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INT J LANG COMMUN DISORD, SEPTEMBEROCTOBER

VOL.

2014,

49, NO. 5, 511526

Review
Conversation therapy for aphasia: a qualitative review of the literature
Nina Simmons-Mackie, Meghan C. Savage and Linda Worrall
Communication Sciences & Disorders, Department of Health & Human Sciences, Southeastern Louisiana University,
Hammond, LA, USA
NHMRC CCRE in Aphasia Rehabilitation, School of Health & Rehabilitation Sciences, University of Queensland, QLD,
Australia

(Received December 2013; accepted March 2014)


Abstract
Background: A diverse literature addresses elements of conversation therapy in aphasia including intervention
rooted in conversation analysis, partner training, group therapy and behavioural intervention. Currently there
is no resource for clinicians or researchers that defines and organizes this information into a coherent synopsis
describing various conversation therapy practices.
Aims: To organize information from varied sources into a descriptive overview of conversation therapy for aphasia.
Methods & Procedures: Academic search engines were employed to identify research articles published between
1950 and September 2013 reporting on conversation therapy for aphasia. Thirty articles met criteria for review
and were identified as primary sources for the qualitative review. Using qualitative methodology, relevant data were
extracted from articles and categories were identified to create a descriptive taxonomy of conversation therapy for
aphasia.
Main Contribution: Conversation interventions were divided into descriptive categories including: treatment participants (person with aphasia, partner, dyad), primary guiding orientation (conversation analysis, social model, behavioural, relationship centred), service delivery (individual, group), focus of intervention (generic/individualized;
problem/solution oriented; compensatory), training methods (explicit/implicit; external/embedded), activities or
tasks, and outcomes measured. Finally, articles were categorized by research design. There was marked variation
in conversation therapy approaches and outcome measures reported and a notable gap in information about
one-on-one conversation therapy for individuals with aphasia.
Conclusions & Implications: This review provides a description of various conversation therapy approaches and
identified gaps in the existing literature. Valid measures of natural conversation, research on one-on-one conversation approaches for individuals with aphasia, and a systematic body of evidence consisting of high quality research
are needed.
Keywords: aphasia, conversation, therapy, qualitative.

What this paper adds?


Currently information related to conversation therapy for aphasia is published in various contexts and includes a wide
variety of methods. For example, some reports describe conversation therapy that focuses on the partner of the person
with aphasia, while other reports describe conversation therapy delivered to groups of people with aphasia. It would
be helpful for information on conversation therapy to be presented in an organized synopsis that allows clinicians and
researchers to grasp the varied approaches and their similarities or differences. By reviewing the published research
literature, this article provides a descriptive review and taxonomy of conversation therapy for aphasia and identifies
gaps in the existing literature such as disparity in outcome measures used.

Address correspondence to: Nina Simmons-Mackie, 580 Northwoods Drive, Abita Springs, LA 70420, USA; e-mail: nmackie@selu.edu
International Journal of Language & Communication Disorders
C 2014 Royal College of Speech and Language Therapists
ISSN 1368-2822 print/ISSN 1460-6984 online 
DOI: 10.1111/1460-6984.12097

512

Nina Simmons-Mackie et al.


Introduction

Conversation has been described as the heart of human communication (Armstrong and Mortensen 2006,
Clark and Wilkes-Gibbs 1986). It is critical for exchanging information, maintaining social relationships, negotiating a sense of self and managing emotional health.
For people with aphasia engaging in conversation can
be difficult or even impossible. Since conversation is an
essential element in human communication, improved
conversational skill and improved participation through
conversation should be a primary objective of aphasia
therapy (Wilkinson 2010).
Most aphasia therapies ultimately aim to enhance
natural communication and conversation. However, a
variety of aphasia interventions have been explicitly described as conversation therapy. These approaches are
distinct from interventions that aim to generalize trained
skills from linguistic or functional tasks into natural conversation. Rather, conversation-oriented therapies focus
overtly on changing behaviours within the context of
conversation. Information related to conversation therapy in aphasia has been published within a variety of
different approaches such as communication partner
training (e.g. Kagan et al. 2001), group aphasia therapy
(Elman and Bernstein-Ellis 1999), approaches to communication support (Hux et al. 2010, Rautakoski 2011)
and interaction-focused therapies (Wilkinson 2010,
Wilkinson et al. 2011). A Cochrane review of speech
language therapy for aphasia suggested that conversation
as part of aphasia intervention should be considered
social stimulation (Brady et al. 2012). Given the varied approaches to conversation therapy reported in the
aphasia literature, it is not surprising that in a recent survey of 100 speechlanguage pathologists in the United
States and Australia, respondents demonstrated difficulty clearly describing methods associated with conversation therapy for aphasia (Simmons-Mackie et al.
2013).
A descriptive review of the conversation therapy
literature would help to organize existing information
from diverse sources and provide a resource to clinicians
and researchers. Therefore, the current project was designed to conduct a qualitative or narrative literature
review of conversation therapy for aphasia. The goal of
a narrative literature review is to present an up-to-date
synopsis of a particular topic in order to describe current
or proposed practices, influence policy or suggest future
research (Cronin et al. 2008). This type of descriptive
review is contrasted with a critical systematic review of
the literature that seeks to critically and systematically
evaluate the quality of research evidence on a particular topic (Garrett and Thomas 2006). A narrative or
qualitative literature review was chosen since the topic
of conversation therapy requires refinement and a con-

ceptual framework prior to a critical review determining


whether conversation therapy is effective (Cronin et al.
2008).

Selection of articles for review


In order to describe conversation therapy for aphasia, a
descriptive review of the aphasia literature was undertaken by identifying and examining research articles reporting on conversation therapy. Articles were identified
using an online search of academic search engines using the terms conversation and aphasia and including
published literature from 1950 to September 2013. Electronic databases searched included PubMed, CINAHL,
PsychINFO, Web of Science and ComDisDome. In
addition, references of identified articles were searched
for additional relevant publications. Publications were
excluded from the review if they did not describe intervention that fit the definition of conversation therapy,
did not address aphasia in adults, were not published in
a peer-reviewed academic journal, were not published
in English or were duplicates.
For purposes of the review the term conversation
therapy was defined as direct, planned therapy that is
designed to enhance conversational skill and confidence
using activities that directly address conversation and focus on changing behaviours within the context of genuine conversation (Simmons-Mackie 2008: 170). Thus,
the goal of conversation therapy is to explicitly improve
skill or participation in conversation for people with
aphasia. Conversation was defined as interaction between two or more people in which thoughts, information, ideas or feelings are transmitted in a free exchange
of turns and the interaction is characterized by spontaneity, extemporaneity and context sensitivity (Clark
1997). Heritage (2005: 104) distinguished conversation
from communicative interactions confined to specialized settings or to the execution of particular tasks.
For example, responding to preselected picture cards in
a barrier task such as that used in Promoting Aphasics
Communicative Effectiveness (PACE; Davis and Wilcox
1985) fulfils certain elements of conversation (e.g. taking
turns, self-determination of modality, natural feedback)
(Davis 2005), but the situation does not allow for other
elements of conversation such as spontaneous shifts in
topic or task, or elaboration beyond the task demands.
Therefore, therapies that included elements of conversation, but did not work specifically on conversational
participation, were excluded from the review. In addition, approaches that focused on specific linguistic skills
or impairments with the ultimate intent of generalizing to conversation (e.g. working on naming) were not
included in the review.

