Professional Documents
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VOL.
2014,
Review
Conversation therapy for aphasia: a qualitative review of the literature
Nina Simmons-Mackie, Meghan C. Savage and Linda Worrall
Communication Sciences & Disorders, Department of Health & Human Sciences, Southeastern Louisiana University,
Hammond, LA, USA
NHMRC CCRE in Aphasia Rehabilitation, School of Health & Rehabilitation Sciences, University of Queensland, QLD,
Australia
Address correspondence to: Nina Simmons-Mackie, 580 Northwoods Drive, Abita Springs, LA 70420, USA; e-mail: nmackie@selu.edu
International Journal of Language & Communication Disorders
C 2014 Royal College of Speech and Language Therapists
ISSN 1368-2822 print/ISSN 1460-6984 online
DOI: 10.1111/1460-6984.12097
512
Conversation has been described as the heart of human communication (Armstrong and Mortensen 2006,
Clark and Wilkes-Gibbs 1986). It is critical for exchanging information, maintaining social relationships, negotiating a sense of self and managing emotional health.
For people with aphasia engaging in conversation can
be difficult or even impossible. Since conversation is an
essential element in human communication, improved
conversational skill and improved participation through
conversation should be a primary objective of aphasia
therapy (Wilkinson 2010).
Most aphasia therapies ultimately aim to enhance
natural communication and conversation. However, a
variety of aphasia interventions have been explicitly described as conversation therapy. These approaches are
distinct from interventions that aim to generalize trained
skills from linguistic or functional tasks into natural conversation. Rather, conversation-oriented therapies focus
overtly on changing behaviours within the context of
conversation. Information related to conversation therapy in aphasia has been published within a variety of
different approaches such as communication partner
training (e.g. Kagan et al. 2001), group aphasia therapy
(Elman and Bernstein-Ellis 1999), approaches to communication support (Hux et al. 2010, Rautakoski 2011)
and interaction-focused therapies (Wilkinson 2010,
Wilkinson et al. 2011). A Cochrane review of speech
language therapy for aphasia suggested that conversation
as part of aphasia intervention should be considered
social stimulation (Brady et al. 2012). Given the varied approaches to conversation therapy reported in the
aphasia literature, it is not surprising that in a recent survey of 100 speechlanguage pathologists in the United
States and Australia, respondents demonstrated difficulty clearly describing methods associated with conversation therapy for aphasia (Simmons-Mackie et al.
2013).
A descriptive review of the conversation therapy
literature would help to organize existing information
from diverse sources and provide a resource to clinicians
and researchers. Therefore, the current project was designed to conduct a qualitative or narrative literature
review of conversation therapy for aphasia. The goal of
a narrative literature review is to present an up-to-date
synopsis of a particular topic in order to describe current
or proposed practices, influence policy or suggest future
research (Cronin et al. 2008). This type of descriptive
review is contrasted with a critical systematic review of
the literature that seeks to critically and systematically
evaluate the quality of research evidence on a particular topic (Garrett and Thomas 2006). A narrative or
qualitative literature review was chosen since the topic
of conversation therapy requires refinement and a con-
513
People with aphasia
Although traditional aphasia therapy typically involves
treatment directed at the person with aphasia in individual or group therapy, there was a dearth of literature addressing conversation therapy targeting people with aphasia independent of conversation partners
(Basso 2010, Savage et al. 2014). Conversation therapy
directed at the person with aphasia (without the communication partner present) was represented primarily
in descriptions of group aphasia therapy (Bernstein-Ellis
and Elman 2007, Elman and Bernstein-Ellis 1999, Ross
et al. 2006).
Communication partners
Perhaps the most widely published method of targeting
conversation in aphasia involves training conversation
partners. Various labels have been used to characterize partner training in aphasia such as Communication
Partners (Lyon 1996, 1997, Lyon et al. 1997), Supported Conversation for Adults with AphasiaTM (SCA)
(Kagan et al. 2001), the Conversation Partner Scheme
(McVicker et al. 2009) or Conversation Partner Training
(CPT) (Bradley and Douglas 2008). Theoretical support
for partner training draws from the collaborative nature
of conversation, and the assumption that a change in the
behaviour or skill of the non-aphasic communication
partner will result in changes in the communication,
conversational behaviour or participation of the aphasic partner. A body of literature has emerged addressing
partner training in aphasia (see reviews by Bradley and
Douglas 2008, Simmons-Mackie et al. 2010, Turner
and Whitworth 2006), and a systematic review of partner training research suggested that training typically
improves the skill of communication partners and enhances conversational participation of the person with
aphasia (Simmons-Mackie et al. 2010).
