1 of Connie and Sam’s 4 intervention sessions focused on topic 1. Raising awareness of topic initiations in general - normal topic initiation discussed using SPPARC handouts 2. Raising their awareness of their own patterns of topic initiations - using Connie and Sam’s videos - ie highlighting Connie’s topic initiations appear ‘out of the blue’ and therefore hard for Sam to understand - currently done as quite unilateral by Connie rather than collaborative 3. Strategies for change -Connie to draw Sam’s attention to topic initiation with ‘alerters’ eg ‘anyway’ -if Sam recognizes this as topic initiation, he should collaborate with it (eg through using a continuer such as ‘mm hm’) -what currently done unilaterally by one to be done collaboratively by two

Topic initiations by Connie: Post-intervention In similar length of analysed conversation (9 mins), 5 topic initiations by Connie using this new method But not ‘anyway’ etc Rather: Temporal phrase (‘tomorrow morning’) + pause (ie space for Sam to recognize this is a new topic and produce a continuer to facilitate her to continue)

Post-intervention Ex. 1 ((talking to ‘Soots’, the cat)) shower leaking (0. 3) Soots (0. 3) shower’s leaking. (2. 7) mm (0. 9) ((talking to cat)) lay down. (5. 8) ehm (. ) ((lip smack)) (2. 0) eh: : (. ) ((lip smack)) (1. 3) next Thursday, (2. 3) mm hm eh ten o’clock, (0. 3) a m, (0. 4) mm hm (0. 4) (1. 9) meet? the cousins (. ) Stanst-ead airport. I thought it was Friday you were going. no! (0. 6) Thursday.

Post-intervention Ex. 2 I’m only gonna go (. ) two weeks. (2. 4) a day to get there (n) a day to get back (2. 8) it’s a long way. (0. 9) s- (0. 9) it’s a day out-two days out your life on an aeroplane, ((shrugs)) mm so what? (6. 5) ((lip smack)) ehm, (. ) ((lip smack)) tomorrow? = mm hm, (0. 8) morning, (0. 4) e: leven o’clock, mm hm nomeni (. ) h- (. ) hospital, mm hm midisex hospital, ((nods)) ehm: (0. 5) ((lip smack)) fehm, ((tuts)) (1. 2) heh heh John ((laughs)).

Post-intervention Ex. 3 well I’m glad you’re gonna go (0. 6) with your cousins ‘n (2. 3) good holiday eh ((lip smack)) ehm ((lip smack)) (0. 8) las: t (1. 0) no. (. ) you- mm ((lip smack)) l- (3. 5) ((lip smack)) this morning, ((head nod)) ‘raine phone me (0. 9) Australia. yeah ((yawns)) ehm guess what (1. 0) what (1. 5) you and me she’s moving back (1. 0) you and I yeah no (. ) you and I, you mean you and me ((both laugh)) ehm god-par-ents. (1. 2) godparents. yeah. (0. 8) only if we go there. yeah

Summary of topic initiation intervention New method is idiosyncratic, but successful for this couple Connie’s temporal phrase with rising intonation + pause successfully marked this turn as new topic, discontinuous with prior talk It also enagaged Sam as a co-constructor of the topic Ie topic initiation as collaborative and step-by-step New method involves mutual adaptation – new behaviours for Connie’s topic initiations by both members of the couple All Connie’s topic initiations using this method were understood by Sam – no repair and highlighting of Connie’s impairments

Summary of topic initiation intervention This method slightly different to what was trained Where does this temporal phrase method come from?

Use of temporal phrase pre-intervention she used to lick them to death didn’t she. (. ) licked them to death awwh: : ehm ((lip smack)) (. ) uh (1. 1) ((lip smack)) nine years ago. hh ehm (. ) ((lip smack)) (0. 2) the dog (0. 3) eh died a heart attack awwh that was your alsatian yeah

Maintenance of use of method: 23 months after post-intervention assessment yeah that’s all I been doing part from (0. 2) bit a decorating (0. 8) umm (1. 0) yeah tuh (0. 2) July no- June um (0. 2) tuh three tier wedding cake (0. 2) I make it are you? yeah (0. 3) brilliant

Use of interaction-focused therapy in clinical practice Some publications in professional literature about using this therapy approach in clinical practice (Niewenhuis, 2005; Volkmer, 2006; Waters, 2007) ² With other client groups ² In different settings eg hospital ² Run as group therapy vs couples therapy ² Time issues & resource issues

Conclusions ² Now a growing evidence base that aphasia therapy can change how PWA and SOs have conversations in the home environment (see Wilkinson & Wielaert, 2012, for an overview) ² This means a change not only in terms of improved communication and language use, but also supporting couples to adapt to having conversations with aphasia i. e. psychosocial improvement ² Future work involves examining the role of impairmentfocused therapy in changing conversation, and in expanding how interaction-focused therapy is used both in research and clinical practice

ray. wilkinson@manchester. ac. uk