Conversation therapy for aphasia


The literature search revealed a total of 1220 articles.
Once inclusionary/exclusionary criteria were applied, a
total of 30 research articles were identified as primary
sources for conversation therapy for aphasia (see the appendix). In addition, a number of supporting references
were identified that further explicated approaches represented in primary sources. These secondary sources
were used to flesh out approaches and provide clinicians with additional resources related to the identified
interventions. For example, a primary data source was a
controlled trial of conversation partner training (Kagan
et al. 2001); secondary sources included a book chapter
(Kagan and Gailey 1993) and theoretical article (Kagan
1998) that further describe the approach.
In order to conduct the descriptive review a qualitative approach to analysis of primary sources was undertaken using thematic analysis methods (Graneheim and
Lundman 2004). Each article was inspected to identify
key elements that explicated the approach to conversation therapy. These key elements were then coded and
collapsed into categories that cut across articles. The
resulting categories included: types of participants targeted, primary orientation or roots of the approach,
mode of service delivery, general methods employed,
specific activities reported, method(s) of assessing outcomes. Once categories were identified, then each article
was reread in its entirety and relevant data were extracted
in each category. Extracted data were further analysed to
identify subcategories that could be used to further describe the approaches (Graneheim and Lundman 2004).

Results: taxonomy of conversation therapy


The qualitative review resulted in a descriptive taxonomy
that helps to characterize and contrast key elements of
conversation therapy for aphasia (figure 1) as described
in the aphasia research literature. Following are descriptions of the categories derived from the qualitative
analysis.
Therapy participants
A key element of research studies addressing conversation therapy in aphasia involved who actually participates in therapy sessions. Approaches were divided into
those that focus on conversational skills or participation of the person with aphasia, and those that focus on
conversational collaboration with communication partners. Communication partner approaches could be further divided into those that target dyads involving both
people with aphasia and their conversation partners,
and those that target only the communication partner
(table 1).

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People with aphasia
Although traditional aphasia therapy typically involves
treatment directed at the person with aphasia in individual or group therapy, there was a dearth of literature addressing conversation therapy targeting people with aphasia independent of conversation partners
(Basso 2010, Savage et al. 2014). Conversation therapy
directed at the person with aphasia (without the communication partner present) was represented primarily
in descriptions of group aphasia therapy (Bernstein-Ellis
and Elman 2007, Elman and Bernstein-Ellis 1999, Ross
et al. 2006).
Communication partners
Perhaps the most widely published method of targeting
conversation in aphasia involves training conversation
partners. Various labels have been used to characterize partner training in aphasia such as Communication
Partners (Lyon 1996, 1997, Lyon et al. 1997), Supported Conversation for Adults with AphasiaTM (SCA)
(Kagan et al. 2001), the Conversation Partner Scheme
(McVicker et al. 2009) or Conversation Partner Training
(CPT) (Bradley and Douglas 2008). Theoretical support
for partner training draws from the collaborative nature
of conversation, and the assumption that a change in the
behaviour or skill of the non-aphasic communication
partner will result in changes in the communication,
conversational behaviour or participation of the aphasic partner. A body of literature has emerged addressing
partner training in aphasia (see reviews by Bradley and
Douglas 2008, Simmons-Mackie et al. 2010, Turner
and Whitworth 2006), and a systematic review of partner training research suggested that training typically
improves the skill of communication partners and enhances conversational participation of the person with
aphasia (Simmons-Mackie et al. 2010).
One approach to partner training in aphasia involves
training communication partners without the person
with aphasia present. In fact, the earliest research on
partner training in aphasia entailed a single subject experimental investigation in which a wife participated
in partner training independent of her husband with
aphasia. Although her husband with aphasia was not included in therapy, his participation in conversation improved following the wifes training (Simmons-Mackie
et al. 1987, 2005). A number of studies subsequently described training of communication partners without the
person with aphasia present. Various types of partners
have been trained in order to explicitly improve conversational participation of people with aphasia. Regular partners such as family members or caregivers (e.g.
Simmons-Mackie et al. 2005) as well as volunteers (e.g.
Hickey et al. 2004, Kagan et al. 2001, McVicker et al.

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Person with Aphasia
Therapy Participants

Conversation Partner
Dyad
Conversation Analysis
Social Model

Principal Roots

Functional, Behavioral
Relationship oriented
Individual
Conversation Therapy

Service Delivery
Group
Focus of Intervention

Generic/Individualized
Problems/Solution
Compensatory

Training Methods
Explicit/Implicit
Activities
External/Embedded
Outcomes

Research Design

Figure 1. Categories comprising a descriptive taxonomy of conversation therapy for aphasia.

2009, Rayner and Marshall 2003) have been the targets


of communication partner training.
It should be noted that while partner training is relevant to conversation therapy, not all partner training
approaches were designed to specifically address conversation. There is research that directly addresses partner
training within the context of improving conversation in
aphasia and/or includes outcome measures designed to
capture aspects of conversation of the partner or person
with aphasia (e.g. Kagan et al. 2001, Hickey et al. 2004,
Rayner and Marshall 2003, Simmons-Mackie et al.
1987, 2005). However, some of the partner training
literature does not explicitly discuss conversation, and
research investigating partner training does not always
include outcome measures specific to conversation. For
example, Simmons-Mackie et al. (2007b) used partner
training to improve access to information and decision
making in health care for people with aphasia; outcomes specific to conversation were not measured. Legg
et al. (2005) used partner training to improve interview

skills of future physicians. It is useful to draw from the


partner training literature to inform conversation therapy; however, the partner training literature should not
be over-interpreted as synonymous with conversation
therapy.

