PRINCIPLE ONE: Although aphasics employ communication/conversation
for both transactional (informational exchange) and
interactional (social exchange), interactional motivation
is the primary driving force.
IMPLICATION: Assessment and intervention
should be built around
socialization and the establishment of social affiliation
primarily. The use of communicative partners and social
activities should be a primary vehicle for intervention.
PRINCIPLE TWO: Conversation is a co-participatory process between
two
or more interactants that work together to establish and
sustain communicative intent, linguistic meaning,
interactional thrust, and social significance.
IMPLICATION: The responsibility
for communicative success resides
in the dyad not the individual. Focus on this
"collusional" approach when working in aphasia
and when building a supportive context within which
they can live and interact. Employ Communicative
Partners, Reciprocal Teaching Peers, Conversational
"Ramps".
PRINCIPLE THREE: There is a powerful desire to establish social
affiliation and be successful. Various strategies are
employed to overcome transitory barriers in normal
communication. Aphasic individuals have the same
motivations, desires, and flexibility of resources.
IMPLICATION:
Since the same desires hold for aphasics, they
employ strategies and measures that are extraordinary
to overcome their specific barriers. We should focus
on the exploitation of the naturally-developed
compensatory strategies and the power of the social
dyad in assessment and intervention.
PRINCIPLE FOUR: Conversational conventions and the
cues and clues
to sustain these conventions are not only (or
typically) transmitted by overt verbalizations. Rather,
the strategies employed to maintain and control the
flow of conversation are also (and typically)
transmitted via nonverbal and prosodic means.
These are known as "contextualization cues".
IMPLICATION:
To be maximally effective, clinicians, aphasics, and
their partners should become aware of the
culturally specific contextualization cues that
direct conversation.
PRINCIPLE FIVE: Formulaic expressions,
interactional strategies, and
interactional resources are often used in context-
bound instances to increase fluency and ease
interactional negotiation.
IMPLICATION:
Determine several context-bound instances that
the aphasics are frequently in and work on
appropriate formulaic expressions, resources, and
strategies. The range of context-bound instances
can be increased as the aphasic become more
proficient.
PRINCIPLE SIX: There
are a number of discourse strategies/structures
that are routinely/systematically employed to
overcome rigid adherence to "preferred actions",
interactional barriers, problems, or "friction points".
IMPLICATION:
These discourse structures/strategies may be
employed by aphasics and/or their co-participants
to increase the effectiveness of their conversational
interactions, select a few of these culturally
appropriate discourse strategies (or identify those
of aphasics/co-participants) and teach (or increase
use) aphasics and/or co-participants to employ
them. Examples are "Adjacency principle",
"adjacency counter-strategies", "recycled turn
beginnings", accountings, turn completion
productions, word search joint productions, and
compensatory strategies.
PRINCIPLE SEVEN: There are a number of sequentially dependent
structural elements which bracket units of talk to
help control the flow of the interaction in various
ways. These are culturally-specific, and are
systematically and widely employed. They are
referred to as "discourse markers".
IMPLICATION:
It is possible that the aphasic may create
compensatory strategies that can be applied in
this manner and it is possible for aphasics and/or
co-participants to learn to increase their control
of various aspects of conversational interaction
by learning to employ discourse markers during
their interactions.
PRINCIPLE EIGHT: The full range of conversational
actions are typically
constrained in "institutional" settings due to the
manifestation of various social identities, voices, or
objectives.
IMPLICATION:
Close attention to various institutional settings
and their unique characteristics and constraints
can provide information that can be used to inform
and improve performance in those settings.
Therapy and how its constraints impact aphasic
competencies is an example.
PRINCIPLE NINE: The power,
dynamism, and complexity of the social
event known as conversation is often constrained
by constructed contexts. While valid, they only
reflect that contextual setting.
IMPLICATION:
To ensure that the view of the aphasic is an authentic
one, you must assess and intervene in more natural
and authentic contexts.
PRINCIPLE TEN: There
are some "formal constructs" that have be
extracted from the "Method of Instances" that can
be employed to comment on generalized adequacy".
