Firle Beckley

Conversation focused aphasia therapy: investigating the adoption of strategies by people with agrammatism.

Background: A recent review of interaction (or conversation)-focused therapy highlighted the potential of programmes targeting the person with aphasia (PWA) directly. However, it noted the key limitations of current work in this field to be a reliance on single case analyses and qualitative evidence of change, a situation that is not unusual when a complex behavioural intervention is in the early stages of development and evaluation. Aims: This article aims to evaluate an intervention that targeted a PWA and their conversation partner (CP), a dyad, as equals in a novel conversation therapy for agrammatic aphasia, using both quantitative and qualitative evidence of change. The intervention aimed to increase the insight of a dyad into facilitator and barrier conversation behaviours, to increase the understanding of the effect of agrammatism on communication, and to support each speaker to choose three strategies to work on in therapy to increase mutual understanding and enhance conversation. Methods & Procedures: Quantitative and qualitative methods are used to analyse multiple pre-therapy and follow up assessments of conversation for two dyads. Outcomes & Results: Results show that one person with severe and chronic agrammatic aphasia was able to select and practise strategies that led to qualitative and quantitative changes in his post-therapy conversations. The other PWA showed a numerical increase in one of his three strategies post therapy, but no significant quantitative change. Although both CPs significantly reduced barrier behaviours in their post-therapy conversations, neither showed a significant increase in the strategies they chose to work on. For one CP, there was qualitative evidence of the use of different turn types. Conclusions: Individually tailored input from a speech and language therapist can assist some people with chronic agrammatism to develop conversational strategies that enhance communication. Outcomes are influenced by the severity and extent of language deficits affecting, for example, single word writing. In terms of behaviour change for CPs, it appears that it may be easier to reduce barrier behaviours rather than to increase the use of facilitatory strategies. The results have implications for collaborative goal setting with clients undergoing conversation therapy.

Conversation therapy for agrammatism: exploring the therapeutic process of engagement and learning by a person with aphasia.

BACKGROUND & AIMS A recent systematic review of conversation training for communication partners of people with aphasia has shown that it is effective, and improves participation in conversation for people with chronic aphasia. Other research suggests that people with aphasia are better able to learn communication strategies in an environment which closely mirrors that of expected use, and that cognitive flexibility may be a better predictor of response to therapy than severity of language impairment. This study reports results for a single case, one of a case series evaluation of a programme of conversation training for agrammatism that directly involves a person with aphasia (PWA) as well as their communication partner. It explores how a PWA is able to engage with and learn from the therapy, and whether this leads to qualitative change in post-therapy conversation behaviours. METHODS & PROCEDURES A 55-year-old man with chronic agrammatism and his wife took part in eight weekly sessions of conversation therapy, adapted from Supporting Partners of People With Aphasia in Relationships and Conversation (SPPARC). Language and conversation were assessed before and after therapy, and the couples views on conversation and disability were elicited. Conversation analysis was used to analyse: (1) pre-therapy conversation patterns, (2) how the PWA engaged and learned during therapy and the forms of facilitation that aided this process, and (3) qualitative change in post-therapy conversation behaviour. OUTCOMES & RESULTS After therapy, the PWA showed increased insight and acceptance of the use of strategies such as writing and drawing in the face of conversational difficulty. However, use was prompted by his wife and was rarely spontaneous. CONCLUSIONS & IMPLICATIONS This single case study suggests that conversation training based around an experiential learning process is able to engage a PWA directly in learning about the effects of aphasia on conversation. Key facilitators were self-study via video and experience of practising conversation whilst receiving online feedback from a speech and language therapist. However, increased insight did not automatically change conversation behaviour. Although he better understood the effects of his aphasia on conversations with his wife, learning stopped short of the ultimate goal of the conversation training programme; the spontaneous use of strategies worked on in therapy when faced with conversation breakdown. One explanation may be that limited cognitive flexibility lead to problems with switching from one strategy to another.

Enabling Better Conversations Between a Man With Aphasia and His Conversation Partner: Incorporating Writing Into Turn Taking

This article reports an intervention in the conversations between a man with chronic aphasia, Barry, and his wife, Louise (both names are pseudonyms). Preintervention analysis revealed the potential of writing as a resource for turn construction. Intervention consisted of enabling Barry to use writing to produce more complete turns at talk, thereby increasing the likelihood of mutual understanding, and encouraging Louise to modify her responses to Barry’s turns and thus enhance his interactional potential. Quantitative analysis revealed that Barry significantly increased his use of writing after intervention, but there was no change in other trained strategies. Louise eradicated correct production sequences (designed to elicit the correct production of a word despite her knowing the target) but did not implement trained strategies. In conclusion, individually tailored input underpinned by Conversation Analysis principles can alter the conversational behavior of a person with aphasia. It appears easier for a conversation partner to reduce unhelpful behaviors than to adopt facilitatory strategies. Data are in British English.