Dyad approaches
Several approaches to conversation in aphasia involve
working directly with a dyad a person with aphasia and a communication partner. Examples of therapies that involve dyads include conversational coaching
(Hopper et al. 2002), couples therapy (Boles 1997,
2011), interaction-focused therapy (Wilkinson 2010,
Wilkinson et al. 2011) and communication partner
training (CPT) (e.g. Blom Johansson et al. 2013, Saldert
et al. 2013). A commercially available partner training
program, Supporting Partners of People with Aphasia in
Relationships and Conversation (SPPARC) is applicable

Conversation therapy for aphasia

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Table 1. Primary data sources addressing conversation therapy for aphasia categorized by the participant(s) who is actually the target
of training and the mode of service delivery (group versus individual sessions)
Partner approaches

Person with Aphasia Approaches

Partner only being trained


Group

Dyad being trained


Individual

Booth and Perkins


Blom Johansson et al.
(1999), Booth and
(2013), Hickey et al.
Swabey (1999),
(2004),
Kagan et al. (2001),
Simmons-Mackie
Lock et al. (2001a),
et al. (1987, 2005)
McVicker et al.
(2009), Rayner and
Marshall (2003)

Group of
dyads

Individual dyad

Group

Beckley et al. (2013), Beeke et al. Elman and


(2007, 2011)a , Blom Johansson Bernstein-Ellis
et al. (2013), Boles and Lewis
(1999), Ross et al.
(2003), Boles (1997, 1998),
(2006),
Booth and Perkins (1999),
Simmons-Mackie
Cunningham and Ward (2003), et al. (2007a)
Fox et al. (2009), Hopper et al.
(2002), Johansson et al. (2013),
Lesser and Algar (1995), Lock
et al. (2001a), Lyon et al.
(1997), Saldert et al. (2013),
Sorin-Peters (2004), Wilkinson
et al. (1998, 2010, 2011)

Individual
Basso (2010),
Savage et al.
(2014)

Note: a Beeke et al. (2007) present an analysis of cases from Burch et al. (2002) and Lock et al. (2001a). Thus, the paper by Beeke et al. is technically not original research. However, the
Burch et al. case was not previously published in a refereed journal and not cited in the academic search engines employed in this study. Therefore, we have chosen to include the paper
by Beeke et al. as a primary source, but wish to credit the original sources: Burch et al. (2002) and Lock et al. (2001a).

to training partners alone or for working with couples


(Lock et al. 2001a,b).
Principal roots
Conversation therapy for aphasia appears to draw from
a variety of philosophical, theoretical or practical origins such as social or participation models, conversation analysis (CA), behavioural treatment and counselling. Many of these studies may be classified in more
than one category since considerable overlap occurs.
However, descriptions below help orient to the primary
roots or origins of approaches.

fulfil this aim as volunteer conversation group leaders


(Kagan 1998) or as ongoing visitors to the person at
home (McVicker et al. 2009).
Descriptions of group conversation therapy suggest that this method is rooted largely in social
model and life participation philosophy (BernsteinEllis and Elman 2007, Elman and Bernstein-Ellis 1999,
Simmons-Mackie and Damico 2009, Simmons-Mackie
et al. 2007a). Group conversation therapy provides
a social context for people with aphasia to participate in authentic conversation and develop social
relationships.

Life participation

Functional, behavioural orientations

There are approaches to improving conversation that are


explicitly described in relation to social model philosophies or participation models of intervention (Byng and
Duchan 2005, LPAA Project Group 2000, SimmonsMackie 1998, 2000, 2008). These models focus directly
on enhancing engagement in life situations for people
with aphasia. For example, Supported Conversation for
Adults with AphasiaTM (SCA) (Kagan 1998, Kagan and
Gailey 1993, Kagan et al. 2001) and the Conversation
Partner Scheme (McVicker et al. 2009) overtly aim to
improve access to and participation in conversation for
people with aphasia. The intent of both approaches is
to improve the skill of volunteer conversation partners
who then fulfil the primary objective of providing ongoing opportunities for people with aphasia to engage
in conversation and social interaction. The volunteers

Other approaches to improving conversation in aphasia


are based on practical and behaviourally oriented assessment and intervention (e.g. Boles 1997, 1998, Hickey
et al. 2004, Hopper et al. 2002, Simmons-Mackie et al.
1987, 2005). These approaches draw from knowledge
and experience of speechlanguage pathologists (SLP)
and involve training to modify behaviours. For example,
Family Member Training (Simmons-Mackie et al. 1987,
2005) and Conversational Coaching (Hopper et al.
2002) involve videotaping a conversation between the
person with aphasia and the conversation partner, identifying behaviours that impede conversation and working to change the behaviours. No specific philosophical
orientation is described for these approaches; rather they
appear to be practical, behavioural treatments directed
specifically at conversational interactions.

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Table 2. Examples of behaviours targeted in conversation therapy

Behaviour targeted

Person targeted

Reference

Reduce correcting or teaching


behaviours

Communication partner

Reduce asking for known


information or test questions
(e.g. whats my name?)
Improve repair of communicative
breakdown

Communication partner

Reduce restrictive discourse


behaviours (e.g. closed
questions)
Increase minimal turns (to
increase participation of person
with aphasia)
Reduce interruptions

Communication partner

Booth and Perkins (1999), Booth and Swabey


(1999), Boles (1997, 1998), Cunningham and
Ward (2003)
Wilkinson et al. (2010)

Communication partner

Wilkinson et al. (2010)

Communication partner
Communication partner

Fox et al. (2009), Simmons-Mackie et al. (1987,


2005), Cunningham and Ward (2003)
Booth and Swabey (1999)

Communication partner

Kagan et al. (2001), Rayner and Marshall (2003)

Communication partner

McVicker et al. (2009), Rayner and Marshall


(2003), Hickey et al. (2004), Kagan et al. (2001)
Beeke et al. (2013), Boles (1997, 1998),
Cunningham and Ward (2003), Hopper et al.
(2002), Lyon et al. (1997), Sorin-Peters (2004)
Elman and Bernstein-Ellis (1999), Ross et al.
(2006), Simmons-Mackie et al. (2007a)
Beeke et al. (2011)
Wilkinson et al. (2011)
Fox et al. (2009)
Ross et al. (2006), Savage et al. (2014), Wilkinson
et al. (2011)
Ross et al. (2006), Boles (1997, 1998)
Elman and Bernstein-Ellis (1999), Ross et al.
(2006), Fox et al. (2009), Cunningham and Ward
(2003), Wilkinson et al. (2010), Savage et al.
(2014)

