Functional and First-Rate Aphasia

Treatment

Jacqueline Hinckley, PhD, CCC-SLP

Board Certified – Neurogenics (ANCDS)
Associate Professor, Speech-Language Pathology
Nova Southeastern University

©Hinckley/NSS
Disclosures

• Relevant Financial Disclosures:

• Receive royalties from NSS
• Relevant Nonfinancial Disclosures:
• Advisory Board, National Aphasia Association
• Executive Director Emeritus, Voices of Hope for Aphasia

©Hinckley/NSS
Learning Objectives

After completing this course, you will be able to:

• Identify one tool for assessing factors that determine what clients
actually will be able to do.
• Use 5 evidence-based therapies in different clinical settings.
• Discuss how to use these 5 therapies for different therapy goals.

©Hinckley/NSS
You arrive to see your new client. The previous reports stated that Alan
is a 58-year old gentleman who had a stroke 3 months ago and now
has a moderately severe expressive aphasia.

You introduce yourself.

Your client says, “Therapy?...No!”

©Hinckley/NSS
“Patient- and family-centered care is working ‘with’
patients and families, rather than just doing ‘to’ or
‘for’ them.”

Institute for Patient and Family-Centered Care:

http://www.ipfcc.org/about/pfcc.html
©Hinckley/NSS
 Client and clinician
determine priorities

Client’s priorities are

Client-centered care primary focus of
(model modified from Hinckley, 2017)
clinician’s assessment

Client and clinician set

goals collaboratively

Clinician selects
treatment based on
client’s priorities and
©Hinckley/NSS
goals
“The overall objective of speech-language pathology services is to
optimize individuals' abilities to communicate and to swallow, thereby
improving quality of life.” [italics mine]

Scope of Practice in Speech-Language Pathology, ASHA.

http://www.asha.org/policy/SP2016-00343/

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https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935365&section=Key_Issues
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Impairment measures are related to functional
abilities at one timepoint.

• Severity of language impairment is related to severity of functional

communication abilities
• Impairment-type assessment (like Western Aphasia Battery) has
been associated with functional assessments and pragmatic
performance

(Avent et al, 1998; Ross & Wertz, 1999; Irwin, Wertz, & Avent, 2002)

©Hinckley/NSS
“…measurement of the impairment of aphasia pre-
and post-treatment is inadequate for describing its
functional outcome.” (Holland, 1998, p. 250)

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Impairment measures don’t seem to predict
functional abilities

• Although impairment-level performance is related to

functional performance at a single point in time, change in one
does not necessarily equal change in the other (Meier, Johnson,
Villard, & Kiran, 2017)
• Impairment measures may also not be associated with daily
stress and self-reported communication difficulty (Doyle,
Matthews, Mikolic, Hula, & McNeil, 2006).

©Hinckley/NSS
Factors that Help Make the Therapy Functional

©Hinckley/NSS
Factor #1: Impairment

• Scores on impairment-focused measures, such as standardized

aphasia batteries, will probably not predict functional abilities
• Scores on impairment-focused measures may help the clinician
consider underlying skills that will impact functional abilities

©Hinckley/NSS
Boston Diagnostic Aphasia Examination
(Goodglass, Kaplan, & Barresi, 2001)

©Hinckley/NSS
Alan, a home health client
• Spoken word-picture matching (word discrimination subtest) = 40%
• Able to follow one-step commands only
• Visual confrontation naming = 55%
• Written word-picture matching = 60%
• Written confrontation naming = 20%

What will Alan be able to do?

©Hinckley/NSS
Typical assessments are an attempt to measure a
decontextualized skill.

• They do this by including a variety of test stimuli to get an “average”

performance across words that may vary based on
• Word frequency in the language
• Familiarity
• Personal relevance
• Other factors…

©Hinckley/NSS
Although such assessments are useful, those principles
are the opposite of functional therapy goals.

