repli cati on

if you w ant t o
support carers further
use video as a therapy
tool
understand uptake of
your service
'Supporting Partners of People
with Aphasia in Relationships
and Conversation' (SPPARC)
was developed in London and
is a proven method of
improving interpersonal
communication. But can its
positive findings be
replicated in a rural area
where distance and population
figures are so different?
Linda Armstrong and Helen
McGrane investigate.
upporting Partners of People 'i Aphasia in
Relat ionships and Conversation (SPPARC) (Lock et ai,
2001 ) brings together very successfully two threads of
speech and language therapy for people with aphasia
carer support and conve rsational analysis, Carer support
has been an integral part of the rna agement of aphasia
for some t ime now. Conversational analysis is a relatively
new concept in aphasia therapy but has already ~ shown to be an
effective techni que for the assessment and anagement of acquired
language proble ms (Wilkinson et ai, 1998).
In SPPARC, he conversational part ners of pei>p e . h aphasia are
included in 0 separate group programmes, eoch ru ning once a week
for eight weeks. SPPARC can also be provided 0 a - ,,-to-one bas is.
Althou gh t e effectiveness of the progra mme IS proven, it cannot be
pres umed that ' will be easily implemented in a r -al area, particularl y
where there are small population centres, as rba a rural areas pro
vide many different challenges in servi ce pro isi n. r roject aimed to
investigate het her t his method of improving irrrerp..,dfSOnal communi
cation coul d be replicated in our rural area. We v e pleased to find
that it could, although the number of carers we rea( ~ as small and
we identified a number of logisti cal problems for co "de ation if the
programme ere to be repeated in our area.
Discussion of possible group participants with
speech and language therapy colleagues
Familiarisation with the programme
Decision re: location of proj ect group'S
Weeks 7-14 Eight-week support programme
Video recordings of person with aphasia and
partner
Analysis of videos
Weeks 15-22 Eightweek conversational t raining programme
Weeks 2328 Second video recording
Analysis of videos
Project report
Information and support
We allocated 28 once weekly sessi ons for prepara ' ni ng and
reporting of the project (table 1) . The first half o _ rogramme pro
vides the pal1icipants with information and suppo 'or example on
stroke and aphasia, and has been demonstrated by the programme's
authors to be a necessary precursor to the second ' .lD( and her col
leagues found that, following a stroke, the conversa:' al styl e of the
partner often changes in an attempt to adapt t communica
tion situation, for example they may adopt a more tea( e -t herapist'
style of con ersation and try to correct speech SO!) rors, even when
the message is clear. The second group programme is sp-e<ifically aimed
at increasi ng e participants' knowledge of con ersa: n (turn -taking,
topic and so on). Int egral to this second part of e _ amme are pre
and post-trai ning vi deo recordings of the person '.i h oil sia and their
conversational partner. Lock and her colleagues ve been able to
effect significant and lasting change to the conver;af al 'style' of the
non-aphasic conversational partner, thus all o 'l19 _ person wi th
aphas ia maximal opportunity to get their message aero, Changes
include, for example, conversational partners as iog ew- yes-no ques
ti ons and engaging in fewer ' repeat after me' exch- .g5.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 8
ISSN (online) 2045-6174 www.speechmag.com
IIII
A set of sequential selection exclusion criteria was established to help
ascertain which carers would be invited to part icipate in the pro
gramme. 'Carer' here means a family member or friend who regularly
participates in conversation with the person with aphasia (it does not
imply dependency on the part of the person with aphasia). The speech
and language therapists in our adult service evaluated each client on
their case load for the client's and their carer's suitability for inclusion.

At the time of this audit, the adult ser Changes include,
vice caseload totalled 174 clients. The
for example,
results of this exercise are shown in table 2,
conversational
which lists the criteria and the number of
partners asking fewer
clients and carers who did not meet each
of the criteria. Eleven per cent of the clients
yes-no questions and
and carers were suitable for inclusion. engaging in fewer
The ease of delivery of the pro
'repeat after me'
gramme, its excellent resources and
exchanges.
carer-perceived benefits outweigh any
difficulties encountered along the way. However, as with all groups,
problems did arise which we had to try to overcome.
Initially, 89 per cent of our caseload was not suitable (see table 2). In
total 19 carers were invited to participate in the programme. From table
2, the biggest number excluded were those with a range of medical
diagnoses apart from stroke (a). As our adult service also includes a ther
apist with a commitment to voice, this number may be disproportion
ately high in comparison to adult services that may be neurology-based.
The other main reasons for exclusion were those stroke clients who
were not dysphasic (mainly clients with dysphagia only) (b), followed by
a lack of carFr (c) or the carer not being fit for participating in the pro
gramme (d) . Other reasons for exclusion were that the person with
aphasia was very unwell (2); the carer was not motivated to participate
in speech and language therapy (2); the aphasia was so mild that it did
not affect conversational ability (1); the person with aphasia had multi
ple medical problems (2); and one person with aphasia was very new to
the service and had yet to be assessed.