Slow down, emphasize key


elements
Use strategies for revealing and
acknowledging competence of
person with aphasia
Increase multimodality or total
communication

Communication partner, dyad

Dyad
Person with aphasia
Strategically manage turns
Improve topic management
Ask more questions
Improve introduction of new
topics/management of topics
Improve self-repair
Increase initiation/taking
turns/participation in
conversation

Beeke et al. (2007), Booth and Swabey (1999), Fox


et al. (2009), Wilkinson et al. (1998),
Simmons-Mackie et al. (1987, 2005)
Beeke et al. (2007), Simmons-Mackie et al. (1987,
2005)

Dyad
Dyad
Person with aphasia
Person with aphasia
Person with aphasia
Person with aphasia

Conversation analysis (CA)


A large literature has emerged focusing on improving
conversation in aphasia guided by CA. CA is a rigorous
approach to analysing naturally occurring talk with particular attention to the structural features and resources
that people use to achieve conversational goals such as
collaboratively negotiating meaning, taking turns, and
repairing communicative breakdowns (Goodwin and
Heritage 1990, Hutchby and Wooffitt 2008). CA has
been used to describe the nature of the communication
of a person with aphasia, as an outcome measure and
as a guide for intervention (Booth and Perkins 1999,
Heeschen and Schegloff 1999, Lock et al. 2001a,
Whitworth et al. 1997). Approaches that draw from
CA roots are distinguishable by the emphasis on
terminology and methods that focus on features of
naturally occurring talk-in-interaction such as topic

management, repair, turn construction or use of


sequentiality (for a discussion of CA-driven intervention, see Wilkinson 2010).
CA-driven approaches train partners either alone or
with the person with aphasia present (i.e. dyad). For
example, Supporting Partners of People with Aphasia in
Relationships and Conversation (SPPARC) (Lock et al.
2001a, b) is based on CA. SPPARC is designed to help
clinicians implement conversation training for groups
of partners or for dyads (e.g. Beckley et al. 2013). It
includes manuals, handouts and videotaped examples
to aid intervention. Results of a 3-year study of intervention using SPPARC is reported in the SPPARC
clinicians manual (Lock et al. 2001a: 140147).
Related to SPPARC is a CA-driven intervention
called interaction-focused therapy that has been described by Wilkinson et al. (e.g. Wilkinson 2010,
Wilkinson et al. 2010, 2011, Wilkinson and Wielaert

Conversation therapy for aphasia


2012). Recently, a new online conversation therapy resource, Better Conversations with Aphasia, draws from
CA, SPPARC and sociolinguistic principles as well as
current conceptions of communication support in aphasia (Beeke et al. 2013; Better Conversations with Aphasia, https://extend.ucl.ac.uk/).
CA-guided approaches to conversation therapy typically require analysis of a dyads conversation using CA
before intervention to identify conversational patterns
to target in therapy, and CA analysis post-intervention
to assess the outcome of intervention. Interactional
behaviours addressed in treatment typically include
conversation level or discourse features of interaction
such as managing topics or repairing breakdowns in
conversation. Therapy usually includes regular communication partners such as family members, and may target behaviours of either person in the conversational
dyad. The emphasis is on creating conversational interactions that help participants achieve the goal of
co-constructing meaning and managing their social relationship and does not necessarily entail traditional linguistic or grammatical accuracy. While conversation
analytic approaches can also be considered life participation approaches (due to the focus on building conversational participation and relationships), CA interventions are afforded a separate category due to the highly
developed roots within sociolinguistic theory.

Counselling-oriented approaches
Several approaches to conversation in aphasia are best
described as counselling or relationship oriented. Although many conversation therapies address the relationship or interaction within a dyad (e.g. Lock et al.
2001a), counselling- and relationship-oriented approaches explicitly incorporate elements drawn from
the counselling literature. For example, an approach to
working with conversational dyads that is now referred
to as Couples Therapy is rooted in principles of marital and relationship counselling as well as knowledge of
linguistics and communication (Boles and Lewis 2003,
Fox et al. 2009). In a somewhat different orientation,
Sorin-Peters (2004) describes conversational work with
couples based on counselling and adult learning theory. While these approaches aim to improve conversation, they emphasize that the relationship of couples
cannot be separated from their communicative interactions. Group conversation therapy as described by Elman et al. draws from the counselling literature relative
to group dynamics in addition to adhering to social
model philosophy (Bernstein-Ellis and Elman 2007,
Elman and Bernstein-Ellis 1999, Ewing 1999). Thus,
relationship oriented approaches explicitly incorporate
methods adapted from counselling or family therapy.

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Mode of service delivery
Modes of delivering conversation therapy include both
individual therapy in which the SLP works with one
person or one dyad, and group therapy in which the SLP
works with a group of partners, people with aphasia, or
dyads (table 1).

r Individual intervention: There are descriptions


of individual work with a communication partner (e.g. Simmons-Mackie et al. 1987, 2005) or
work with an individual dyad (e.g. Beeke et al.
2007, Boles 1997, 1998, Boles and Lewis 2003,
Burch et al. 2002, Cunningham and Ward 2003,
Hopper et al. 2002). However, to date there are
few published research studies involving one-onone conversation therapy for people with aphasia
with no partner involved. Savage et al. (2014)
studied two participants with anomia in one-onone conversation therapy between the person with
aphasia and a clinician. Training consisted of practising conversational strategies based on individual need in the context of a conversation. Basso
(2010) described a single case in which conversation was targeted as part of individual language
therapy.
r Group intervention: Group intervention has been
studied for individuals with aphasia (Elman and
Bernstein-Ellis 1999, Ross et al. 2006, SimmonsMackie et al. 2007a) and for communication partners (e.g. Booth and Swabey 1999, Kagan et al.
2001, McVicker et al. 2009). Group conversation therapy approaches for people with aphasia
involve conversational interactions of people with
aphasia facilitated by a skilled clinician. Group approaches for communication partners typically involve workshop or classroom style presentations.
Focus of intervention
Conversation therapy approaches tend to vary in the
general emphasis of intervention; that is, what clinicians
actually work on tends to differ across approaches.

r Generic versus individualized training: Some conversation therapies include relatively generic
strategies, skills or resources believed to improve
conversational interactions. Generic training is
often associated with group approaches such as
partner training workshops in which partners are
taught general skills (e.g. using multiple modalities, giving people with aphasia time to respond)
(Kagan et al. 2001, McVicker et al. 2009, Rayner
and Marshall 2009). Individualized training involves targeting behaviours that are specific to an