A typical standardized assessment Functional therapy goals

• Decontextualized • Contextualized
• Not based on personal relevance • Should be based on personal
or familiarity of items to client relevance to the client
• An attempt to measure a • An attempt to improve an
language “domain” or activity or language
competence performance
• Typically measures language • Typically focuses on activities
“impairment” (per WHO ICF) and life participation

©Hinckley/NSS
Factor #2: Activity & Participation
• Overall scores may be somewhat useful in predicting functional
abilities
• Item analyses of strengths and challenges may lead to identification
of realistic functional goals and outcomes
• Activities that are priorities for the client can be specifically evaluated
by relevant items in a non-standardized assessment

©Hinckley/NSS
 Communicative Abilities in
Daily Living (Holland, Fromm &
Wozniak, 2018)

©Hinckley/NSS
What can a standardized assessment of activity &
participation tell us?

1. A general measure of 1. Not a specific measure

the patient’s ability to of any specific task
do daily tasks
2. Not performance on
2. Performance on functional tasks in the
functional tasks relative individualized context
to others of that patient

©Hinckley/NSS
Alan: Activity Assessment

No previous reports, data from interview with spouse and client.

• Answers the phone (picks it up, says “hello”) but cannot converse or
pass message
• Watches TV
• Seems to understand simple context-focused conversation around
immediate referents

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 ICF Checklist
http://www.who.int/classifications/icf/icfchecklist.pdf

©Hinckley/NSS
Factor #3: Environment

• The barriers or facilitators in the

environment are critical to
considering what activities the person
is most likely to do
• Trained vs. untrained partners?
• Environment supportive or modifiable in
other ways?
• Distractions, noise
• Scheduling
• Seating, item placements, communication
supports

©Hinckley/NSS
Example: Self-Efficacy

ICF Checklist
http://www.who.int/classifications/icf/icfchecklist.pdf

©Hinckley/NSS
Factor #4: Personal and Social Factors
• Some examples of personal and social factors:
• Visual Analogue Self-Esteem Scale (Brumfitt & Sheran, 1999)
• Communication Confidence Rating Scale for Aphasia (Babbitt & Cherney,
2010)
• Measures for depression and mood, such as Geriatric Depression
Screening (Sheikh & Yesavage, 1986)
• These personal factors also mediate what a person will actually
do
• Someone with mild impairments may lack confidence to try
• Someone with depressed mood may be unable to initiate

©Hinckley/NSS
What will Alan be able to do?

©Hinckley/NSS
Determining the client’s priorities
• Interview questions from Appendix 2 of the WHO ICF
Checklist (using supports)
• Life Interests and Values assessment
• Key Life Activities

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 Tools: ICF Checklist, Appendix 2
http://www.who.int/classifications/icf/icfchecklist.pdf

©Hinckley/NSS
Life Interests and Values (L!V) cards

• Pictorial support for individuals with restricted communication ability

to indicate activities and life participation which is most relevant to
them

• https://www.med.unc.edu/ahs/sphs/card/resources/liv-cards/

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L!V cards: Interview

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Key Life Activities
(Simmons-Mackie, 2001)

Prior to Onset Currently Treatment Outcome

Teaching 1st grade Church on Sunday Preschool volunteer

Church on Sunday Church on Sunday
Cook for church
(Wed) Carnival Club
Carnival Club attendee
Secretary
Walk 2 miles daily Babysit grandchild Walk with friend daily
Prepare family dinner Host family dinner
Babysit grandchild Gardening (some) Babysit grandchild
Garden Club Reading (some
Gardening Television Gardening (some)
Reading Reading (some
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Alan’s Priorities

Prior to Onset Currently Treatment Outcome

Employed full-time as a sales Unemployed; no volunteer

representative for a medical supply position
company

Attends or watches baseball and Watches TV alone

football games with “buddies”

Talk on the phone with two adult

children Tries to talk on the phone but gives
up easily; has difficulty following
Maintained the yard and exterior conversation and speaking
of the home

©Hinckley/NSS
What will Alan be able to do? Treatment Aims

• Help Alan have satisfying conversations with his adult children on the
phone.
• Help Alan participate in activity-focused conversations (e.g., during
football games) with friends.

