Sunday, 12 March 2017

Aphasia Therapy: A Case Study by Geraldine Wotton Bsc Hons DipPsych
The Abstract

Working with people with dysphasia as an SLT is extraordinarily challenging and yet extremely rewarding. Many of us in Independent Practice offer Impairment Based Therapy working in some instances with clients for many years. Consequently we often observe the considerable changes this work can bring about; not just in the client’s communication per se but also in the significant recovery of some individuals speech and language. However these practices and their successes are rarely reflected within the literature.*

But more concerning however are the research findings indicating there is little difference in outcomes where ‘the work’ has been conducted by volunteers as opposed to fully qualified SLTs. (Lincoln et al 1984) Those of us who work clinically categorically refute that claim. But what we would agree on is that aphasia is such a complex disorder and with each client presenting quite uniquely, so often we are working in the dark.*

Unfortunately the often perceived ‘schism’ between some within the research arena and the clinical communities especially those of us in IP only compounds the difficulty we face clinically, articulating the changes we see and understanding why they are happening. (Wotton2013)
The following article is a presentation of a case worked on from 2001 to 2016. After which I will highlight several aspects of the work that need to be considered when evaluating the efficacy of work undertaken in this field.

The Case Study.
In 2000 Jack, a 69 year old man collapsed on his return home from a football match. He was rushed to hospital unconscious and admitted into intensive care where he was diagnosed with having had a left CVA with a resultant right sided hemiplegia effecting his arm and his leg. Whilst in rehabilitation Jack received regular and intensive SLT and Physiotherapy however once at home the therapeutic input was spasmodic. Despite this, Jacks wife Molly and his two sons continued the physical work at home encouraging him to use his hemiplegic side. 

In June 2001 I undertook my first visit at the request of his wife. At that initial session there was no evidence of the hemiplegia. However Jack’s speech and language remained severely globally impaired. He experienced: a right sided hemianopia which impacted on his scanning of materials and orientating himself physically.

The approach used to assess and subsequently work with Jack was based on the psycholinguistic model

"Psycholinguistics is the study of the mental mechanisms that make it possible for people to use language. It is a scientific discipline whose goal is a coherent theory of the way in which language is produced and understood." (Garnham1985).

Jack was unable to focus for any period of time on the material presented to him and found it difficult to follow requests. Conversationally he was verbose and although using “recognisable sentence/phrase type structures” the content within was 100% unintelligible. The innards being a composite of recognisable words and paraphasias.  Given the severity of his expressive impairments it was impossible to assess the extent to which he had grasped the meaning of my contribution or questions. Jack was unable to monitor/oversee his output or restrain the tsunami of language triggered as he attempt to respond.

During the more structured tasks e.g. picture pointing, Jack struggled to shift his mental focus from item to item. Differentiating responses and shifting mental set occurs where people experience higher executor deficits, which unless identified can lead to the mistaken observation that the problem is with their understanding. His right sided hemianopia obviously compounded these difficulties. Providing prompts and pre task practice enabled Jack to shift focus from one item to another with greater ease and consequently his accuracy on task improved. As a result he could demonstrate understanding of pictures of everyday objects and some familiar verbs. He was not able to name the items at this stage.

Despite the severity of his impairments when processing verbal language, Jack’s use and recognition of written words letter and sounds was more robust. He was able to write some simple words and this then triggered his ability to name or repeat simple words. Once he accessed the written form he was able to identify the orthographic sound of the letters. His phonic retrieval was very poor.
Ultimately it was his ability to retrieve the visual imprint of the words and letters that provided the therapeutic backbone for the subsequent recovery of Jack’s speech and language.

Therapy commenced with Jack once weekly and in 2005 he attended the UCL Dysphasic Group for weekly term time therapy. In the subsequent 16 years Jack had a further stroke in 2004 and a heart attack in 2005 and was pronounced clinically dead. He was also diagnosed with diabetes and has had several bouts of ill health. Although not officially diagnosed with depression, he experienced several cycles of downward mood throughout a year and has a low tolerance to any sustained pressure.
Consequently the work has been painfully slow as gains were harder to embed as lasting and permanent features during times of stress depression and ill health. In this last year Jacks wife Molly has sadly been diagnosed with dementia. However he has managed to sustain the achievements made thus far.

Today Jack can engage in conversation not just in one to one settings but within a small group. His word-finding and subsequently uncovered working memory difficulties are far less intrusive; as a result he is freer to think about and express his ideas with greater precision.
The following is a transcript of a conversation we had this year about the football
“I see the football on it was funny er because one half Everton was leading and in the other half Spurs got back…er we…we looked as if we were going to win…its one of those days…er one of those games when half of it we look like we are in trouble and the second half we look like we are going to win.. we should have won it though...” August 2016

This success I concluded was in part the result of improvements in the verbal rehearsal skills he developed therapeutically which were so necessary for breaking words down when reading and writing. This acquired skill means Jack now reads aloud from and understands newspaper articles about football which up until 4 years ago was impossible.
Jack’s processing system will though still falter when tired, stressed or when the linguistic/cognitive demands increase i.e. where there is little or no contextual support. However Jack is learning to cope better with these dips in his performance as he realises these are temporary blips and not a sign of permanent regression.
Jack remains ‘a willing participant’ Holly Bridges 2015 in this work and his speech and language globally continues to improve.

