Sue Sherratt

What people with aphasia want: Their goals according to the ICF

Background: The goals of people with aphasia should guide service delivery. Services are increasingly influenced by the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001), but little is yet known about whether the goals of people with aphasia span the full spectrum of the ICF. Aims: The purpose of this study was to describe the goals of people with aphasia and to code the goals according to the ICF. Methods & Procedures: A qualitative descriptive research approach was used involving semi-structured in-depth interviews with 50 participants with aphasia post-stroke. Interviews were videotaped and transcribed verbatim and then analysed using qualitative content analysis. The goals of a 30% consecutive subsample were then coded using the ICF. Outcomes & Results: Nine broad categories of goals were identified. Participants with aphasia wanted to return to their pre-stroke life and to communicate not only their basic needs but also their opinions. They also wanted information about aphasia, stroke, and available services; more speech therapy; greater autonomy; and dignity and respect. They identified the importance of engagement in social, leisure, and work activities as well as regaining their physical health. Interestingly, their goals included wanting to help others. Goals could be linked to all ICF components within the ICF, with the majority linked to Activities and Participation, followed by Environmental Factors, Body Functions and Structures, and Personal Factors. Conclusions: People with aphasia in this study were able to articulate a wide range of goals post-stroke that encompassed all of the ICF components but had a particular focus on the Activity and Participation components.

Multi‐level discourse analysis: A feasible approach

Background: The analysis of discourse has now become commonplace but the focus continues to be on discrete aspects or levels of discourse processing. Although this has provided the necessary groundwork, investigating the relationships and interconnections between these levels continues to be stressed. Recently, some studies have formulated multi‐level discourse‐processing theories and models that explain these inter‐relationships and that identify the sub‐processes involved in producing discourse. This study has used one such model to analyse different levels of discourse and investigate the interconnections between them. A preliminary version of this article was presented at the 26th World Congress of the International Association of Logopedics and Phoniatrics Conference, Brisbane, Australia, August 2004. Aims: To assess the applicability and utility of using a multi‐level discourse‐processing model to examine the interaction between levels of discourse produced by individuals without brain damage. Methods & Procedures: A total of 14 narrative and procedural discourse samples were elicited from 32 non‐brain‐damaged males of different ages and socioeconomic status groups, yielding a total of 394 samples. These samples were analysed in terms of seven broad features (comprising 23 measures), relating to the levels of the multi‐level discourse model. The correlations between these measures were determined using the Spearmans rho correlation test. Outcomes & Results: From the clustering of correlations, a number of fruitful relationships were revealed. Greater relevance was related to more appropriate discourse grammar as well as greater cohesion and syntactic complexity. Longer samples were correlated with an increased proportion of cohesive ties, cohesive errors, and syntactic complexity. An increase in non‐specific elements was related to reduced syntactic complexity and cohesion. A higher occurrence of left‐branching clauses was associated with increased dysfluency. These correlations are explained in terms of the multi‐level discourse model. Conclusions: Three conclusions can be drawn. First, using a multi‐level discourse‐processing model can offer a more realistic perspective of discourse than the analysis of individual aspects. The differential diagnosis of relatively similar discourse impairments (e.g., following head injury, dementia, right brain damage) may ultimately rely on a comparison of the relative deficits at different levels. Second, certain discourse features that can be assessed more objectively (e.g., the number and type of conjunctions) can signal a breakdown at a more conceptual discourse level (e.g., the linking of propositions to each other at a semantic level). Third, these correlations can provide explanatory information regarding more subjective concepts that are difficult to define and measure (e.g., the perception of “relevance” relates to more structured discourse at the macro and micro level). Although this approach to discourse is challenging, it can provide a starting point for more productive investigations of discourse.

SMARTER goal setting in aphasia rehabilitation

Background: There have been numerous calls for rehabilitation professionals to involve patients or clients in decisions about the goals of therapy. And yet collaborative goal setting in rehabilitation remains uncommon and is particularly difficult to achieve for people with aphasia. Aims: This discussion paper describes a new framework for conceptualising and structuring collaborative goal setting in aphasia rehabilitation. The framework has been developed based on the results of a large, multi-centred Australian study, the Goals in Aphasia Project, which explored client, family, and speech pathology experiences of rehabilitation goal setting. This framework, called SMARTER Goal Setting, describes a process of goal setting that is Shared, Monitored, Accessible, Relevant, Transparent, Evolving and Relationship-centred. Methods & Procedures: The methods and results from the Goals in Aphasia Project have already been published elsewhere but involved in-depth interviews with 50 people with aphasia, 48 family members, and 34 treating speech pathologists. This paper reviews the broader literature and summarises relevant findings from the Goals in Aphasia Project as a basis for discussion of each category of SMARTER. Outcomes & Results: Our new SMARTER framework both challenges and complements elements of the pervasive SMART goal paradigm (that goals should be Specific, Measurable, Achievable, Realistic and Time-bound), which currently dominates rehabilitation goal setting. SMARTER offers an easy way to summarise much of the collaborative work that already takes place in clinical practice but also emphasises aspects that could be improved. SMARTER does not replace SMART, but we suggest that SMART goals can be negotiated in a SMARTER way. Conclusions: While this paper discusses SMARTER goal setting within aphasia rehabilitation, a particularly challenging context for the implementation of collaborative practice, it may be applicable to rehabilitation more broadly. Given that person-centred goal setting within stroke rehabilitation remains infrequent, we suggest that there is an urgent need to raise awareness of its importance and challenge current practice. The SMARTER framework provides a useful structure to support collaborative goal setting.