Locating the programme
Initially we thought that two groups would run. We had envisaged
locating the programme away from the hospital environment. One was
Table 2 Participant selection
Criterion 10 Criterion description No. failing
criterion (%)
a Medical diagnosis of 110 (63.2%)
cerebrovascular accident (in the
absence of head injury, dementia
or other progressive illness)
b Has dysphasia (plus other 18 (10.3%)
communication or swallowing
diagnosis)
c Has a carer 8 (4.6%)
d Carer able to participate 8 (4.6%)
physically, cognitively and
emotionally
e Carer able to commit to 16 3 (1 .7%)
two-hour sessions
f Carer able to travel, if necessary 0
g Any other reason for unsuitability 8 (4.6%)
for SPPARC
Total 1SS(89%)
participate in SPPARC. Ten responded that they were interested and
able to attend. Tab le 3 shows their relationship to the people with aphasia.
Table 3 Initial parti cipants
Relationship Perth group Blairgowrie group
Husband 4 1
Wife 2 1
Partner 1
Daughter 1
TOTAL 6 4
Unfortunately, half of the Blairgowrie group carers had to withdraw
for family reasons before their group began and so it was cancelled . The
speech and language therapist whose geographical area includes
Blairgowrie tried to offer the programme on an individual basis to the
two remaining possible participants, who lived 30 miles apart, but
found it could not be done within her usual service delivery pattern.
Two of the Perth group participants had to withdraw during the pro
gramme because of personal or family illness.
repl c ~ ~ ( : > n
planned for the main population centre in our area (Perth) where an ini
tial group of six carers could participate. Being a city, it was not difficult
to identify suitable premises, and we arranged to locate the group in
the local Association of Voluntary Services building in the afternoon.
We planned to run the other group in a small rural town (Blairgowrie)
in the morning. Finding a suitable venue for this took some more inge
nuity but a local GP's surgery was the final choice. During this search, a
referral was made for a past client, so 20 carers received an invitation to
While a nine-to-five programme fits in nicely with a speech and lan
guage therapist's remit, it does not suit many carers who may be the
main 'bread-winners' or full-time carers of the family. This was high
lighted in criterion (e), where two carers were excluded as they were
known to be in full-time employment and a third was the main carer of
four young children. Again this cropped up as the main reason for the
five ' invited' carers who were interested but not able to participate, as
they worked or for other reasons could not commit to a daytime pro
gramme. Unfortunately, at the time of the project, this problem could
not be specifically addressed.
The wide geographical distribution of potential participants for our
mainly rural service is 2500 square miles. The possible distances to be
travelled to a speech and language therapy event are vast compared to
a city-based programme. In some households the person who survived
the stroke was the only driver, with the carer being left without private
transport. A rural bus service is obviously less frequent, may not be
direct to location and, with greater distances to be travelled, incurs
expense of time, energy and money (often by older people) . From our
own experience of SPPARC, this was a de-motivating factor for some
participants. There are several possible solutions to the problem of dis
tance and transport:
if group numbers were larger, we could position groups as near as
possible to the participants' homes - but it may be difficult to find
suitable premises and, practically, it is very difficult to get sustainable
group numbers in rural areas
prior to the programme beginning, we could find out if people with
private transport can give lifts to those who do not have transport
if we had funds, bus or taxi hire could be arranged or we could use a
volunteer driver scheme
in years to come, the greater availability of telemedicine could help.
The current solution is to locate the group in the largest urban area,
with best public transport links.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 9
ISSN (online) 2045-6174 www.speechmag.com
repl ication
Video recording
An integral part of the programme is a video
recording between the person with aphasia and
their carer, which is made before and after con
versational training. This is then used as person
alised examples of good conversational strategies and
highlights those that may be adapted to facilitate
more effective two-way conversation. Only two
of the carers (and their partners) were willing to
video themselves so, for us, this was the least
effective part of the programme delivery. A further
problem was with the actual recordings that were
made. For one dyad, for example, we felt that the
recording was not representative of the conversa
tional style of the couple. Instead of the usual
supported chat, the video recording showed a
series of test questions. To improvise we decided
to use the programme's many video clips of people
with aphasia and their carers, instead of person
alised clips. The participants found these very useful
in consolidating the materials with 'live' examples.
Although the recordings that were made were
not used as part of the individualised training, we
were able to use them as training for ourselves in
analysis. This analysis would also be used as a
measure of effectiveness. The checklists are very
user-friendly and we found that our individual
analyses were very similar, so we felt quite secure
about the reliability of our observations.
From the point of view of the del ivery of the pro
gramme, the detailed session plans and handouts
provided an excellent resource, which has not had
to be adapted. The materials are clear and well
explained. SPPARC really is an 'off-the-shelf' pro
gramme. It could probably be run in conjunction
with experienced speech and language therapy
assistants.