©Hinckley/NSS
 Client and clinician
determine priorities

Client’s priorities are

Client-centered care primary focus of
(model modified from Hinckley,
2017) clinician’s assessment

Client and clinician set

goals collaboratively

Clinician selects
treatment based on
client’s priorities and
©Hinckley/NSS
goals
 Treatment Aim #1: Talking on the phone with family

Difficulty understanding
sentences/conversation;
expression is limited to 1-3
word utterances

©Hinckley/NSS
 Treatment Aim #1: Talking on the phone with family

Role-play item on CADL;

Difficulty understanding difficulty dialing, unable to
sentences/conversation; respond beyond “hello”
expression is limited to 1-3 word
utterances

©Hinckley/NSS
©Hinckley/NSS
 Treatment Aim #1: Talking on the phone with family

Difficulty Role-play item on CADL;

understanding difficulty dialing, unable to
sentences/conversatio respond beyond “hello”
n; expression is
limited to 1-3 word
utterances

Spouse gets angry and frustrated

when he answers the phone

©Hinckley/NSS
 Standardized form for partner’s perceptions:
Communicative Effectiveness Index (CETI)
(Logan et al, 1989)
• Significant other (primary communication partner) rates the PWA’s
ability to do specific communication tasks
• Mark an X on a visual analogue scale
• Anchors: “as able as before stroke” – “not at all able”
• Usually considered a measure of social validity
• “Score” is measure of distance between pretest rating and posttest
rating
• Designed to assess perceived change over time according to
important others

©Hinckley/NSS
CETI

©Hinckley/NSS
Aphasia-friendly version of CETI (Rautakoski et
al, 2008)

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Self-efficacy

• Self-efficacy = belief in one’s ability to do a specific task

• Task-specific; not a general trait like self-esteem or self-confidence
• Based on Bandura’s social learning theory; thousands of studies
across different domains

©Hinckley/NSS
Informal assessment of self-efficacy
Are you able to talk on the phone?
(Is Alan able to talk on the phone?)

__________________________________________________________

Not at all As able as

able before stroke

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How difficult is it for you to talk on the phone?
(How difficult is it for Alan to talk on the phone?)

____________________________________________________
_
Very Difficult Very Easy

©Hinckley/NSS
How important is it for you to talk on the phone?
(How important is it for Alan to talk on the phone?)

____________________________________________________
__
Very Difficult Very Easy

©Hinckley/NSS
 Treatment Aim #1: Talking on the phone with family

Difficulty understanding
sentences/conversation;
expression is limited to 1-3
Role-play item on CADL;
word utterances
difficulty dialing, unable to
respond beyond “hello”

Alan wants to talk on the Spouse gets angry and frustrated

phone; it is very important when he answers the phone
to him

©Hinckley/NSS
Treatment Aim #2: Conversations with friends during
sports games

Difficulty understanding
sentences/conversation;
expression is limited to 1-3
word utterances

©Hinckley/NSS
 Treatment Aim #2: Conversations with friends during
sports games

Difficulty understanding
sentences/conversation;
expression is limited to 1-3
word utterances
Sample “football” conversation
with clinician; track content
units/correct information
units/responses/initiations

©Hinckley/NSS
 Treatment Aim #2: Conversations with friends during
sports games

Difficulty understanding
sentences/conversation; Sample “football” conversation
expression is limited to 1-3 with clinician; track content
word utterances units/correct information
units/responses/initiations

Trained vs. untrained

partners

©Hinckley/NSS
©Hinckley/NSS
 Treatment Aim #2: Conversations with friends during
sports games

Difficulty understanding
sentences/conversation; Sample “football” conversation
expression is limited to 1-3 with clinician; track content
word utterances units/correct information
units/responses/initiations

Trained vs. untrained Football conversations are very important

partners to Alan

©Hinckley/NSS
Self-efficacy measurement for football
conversations - example

Are you able to have football conversations with your friends?

