Language and CognitionColombo 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 p292 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 58yr• 4-178m 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

3m 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