Although the final number of carer participants
numbered only four, for them it was a new and
extremely worthwhile experience as reported in
their written evaluations throughout the pro
gramme (half-way and final reviews of both
parts) . Not all carers were able to attend the Perth
group every week, as they also had unexpected
health and other family problems/commitments.
However, their return to the group following res
olution of these crises indicated the importance of
the programme to them. The evaluations were
unanimously very positive about the benefits of
SPPARC and about the concept of them being
together as carers to share experiences:
' .. even though we were learning we could also
laugh (very important).'
'I have found out lots of things I didn't know
about.'
' .. we all had similar experiences.'
'Yes I have really enjoyed it, as we have all been
able to discuss our partners' difficulties.'
Carers' group
As a result of this project, a monthly evening carers'
group has been piloted for the carers who attended
the Perth group as well as for those carers who
are unable to attend sessions during the day. A
speech and language therapist was responsible
for both the administration and facilitation of the
group. This group has been evaluated very positive
ly by the carers who attended (mainly two of the
Perth group carers and two younger carers who had
been unable to attend that group) and a proposal
has been made for funding so that it can continue.
As the numbers remain very small, the proposal is
for a group for carers of people with any acquired
neurological communication impairment, and for
staffing to include a speech and language therapy
assistant (to undertake the group's administration)
and a speech and language therapist.
Discussion 's taking place about the programme
with local speech and language therapy colleagues
who work wit h chi ldren with autism. Although the
programme materials are quite specific to stroke
and dysphasia, its framework has the potential to
be more widely applied in speech and language
therapy.
Linda Armstrong is employed by Tayside Primary
Care NHS Trust and is based at the Speech and
Language Therapy Department, Perth Royal
Infirmary. and Helen McGrane at the School of
Speech and Language Sciences, Queen Margaret
University College, Edinburgh.
Acknowledgement
The Speech and Language Therapy Department
of Perth and Kinross Local Heal and Social Care
Co-operative thanks the Chest Heart and Stroke
Scotland for funding th is project.
References
Lock, S., Wilkinson, R. & Bryan, K. (2001)
Supporting Partners of People with Aphasia with
Relationships and Conver sat i ons (SPPARC).
Speech mark Publishing: Bicester.
Wil kinson, R., Bryan, K. & Lock. S. e al (1998)
Therapy using conversation a alysi>: hel ping cou
pl es adapt to aphasia in conversation.
In ternational Journal of Language &
Communication Disorders 33 (Supplement).
Reflections
Do I offer a service that is flexi ble
enough to meet t he needs of
people with complex r5ponsibili ties?
Do I look at why people may not
be using my service and work
towards solut ions?
Do I adapt programmes to suit
t he nat ure of the location?
"
Training directory
If you are looking for counselling and psy
chotherapy related training in the UK, the
19th edition of the British Association for
Counselling and Psychotherapy's Directory
includes over 1200 courses .
Grandpa's had a stroke
The Stroke Association has produced a leaflet to help children
come to terms with f amily members who have had a stroke.
A spokesman said, ot only does it explain to chil dren what
a stroke is, in easy to understand terms, but it also t eac es
them that it is okay t o be scared."
people, the Foundat ion eople with
For a copy of Grandpa's had a stroke, tel. 01604623933. Training in Counselling and Psychotherapy
11-----------------------11 Learning Disabilities has shed two
Directory 2003, [19, tel. 0870443 5172 or
order online at www.bacp.co.uk. Proud Owner of a Speech
__ 1mped i ment
Mac' version
Topologika have released the early language
pack Speaking for Myself for Apple Macintosh.
An updated Windows version Speaking for
Myself 2 will be released early in 2004.
Prices from 34.95 + VAT for a single user.
Available for Apple Macintosh OS 8.5 and above
(including OSX in Classic mode) and Windows.
Author Tom Cribbin, ho has cerebral palsy, wants to inspi re
readers with this book by demonstrating that all peoplE have
ability despite their disabilities. Using humorous or emo ionaJ
anecdotes to emphasise his points, he says that the t itle of
the book is about an attitude which not only helps impro e
his speech fluency bu allows him to regard his speech in a
lighthearted way.
[8.94 inc. airmail posting from Canada, for details e-mail
See www.topologika.com.thomas.cribbin@sympatico.ca.
information booklets to sllJIport their
mental health and e ellbeing.
The booklets draw dire<tJy on e first
hand experiences of yo 9 peopl e with
learning disabilities ana
All About Feeling
Young People with le
Meeting the emotiona JtrEds of young
people with learni 9 disa . 1:5: A
booklet for parents an (ara>
See www.learningdisab-- OI9..tJ .
Meeting emotional
needs
As young people with lea . disabili
ties are four times as likely to experience
mental health problem as ot young
see p.1 e Resources
10 SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
ISSN (online) 2045-6174 www.speechmag.com