Extended turn construction and test question sequences in the conversations of three speakers with agrammatic aphasia

Abstract The application of Conversation Analysis (CA) to the investigation of agrammatic aphasia reveals that utterances produced by speakers with agrammatism engaged in everyday conversation differ significantly from utterances produced in response to decontextualised assessment and therapy tasks. Early studies have demonstrated that speakers with agrammatism construct turns from sequences of nouns, adjectives, discourse markers and conjunctions, packaged by a distinct pattern of prosody. This article presents examples of turn construction methods deployed by three people with agrammatism as they take an extended turn, in order to recount a past event, initiate a discussion or have a disagreement. This is followed by examples of sequences occurring in the talk of two of these speakers that result in different, and more limited, turn construction opportunities, namely “test” questions asked in order to initiate a new topic of talk, despite the conversation partner knowing the answer. The contrast between extended turns and test question sequences illustrates the effect of interactional context on aphasic turn construction practices, and the potential of less than optimal sequences to mask turn construction skills. It is suggested that the interactional motivation for test question sequences in these data are to invite people with aphasia to contribute to conversation, rather than to practise saying words in an attempt to improve language skills. The idea that test question sequences may have their origins in early attempts to deal with acute aphasia, and the potential for conversation partnerships to become “stuck” in such interactional patterns after they may have outlived their usefulness, are discussed with a view to clinical implications.

Identifying mechanisms of change in a conversation therapy for aphasia using behaviour change theory and qualitative methods

Abstract Background Conversation therapy for aphasia is a complex intervention comprising multiple components and targeting multiple outcomes. UK Medical Research Council (MRC) guidelines published in 2008 recommend that in addition to measuring the outcomes of complex interventions, evaluation should seek to clarify how such outcomes are produced, including identifying the hypothesized mechanisms of change. Aims To identify mechanisms of change within a conversation therapy for people with aphasia and their partners. Using qualitative methods, the study draws on behaviour change theory to understand how and why participants make changes in conversation during and after therapy. Methods & Procedures Data were derived from 16 participants (eight people with aphasia; eight conversation partners) who were recruited to the Better Conversations with Aphasia research project and took part in an eight session conversation therapy programme. The dataset consists of in‐therapy discussions and post‐therapy interviews, which are analysed using Framework Analysis. Outcomes & Results Seven mechanisms of conversational behaviour change are identified and linked to theory. These show how therapy can activate changes to speakers’ skills and motivation for using specific behaviours, and to the conversational opportunities available for strategy use. Conclusions & Implications These clinically relevant findings offer guidance about the processes involved in producing behavioural change via conversation therapy. A distinction is made between the process involved in motivating change and that involved in embedding change. Differences are also noted between the process engaged in reducing unhelpful behaviour and that supporting new uses of compensatory strategies. Findings are expected to have benefits for those seeking to replicate therapys core processes both in clinical practice and in future research.

Conversation Therapy with People with Aphasia and Conversation Partners using Video Feedback: A Group and Case Series Investigation of Changes in Interaction

Conversation therapies employing video for feedback and to facilitate outcome measurement are increasingly used with people with post-stroke aphasia and their conversation partners; however the evidence base for change in everyday interaction remains limited. We investigated the effect of Better Conversations with Aphasia (BCA), an intervention that is freely available online at https://extend.ucl.ac.uk/. Eight people with chronic agrammatic aphasia, and their regular conversation partners participated in the tailored 8 week program involving significant video feedback. We explored changes in: (i) conversation facilitators (such as multi-modal turns by people with aphasia); and (ii) conversation barriers (such as use of test questions by conversation partners). The outcome of intervention was evaluated directly by measuring change in video-recorded everyday conversations. The study employed a pre-post design with multiple 5 minute samples of conversation before and after intervention, scored by trained raters blind to the point of data collection. Group level analysis showed no significant increase in conversation facilitators. There was, however, a significant reduction in the number of conversation barriers. The case series data revealed variability in conversation behaviors across occasions for the same dyad and between different dyads. Specifically, post-intervention there was a significant increase in facilitator behaviors for two dyads, a decrease for one and no significant change for five dyads. There was a significant decrease in barrier behaviors for five dyads and no significant change for three dyads. The reduction in barrier behaviors was considerable; on average change from over eight to fewer than three barrier behaviors in 5 minutes of conversation. The pre-post design has the limitation of no comparison group. However, change occurs in targeted conversational behaviors and in people with chronic aphasia and their partners. The findings suggest change can occur after eight therapy sessions and have implications for clinical practice. A reduction in barrier behaviors may be easier to obtain, although the controlled case series results demonstrate a significant increase in conversation facilitators is also possible. The rehabilitation tool is available online and video technology was central to delivering intervention and evaluating change.