Although not truly formulated from CA, a basic
structural/strategic feature of interaction is the
maintenance and defense of one's own "face" and
the "face" of the other participants.
IMPLICATION:
Use this foundational motivation of face-to-face
interaction to assist you, the aphasics and their
partners to understand why some conversational
and social strategies work better than others.
Functional End Points for Aphasia Treatment
Items that should always be considered for Quality of Life Issues
What can be accomplished within 10 sessions?
1. Being able to signal and get help in an emergency
(e.g., can
call 911 and succeed in getting someone to come)
2. Being able to disclose feelings
(e.g., can
make likes and dislikes known)
3. Being able to demonstrate the retained competencies that
are
masked by aphasia
(e.g.,
with maximum support from others, can he/she get enough
across to make it clear that he or she is competent to keep power
of attorney, sign release forms, and participate to whatever
limited degree in conversational interchange
4. Being able to express needs
(e.g.,
can communicate that he/she is hungry, tired, wants
some time alone)
5. Being able to write his/her own name
6. Being able to follow current events of interest
(e.g.,
can read newspaper headlines, or follow events on TV)
7. Being able to derive some pleasure from activities that
were
pleasurable before aphasia
(e.g.,
can demonstrate pleasure with grandchildren or buddies)
8. Being able to participate in social interactions
(e.g.,
with maximum support from others, can demonstrate a
degree of enjoyment in social interaction commensurate with
pre-traumatic level)
9. Being able to assert autonomy and independence, if not
of action,
at least of thought and opinion
(e.g., can signal disagreement, differences of opinion, take
an unpopular stand)
10. Being able to forget about being aphasic for at least limited
periods
of time
(e.g., can assume a societal role in some circumstances in
which aphasia can be minimized, such as attending church
or movies with some sign of benefit, participating in limited
ways in conversation)
11. Being able to assume some responsibility
(e.g. activities/responsibilities around the home)
12. Being able to follow simple instructions
(e.g., can be expected to take own medications correctly)
13. Being able to self-monitor
(e.g., know when you have failed or succeeded in communication)
14. Being able to verify understanding
15. Being able to correct misinformation
Strategy One:
FACILITATING AUTHENTIC COMMUNICATION
– This is a modification of Aten's work with that
of Damico, Simmons-
Mackie, & Oelschlaeger
– It can serve as an example of a more functional/social
approach
– Requirements:
*
Must do a careful analysis of the problems the individual
has with communicating
*
Must determine what compensations the individual with
aphasia has started developing
*
Must determine what behaviors truly serve as barriers to
communication and socialization (remember Simmons-
Mackie & Damico on compensatory strategies).
– Guiding Principles linked with this
approach
*
Communication is stressed over linguistic accuracy
*
Work to make use of the naturalness and power of
the interactive dyad
*
The goal is to maximize communication and socialization
regardless of the channel or strategy employed.
*
Encourage the strategies that will facilitate conversation or
communication
*
Stress naturalistic and authentic context, settings, situations
*
What you focus on is based upon an individualized analysis
of the aphasic's actual strengths and weaknesses.
– Steps
1. Start with Assessment
*
Employ the strategies mentioned under the behavioral analysis
technology.
*
Use informal assessment approaches
- Look for strategies already in use
Focus on the conversational framework
*
Distinguish between those aspects that are facilitative and
those that are obstructive
- Examples of Facilitative
Speaking more slowly to improve word search or
intelligibility of speech
Asking others to speak more slowly to improve
comprehension
Learning to use various linguistic resources
Learning to use "mediational resources"
- Examples of Obstructive
Failing to comply with listeners request for
helping them to understand
Not signaling for assistance
Excessive talking – failure to relinquish turn
*
Look for places that could have been improved with
strategy use, but they were not used or inefficiently used.