(Is Alan able to have football conversations with friends?)

__________________________________________________________
__
Not at all As able as
able before stroke

©Hinckley/NSS
How difficult is it for you to have football conversations with
friends?
(How difficult is it for Alan to have football conversations with
friends?)

____________________________________________________
Very Difficult Very Easy

©Hinckley/NSS
How important is it for you to have football conversations with
friends?
(How important is it for Alan to have football conversations with
friends?)

____________________________________________________
_
Very Difficult Very Easy

©Hinckley/NSS
Summary: Factors contributing to what a client
will really do

A client’s functional ability = The impairment while doing a particular activity, in a particular
environment, mediated by personal characteristics such as belief in their own abilities.

For Alan:
Moderately-severe word comprehension and naming abilities make it difficult for him to speak on
the phone with his children/have satisfying conversations with close friends in the at home facing
his wife’s frustrations despite how important these tasks are to him.

©Hinckley/NSS
Now that we have some functional goals, how can
we make the treatment first-rate?

©Hinckley/NSS
A typical model for selecting treatment
Assessment of impairments
by administering standardized
aphasia tests

Identify most problematic

impairment(s) by interpreting
test results and integrating
client perceptions

Select therapy from among

impairment-focused
therapies.

©Hinckley/NSS
An additive model to selecting therapy
Assessment of impairments Determination of client’s
by administering standardized preferred activities and
aphasia tests priorities supported with
interview tools.

Identify most problematic

impairment(s) by interpreting
test results and integrating
client perceptions
+ Assess skills and supports
needed for those specific
activities by evaluating client’s
abilities, environment, partners.

Select therapy from among Select therapy from

impairment-focused among
therapies. activity/participation
focused therapies.

©Hinckley/NSS
 An additive model

• Allocate some of our time to an impairment-focused therapy

• Allocate the rest of the therapy to an activity/participation-focused
therapy, like practicing conversation
• We believe that we are working on the impairment (word-finding)
and its generalization or transfer to a target task

©Hinckley/NSS
 15 min 15 min

Problem: word-finding Problem: Using word-finding skills in

daily activities (e.g., conversation)

Practice “skill” of word-finding

across exemplars Practice use of skill in conversation

©Hinckley/NSS
 Does level of language impairment predict activity and
life participation?

A typical standardized assessment Functional therapy goals

Typically measures language Typically focuses on activities

“impairment” (per WHO ICF) and life participation

NO!
Ross & Wertz, 1999; 2002
©Hinckley/NSS
 Most therapies rarely generalize to untrained items.

That means that training a

variety of items may not
make any meaningful
difference in your client’s
daily functioning.

©Hinckley/NSS
Most therapies rarely generalize to untrained items.

But, it also means that

X
training specific items that
are important to your client
will help. X

©Hinckley/NSS
In order for therapy to make a functional,
meaningful difference,
we must

1. Take the time to find out what is most important for your client.
2. Use an evidence-based therapy so that the therapy has the
greatest chance of achieving the desired results.
3. Target goals and therapy on the items and activities that will
matter most.

©Hinckley/NSS
From: Hinckley, J.
(2017). Selecting,
combining, and
bundling different
therapy
approaches. In:
Coppens, P. &
Patterson, J. (Eds.)
Aphasia
Rehabilitation:
Clinical Challenges.
Burlington, MA:
Jones & Bartlett
Learning.

©Hinckley/NSS
Best Practices Help Ensure Our Therapy is First-Rate

©Hinckley/NSS
 What Is a “Best Practice”?