Better conversations with aphasia: what are the interactional challenges of Wernicke’s aphasia and how do people deal with them?

Background: People with Wernicke’s and other fluent aphasias often have severe and entrenched communication problems resulting from impaired comprehension and fluent yet semantically empty speech with neologisms and jargon. Impaired self-monitoring, leading to failure to correct speech errors is seen as a key challenge to successful communication. Speech and language therapists and key communication partners (CPs) report to us informally of the need for effective communication support for this client group. People withWernicke’s aphasia are considered unsuitable for many interventions; however, there is some evidence of adaptive strategy use (Panzeri, Semenza, & Butterworth, 1987) and a few studies reveal awareness of speech errors in conversation (Laakso, 2003). This suggests there is conversation rehabilitation potential. This study reports on ongoing work to adapt the intervention techniques and materials of Better Conversations with Aphasia (BCA; Beeke et al., 2013) for speakers with Wernicke’s and other severe fluent aphasias and their CPs. Aims: To investigate the interactional challenges and adaptive strategies evident in family conversations of people with Wernicke’s and other severe fluent aphasias. To use this understanding to advise on the use of conversation therapy for these speakers and their CPs. Methods and procedures: Five people with Wernicke’s aphasia (as ascertained using the Western Aphasia Battery) were recruited via successive projects carried out by student speech and language therapists at UCL. Ethical approval for this programme of work was granted by the Language and Cognition Departmental Ethics Chair on behalf of the Division of Psychology and Language Sciences. The person with aphasia and a familiar CP were asked to video record at least 20min of conversation in their home environment. No topics were set or suggested; participants were encouraged to video record at a time when they had new information to share – for example, when catching up about the day’s events. The data were analysed using Conversation Analysis (CA), a qualitative sociolinguistic method for the systematic examination of interactional strategies and challenges. Patterns of interactional behaviour were sought across each dyad, followed by analysis of commonalities across dyads. Outcomes and results: CA revealed common conversational barriers around repeated and often unsuccessful attempts at self-repair of speech errors. One particularly complex

The impact of Better Conversations with Aphasia on current practice by UK speech and language therapists

Background: Better Conversations with Aphasia (BCA; Beeke et al., 2013) is a freely available conversation therapy programme underpinned by conversation analytic theory that currently has more than 5400 registered users worldwide, approximately 60% of whom are in the UK. It engages both a person with aphasia (PWA) and their conversation partner (CP) in video-feedback exercises to reinforce good conversation strategies, and to identify barriers to conversation. They then jointly set goals to practise up to three facilitatory behaviours in coached conversation tasks with the speech and language therapist (SLT). There is evidence of the effectiveness of BCA, namely a significant reduction in barriers to conversation at the group level, and for some PWAs and their CPs, a significant increase in facilitatory conversation behaviours (Best et al., 2016). The online resource provides SLTs with access to the BCA intervention programme and training materials including videos showing BCA therapy being delivered, guidance on goalsetting and outcome measurement, and advice from experienced SLTs. However, it is not clear how current BCA practice compares with the published research evidence, both for BCA and for CP training in general (Simmons-Mackie, Raymer, & Cherney, 2016). For example, Sirman, Beeke, and Cruice (2017) reported a significant evidence-to-practice gap for conversation therapy practice by UK SLTs. It is also pertinent and timely to explore the factors that influence the implementation of BCA in UK practice. Aims: To explore current BCA practice by UK SLTs and to investigate facilitators and barriers to the implementation of BCA by SLTs in practice. Methods & Procedures: An online survey is underway. The survey inclusion criterion is qualified SLTs practising in the UK who are registered users of the BCA resource. The aim is to target 20% of UK users, aiming for 600 respondents. A mixture of question types including multiple choice, rating of statements, and open-ended focus on (1) participant demographics; (2) general BCA resource use; (3) BCA delivery, including client groups, settings, what outcomes are measured, techniques (video feedback, practice), materials (handouts, personal videos, resource videos), and acceptability to client/CP; (4) knowledge, understanding, and confidence of the SLT prior to and after use of the BCA resource; (5) facilitators and barriers to implementation; and (6) additional comments. Data analysis will involve descriptive statistics (demographics, frequency of use, client groups and