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individual with aphasia or particular dyad. For
example, a number of approaches such as interaction focused therapy, conversational coaching,
family member training and couples therapy involve working on dyad specific behaviours that are
identified in video recordings of the person with
aphasia conversing with a partner (e.g. Beckley
et al. 2013, Boles 1997, 2011, Hopper et al. 2002,
Simmons-Mackie et al. 1987, 2005, Wilkinson
et al. 2011).
r Addressing problems versus solutions: Descriptions of conversation therapy include approaches
that focus on eliminating problematic or maladaptive conversational behaviours and approaches
that focus on teaching positive or facilitative
conversational strategies (table 2). For example,
interventions have attempted to reduce problematic behaviours of conversation partners such
as asking test questions (Beeke et al. 2007,
Lock et al. 2001a, Simmons-Mackie et al. 1987,
2005), limiting participation via closed questions
(Wilkinson et al. 2010) or engaging in inefficient repair of breakdowns (Booth and Perkins
1999, Booth and Swabey 1999). Ineffective or
inefficient conversational behaviours of the person with aphasia have also been targeted such as
vague topic introduction (Wilkinson et al. 2010)
and lack of self-repair (Boles 1997, 1998). In
contrast to problem-oriented approaches, there
are conversation therapies that are oriented towards reinforcing or teaching beneficial strategies
or behaviours. For example, reports have described
training focused on increasing the effective use of
multimodality communication (e.g. Hickey et al.
2004, McVicker et al. 2009, Rautakoski 2011) or
using strategic behaviours to manage turns (Beeke
et al. 2011). Certainly there is significant overlap
in these orientations, since eliminating a problem often requires substitution of a facilitative
strategy or behaviour. In fact, some approaches
require eliminating problem behaviours as well
as introducing beneficial strategies. For example,
Boles and Lewiss (2003) solution-focused couples therapy involves identifying what is working
or not working, doing more of what is working
and doing less of what is not working (p. 154).
r Compensatory strategies: a feature of all conversation therapy approaches was the incorporation
of strategies to improve conversational interaction. While the term compensatory strategy was
not typically used in this literature, most of the
approaches described strategies consistent with a
definition of compensation as finding a different
way to achieve an end. For example, a subset of approaches focused heavily on encouraging the per-

son with aphasia and/or the conversation partner


to use multimodal or total communication (e.g.
writing, drawing, gestures, pictographs, props, devices) (Hickey et al. 2004, Kagan et al. 2001, Lyon
et al. 1997, McVicker et al. 2009, Rautakoski
2011). These approaches have been expanded in
the augmentative communication literature where
specific material resources to enhance conversation are described such as using picture or remnant books, visual scenes, pictographs, written key
words or computer supports (e.g. Ho et al. 2005,
Hux et al. 2010, Yasuda et al. 2007). In fact, Kagan
emphasizes the role of material resources in her
description of conversation in aphasia as an equation consisting of the skill and experience of the
aphasic communicator, the skill and experience
of the conversation partner and the availability
of appropriate communication resources (Kagan
1998: 817).
A second subset of conversation therapy approaches
to aphasia relies less on different modes of communication or material resources, and more on doing conversation a different way. For example, Wilkinson et al.
(2011) report helping a couple with topic management
by teaching the person with aphasia to introduce new
topics using topic alerts. The authors note that while
this type of word/phrase is not a particularly common
method of initiating a topic in normal conversation
it would serve as a clear signal of a new topic and
avoid vague and confusing topic initiations (Wilkinson et al. 2011: 81). Much of the traditional CA-guided
conversation therapy focuses on these interactive strategies for managing discourse in conversation. However,
there does appear to be a recent trend in CA-driven
approaches to introduce doing conversation differently
along with encouragement of multimodal communication (e.g. Beckley et al. 2013, Beeke et al. 2013).
Methods
Explicit versus implicit training
Approaches to conversation therapy might be roughly
divided into relatively explicit and relatively implicit
approaches. Explicit conversation approaches involve
overt discussion of the behaviours and goals that are
being targeted. For example, the dyad might watch a
video recorded example of a problem behaviour or read
an operationalized definition of a behaviour. The behaviour, strategy or conversational pattern is labelled,
described and made explicit for purposes of intervention
(e.g. Boles 1997, 2011, Boles and Lewis 2003, Beeke
et al. 2007, Booth and Swabey 1999, Cunningham
and Ward 2003, Fox et al. 2009, Hickey et al. 2004,

Conversation therapy for aphasia


Hopper et al. 2002, Kagan et al. 2001, Rayner and Marshall 2001, Simmons-Mackie et al. 1987, 2005, Wilkinson et al. 2010).
At the other end of the continuum would be more
implicit approaches that involve modelling and mediating without overtly practising or instructing clients regarding particular skills or behaviours. Simmons-Mackie
et al. (2007a) and Simmons-Mackie and Damico (2009)
describe methods that clinicians use within the context
of actual conversation to modify client behaviour via
subtle and indirect strategies. Implicit approaches effect
behaviour change through the interaction between the
clinician and the client as opposed to overt instruction.
For example, the clinician might use gaze and silence to
elicit a turn from the person with aphasia (as opposed
to an explicit instruction to take a turn).
It is likely that the explicitimplicit distinction
is more of a continuum as opposed to two discrete
approaches. For example, descriptions of group conversation therapy (Bernstein-Ellis and Elman 2007,
Simmons-Mackie et al. 2007a) depict conversational
interaction with implicit management by the clinician
including modelling and scaffolding with natural feedback; however, at times explicit direction occurs to guide
participants (show me with your hands).
External versus embedded approaches
Conversation therapy can involve instruction or education outside of actual conversational interaction. These
external approaches include discussion of generic or individually relevant behaviours prior to practice within
actual conversation. For example, workshop approaches
often consist of lecture presentations about aphasia and
discussion of methods for facilitating conversation with
people with aphasia (Kagan et al. 2001, Lock et al.
2001a, Rayner and Marshall 2003). The training does
not take place within the context of actual conversation,
although guided practice and measurement of outcomes
entails actual conversation (e.g. Kagan et al. 2001, Lock
et al. 2001a, b). In some approaches, video recordings
of actual conversations are used in therapy. Since the
feedback does not occur during the conversation, these
approaches are considered external. For example, an approach by Simmons-Mackie et al. (1987, 2005) required
the non-aphasic partner to watch video recordings of
her actual conversations with her aphasic husband to
learn to identify non-facilitative behaviours and judge
her improvement over time. While the treatment targeted actual conversational interactions (using pre- and
post-video recorded conversations and feedback about
conversations), no feedback was provided while she and
her husband were actually engaged in conversation.
Embedded approaches involve changing conversational behaviours online within the context of actual