“Well it has to be language-related”: Speech-language pathologists' goals for people with aphasia and their families

Goal-setting is considered an essential part of rehabilitation practice and integral to person-centredness. However, people with aphasia are not always satisfied with goal-setting, and speech-language pathologists are concerned about the appropriateness of therapy. Furthermore, family members are often excluded from goal-setting, despite the impact aphasia has on them. The actual goals set by clinicians for clients with aphasia and their family members have not yet been investigated. This study aimed to examine the goals that clinicians set for their clients with aphasia and their family members. Data from in-depth interviews with 34 speech-language pathologists describing 84 goal-setting experiences with people with aphasia were coded into superordinate goals for both groups. Clinicians expressed a wide range of goals for people with aphasia and their family members, relating to communication, coping and participation factors, and education. In addition, evaluation was considered a goal for the clients. There were clients for whom no goals were set, particularly for family members, due to a lack of/limited contact. The goals described broadly addressed all aspects of the International Classification of Functioning, Disability and Health (ICF) and reflected the use of both functional and impairment-based therapeutic approaches; they also emphasize the importance of providing goal-setting options for the family members of these clients.

The evidence for a life-coaching approach to aphasia

Background: A life-coaching and positive psychology approach to aphasia has recently been advocated by Audrey Holland, to whom this issue is dedicated. Aims: This paper reviews our recent research which informs the three basic assumptions behind a life-coaching approach to aphasia: (1) learning to live successfully with aphasia takes time; (2) aphasia is a family problem; and (3) the goal is to help people with aphasia fit it into their lives. Methods & Procedures: We assimilate results from three independent qualitative data sets: (1) a project that sought the perspective of 50 people with aphasia, their families, and their treating speech-language pathologist about their goals over time; (2) a project that seeks the views of 25 people with aphasia, their family, and speech-language pathologists about what it means to live successfully with aphasia; and (3) a qualitative structured interview on quality of life with 30 people with aphasia. Outcomes & Results: The three basic assumptions of the life-coaching approach to aphasia are supported and extended by the data. Participants with aphasia in our studies report how their goals change over time to reflect how they are learning to live with aphasia, but the journey is different for each person. The stories from families elucidate how aphasia is indeed a family concern and requires family involvement. Finally, not only did participants in our studies fit aphasia into their lives, but they also fitted it into a new lifestyle after their stroke. Conclusions: The assumptions behind the life-coaching approach are well supported by the narratives of people living with aphasia. Even if the life-coaching approach is not adopted wholeheartedly by the profession, the principles of positive psychology and the life goal perspective appear highly relevant to living successfully with aphasia.

Right brain damage and the verbal expression of emotion: A preliminary investigation

Background: Emotional expression or evaluation is intrinsically involved in all communication. In discourse, it has the function of expressing the speakers opinions, building rapport with the listener, and providing a discourse framework. Emotion may be expressed verbally (lexically), nonverbally (e.g., gesture), or extralinguistically (e.g., prosody). Although it has been established that individuals with right brain damage (RBD) are impaired in the comprehension and production of emotion, research to date has focused on nonverbal and extralinguistic channels. The verbal expression of emotion in this population has been investigated in some studies but most of these have used global rating scales. Therefore, data at the verbal or lexical level of emotional expression following RBD are scarce. Aims: To explore the quantity and type of verbal emotional expression produced by individuals with RBD in their personal experience narratives. Methods & Procedures: Two personal experience narratives (using a negative and a positive emotional discourse topic) were elicited from a group of 7 males with RBD and a matched group of 10 non‐brain‐damaged (NBD) males. The discourse samples were transcribed and analysed in terms of the frequency and type of appraisal resources, i.e., the semantic choices made to express emotions, judgements, and valuations, and the way these can be graded (Martin, 2000; Martin & Rose, 2003). Outcomes & Results: The RBD group used fewer total appraisal resources in the verbal expression of emotion, particularly on the negative topic. Overall, they graded their emotional expression less and evaluated phenomena more than the NBD group. The major differences between the two groups were observed in the proportion of resources used in the negative topic: the RBD group evaluated phenomena more frequently than they expressed their own feelings, whereas the reverse was observed for the NBD group. On the positive topic, both groups used similar proportions of appraisal resources. Conclusions: This preliminary investigation has revealed that individuals with RBD may be impaired in the quantity and choice of verbal emotional expression produced in personal experience narratives on a negative, but not a positive, topic. The novel application of the appraisal framework to the discourse of this population has indicated that this method has considerable merit in highlighting differences in lexical emotional expression. It can also provide further insight into the assessment and treatment of the interpersonal and social integration deficits observed in individuals with acquired neurogenic disorders. A preliminary version of this article was presented at the 26th World Congress of the International Association of Logopedics and Phoniatrics Conference, Brisbane, Australia, August 2004.