Impairment Based Therapy and the Psycholinguistic Model
The aim of the Jack’s therapy was to recover as much of his speech and language as possible; the intervention chosen was an Impairment Based  

“A treatment approach that addresses all communication modalities (spoken, written, and gestures) and focuses on training those areas in which a person makes errors.” ASHA 2016  

But applying the Psycholinguistic Model (Garrett 1982) as the therapeutic framework.  Unlike other approaches, this latter model does not target the presenting impairment, instead we search for the underlying linguistic and cognitive forces from which the impairment arises and thereby identifying the locus of breakdown.

In the 80’s Eirean Jones became a driving force for the promotion of the psycholinguistic model. It was through her work that this model took prominence in the field of aphasiology making it a perfect fit for the increasingly popular single case design. For the first time there was a theoretical and statistical rallying point from which we could begin to shine a light on the processes and forces at play during the therapeutic interaction and more confidently begin to devise a clinical rationale. (Jones 1986: Chiat S. & Jones e. 1988)

The therapy evolves as a direct result of the outcomes of the linguistic and cognitive interactions/modifications between client and therapist. Jack’s initial profile indicated severe auditory and verbal processing deficits whilst his recognition of words and letters remained a superior skill. It was working with this area of processing strength throughout that ultimately enabled Jack to tune in and thereby recover his use and understanding of spoken language.
“The emphasis…; between the patient and therapist. Therapy so conceived is dynamic, moving from initial hypotheses about the sort of intervention that will facilitates the patient’s processing, according to the patients response to that intervention” (Chiat 1997)

Since the National Health Service reforms in 90s IBT is mostly undertaken in Independent Practice. IBT is long term and no longer a suitable fit, despite its early promise for the highly budget constrained NHS. Clinicians within the NHS largely work developing clients’ functional abilities using ‘communication books’ and in many authorities this work is undertaken by assistants.
Consequently many clients have to seek such input within the Independent Sector which involves a considerable financial commitment.

“The brains ability to change physiologically and functionally as a result of stimulation” Barbara Arrowsmith Young 2014
Despite the growing number of studies that positively confirm neurological reconfiguration in response to therapy, ( Julius Fridriksson 2011) (Marcotte  et al 2012) clinically at least SLT’s in the UK, remain wedded to approaches and strategies that operate from a principle of a brain that is localised and unchanging e.g. Functional Communication.
There are notable exceptions including Melodic Intonation Therapy (Sparks Helm and Albert 1973) and the most recently prominent Constraint Induced Therapy (CIT) devised by Edward Taub.1994
Jack’s initial presentation was severe in all areas of his language processing yet despite this the recovery he made over time has been significant and lasting.

The psycholinguistic model provides us with a platform from which we view with the client their linguistic and communicative landscape as it emerges throughout the therapeutic process. Throughout this therapy we are constantly encouraging clients to perceive differences in linguistic information whether it is between words, sounds or constituent structures at sentence level.

The evidence within the wider literature indicates it is precisely this inherent reflective process that so powerfully lends it to be a potential trigger of the brains inherent plasticity.  (Norman Dioge 2007)

“The more we can differentiate, get the brain ‘to see’ the pattern, the difference, the more the brain is able to integrate it and absorb the learning” Holly Bridges 2015

The Therapeutic Relationship.
Robert Fourie and his co-contributors in his book Therapeutic Processes for Communication Disorders 2011 urge us to renew our understanding of the importance of the therapeutic relationship, as integral to our work.

The psychological support the therapist provides throughout the work is critical especially in the face of such loss and so much uncertainty for the future. The therapeutic relationship acts like a placebo i.e. brings a sense of wellbeing.
Rupert Sheldrake 2012 discusses the immense power of the placebo effect on healing
“Placebo responses show that health and sickness are not just a matter of physics and chemistry. They also depend on hopes meanings and beliefs. Placebo responses are an integral part of healing” (Sheldrake 2012).
“The placebo we bring as practitioners is the knowledge and experience we have accumulated over the years, which reassures and brings hope and the sense that they, the clients, are in our good hands”.( Wotton 2013).
Throughout the intervention Jack frequently broke into cycles of anxiety and a lowering of mood. Whilst still giving room to these shifts of emotion I had to simultaneously remain focussed on the long term therapeutic goal of remediation and recovery of his speech and language. This presents the therapist with an immense challenge and one that requires considerable skill and experience.
“However the therapeutic relationship is more than a cradle of human comfort. Those of us who work closely with our clients know very well that the relationship is the birthplace of our intervention. The intimacy of our interaction with our clients enables us to accumulate more and more information, from which a picture emerges and it is upon this we develop our insights and our therapeutic intervention.” (Wotton 2013)
The often unknown and complex quality of this work though means that we often work at a subconscious level; providing us with another way of exploring the clients internal processing and facilitating an opening up between therapist and client through which we experience as intuitive leaps.
The power of this innate human ability to process information we are not conscious of is referred to by Malcom Gladwell 2006 as ‘unconscious rapid cognition’ or ‘thin slicing.
“The notion of an ‘adaptive subconscious’, is thought of as a giant computer that quickly and quietly processes a lot of data we need in order to function as human beings” Gladwell 2006
The resultant ‘gut feeling experience’ he argues can be, contrary to conventional thinking, more reliable than information we consciously filter and it is this skill that enables us to get nearer to that, which remains unknown to us.