• A benchmark or a standard of how things should be done

• The “best” that we can do to meet needs of people with aphasia,

family members, or other stakeholders

©Hinckley/NSS
 Best Practice Recommendations vs.
Evidence-Based Reviews
• Evidence-based reviews usually focus on level of evidence and require
the “consumer” (e.g., clinician, policy maker) to decide what
intervention is appropriate, necessary, or best in which circumstances
(based on evidence)

• Best practices usually provide a template of what should be provided

©Hinckley/NSS
 Examples

EBP Review
“…caregiver education may be associated with improvement in caregiver
stress”
(Evidence-Based Review of Stroke Rehabilitation, www.ebrsr.com)

Best Practice Recommendation

“Families of persons with aphasia should be engaged in the entire
rehabilitation process, including family education and training in supported
communication”
(Canadian Stroke Best Practices)

©Hinckley/NSS
 Best Practice Recommendations For Stroke
• Stroke practice guidelines exist in every English-speaking country
• Usually include statements about best care for those with aphasia and
other communication disabilities due to stroke

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Best Practice Recommendations For Aphasia

• Aphasia United has compiled these guidelines, and their levels of

evidence, in an international best practice guideline for aphasia
• 10 best practice points
• Assessment
• Education and counseling
• Treatment
• Written materials

www.aphasiaunited.org

©Hinckley/NSS
 Best Practice For Aphasia:
Assessment Guidelines
• Anyone with brain damage or progressive brain disease should be screened
for possible communication impairment
• Those with suspected communication impairments should receive a full
evaluation that determines the nature, severity, and personal consequences
of the suspected impairment

www.aphasiaunited.org

©Hinckley/NSS
 Best Practice For Aphasia: Education

• People with aphasia should receive information about aphasia, etiology of

aphasia, and treatment options throughout the health care process
• Information intended for people with aphasia should be available in aphasia-
friendly formats
• All health and social care providers should be educated about aphasia and
trained to support communication

www.aphasiaunited.org

©Hinckley/NSS
Aphasia-Friendly Written
Materials: Example
Simple sentences

Large print

Plenty of white space

Easy reading/reading level grades 5-6

http://www.aphasiafriendly.co/free-resource-library.html
©Hinckley/NSS
 Train Other Providers to Use Supported
Communication For Aphasia: Example
“Supported Conversation for Adults with Aphasia (SCA) is a
communication method that uses a set of techniques to encourage
conversation when working with someone with aphasia through:
üSpoken and written keywords
üBody language and gestures
üHand drawings
üDetailed pictographs”

Aphasia Institute, http://www.aphasia.ca/communicative-access-sca/

©Hinckley/NSS
 Best Practice for Aphasia: Treatment – 1

• Therapy should be offered that is designed to have a meaningful

impact on communication and life
• Therapy should be culturally appropriate and personally relevant
• Communication partner training should be provided to improve the
communication of the person with aphasia

©Hinckley/NSS
 Best Practice for Aphasia: Treatment –
2
• Family members should be included in the rehabilitation process
• Should receive information about aphasia
• Should be trained to communicate with the person with aphasia
• No one with aphasia should be discharged from services without a
means to communicate (e.g., AAC, supports, trained partners) or a
documented plan for how and when this will be achieved

©Hinckley/NSS
Download a copy of the International Best
Practices for Aphasia

http://www.aphasiaunited.org/best-practice-recommendations/

©Hinckley/NSS
©Hinckley/NSS
 Best Practice Guidelines Summary

• Will the therapy you are offering your client with aphasia
• Have a meaningful impact on communication?
• Have a meaningful impact on life?
• Be culturally appropriate?
• Be personally relevant?
• Do you train communication partners so that the communication of the
person with aphasia is improved?
• Do you provide family members with information?
• Do you train family members to communicate?
• Do you ensure that the person with aphasia has a means to communicate by
discharge?

