Language and Cognition Colombo June 2011 Day 7

Language and Cognition Colombo June 2011 Day 7 Working with conversational partners

Models of Service Delivery • Impairment based approach – – Restorative/rehabilitative Reliant on formal testing Little generalisation to everyday life Gains made may be small and not functionally relevant. Gaps in linguistic measures and real-life functional performance • Functional Skills approaches – Ability to utilise compensatory strategies – Reliant on tasks used in everyday life e. g. Using phone – Still does not account for personal experiences/lifestyle adjustments

Rationale for Social model approaches • Aphasia – chronic disorder – Long term communication deficits impacting on daily life – Need to acknowledge impact of aphasia on psychosocial aspects – Self-esteem – Role and identity within a family unit – Relationships – Acknowledgement of PWA limitations in rights and opportunities

Values Supporting the Social Model • Disability if a consequence of disabling attitudes and barriers imposed by society, not just an impairment within the individual. • Aphasia is a diagnosis but also a socially constructed way of being that is created through the experiences of the person with aphasia, those around the person and society (Penn 2004 p 292 in Chapey 2008) • PWA and their families share control and decision making with clinicians

Principals of a Social Model Approach (Chapey 2008) • Addresses both information exchange and social needs as dual goals. Less focus on transaction of a specific message, and more on the interactive process • Addresses communication within relevant and natural contexts • Views communication as dynamic, flexible and multidimensional • Focus on the collaborative nature of communication • Focus on natural interaction particularly conversation • Focus on personal and social consequences of aphasia • Focus on adaptations to impairment • Embrace the perspective of those affected by aphasia • Encourage qualitative as well as quantitative measures.

Objectives of Partner Training • Speaking partners learn strategies to support communication when aphasia interferes. • Use of augmentative tools by the partner to encourage the PWA to use the same • Altered expectations and perceptions of PWA • Expand opportunities for conversation by alleviating embarrassment, helplessness, fear • Encourage life participation and reinforce joint responsibility for success

Creating Authentic Communication Events • Relevant life activities: – Leisure, exercise and conversation groups, e. g. Book club with adapted materials and facilitated group discussion. • Relevant client centred life situations – Cooking, gardening, volunteering • NB Not aiming for pre-aphasia lifestyle. Aim for satisfying life with aphasia Simmons Mackey in Chapey 2008

Providing support systems within the community • Training of family and friends of the individual to build expanded support systems • Set up of peer mentors: PWA + PWA pair • Community education through church groups, businesses, education institutions to increase public knowledge

A review of Conversational Partner Training Turner and Whitworth 2006 • Review of current literature to examine: – The reported success of studies adopting conversational partner training approaches – What aspects of communication were being improved and how these were being measured. – How participants were being selected and subsequently reported. – The nature of the participants’ involvement in the intervention, examining how influential (if at all) their individual characteristics were considered to be to the outcome.

Methods • Extensive literature review of databases • Reviewed; data extracted on: – Participants, – CPT approach used – Outcomes – Maintenance of effect

Results • 9 papers included • 3 intervention approaches used: – Conversational Analysis – Supported Conversation for Adults with Aphasia (competence of PWA exposed through skilled CP) – General total communication approach with conversational coaching (examines message exchange plus social communication skills appropriate to specific events)

Characteristics of the Person with Aphasia • Mean age 58 yr • 4 -178 m post onset of stroke • Functional comprehension in conversation (Mild/mod receptive impairment) • Mild-severe expressive difficulties • Medically stable with few cognitive impairments

Characteristics of the Conversation Partners • Family members (spouse) or volunteers (often university students = younger) • Factors influencing selection of participants: – Carer availability – Marital harmony – Motivation – Potential to change communicative behaviour (of both parties)

Focus and Format of Training • Information was given initially on the nature of aphasia, followed by information specific to the person. • Raising awareness of maladaptive conversation behaviours via the use of video feedback • Experiential teaching, allowing the opportunity for practice (role-play situations) with feedback. • Volunteers: teaching of generic conversation skills to provide participants with the skills to offer conversational support for any person with aphasia in their volunteer role

Outcomes Used • Conversational Analysis parameters (turns in a repair, proportion of successful repairs) • Story telling (% of utterances using supportive communication) • Scales by Kagan et al (1999) (assess partner skill and level of participation of PWA) • Confidence and satisfaction questionnaires • VASES and HADS • BDAE, CAT, and CADL-2

Efficacy • Very favourable outcomes: – Positive changes in interaction of familiar partner (reduced interruptions & use of test questions, Increased number of successful repairs etc) – Volunteers increasingly able to reveal communicative competence of PWA, knowledgeable about aphasia and useful strategies – Increased attempts at interaction for PWA

But. . . • Despite clear efficacy demonstrated it still remains unclear as to whether one particular approach may be more successful than another. . . • Or whether the stage in a person’s rehabilitation is influential in the success of the programme.

Long Term Effects of CPT • Many articles did not follow up. • Those that did found maintained effects up to 3 m post training

Possible Factors Influencing Outcome • Relationship harmony between spouses and premorbid communication styles • Impact of age, cultural background, education and motivation on volunteers as conversational partners

Conclusions • Favourable outcomes for CPT schemes • But: – Poor information regarding conversation partners esp. volunteers (e. g. Selection criteria, success of communication prior to training) – Methodological weaknesses in some studies – Functional state of relationship and mood, partner attitudes may influence outcomes • More research in these areas = better understanding into what makes communicative success.

Summary • The training of communication partners falls within a social model approach to intervention. • Based on the belief that communication is a social act expressive of ideas/values • The ultimate aim of a social approach is to enhance the living of life with aphasia. Simmons-Mackey in Chapey 2008