2. Share your notes/observations
with the aphasic person and family
3. Provide examples of effective
strategies that could be used with
this person's
problems
4. Determine TOGETHER which strategies
are to be stressed
5. Write concrete steps for implementation/acquisition/practice
can
be directed toward patient, family member or both
6. Practice in controlled settings
7. Move toward conversation
– Examples of some of the more basic strategies
(From
Claire Penn,
A. Holland, J. Damico)
* Simplify
Strategies
- Keep conversational turns short
(Limit speech to substantive words)
- Change word order
(Put salient words first, followed by adjective)
- Simplify phonologic structure
(Eliminate unstressed syllable "nana" for "banana")
- Speak directly
(Avoid embedding, "boys, six, long hair)
- Pronominalize
(Use pronoun for noun but must contextualize with
gesture or adjacency principle)
* Elaboration
Strategies
- Circumlocute
(The rug is made of .. Black and white, horsey hair, Africa)
- Describe function
(You know, one of those things that help walkin')
- Eliminate Alternatives
(It's not raining....snowing)
- Say key word - then modify
(Office...doctor's office)
* Repeat
Strategies
- Repeat what you just said
(Book - a book)
– Examples of some of the more basic strategies
(From Claire Penn,
A. Holland, J. Damico)
* Simplification
Strategies
- Keep conversational turns short
(Limit speech to substantive words)
- Change word order
(Put salient words first, followed by adjective)
- Simplify phonologic structure
(Eliminate unstressed syllable "nana" for "banana")
- Speak directly
(Avoid embedding, "boys, six, long hair)
- Pronominalize
(Use pronoun for noun but must contextualize with
gesture or adjacency principle)
* Elaboration
Strategies
- Circumlocute
(The rug is made of .. Black and white, horsey hair, Africa)
- Describe function
(You know, one of those things that help walkin')
- Eliminate Alternatives
(It's not raining....snowing)
- Say key word - then modify
(Office...doctor's office)
* Repeat
Strategies
- Repeat what you just said
(Book - a book)
- Repeat before answering
(Do I want soup? Yes)
- Repeat and Revise
(I want scrambled..well scrambled eggs)
- Inflect the stereotypic responses
( inflect "1-2-3!" {negative} vs "1-2-3-" {positive})
* Flexibility
Strategies
- Substitute
(If one word won't come, try another "Levis" for
"bluejeans")
- Eliminate
(Determine what's the most important word to say?
Determine what is the most salient word?)
- Analogize
(It's like.....)
* Strategies
that the Aphasic can use to engage others to
their level
- find ways according to the aphasic's communicative
system for them to do the following:
Self-correction
Take your turn
Note your own difficulties
Shift topics
Request clarification
Request repetition
Request Slowdown
Signal that you need to engage in "searching" for the word
* Nonverbal
Strategies
- Gesture and pantomime
- Use alternative modality (Draw, write, maps)
Strategy Two:
CONVERSATIONAL COACHING
– This technique was developed and advocated
by Audrey Holland
– Points to make about her approach:
*
Several stages but they don't need to be slowly worked
through
*
Rather, work at the individual's level of behavioral
competence
– Use the progressive mediation framework
*
Start with video analysis
*
Move to role playing
- In vivo Training
Guided Observation
Coached Interaction
Follow-along Coaching
-- Start from structured, short and familiar texts
-- Move to more naturalistic texts
– The Technique
I. Rules for script writing
A. Scripts should be short and at the edge of a
patient's ability to communicate. A 4-10
utterance script can fill a clinical hour.
B. Scripts should include either speaker or listener
features that the clinician wishes to emphasize.
Example, if the clinician wants the patient to
use gestures, the script should include gestural
material. Or to train listeners to guess, scripts
should have "guessable" material built in.
Or to train alternative wordings, build in things
with good alternatives.
C. Scripts must be written in conversational English.
D. Scripts must be written in short units to allow
listeners to check their comprehension of them.
II. Examples of Scripts at Three levels of Communicative
Difficulty
Sharing old (known) information with an experienced
listener*
Football
1. I watched the Steelers lose to Cleveland
on Saturday
2. I talked to Eric on the phone at the half.
3. After the Steeler game, I watched the Vikings.
4. Then we had dinner.
5. We had steak, baked potatoes, salad and
chocolate ice cream.