Written media coverage of aphasia: A review

Background: Public knowledge of aphasia and its effects is consistently low, and significantly lower than other disorders with a similar prevalence. Knowledge of aphasia among the general public is critical, not just for its effect on funding and policy, but most importantly for the person with aphasia and their reintegration into the community. Aims: As the public hear about health issues from the media, this study investigates the quantity of aphasia-related news in the written media in 1999 and 2009, compared to Parkinsons disease (PD); it also describes the content of aphasia news for both years. Methods & Procedures: A number of written news databases (covering international English-only national and regional newspapers accessible to the public) were searched for the term “aphasia” and “Parkinsons disease”. The nature and extent of information on aphasia was also determined. Outcomes & Results: Although the frequency of aphasia-related items increased four-fold across this decade, it is still mentioned only once for every 27 PD-related articles. In both years the information on aphasia imparted to the public is limited; it lacks detail regarding aphasias complex nature, the effects on the person and their family, recovery, and rehabilitation. The depiction of aphasia is often confusing and inaccurate, with media focusing on dramatic aspects or medical opinion. Aphasia is also used colloquially to indicate silenced or tongue-tied, or for a naming difficulty in non-medical sources. Conclusions: Considering the limited coverage of, lack of information on, and bewildering interpretations of aphasia in the media, it is not surprising that public knowledge of aphasia is sparse and confused. These findings intensify the urgent need to enhance and extend aphasias representation in all forms of media, and can provide professionals, those affected by aphasia, and the public with a focus for education and awareness raising.

Evaluating Creativity in Parametric Design Processes and Products: A Pilot Study

Parametric design is an emerging research issue in the design domain. However, our current understanding of creativity in relation to either a process or product standpoint is limited. This paper presents a formal approach for the description and identification of creativity from both perspectives. The framework combines: (1) protocol analysis for encoding cognitive design activities, providing a process-based evaluation of creativity, and (2) consensual assessment of parametric products, providing a product-based evaluation of creativity. The coding scheme is based on the creative acts: Representation, Perception, and Searching for a Solution. The consensual assessment technique is based on a series of creativity evaluations undertaken by an expert panel. The effectiveness of this approach was examined in a pilot study. Findings show the capture of cognitive activities and identification of creative patterns, revealing how they correspond to the creativity levels of parametric design products. The results identify conditions that have the potential to enhance creativity in parametric design. This research provides a promising procedure not yet available and contributes to the development and verification of a formal approach for evaluating creativity in parametric design.

An analysis of the “goal” in aphasia rehabilitation

Background: Despite the central importance of goal setting in aphasia rehabilitation, the notion of the goal itself has not been fully explored. Aims: This paper considers how speech pathologists conceptualise the nature of the “goal” in aphasia rehabilitation. Methods & Procedures: The researchers conducted a qualitative study involving 34 speech pathologists (32 female and 2 male; mean age 41 years, range 24–60 years) from Adelaide, Brisbane and Newcastle, Australia, who worked across acute and rehabilitation inpatient, outpatient, community, and domiciliary services. The speech pathologists participated in semi-structured in-depth interviews about their experiences of providing therapy to people with aphasia post stroke and their family members. Transcriptions of the recorded interviews were subjected to an interpretive thematic analysis involving careful reading and re-reading for recurring themes around notions of goals. Outcomes & Results: The analysis of the transcripts revealed six main categories of goal concepts: goals as desires; SMART goals; impairment and functional goals; goals as steps; goals as contracts; and implicit goals. The first two of these conceptual categories competed with each other reflecting broader tensions within speech pathology practice, and the relative prominence of these goal categories differed according to the rehabilitation context. Conclusions: The findings suggest that the notion of the goal is multifaceted, dynamic, context dependent, and involves inherent tension. A more detailed understanding of the different facets of a goal might assist speech pathologists in their efforts towards collaborative goal setting. A conceptual shift to include the goal as a vehicle of empowerment may be helpful as a precursor to effective, collaborative, and person-centred goal setting with people with aphasia.

“You feel like family …” Professional boundaries and social model aphasia groups

In this theoretical paper, we argue that the adoption of the social model to aphasia rehabilitation within group settings changes the metaphorical location of the boundaries between clinicians and clients. Despite a growing literature on group work for aphasia and social model applications for people with chronic aphasia, there has been almost no attention paid to how professional boundaries are negotiated. This paper reviews how this issue is dealt with within professional codes of ethics and what is written more broadly on professional boundaries, and then uses a number of real case examples to encourage further discussion and awareness of this important issue in aphasia rehabilitation within group settings.