519
conversational interaction. In other words conversation
is the target of treatment and the context of treatment.
For example, several approaches involve online coaching
or feedback while the person with aphasia and partner
engage in conversation (Beckley et al. 2013, Boles 1997,
1998, Boles and Lewis 2003, Fox et al. 2009, Hopper et al. 2002, Savage et al. 2014, Wilkinson et al.
2010, 2011). Group conversation therapy is considered
an embedded approach since behaviours are being targeted within the context of actual conversation (Elman
and Bernstein-Ellis 1999, Ross et al. 2006, SimmonsMackie et al. 2007a). Like the explicitimplicit division,
embedded versus external approaches probably fall on a
continuum with some approaches involving a combination of work within and outside of actual conversations.
Activities
The activities involved in conversation therapy tend to
be a natural extension of the characteristics already discussed (table 3). For example, explicit approaches often
involve education, discussion, role-play and video examples to build awareness of particular behaviours as a
prerequisite to behaviour change. These techniques are
particularly prevalent in communication partner training and dyad approaches where the clinician records
conversations and/or transcribes conversations to assess
conversational patterns, identifies potential problems
and solutions, and then uses instruction, discussion
and feedback to help participants change their own behaviours. Education regarding aphasia, elements of natural conversation and/or conversational strategies and
resources is sometimes a first step in raising awareness
of conversational patterns (e.g. Kagan et al. 2001, Lock
et al. 2001a). Video recorded examples have been used
including general examples of conversational behaviours
and video recorded examples of a dyads own conversations (e.g. Beckley et al. 2013, Beeke et al. 2011, Hopper
et al. 2002, Lock et al. 2001b, Simmons-Mackie et al.
1987, 2005). Other training methods have included
role-play (Cunningham and Ward 2003, Kagan et al.
2001, Rautakoski 2011) and reviewing written samples or transcripts of ones own conversations to build
awareness of targeted behaviours or strategies (Booth
and Swabey 1999, Lock et al. 2001a, 2001b, Wilkinson
et al. 2010, 2011). Sorin-Peters (2004) and Boles and
Lewis (2003) encourage dyads to reflect on their relationship, pattern of communication and goals, and these
are discussed in the context of strategies for improving
conversation.
The primary activity in embedded approaches is
conversation. That is, participants engage in conversational interaction that is either facilitated by the clinician
(Bernstein-Ellis and Elman 2007, Simmons-Mackie et
al. 2007a) and/or the clinician provides online coaching

520

Nina Simmons-Mackie et al.


Table 3. Examples of methods employed to change
conversational skill or participation

Using supports for message transmission


Communicative drawing (Lyon 1995)
Gestures
Writing
Vocalization, facial expression, body language
Graphic choices or written key words (Garrett and
Beukelman 1995, Kagan and Gailey 1993)
Pictographs, visual scenes or photographs
Technology
Use of other material resources (communication books, rating
scales, maps, props such as magazines)
Facilitating routinized elements of conversation
Scripting (Elman and Bernstein-Ellis 1999, Youmans et al.
2005)
Practising specific skills
Role play (Kagan 1998)
Engaging in creative communication (e.g. mime, Elman and
Bernstein-Ellis 1999; theatre, Cherney et al. 2011)
Video recognition and substitution training (identifying
problem behaviours and monitoring implementation of a new
skill) (Simmons-Mackie et al. 1987, 2005)
Promoting conversational participation
Asking person with aphasia to lead a topic or share the
facilitator role in group (Elman and Bernstein-Ellis 1999)
Clinician using gaze, silence to engage participation of person
with aphasia (Simmons-Mackie et al. 2007a, Simmons-Mackie
and Damico 2009)
Educational external methods
Defining and demonstrating behaviours or elements of
conversation in general or problem behaviours specific to
individuals or dyads (Kagan 1998, Lock et al. 2001a, 2001b)
Handouts
Lecture
Discussion
Video examples
Role play
Embedded methods used while engaging in conversation
Mediating meanings
Scaffolding
Modelling
Reinforcing target behaviours within the context of
conversation
Coaching (e.g. pointing out a potential strategy)

(Boles and Lewis 2003, Hopper et al. 2002). Techniques


such as modelling of strategies, natural reinforcement,
scaffolding, subtle prompting and reinforcement of
successful conversational behaviours are employed to
improve conversation (Simmons-Mackie et al. 2007a).
Group conversation therapy (e.g. Ewing 2007, Ross et
al. 2006) and couples therapy (Boles 2011) also include
techniques drawing from the counselling literature
such as reflecting back, summarizing, reinforcing and
mediating during conversation.
Measuring outcomes
A variety of approaches to measurement of conversation were identified in the reviewed research. Measures

that did not directly address conversation (e.g. measures


of mood; formal aphasia tests) are not included in the
following discussion of outcome measures.
Conversation analysis as outcome
Several studies reported outcomes using traditional CA;
typically these reports included excerpts of transcripts
to demonstrate changes in conversational behaviours
(Beeke et al. 2011, Booth and Perkins 1999, Cunningham and Ward 2003, Wilkinson et al. 1998, 2010,
2011). The assessment included in the SPPARC program or the Conversation Analysis Profile for People
with Aphasia (CAPPA) (Whitworth et al. 1997) were
used in several studies to assess outcome (Beeke et al.
2007, Booth and Perkins 1999, Booth and Swabey
1999, Lock et al. 2001a, Ross et al. 2006, Wilkinson
et al. 1998). Both the SPPARC and the CAPPA are based
on CA. The outcomes reported based on these measures
are individualized and reflect the behaviours or patterns
targeted for treatment. In addition to the qualitative CA
analyses, Beeke et al. (2011) piloted a quantitative measure adapted from CA; this approach involves measuring
generic turn-based behaviours as well as dyad-specific
conversational behaviours (the pilot measure is available online through Better Conversations with Aphasia,
https://extend.ucl.ac.uk/).
Measurement of discrete behaviours
A number of studies measured discrete behaviours considered relevant to conversation; this often involved frequency counts of behaviours. Boles (1997, 1998) measured word output and speaking rate of both members
of dyads to determine their levels of contribution to the
conversation. Similarly, Simmons-Mackie et al. (1987,
2005) measured words per utterance and initiation in
conversation for the person with aphasia in order to
judge the effects of partner training on conversational
participation of the person with aphasia. Wilkinson et al.
(2010) measured behaviours targeted in treatment such
as sentence attempts and questions. Specific measures
of repair were reported by Booth and Swabey (1999)
and Boles (1998). For example, Boles (1998) counted
the number of self-repairs by the person with aphasia as evidence of improvement. Savage et al. (2014)
measured proportions of utterances coded as facilitative
(initiation, response, continuation) or non-facilitative
(feedbacks, repairs/revisions).
Frequency counts of non-verbal or multimodality
behaviours were another data source (Cunningham and
Ward 2003, Hickey et al. 2004). Ho et al. (2005) measured conversational turns, topics initiations, communication breakdowns, negative affect and pointing. Hopper et al. (2002) measured the number of main concepts