* This information will be New information to a
inexperienced listener.
Sharing new (unknown) information with an
experienced listener
The Wreck
1. On the way home from the Highland
Drive VA
2. Audrey had a car accident
3. The road was icy.
4. A car coming down Washington Boulevard lost
control
5. It hit the right side, knocked out her headlight, and
ruined the fender.
6. The repair estimate was $2100.
7. The guy had insurance.
Sharing improbable information
Gossip
1. Davida and Mark ran off to join the circus.
2. Mark is going to be an acrobat on the flying
trapeze.
3. Davida is going to be a lion tamer.
4. Audrey bet $500 on the horses last Friday
and lost it all.
5. Then she won $1000 betting on the Steelers
on Sunday.
III. Implementation
A. The patient reads the script, one unit at a time, to the
clinician.
B. Clinician's goal is to evaluate performance and to
point out ways to get the information across.
(Examples from "Football" script:)
1. "Try ice cream...chocolate, rather than chocolate
ice cream."
2. "How else could you signal "Vikings?"
3. "Which is more important? Talking to Eric or
talking at the half? If you can't say it all, say
what's important."
C. Patient next communicates contents of script with
a familiar listener who does not know its contents.
D. Clinician's goal is to coach LISTENER:
1. "If you don't understand; it's probably better
to ask him to say it another way."
2. "Remember, if you don't get all the words,
try to get the general idea, anyway."
E. AND to continue to coach the patient:
1. "Oops, that was a great opportunity for a
gesture. You forgot. Wanna try it?"
2. "You weren't listening. Your wife just
asked you a helpful question, but you tried
to say it again the same way and it just
confused her."
F. Videotape interaction. Then clinician, patient and
listener watch tape and evaluate it according to
these guidelines:
1. How successful was the interchange?
2. What was most helpful?
3. What was least helpful?
4. What could be done differently by clinician,
speaker, and listener?
G. Patient then communicates script to a less
experienced listener who also does not know
The script. Therapist's role is the same.
Evaluate as above.
H. Examples of scripts for Special Problems
Patient who can read silently, but cannot do
grapheme-to-phoneme conversion.
1. Hullo. Eye um maathu o breye uhn.
2. Eye cum frum meelz on weelz.
3. Eye brot ure fuuud.
4. Eyell seee yuh turnahruh.
Patient who cannot read
1. On we went
to the
2. The beat The
3. We 8 and
Patient who can read but is minimally verbal
1. I'm having trouble with my talking.
2. Please be patient with me.
3. Help me with my words if you can.
4. If you can guess what word I want, say it for me.
– Advantages
1. Approximates natural communication in highly
controlled setting.
2. Modifies both patient and interactant behavior
3. Generalizes to other settings and conversations.
4. Allows the clinician simultaneously to manipulate
content and strategies.
5. Provides the clinician with an opportunity to observe
the patient as a conversational interactant.
6. Can be modified to patients needs through manipulation
of a script's content.
Strategy Three
CREATING A COMMUNICATION CULTURE
– Developed and advocated by Mark Ylvisaker
in1992 for TBI
– Adapted for aphasia
– Designed to make the overall context – both
the physical and the
interactional more conducive to
the development of communication
for the aphasic and significant
others.
– The Challenges
* Ylvisaker
found that there are typical kinds of failures or challenges
for the partners of neurologically impaired
* These
may be failures or difficulties that all or some of the
significant people in the environment manifest.
* They
result in an environment that is NOT conducive to
communicative improvement.
* As clinicians
should look especially at ourselves with regard
to these behaviors. We should led and assist other not only by
counseling and instruction --- BUT BY EXAMPLE.
* Some
of examples of problems for major levels of severity or
stage of recovery:
Severe Impairment or Early Stages of Recovery
– Failing to talk to patient
– Failing to communicate nonverbally
with patient
– Failing to prepare the individual
for other services
like nursing care or PT/OT with natural gestures
and physical prompts in combination with simple
verbal cues.
– Failing to use physical contact during
nursing and
therapy to communicate security and acceptance.
