Elizabeth Armstrong

A multinational comparison of aphasia management practices

The effect of restructuring of healthcare on the quality, quantity, and nature of aphasia management is largely unknown. The current study is the first to examine access, diagnostic, treatment, and discharge patterns of patients with aphasia in Australia, Canada, the UK, the US private sector (US-Private), and the US Veterans Health Administration in the Department of Veterans Affairs (US-VA). The authors developed a 37-item survey to be completed by clinicians working with aphasic patients. The survey focused on eight areas: access to care, evaluation procedures, group treatment, number and duration of treatment sessions, limitations of the number of sessions, termination of treatment, follow-up practices, and resumption of treatment. 394 surveys were distributed and 175 were returned completed (44% return rate). Respondents represented a range of ages, work experiences, and work settings. There was considerable consistency among respondents from our five healthcare systems. Results suggest that patients may be routinely denied treatment in direct contradiction to the research literature. Just as we carefully monitor the progress of patients receiving our treatment, we are obliged to monitor the effects of managed care on our patients, fellow clinicians, and our profession.

Qualitative methods in aphasia research: basic issues

As clinical aphasiologists seek different ways to understand the complexity of aphasia within naturalistic and social contexts, there is an increasing need to provide background information on various research paradigms not widely used in the field. Consistent with recent calls for qualitative research in clinical aphasiology, this article provides information on the rationale, design characteristics, strengths and weaknesses of this research paradigm and its usefulness in clinical aphasiology.

What is aphasia? Results of an international survey

Background: Although the literature implies that there is limited public awareness of aphasia, direct data have been lacking. Aims: Therefore, a survey was undertaken to sample public awareness of aphasia. Methods & Procedures: A face-to-face survey of individuals in public places in England, the USA, and Australia was undertaken. A total of 978 individuals were surveyed. Data were analysed to determine the number of informants who had “heard of aphasia” and the number with “basic knowledge of aphasia”. In addition, characteristics of informants were analysed. Outcomes & Results: Of the individuals surveyed, 133 said they had heard of aphasia (13.6%), but only 53 (5.4%) met the criterion of having “basic knowledge of aphasia”. Conclusions: These findings lend support to the notion that the public lacks awareness or understanding of aphasia. As public awareness can affect funding, quality of services, and public acceptance of individuals with a disorder, public awareness and advocacy campaigns are needed.

Conversational treatment in mild aphasia: A case study

Background: The literature suggests that mild aphasia negatively affects everyday experiences, social life, and identity. However, while mild word‐finding problems and difficulty understanding abstract or grammatically complex language are typical clinical characteristics, their impact on everyday discourse and conversation partners remains relatively unexplored. Similarly, treatment studies addressing conversational difficulties have predominantly included those with moderate to severe aphasia, rather than those at the mild end of the severity scale. Aims: The current study examines conversational difficulties in mild aphasia and their accessibility to a conversational treatment procedure. Methods & Procedures: A woman with mild aphasia and her husband participated in the study. They underwent 14 sessions of conversational therapy, based on the procedures of Boles (1998) and Boles and Lewis (2003). Outcome measures included subjective ratings by the couple regarding conversational parameters they deemed important, ratings of their interactions by independent judges on the Measure of skill in Supported Conversation (MSC) and the Measure of Participation in Conversation (MPC) (Kagan et al., 2004), independent judgments of whether interactions were pre or post‐treatment, as well as a series of behavioural measures related to specific goals collaboratively set by the couple and the clinician. Outcomes & Results: Improvements were noted in both the participants’ ratings and the independent judges’ ratings. While some changes were noted on behavioural measures, clear patterns were not always evident. Conclusions: The study suggests that conversational treatment may be beneficial to couples dealing with mild aphasia as well as those at the more severe end of the continuum as reported previously. However, measures of the effects of treatment need to be further explored in terms of sensitivity to conversational changes in mild aphasia.

Making stories: Evaluative language and the aphasia experience

Background: Language used for expressing feelings and opinions—so‐called evaluative language—is essential to the expression of the individuals identity. Illness narratives involving evaluative language are known to be important vehicles for coping with identity change during chronic illness, as well as reflecting on and sharing the experience. However, relatively little is known about the aphasic persons ability to engage in such narratives—in particular, the effects of their language difficulties on this endeavour. Aims: This study discusses different types of evaluative language and ways in which they are relatively impaired or preserved in aphasia, focusing on stroke narrative. Methods & Procedures: Examples from the stroke stories of three aphasic speakers are used as illustrations of their evaluative abilities. The stories were analysed according to evaluative language categories defined by Labov (1972) and Martin (2003). The function of each of these categories is described in terms of its contribution to the emotive nature of the discourse. Outcomes & Results: The aphasic speakers were successful in using evaluative language and used similar devices to non‐brain‐damaged speakers. However, the realisation of the devices was simplified at both lexical and syntactic levels and in terms of quantity. Conclusions: Emotive/evaluative language promises a different perspective on language usage across speakers of differing levels of severity for both assessment and treatment purposes. We will discuss implications of the use of emotive recounts in the clinical situation for facilitating language and working through identity issues.

The potential of cohesion analysis in the Analysis and Treatment of Aphasic Discourse

This paper describes Halliday and Hasans cohesion analysis (1976) and Hasans later extension of this work to the cohesive harmony analysis (1985), and relates both to aphasic discourse. The roles of both lexical and grammatical cohesive devices are outlined, the lexical devices including repetition and collocation and the grammatical devices including reference (through the use of pronouns, definite articles, demonstratives and comparatives), substitution and ellipsis. The applicability of these analyses to treatment of the aphasic deficit is also discussed, with the notions of discourse and cohesion being related to communication across aphasic types and from the mild to the severe end of the aphasic continuum.

