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 Saturday...er 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.
Plasticity.
“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.
Summary
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.
Bibliography
*The
opinions have been drawn by those expressed on the British Independent
Practitioners Yahoo Forum
ASHA 2016
on line Portal
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