The Gift of Experience.
Malcom Gladwell goes on to state that the volume and quality of information extracted from the thinnest slice of experience correlates to the inherent expertise and experience of the professional.
“To a novice that experience would be missed or misinterpreted but to the trained and tutored eye the experience and its discrete parts are recognised and every one of those parts offers an opportunity for intervention reform and correction.” (Gladwell 2006)
It is therefore our ability to make sense of what we ‘see’ through the filter of our experience and knowledge base that ultimately contributes to understanding of what is happening in real time between us and the client. In doing so we with the willing participation of our clients trigger the neurological re-configuration so necessary for permanent recovery.

Working with clients like Jack presents us with challenges at all levels, especially as so much of what we encounter is still unknown to us. Despite this our clients can show improvements in their use and understanding of language following our intervention. This phenomenon is otherwise referred to as ‘acquired unconscious competence. (Flower 1999) and is well recognised in the early stages of new areas of enquiry (Birch 1970)
By drawing on the wider literature it was the purpose of this paper to highlight aspects of this work that may play a powerful part in bringing about these changes, even in the face of our not knowing.
There has been wide dissatisfaction expressed by those of us within this field as to the inadequacy of the current methodologies to reflect the complexity of the work. Statistical methodologies in particular are at this early stage of our understanding, unsuitable for our purposes.*
“Quantitatively researched data, inevitably offers a reductionist regularised picture which at best offers significant signposts but tell us very little about the individualised needs of the person they are meant to be treating “(Wotton 2003)
It is therefore up to those of us working clinically in this field to argue our case more cogently as to the interventions, protocols and methodologies we need to adopt. Thereby more accurately reflecting the complexities of this intervention and to set in motion a process of enquiry that will help us to properly articulate, what it is we are doing and why.


*The opinions have been drawn by those expressed on the British Independent Practitioners Yahoo Forum
ASHA 2016 on line Portal

Albert, M. L., Sparks, R. W. & Helm, N. (1973). Melodic Intonation Therapy for aphasia. Archives of Neurology, 29(2), 130–131

Bridges H. Reframe Your Thinking around Autism pub Jessica Kingsley 2015

Birch N. Four Stages of Learning Any New Skill 1970 Dvpd at Gordon Training International

Chiat, S. and E. Jones. 1988. Processing language breakdown. In M. Ball (ed). Theoretical
L inguistics and disordered language. London: Croom-Helm. 

Chiat, J Law, & J Marshall (1997) Language Disorders in Children and Adults. Whurr Publishers

Doige N. The Brain that Changes Itself pub Penguin 2007

Fridriksson J. 2011) Therapy-induced neuroplasticity in chronic aphasia
NeuropsychologiaVolume 50, Issue 8, July 2012, Pages 1776–1786

Flower J (1999). "In the Mush". Physician Exec. 25 (1): 64–6.

Fourie R Therapeutic Processes for Communication Disorders 2011

Garrett, M.F. (1975). Syntactic process in sentence production In G. Bower (Ed.). Psychology of learning and motivation: Advances in research and theory. 9:133-177.

Garnham A. Psycholinguistics: Central Topics. Psychology Press, 1985).

Gladwell M. Blink pub Penguin 2005

Jones, E.V. 1986. Building the foundations for sentence production in a non-fluent aphasic.
British journal of disorders of communication 21: 63-82.

Harris, M. and M. Coltheart. 1986. Language processing in children and adults: an
Introduction. London: Routledge.

Lincoln McQuirk Mulley Mitchell Effectiveness of speech therapy for aphasic stroke patients. A randomised controlled The Lancet 1(8388):1197-200 · July 1984

Marcotte , Adrover- Roige, Damien, de Preaumont, Genereux, Hubert, Ansaldo 2012) Measuring and inducing brain plasticity in chronic aphasia

Sheldrake R. The Science Delusion pub Coronet 2012
Taub, E. (1994). Overcoming learned nonuse: A new behavioural medicine approach to physical medicine. In J. G. Carlson, S. R. Seifert, & N. Birbaumer. (eds.) Clinical applied psychophysiology (pp. 185–220). New York:
Wotton G. The Consultative Model Advancing the Stereotype.2003 Presentation at CPLOL Conference
Wotton G. The Power of the Therapeutic Relationship Presentation at Association of Independent Practitioners in Independent Practice Conference 2013

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