©Hinckley/NSS
©Hinckley/NSS
ASHA’s Practice Portal

©Hinckley/NSS
 From ASHA’s Practice Portal

©Hinckley/NSS
Treatment Aim #1: Have
short phone
conversations with
family

©Hinckley/NSS
Treatment Aim #2: Have
satisfying “football
conversations” with
friends

©Hinckley/NSS
Treatment Aim #1: Phone Treatment Aim #2: Football

• RET • RET
• PACE • PACE
• Supported Conversation training • Supported Conversation training
• Conversational Coaching • Conversational Coaching
• Script Training • Script Training
• AAC/Device Use • Semantic Feature Analysis

©Hinckley/NSS
Response Elaboration Training (RET):
Evidence Support
• Type of “loose training”
• Works to improve lexical retrieval and the number of content words
produced by an individual with aphasia (Conley & Coelho, 2003)
• Focuses on initiation of responses and conversation through the use of
forward chaining, or elaboration of the client’s responses by the clinician
• Kearns (1985) has demonstrated that RET is an effective intervention
program for improving verbal production in conversation and for
generalization of improved skills across types of aphasia

©Hinckley/NSS
Response Elaboration Training:
Evidence Support
• Has been found to have positive generalization of responses and stimuli as
well as positive acquisition on the behalf of patients with aphasia
(Wambaugh, Martinez, & Alegre, 2001)
• Conley and Coelho (2003) found that a combination of RET with semantic
feature analysis (a more instructive type of lexical retrieval treatment)
aided response elaboration as well as word retrieval
• Since the participants did not have restrictions to their use of language, it
was found that creative utterances facilitated word retrieval through
patient-initiated carrier phrases
• Result of this combination of treatment methods was found to promote
more effective generalization of learned skills

©Hinckley/NSS
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video example

©Hinckley/NSS
Promoting Aphasics’ Communicative
Effectiveness (PACE)
(Davis & Wilcox, 1985; Davis, 200, 2005)

Overview: A conversational treatment in which any modality can be used

to communicate ideas from one partner to the other; the client and
clinician take equal turns in the sender and receiver roles, and this
promotes conversational participation
Candidacy: Procedures can be adapted to specific linguistic impairments;
thus people with a variety of types and severities of aphasia can benefit
from this treatment
Goals and Expected Outcomes: Use appropriate communication
modalities (speaking, writing, drawing, gesturing, communication
notebook or other AAC strategies) to effectively participate as sender
and receiver

©Hinckley/NSS
The Four Principles and Procedures of
PACE – 1
1. The clinician and patient exchange
new information
2. The clinician and patient
participate equally as senders and
receivers of messages
©Hinckley/NSS
1. Instead of having a picture of an
object or event (called the message)
in simultaneous view of the clinician
and patient, a stack of message
stimuli is placed face down to keep
messages from the view of a
message receiver. A client selects a
card and attempts to convey the
message on the card.
2. The clinician and client simply
alternate in drawing a card and
sending messages.
The Four Principles and Procedures of
PACE – 2

3. The patient has a free choice
as to the communicative
modes used to convey a
message
4. The clinician’s feedback as a
receiver is based on the
patient’s success in
conveying the message
3. The patient is left to choose the
mode that is used for any
message. The patient has a free
choice as to the communicative
modes used to convey a message.
4. Our feedback should let the client
know if he or she got the idea
across.

©Hinckley/NSS
video example

©Hinckley/NSS
PACE: Goals and Measures

• Frequency of successfully communicated message

• Number of attempts prior to success/% of attempts with x number of
attempts or fewer
• Improved efficiency measured by total time required for each
attempt (averaged); can be reported as % faster
• Frequency/% of attempts using a particular strategy

©Hinckley/NSS
PACE Rating Scale
5 – message conveyed at first attempt
4 – message conveyed after general feedback from the clinician
3 – message conveyed after specific feedback from the clinician
2 – message partially conveyed
1 – message not conveyed
0 – no attempt to convey message

(Davis, 1980; Edelman, 1987)

©Hinckley/NSS
 Communication Partner Training (CPT)

• Training any communication partner with strategies designed to

improve the communication participation and effectiveness of adults
with aphasia (Turner & Whitworth, 2006, among others)
• Results in improved communicative access and participation for
adults with aphasia
• Training partners may result in direct improvement in the
communication behavior of the adult with aphasia (Simmons-Mackie
et al, 1987)