A different story on “Theory of Mind” deficit in adults with right hemisphere brain damage

Background: Difficulties in social cognition and interaction can characterise adults with unilateral right hemisphere brain damage (RHD). Some pertinent evidence involves their apparently poor reasoning from a “Theory of Mind” perspective, which requires a capacity to attribute thoughts, beliefs, and intentions in order to understand other peoples behaviour. Theory of Mind is typically assessed with tasks that induce conflicting mental representations. Prior research with a commonly used text task reported that adults with RHD were less accurate in drawing causal inferences about mental states than at making non‐mental‐state causal inferences from control texts. However, the Theory of Mind and control texts differed in the number and nature of competing discourse entity representations. This stimulus discrepancy, together with the explicit measure of causal inferencing, likely put the adults with RHD at a disadvantage on the Theory of Mind texts. This project was supported in part by grant # DC01820 from the National Institute on Deafness and Other Communicative Disorders. The authors are indebted to Denise Balason, Meghan Capellini, Bethany Peters, Anita Lewis, Sara Byers, and Annie Palaika for their assistance. Aims: This study revisited the question of Theory of Mind deficit in adults with RHD. The aforementioned Theory of Mind texts were used but new control texts were written to address stimulus discrepancies, and causal inferencing was assessed relatively implicitly. Adults with RHD were hypothesised not to display a Theory of Mind deficit under these conditions. Methods & Procedures: The participants were 22 adults with unilateral RHD from cerebrovascular accident, and 38 adults without brain damage. Participants listened to spoken texts that targeted either mental‐state or non‐mental‐state causal inferences. Each text was followed by spoken True/False probe sentences, to gauge target inference comprehension. Both accuracy and RT data were recorded. Data were analysed with mixed, two‐way Analyses of Variance (Group by Text Type). Outcomes & Results: There was a main effect of Text Type in both accuracy and RT analyses, with a performance advantage for the Theory of Mind/mental‐state inference stimuli. The control group was faster at responding, and primed more for the target inferences, than the RHD group. The overall advantage for Theory of Mind texts was traceable to one highly conventional inference: someone tells a white lie to be polite. Particularly poor performance in mental‐state causal inferencing was not related to neglect or lesion site for the group with RHD. Conclusions: With appropriate stimulus controls and a relatively implicit measure of causal inferencing, this study found no “Theory of Mind” deficit for adults with RHD. The utility of the “Theory of Mind” construct is questioned. A better understanding of the social communication difficulties of adults with RHD will enhance clinical management in the future.

Language Disorder: A Functional Linguistic Perspective.

This paper explores the issues involved in the linguistic characterisation of disordered discourse and the ways in which a Systemic Functional Linguistic framework addresses these issues. For many years, language disorders were described in terms of formal grammars, with “breakdown” discussed in terms of one or more of the traditional levels of language, i.e., phonology, syntax, and semantics. While it was acknowledged that an individual could have difficulty at one or more of these levels, each was viewed quite separately, with semantics viewed largely from a referential perspective. More recent approaches using functional grammar have broadened this view of language and have provided a model of language that re‐conceptualises the notion of meaning and embraces context as integral to its organisation. Such a model has introduced a different perspective on language into clinical fields, and has enabled researchers and clinicians to explore the skills of speakers with language disorders across a variety of situations and contextual variables, examining the linguistic resources still available to them. This paper introduces principles involved in a functional framework and provides an overview of how these principles have been applied to language disorders to date. In addition, the notion of “disorder” itself is discussed as it is situated in this alternative model.

Language, meaning, context, and functional communication

Background  : In the 1970s Audrey Holland first emphasised the importance of “functional communication” rather than “linguistic accuracy” for individuals with aphasia, noting that they could often “communicate” better than they could “talk”. Her approach inspired many to explore why and how this could be so, and to look for avenues that tapped everyday communication skills, rather than the person with aphasias performance on decontextualised language tests. Aims: This paper addresses the kinds of issues that are involved in “functional communication” and specifically addresses the role of language in this endeavour. It aims to highlight language as a set of “meaning-making resources” rather than as a set of syntactic/semantic constructs that exist outside of the communicators everyday environment, that have to be mastered before being put into practice and that exist regardless of specific contexts. Main Contribution: The paper discusses languages role in social life in which speakers not only convey information to each other but also maintain social relationships through communication. A taxonomy of the different kinds of social meanings that speakers use to communicate is proposed for use in aphasia research, based on the work of Halliday (1994)—those related to conveying ideas and experiences (e.g., vocabulary related to particular experiences, topics), those related to interpersonal relationships (e.g., speech acts, evaluative language devices, exchange structure), and those related to maintaining continuity and coherence across the speakers discourse (e.g., cohesion). In addition, the systematic relationship existing between language and context and its clinical implications are explored. Conclusions: Language as information is only one form of language use. The paper argues for further consideration in aphasiology of the importance of multiple language uses and their relation to context. It is proposed that regarding language forms from these different perspectives of use will enable clinicians to further address the different aspects of communication required for meaningful and satisfying interactions in everyday social life.

Connecting lexical patterns of verb usage with discourse meanings in aphasia

The paper describes the impact of lexical patterns found in the discourse of aphasic speakers on overall discourse meanings and ability to participate in everyday genres such as the recount. In particular, the usage of different types of verbs by four aphasic speakers and their functions in the discourse are examined and compared with that of normal control speakers. Results suggest that the semantic patterns of verbs used by aphasic speakers are different from those of normal speakers, leading to restricted variety of meanings conveyed in recounts and for some speakers, restricted communicative functions. Effects of word frequency and imageability are also discussed.