– Failing to notice, interpret, or
respond to the individual's
natural communication gestures.
– Failing to prompt communicative gestures
in
appropriate contexts.
– Attempting to establish yes/no communication
before
the individual is neurologically ready.
– Talking about the individual as if he were
not present
– Creating an environment that is overstimulating
and
confusing
– Misinterpreting negative behavior as intentionally
communicative.
– Not engaging in meaningful behaviors
Moderate Impairment or Later Stages of Recovery
– Trying to communicate in a confusing environment
– Saying too much or too little
– Failing to provide nonverbal cues to make
comprehension easier
– Failing to provide sufficient routine and
regularity
for individuals to feel oriented and secure
– Taking inappropriate or aggressive language
personally
– Becoming frustrated and expressing frustration
when
the injured individual forgets a task, and, or fails to
comply
– Ridiculing bizarre utterances
– Failing to decipher the communicative intent
underlying
unusual (e.g., perseveration) or aggressive behavior
– Failing to provide choices
– Not understanding or using the individual's
expressive
communication system if other than speech
– Expecting that an individual who is capable
of using a
nonverbal system will initiate functional communication
with the system and transfer its use to other contexts.
– Labeling people by their behavior (e.g.,
"The evil eye",
"The hitter").
Mild Impairment or Chronic Stage of Recovery
– Speaking too fast; saying too much
– Overcompensating by speaking too slowly,
speaking for
the individual, or in other ways infantilizing people
capable of interacting at a higher level.
– Not giving the injured individual
the opportunity to
communicate
– Failing to provide natural consequences
for communicative
successes or failures.
– Failing to encourage new strategies
– Failing to account for their natural
compensatory strategies
– Addressing the individual in a patronizing
and
disrespectful manner.
– General Points About Creating a Communicative
Culture
* This
is a way to ensure that you don't make the mistakes
listed above or that you can overcome these types of
difficulties
*
Most often, the communicative culture should be established
where the aphasic lives – so the "partners" will vary.
* Five
General Points
1. Establish proper values in a communicative culture
– Meaningful and satisfying social relationships
– Meaningful and satisfying communication
– Recognize that communication has both
transactional and interactional functions
– Recognize that communication is multimodal
and that it has a great impact on one's FACE.
2. Establish a method or means of communicating these values
within the Communicative Culture (CC)
– Should do this with proper orientation and training
of hospital/nursing staff and family.
3. Establish a collaborative attitude to "barrier reduction"
or
"communicative success" for the aphasic within the CC.
– "What is he trying to tell us?"
– "How can we make this easier for him?"
4. Establish definite roles and expectations for individuals
within the CC
– Provide orientation and "job descriptions"
for all staff.
5. Provide rewards and/or for effectively establishing an
appropriate Communicative Culture.
– Merit Awards
– Improved environment in which
to work
and interact
– What Communicative Competencies are needed
to create a
Communicative Culture?
*
The question is: "what the appropriate competencies need to
be for assisting the aphasic -- whether you are the SLP, the Staff,
or the family
*
When Communicating with Patients
CONTENT
The Communicative Partner will:
– talk comfortably with patients about topics
of interest to them
– use vocabulary that is meaningful
– use vocabulary that is adequately concrete, yet
respectful of the patient's age.
– give information needed to keep the patient
oriented
FORM
The Communicative Partner will:
– use gestures, writing, and physical prompts
if necessary
– use natural tone and inflection
– repeat information if necessary
– use short sentences if necessary to ensure
understanding
– give adequate processing time between
messages
– use simple grammar if necessary
– Speak clearly
PARTNER ENCOURAGEMENT
The Communicative Partner will:
– initiate topics of interest to the patient
– use appropriate prompts to encourage
communication
– give patients time to respond
– give patients words if they are struggling
– respond to the patients' verbal and nonverbal
communication
– encourage nonverbal communication
– offer choices whenever possible
– seek confirmation of patients' understanding
– reinforce successful communication attempts
with natural consequences
– Avoid ridiculing, teasing, or punishing
inappropriate or unsuccessful communication.