One approach to partner training in aphasia involves
training communication partners without the person
with aphasia present. In fact, the earliest research on
partner training in aphasia entailed a single subject experimental investigation in which a wife participated
in partner training independent of her husband with
aphasia. Although her husband with aphasia was not included in therapy, his participation in conversation improved following the wifes training (Simmons-Mackie
et al. 1987, 2005). A number of studies subsequently described training of communication partners without the
person with aphasia present. Various types of partners
have been trained in order to explicitly improve conversational participation of people with aphasia. Regular partners such as family members or caregivers (e.g.
Simmons-Mackie et al. 2005) as well as volunteers (e.g.
Hickey et al. 2004, Kagan et al. 2001, McVicker et al.
514
Conversation Partner
Dyad
Conversation Analysis
Social Model
Principal Roots
Functional, Behavioral
Relationship oriented
Individual
Conversation Therapy
Service Delivery
Group
Focus of Intervention
Generic/Individualized
Problems/Solution
Compensatory
Training Methods
Explicit/Implicit
Activities
External/Embedded
Outcomes
Research Design
Dyad approaches
Several approaches to conversation in aphasia involve
working directly with a dyad a person with aphasia and a communication partner. Examples of therapies that involve dyads include conversational coaching
(Hopper et al. 2002), couples therapy (Boles 1997,
2011), interaction-focused therapy (Wilkinson 2010,
Wilkinson et al. 2011) and communication partner
training (CPT) (e.g. Blom Johansson et al. 2013, Saldert
et al. 2013). A commercially available partner training
program, Supporting Partners of People with Aphasia in
Relationships and Conversation (SPPARC) is applicable
515
Table 1. Primary data sources addressing conversation therapy for aphasia categorized by the participant(s) who is actually the target
of training and the mode of service delivery (group versus individual sessions)
Partner approaches
Group of
dyads
Individual dyad
Group
Individual
Basso (2010),
Savage et al.
(2014)
Note: a Beeke et al. (2007) present an analysis of cases from Burch et al. (2002) and Lock et al. (2001a). Thus, the paper by Beeke et al. is technically not original research. However, the
Burch et al. case was not previously published in a refereed journal and not cited in the academic search engines employed in this study. Therefore, we have chosen to include the paper
by Beeke et al. as a primary source, but wish to credit the original sources: Burch et al. (2002) and Lock et al. (2001a).
Life participation
516
Behaviour targeted
Person targeted
Reference
Communication partner
Communication partner
Communication partner
Communication partner
Communication partner
Communication partner
Communication partner
Communication partner
Dyad
Person with aphasia
Strategically manage turns
Improve topic management
Ask more questions
Improve introduction of new
topics/management of topics
Improve self-repair
Increase initiation/taking
turns/participation in
conversation
Dyad
Dyad
Person with aphasia
Person with aphasia
Person with aphasia
Person with aphasia
Counselling-oriented approaches
Several approaches to conversation in aphasia are best
described as counselling or relationship oriented. Although many conversation therapies address the relationship or interaction within a dyad (e.g. Lock et al.
2001a), counselling- and relationship-oriented approaches explicitly incorporate elements drawn from
the counselling literature. For example, an approach to
working with conversational dyads that is now referred
to as Couples Therapy is rooted in principles of marital and relationship counselling as well as knowledge of
linguistics and communication (Boles and Lewis 2003,
Fox et al. 2009). In a somewhat different orientation,
Sorin-Peters (2004) describes conversational work with
couples based on counselling and adult learning theory. While these approaches aim to improve conversation, they emphasize that the relationship of couples
cannot be separated from their communicative interactions. Group conversation therapy as described by Elman et al. draws from the counselling literature relative
to group dynamics in addition to adhering to social
model philosophy (Bernstein-Ellis and Elman 2007,
Elman and Bernstein-Ellis 1999, Ewing 1999). Thus,
relationship oriented approaches explicitly incorporate
methods adapted from counselling or family therapy.
517
Mode of service delivery
Modes of delivering conversation therapy include both
individual therapy in which the SLP works with one
person or one dyad, and group therapy in which the SLP
works with a group of partners, people with aphasia, or
dyads (table 1).
r Generic versus individualized training: Some conversation therapies include relatively generic
strategies, skills or resources believed to improve
conversational interactions. Generic training is
often associated with group approaches such as
partner training workshops in which partners are
taught general skills (e.g. using multiple modalities, giving people with aphasia time to respond)
(Kagan et al. 2001, McVicker et al. 2009, Rayner
and Marshall 2009). Individualized training involves targeting behaviours that are specific to an
518
519
conversational interaction. In other words conversation
is the target of treatment and the context of treatment.