Conversation therapy for aphasia


communicated in dyadic conversations. Others measured the frequency of occurrence of non-facilitative
behaviours of the partner (interruptions, test questions)
(e.g. Simmons-Mackie et al. 1987, 2005).
Rating scales
Two rating scales developed to measure (1) the participation of the person with aphasia in conversation and
(2) the skill of the conversation partner in supporting
conversation (Kagan et al. 2004) were used in a number of studies (e.g. Fox et al. 2009, Blom Johansson
et al. 2013, Kagan et al. 2001, Rayner and Marshall
2003). Blom Johansson et al. (2013) used a self-rating of
conversational skill allowing partners to evaluate the person with aphasia and their own conversational skill. Lyon
et al. (1997) asked conversation participants to rate their
conversations with the person with aphasia across a variety of parameters such as feeling of connectedness,
enjoyment and satisfaction. Similarly, Ho et al. (2005)
asked partners to rate comfort or ease, enjoyment and
perceptions of how well the dyad communicated during
the conversation (effectiveness). Self-ratings to determine changes in conversational behaviours addressed in
treatment have also been used to measure outcome (e.g.
amount of initiation, asking questions) (Boles and Lewis
2003, Fox et al. 2009).
Interviews and questionnaires
Interviews eliciting qualitative data regarding outcomes
of therapy were reported by McVicker et al. (2009)
and Sorin-Peters (2004). Rautakoski (2011) developed
a questionnaire, Communication Strategies of Communication Partners (CSCP), to obtain perceptions regarding use of communication strategies in conversations.
Wilkinson et al. (2010) interviewed the conversation
partner after intervention to determine perspectives on
elements of conversation such as turns, sentences and
topic development by the person with aphasia.
Social validity judgments
Several studies asked independent judges to rate aspects of video recorded conversations of therapy participants. For example, Fox et al. (2009) and Wilkinson
et al. (2010) asked judges to identify pre- versus posttreatment video recordings. Hopper et al. (2002) asked
judges to compare the understandability of pre- versus post-treatment conversations. Hickey and Rondeau
(2005) asked nave judges to rate conversations of dyads
relative to the quality of conversational elements such
as comfort level, turn taking, topic management and
amount of information shared.

521
Table 4. Number of research articles addressing conversation
therapy by types of research reported
Type of research
Randomized controlled trial
Group pre-post-/case series
Single participant experimental design
Qualitative study or case study
Total

Number of articles
2
5
8
15
30

Level of evidence
Although this project was not designed to critically evaluate the quality of research on conversation therapy for
aphasia, it seemed important to report on the limited
number of high-level research studies on conversation
therapy that were identified as primary sources (table
4). Fifteen of the reviewed studies were classified as descriptive case reports or qualitative research (Basso 2010,
Beckley et al. 2013, Beeke et al. 2007, 2011,1 Boles and
Lewis 2003, Booth and Perkins 1999, Booth and Swabey
1999, Fox et al. 2009, Lesser and Algar 1995, McVicker
et al. 2009, Simmons-Mackie et al. 2007a, Sorin-Peters
2004, Wilkinson et al. 1998, 2010, 2011). Although
case studies and qualitative research provide important
information about interventions, these studies are not
considered a high level of evidence for efficacy of an
intervention. There were eight articles reporting one
or more single participant experimental designs (Boles
1997, 1998, Cunningham and Ward 2003, Hickey et al.
2004, Hopper et al. 2002, Saldert et al. 2013, Savage
et al. 2014, Simmons-Mackie et al. 2005). Five studies
reported outcomes for groups of people with aphasia
and/or conversation partners before and after intervention (Blom Johansson et al. 2013, Lyon et al. 1997,
Lock et al. 2001a, Rayner and Marshall 2003, Ross
et al. 2006). Two studies were considered randomized
controlled trials (RCTs) including both treatment and
control groups. One of the RCTs (Kagan et al. 2001)
involved training of volunteer conversation partners
and measuring outcomes within semi-structured conversation with people with aphasia. The second RCT
addressed group therapy for aphasia (Elman and
Bernstein-Ellis 1999). This study provided evidence of
the effectiveness of group therapy based on language and
functional test scores and described methods consistent
with conversation therapy; the research report does not
include a measure of conversation as an outcome.
Discussion
Perhaps the most striking finding of this review of conversation therapy for aphasia was the wide variation in
published approaches. In order to address this diversity,
the elements of various approaches were organized and

522
categorized to describe conversation therapies for aphasia. Conversation interventions were classified according
to treatment participants (person with aphasia, partner
or dyad), the primary origins, the mode of service delivery (individual or group), the overall focus of intervention (generic versus individualized; problem versus
solution oriented; compensatory), training methods (explicit versus implicit; external versus embedded), types
of activities or tasks, and outcomes measured. Finally,
primary sources were classified by the type of research
design.
Another major finding was the marked discrepancy between intervention focusing on conversational
skills of partners or dyads and intervention focusing on
conversational skills of individuals with aphasia independent of a particular dyad. Only 17% (five out of
30 articles) of the primary source articles (table 1) described intervention for people with aphasia independent of a communication partner. Certainly, the fact
that conversation is a collaborative event suggests that
both parties require skills and often the skills are dyad
dependent. While skilled partners are critically important for conversational success, it is surprising that so
little attention in the literature has been afforded to improvement of conversational skills of individuals with
aphasia. Many people with aphasia do not have regular
communication partners or reside in situations where
partners change frequently (e.g. residential facilities);
these individuals might profit by intervention aimed at
improving conversational skills that are not dyad specific. Furthermore, the bulk of aphasia therapy occurs
during individual therapy sessions between the person
with aphasia and the clinician; yet, there is little systematic attention to one-on-one therapy with the person with aphasia to improve conversation. In fact, there
is little description regarding methods that clinicians
might employ during individual conversation therapy
for aphasia. With increasing attention to the need to
improve participation in life for people with aphasia,
it would seem important for aphasia therapists to employ evidence-based measures for improving conversational skill and confidence of people with aphasia beyond interactions with a regular partner. The aim of
such improvements would be to promote conversational
engagement outside of immediate family or caregivers,
and ultimately decrease social isolation and increase life
participation.
Related to the discrepancy between intervention for
partners and individuals with aphasia, is the variation in
the literature including communication partners. This
relatively large literature represents a variety of philosophical origins and approaches. Since, as noted earlier,
partner training is not necessarily synonymous with conversation therapy, it is not advisable to generalize broadly
from reviews of partner training to conversation therapy

Nina Simmons-Mackie et al.