COMMUNICATION ENVIRONMENT
The Communicative Partner will:
– minimize distractions
– maintain the patient's attention when
communicating (redirect as necessary; use the
patient's name; touch the patient to gain
attention)
– interact in a familiar setting
– control the number of people present at one time.
COMMUNICATING RESPECT
The Communicative Partner will:
– actively encourage patient's participation in
treatment -- even planning -- at whatever level
they are capable
– not talk about patients in their presence
– avoid a condescending style (e.g., baby talk) and
condescending words (e.g., "sweetie", "honey")
– communicate respect directly (e.g., "I'm sure that
it is difficult for an intelligent fellow like you to
do some of this work. Let me tell you why we
are doing it")
– use polite requests rather than abrupt commands
– choose an appropriate time and place to discuss
personal issues
– pay attention to patient's emotional states and
communicate to them that their feelings are
understood and are appropriate.
– never punish, ridicule, or demean patient's
atypical behaviors.
– use humor that is appropriate and meaningful
to the individual.
*
When Communicating with Family Members
CONTENT
The You and the Professional staff will:
– actively invite family members to identify their
own concerns and interests, rather than make
assumptions about their concerns and interests.
– actively seek information from family members
that will be useful for the treatment team
– provide information to the family members that
will help them stay informed about their family
member's care.
– clearly explain facility programs, treatment
regiments, staff roles, family roles in rehabilitation,
and other related matters.
FORM
You and the Professional Staff will:
– use meaningful vocabulary and avoid jargon
– speak clearly and use natural inflection
– use illustrations and repetition as needed to
ensure comprehension
– communicate openness, warmth, flexibility,
and appropriate humor
– use techniques of "active listening"
– use effective and encouraging coaching
techniques during family training.
ENCOURAGING FAMILY PARTICIPATION
AND COMMUNICATION
You and the Professional Staff will:
– actively invite family members participation
in assessment, goal setting, and intervention.
– actively invite expressions of concern and
family problem solving around treatment issues
– act on family recommendations unless harmful
to the patient or his/her progress.
– be available to family members to discuss
their concerns
COMMUNICATION ENVIRONMENT
You and the Professional Staff will:
– minimize distractions and interruptions during
interaction with family members
– use a private setting to discuss confidential or
personal issues
COMMUNICATING RESPECT
You and the Professional Staff will:
– take family members' questions and
recommendations seriously and act on them
unless contraindicated by the patient's needs
– avoid a condescending or self-righteous
manner in communicating with families
– communicate genuine interest in and concern
for family members' issues
– respond promptly to family letters or calls
– avoid ridiculing or devaluating a family
member's behavior
– respect racial, cultural, ethnic and religious
differences
– respect family's right to self-determination
(freedom of choice)
*
When Communicating with other Staff.
CONTENT
You will:
– provide other staff with information that is
relevant, useful, reliable, and accurate
– Ask relevant questions of other staff
regarding patients, policies, treatment, and
other issues
– describe minor concerns to supervisors
before they become major concerns.
FORM
You will:
– Speak clearly and concisely, avoiding
professional jargon
– use natural inflection and tone of voice
– avoid defensive responses, particularly in
connection with professional "turf" issues
– demonstrate a collaborative attitude and
operationalize this attitude into action
– be supportive of colleagues
– maintain perspective and a sense of humor,
particularly during times of stress
– Give instructions to subordinates in a
respectful manner
PARTNER ENCOURAGEMENT
You will:
-- initiate interaction with other staff
-- initiate problem solving discussions,
actively seeking others' opinions
-- actively seek out whatever guidance
is necessary
-- use techniques of "active listening"
-- make time for communication with other staff
– make expectations of other clear
-- maintain active communication during
stressful times
– Freely admit mistakes
COMMUNICATION ENVIRONMENT
You will:
– Choose correct time and place to discuss
issues, particularly confidential issues
– be respectful of other staff members' need
for work time and quiet in a busy work place
COMMUNICATING RESPECT
You will:
– Treat all staff with respect, fairness, and
courtesy, regardless of academic degrees,
professional training, or level of employment
– assume that all staff members' time with
patients is important
These competencies generally are used to create a training program for the staff at a facility. Such an effort involves FIRST ENSURING THAT YOU FOLLOW ALL OF THESE CONCEPTS AND THEN THAT YOU TRAIN OTHERS TO DO SO.