For example, several approaches involve online coaching
or feedback while the person with aphasia and partner
engage in conversation (Beckley et al. 2013, Boles 1997,
1998, Boles and Lewis 2003, Fox et al. 2009, Hopper et al. 2002, Savage et al. 2014, Wilkinson et al.
2010, 2011). Group conversation therapy is considered
an embedded approach since behaviours are being targeted within the context of actual conversation (Elman
and Bernstein-Ellis 1999, Ross et al. 2006, SimmonsMackie et al. 2007a). Like the explicitimplicit division,
embedded versus external approaches probably fall on a
continuum with some approaches involving a combination of work within and outside of actual conversations.
Activities
The activities involved in conversation therapy tend to
be a natural extension of the characteristics already discussed (table 3). For example, explicit approaches often
involve education, discussion, role-play and video examples to build awareness of particular behaviours as a
prerequisite to behaviour change. These techniques are
particularly prevalent in communication partner training and dyad approaches where the clinician records
conversations and/or transcribes conversations to assess
conversational patterns, identifies potential problems
and solutions, and then uses instruction, discussion
and feedback to help participants change their own behaviours. Education regarding aphasia, elements of natural conversation and/or conversational strategies and
resources is sometimes a first step in raising awareness
of conversational patterns (e.g. Kagan et al. 2001, Lock
et al. 2001a). Video recorded examples have been used
including general examples of conversational behaviours
and video recorded examples of a dyads own conversations (e.g. Beckley et al. 2013, Beeke et al. 2011, Hopper
et al. 2002, Lock et al. 2001b, Simmons-Mackie et al.
1987, 2005). Other training methods have included
role-play (Cunningham and Ward 2003, Kagan et al.
2001, Rautakoski 2011) and reviewing written samples or transcripts of ones own conversations to build
awareness of targeted behaviours or strategies (Booth
and Swabey 1999, Lock et al. 2001a, 2001b, Wilkinson
et al. 2010, 2011). Sorin-Peters (2004) and Boles and
Lewis (2003) encourage dyads to reflect on their relationship, pattern of communication and goals, and these
are discussed in the context of strategies for improving
conversation.
The primary activity in embedded approaches is
conversation. That is, participants engage in conversational interaction that is either facilitated by the clinician
(Bernstein-Ellis and Elman 2007, Simmons-Mackie et
al. 2007a) and/or the clinician provides online coaching
520
521
Table 4. Number of research articles addressing conversation
therapy by types of research reported
Type of research
Randomized controlled trial
Group pre-post-/case series
Single participant experimental design
Qualitative study or case study
Total
Number of articles
2
5
8
15
30
Level of evidence
Although this project was not designed to critically evaluate the quality of research on conversation therapy for
aphasia, it seemed important to report on the limited
number of high-level research studies on conversation
therapy that were identified as primary sources (table
4). Fifteen of the reviewed studies were classified as descriptive case reports or qualitative research (Basso 2010,
Beckley et al. 2013, Beeke et al. 2007, 2011,1 Boles and
Lewis 2003, Booth and Perkins 1999, Booth and Swabey
1999, Fox et al. 2009, Lesser and Algar 1995, McVicker
et al. 2009, Simmons-Mackie et al. 2007a, Sorin-Peters
2004, Wilkinson et al. 1998, 2010, 2011). Although
case studies and qualitative research provide important
information about interventions, these studies are not
considered a high level of evidence for efficacy of an
intervention. There were eight articles reporting one
or more single participant experimental designs (Boles
1997, 1998, Cunningham and Ward 2003, Hickey et al.
2004, Hopper et al. 2002, Saldert et al. 2013, Savage
et al. 2014, Simmons-Mackie et al. 2005). Five studies
reported outcomes for groups of people with aphasia
and/or conversation partners before and after intervention (Blom Johansson et al. 2013, Lyon et al. 1997,
Lock et al. 2001a, Rayner and Marshall 2003, Ross
et al. 2006). Two studies were considered randomized
controlled trials (RCTs) including both treatment and
control groups. One of the RCTs (Kagan et al. 2001)
involved training of volunteer conversation partners
and measuring outcomes within semi-structured conversation with people with aphasia. The second RCT
addressed group therapy for aphasia (Elman and
Bernstein-Ellis 1999). This study provided evidence of
the effectiveness of group therapy based on language and
functional test scores and described methods consistent
with conversation therapy; the research report does not
include a measure of conversation as an outcome.