(e.g. Simmons-Mackie et al. 2010, Turner and Whitworth 2006). Some of the partner training literature
that fits the definition of conversation therapy focuses on
dyads or familiar partners and consists of case studies or
single case designs. After reviewing several of these studies Wilkinson and Wielaert (2012) concluded: There
is evidence that intervention targeting conversations involving an aphasic speaker can achieve change. Future
studies should move beyond single case designs, include
more robust, quantifiable evidence of change, and provide evidence of maintenance of change (p. S70). Thus,
in order to create an evidence base for conversation therapy, it would seem necessary to focus more explicitly on
conversation, regardless of the participants included in
the sessions, and create a distinct literature comprising
research designs that expressly address conversation.
Another finding of the review was the variation in
measurement of conversation across studies. Measures
included counts of discrete behaviours, ratings scales,
self-report measures, qualitative interviews, social validity judgments, and patterns revealed through CA. Not
only were there reports of widely varied measures, but
also the measures targeted different types of outcomes
such as linguistic behaviours (e.g. words spoken), pragmatic behaviours (e.g. repair, turn management), communicative efficiency or effectiveness, level of participation and satisfaction (e.g. enjoyment). It is difficult
to draw conclusions from studies that report such diverse outcomes. In addition, conversation is a complex
and dynamic activity. Discrete or piecemeal measures
often fail to capture the interdependence of behaviours.
For example, an increase in words spoken or syntactic
complexity might actually diminish other elements of
conversation such as efficiency, social acceptability or enjoyment. In other words, conversation involves multiple
levels of processing (beyond word finding and sentence
construction) that dynamically interact and contribute
to success. Participants in conversation not only wish
to impart messages, but also want to do so in a socially acceptable manner and use conversation as a tool
to achieve social goals (e.g. negotiate identity, affiliate
socially). In order to establish an evidence base for conversation therapy, it is imperative that researchers have
access to appropriate measures of conversational skill
and participation. The Kagan scales (Kagan et al. 2004)
provide a method of rating conversational participation
as a whole for the person with aphasia; however, the score
is tied to a particular partner. CA also has the potential
to capture multiple levels of conversational interaction;
however, CA can be time consuming and, like the Kagan
scales, focuses on specific dyads. In fact, there is little information in the aphasia literature to guide clinicians or
researchers regarding general conversational skills that
might be targeted in therapy or measured. Clearly, there
is a need for valid, reliable and clinically feasible methods

Conversation therapy for aphasia


of measuring conversational outcomes that capture the
dynamic nature of conversation in its entirety. Future
studies need to address the effectiveness of conversation
therapy; however, there is also a need for a core set of outcome measures that are used across conversation therapy
trials. Ideally, this should be extended to all aphasia therapy trials. The Core Outcome Measures in Effectiveness
Trials (COMET) initiative (www.comet-initiative.org)
details a process whereby this can be achieved.

523
Conclusion
Conversation is a pervasive element of everyday life.
Therefore, an essential goal of intervention for people
with aphasia should be to improve conversational skill,
confidence and participation. This review has offered
a comprehensive depiction of the diverse literature related to conversation therapy and suggested multiple
directions for future research.
Acknowledgements

Future directions
This review suggests a host of directions for future
research in conversation therapy for aphasia. First,
stakeholders (researchers, clinicians and consumers)
must determine which domains should be measured
as core outcomes and then researchers must identify
meaningful tools or protocols for measuring conversation, particularly measures that capture conversation as
a dynamic whole. Instruments are needed that measure success or achievement of conversational goals (as
described in the CA literature, e.g. Beeke et al. 2007,
Wilkinson 2010) as opposed to discrete behaviours or
linguistic accuracy. Moreover, measures must capture
skills and participation in actual conversation, as opposed to structured or contrived discourse tasks.
Another thrust of future research might be development of one-on-one conversation therapy for individuals with aphasia, including more information regarding
interactive features of conversation (repair, turn management) that might be amenable to individual therapy.
Since little systematic, published research has defined
and evaluated individual conversation therapy for aphasia, such a program of research is needed.
The project reported herein was designed to describe conversation therapy and develop a taxonomy
that organizes features of conversation therapy. Future research should employ robust research designs
to measure outcomes of conversation therapy associated with specific approaches. Ideally a phased approach
(Campbell et al. 2000, Robey and Schultz 1998) to research should slowly develop and build the evidence
for conversation therapy. Ultimately, different conversation therapy approaches might be compared to determine the most effective and efficient methods, and
conversation therapy might be compared with other
approaches such as impairment-oriented intervention.
Finally, while researchers are increasingly measuring the
effects of impairment-focused therapy on conversational
behaviours (e.g. Carragher et al. 2012), it is important to
study the reverse also: the effects of conversation therapy
on linguistic performance (e.g. lexical retrieval, syntax)
as well as natural conversation.

Declaration of interest: The authors report no conflicts of interest.


The authors alone are responsible for the content and writing of the
paper.

Note
1. 1. Representing case study research presented in Burch et al.
(2002) and Lock et al. (2001a).

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Appendix
Articles reviewed as primary data sources
Basso (2010), Beckley et al. (2013), Beeke et al. (2007,
2011), Johansson et al. (2013), Boles (1997, 1998),

526
Boles and Lewis (2003), Booth and Perkins (1999),
Booth and Swabey (1999), Cunningham and Ward
(2003), Elman and Bernstein-Ellis (1999), Fox et al.
(2009), Hickey et al. (2004), Hopper et al. (2002),
Kagan et al. (2001), Lesser and Algar (1995), Lock

Nina Simmons-Mackie et al.


et al. (2001a, 2001b), Lyon et al. (1997), McVicker et al.
(2009), Rayner and Marshall (2003), Ross et al. (2006),
Saldert et al. (2013), Savage et al. (2014), SimmonsMackie et al. (1987, 2005, 2007a), Sorin-Peters (2004),
and Wilkinson et al. (1998, 2010, 2011).