The training typically will involve four or five training sessions where the concept of a communicative culture is firmly established and then specifics are discussed and worked on using various kind of feedback and self-monitoring techniques. See Ylvisaker (1992) for further discussion.
Strategy Four
JON LYON'S CONCEPT OF
COLLABORATIVE INTERVENTION
-- Using Volunteers and/or Partners
Communication Partners
-- Move away from repair or circumvention
of dysfunction
within medical
or clinical settings
-- Move toward fostering models
or methods that promote
our role as
mediators or facilitators in optimizing
communication
in natural settings.
-- Target life enhancement
rather than simply promote
adequate
communication in everyday life. Should strive
to restore
a sense of one's self in daily life.
-- Help reestablish participation
in activities of choice for
the adult
with aphasia.
-- Prefers community
volunteers over familiar family
members initially
-- The stress is on
collaboration within the social dyad
-- Volunteers learn
and promote interpersonal communication
and they serve as a liaison in introducing and carrying out
activities of choice in daily life at home and in the community.
-- Two treatment
Phases
Phase One
* Goal is to establish a way for the individuals to
begin to interact effectively
* No one is expected to become an expert "encoder"
or "decoder"
* It is the give and take between interactants, irrespective
of their status or communicative proficiency, that is
the true objective
* Treatment Chronology
Explain the purpose of communication treatment
-- although transacting content is important, it is
not most important
-- more important is how and why people interact
-- Gives permission to not understand the totality
of what's being conveyed
-- Work on coming to feel comfortable and to
share equally
Review strategies for establishing communication
-- Make this fairly chronological in nature
Modeling of communication strategies
-- Use scenarios to demonstrate
-- As much emphasis on connecting as on
exchanging content
Practicing communication strategies
-- Scenarios with clinician present
Allowing Time to respond
-- Let aphasic complete his message in full
before attempting to respond
-- Pay attention to vocal inflection, hands
and facial gestures
-- Always have a pen and paper at hand while
communicating
Questioning
-- If something seems recognizable in his initial
communique, begin by asking general questions
("Oh, it seems like you are doing something with
your hand, is that right?")
-- Move from general questions that are confirmed
to more specific possibilities
Facilitating the writing or drawing of key concepts
-- If questioning doesn't help, ask if he might
write or draw the most important part of his
message.
-- Allow aphasic to finish before interacting
-- Ask about drawing broadly then when
confirmed go more specific
-- Verify frequently as you go along
-- Have him point to the key element and maybe
even redraw that part and make it bigger.
Provide a model and communicative referent
-- Try drawing your own version of what you think
he is trying to convey.
-- Don't be concerned about accuracy of your guess
its only a referent for the aphasic
Arrange a mutual conclusion to the exchange
-- If still not clear, ask how important it is to
understand this now
-- If not crucial, then ask to return to it at a later
date or time
-- If it is crucial search for the part most urgent
-- If you postpone it, do return to it
-- Returning generally prompts something else
on either part
Phase Two
* Role shifts from only interactant to a catalyst in
promoting and ensuring client Participation in
chosen activities of daily life
* Interested in FLOW
* Establishing Activities of Choice in Daily Life
Finding Activities
-- Sit and accumulate a list of aphasic's interests
-- Initial emphasis on designating areas of potential
exploration not so much on plausibility
Selecting Activities
-- Review choices
-- Rank according to interest, time needed,
skill, needs and motivations
-- Select one or more
Defining Activities
-- Determine how it will be pursued, in what
form and manner
Planning Activities
-- Careful work needed here
Carrying out activities
-- Emphasis is positive experience and active
participation
Reviewing and redefining activities
-- Meet with Clinician to review outing
Completing Activities
-- Move toward independence or support
within the trained environment
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