Discussion
Perhaps the most striking finding of this review of conversation therapy for aphasia was the wide variation in
published approaches. In order to address this diversity,
the elements of various approaches were organized and
522
categorized to describe conversation therapies for aphasia. Conversation interventions were classified according
to treatment participants (person with aphasia, partner
or dyad), the primary origins, the mode of service delivery (individual or group), the overall focus of intervention (generic versus individualized; problem versus
solution oriented; compensatory), training methods (explicit versus implicit; external versus embedded), types
of activities or tasks, and outcomes measured. Finally,
primary sources were classified by the type of research
design.
Another major finding was the marked discrepancy between intervention focusing on conversational
skills of partners or dyads and intervention focusing on
conversational skills of individuals with aphasia independent of a particular dyad. Only 17% (five out of
30 articles) of the primary source articles (table 1) described intervention for people with aphasia independent of a communication partner. Certainly, the fact
that conversation is a collaborative event suggests that
both parties require skills and often the skills are dyad
dependent. While skilled partners are critically important for conversational success, it is surprising that so
little attention in the literature has been afforded to improvement of conversational skills of individuals with
aphasia. Many people with aphasia do not have regular
communication partners or reside in situations where
partners change frequently (e.g. residential facilities);
these individuals might profit by intervention aimed at
improving conversational skills that are not dyad specific. Furthermore, the bulk of aphasia therapy occurs
during individual therapy sessions between the person
with aphasia and the clinician; yet, there is little systematic attention to one-on-one therapy with the person with aphasia to improve conversation. In fact, there
is little description regarding methods that clinicians
might employ during individual conversation therapy
for aphasia. With increasing attention to the need to
improve participation in life for people with aphasia,
it would seem important for aphasia therapists to employ evidence-based measures for improving conversational skill and confidence of people with aphasia beyond interactions with a regular partner. The aim of
such improvements would be to promote conversational
engagement outside of immediate family or caregivers,
and ultimately decrease social isolation and increase life
participation.
Related to the discrepancy between intervention for
partners and individuals with aphasia, is the variation in
the literature including communication partners. This
relatively large literature represents a variety of philosophical origins and approaches. Since, as noted earlier,
partner training is not necessarily synonymous with conversation therapy, it is not advisable to generalize broadly
from reviews of partner training to conversation therapy
523
Conclusion
Conversation is a pervasive element of everyday life.
Therefore, an essential goal of intervention for people
with aphasia should be to improve conversational skill,
confidence and participation. This review has offered
a comprehensive depiction of the diverse literature related to conversation therapy and suggested multiple
directions for future research.
Acknowledgements
Future directions
This review suggests a host of directions for future
research in conversation therapy for aphasia. First,
stakeholders (researchers, clinicians and consumers)
must determine which domains should be measured
as core outcomes and then researchers must identify
meaningful tools or protocols for measuring conversation, particularly measures that capture conversation as
a dynamic whole. Instruments are needed that measure success or achievement of conversational goals (as
described in the CA literature, e.g. Beeke et al. 2007,
Wilkinson 2010) as opposed to discrete behaviours or
linguistic accuracy. Moreover, measures must capture
skills and participation in actual conversation, as opposed to structured or contrived discourse tasks.
Another thrust of future research might be development of one-on-one conversation therapy for individuals with aphasia, including more information regarding
interactive features of conversation (repair, turn management) that might be amenable to individual therapy.
Since little systematic, published research has defined
and evaluated individual conversation therapy for aphasia, such a program of research is needed.
The project reported herein was designed to describe conversation therapy and develop a taxonomy
that organizes features of conversation therapy. Future research should employ robust research designs
to measure outcomes of conversation therapy associated with specific approaches. Ideally a phased approach
(Campbell et al. 2000, Robey and Schultz 1998) to research should slowly develop and build the evidence
for conversation therapy. Ultimately, different conversation therapy approaches might be compared to determine the most effective and efficient methods, and
conversation therapy might be compared with other
approaches such as impairment-oriented intervention.
Finally, while researchers are increasingly measuring the
effects of impairment-focused therapy on conversational
behaviours (e.g. Carragher et al. 2012), it is important to
study the reverse also: the effects of conversation therapy
on linguistic performance (e.g. lexical retrieval, syntax)
as well as natural conversation.
Note
1. 1. Representing case study research presented in Burch et al.
(2002) and Lock et al. (2001a).
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Appendix
Articles reviewed as primary data sources
Basso (2010), Beckley et al. (2013), Beeke et al. (2007,
2011), Johansson et al. (2013), Boles (1997, 1998),
526
Boles and Lewis (2003), Booth and Perkins (1999),
Booth and Swabey (1999), Cunningham and Ward
(2003), Elman and Bernstein-Ellis (1999), Fox et al.
(2009), Hickey et al. (2004), Hopper et al. (2002),
Kagan et al. (2001), Lesser and Algar (1995), Lock