©Hinckley/NSS
Potential Intervention: Supported Conversation for
Aphasia™ (SCA)
www.aphasia.ca

Supported conversation for adults with aphasia based

on the idea that reduced ability and opportunity to
engage in conversation affects the way that adults
with aphasia are perceived. The less opportunity there
is to engage in genuine conversation the less
opportunity there is to reveal competence. (Kagan et
al., 1995)

©Hinckley/NSS
What is SCA™?
SCA™ is:
• a communication method that allows you to have a conversation with
an individual who has difficulty expressing thoughts or understanding
verbal messages.

• SCA™ is useful for addressing a range of speech and language

disabilities, including aphasia.

©Hinckley/NSS
 SCA ™ – A Framework for
Conversation
The SCATM framework is an approach that prompts the care provider
to:

1. Acknowledge Competence: Help the person feel as

though they are being treated respectfully
2. Reveal Competence: Get and to give accurate
information via:
1. In – communicate your message to the person
2. Out – receive information from the person
3. Verify – ensure your understanding is accurate

©Hinckley/NSS
 Acknowledging Competence

Are you treating the person respectfully?

• Some ways to help you acknowledge competence include:
• Speak naturally (with normal loudness), using an adult tone of voice and a
conversational style
• Acknowledge the person’s frustrations and fears of being thought of as
stupid e.g. “I know you know”

©Hinckley/NSS
Kagan et al, 2001

©Hinckley/NSS
Find online training videos and materials here:

https://www.aphasia.ca/home-page/health-care-
professionals/knowledge-exchange/self-directed-sca-module/

©Hinckley/NSS
Conversational Coaching: Overview

• Training the individual with aphasia to use effective communication

strategies – such as gesture, drawing, or writing – similar to PACE
• Includes the primary communication partner, such as a spouse or
other family member
• Clinician serves in the role of coach to both parties
• Targets effective communication strategies for both the person with
aphasia and the primary communication partner
• Primary communication partner plays an equal role in improving
conversation

(Holland, Hopper & Rewega, 2002)

©Hinckley/NSS
Conversational Coaching: Candidacy

• Candidacy:
• Effective for a variety of types and severities of aphasia,
dysarthria, or other
• Best outcome when primary communication partner is
willing and able to learn and maintain communication
strategies
• Goals & Expected Outcomes:
• Desired outcome is the implementation of effective
communication strategies in conversation by both the
person with aphasia and the primary communication
partner

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Conversational Coaching: Steps 1-2

1. Determine a hierarchical list of strategies for each partner

• Based on the needs of the person with aphasia and what will work within
that dyad
• Examples:
• Drawing or writing to aid expression
• Drawing or writing to aid comprehension
• Longer pauses
• Slower speech rate
• Learning a gesture to request more time
2. Clinician presents a short narrative or story to one member of the dyad while
the other is out of the room
• Could be a short video clip (e.g., America’s Funniest Videos)

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Conversational Coaching: Steps 3-4

3. Other partner comes into the room, and first partner explains the
clip or story using the targeted strategies
• Clinician should direct each member to their strategies as
needed or coach one member or the other on more effective
ways to achieve success while engaged in this transaction
• Clinician should provide positive feedback

4. Repeat as needed to master strategy use and practice in a variety

of contexts

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Semantic Feature Analysis (SFA)

• Builds on the interconnections of semantic features and

knowledge, and provides an elaborated network of cues that can
strengthen association with the targeted items
• Has been shown to be successful in patients with aphasia who have
a semantic impairment
• Could be patients with fluent-type aphasias, but some patients
with nonfluent-type aphasias also benefit

(Boyle & Coelho, 1995; Boyle, 2004)

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video example

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Script Training
• Reminiscent of “dialogue training” in foreign language learning
• A specific dialogue or script is trained
• Based on theoretical and conceptual models in which scripts run
automatically as part of how we respond to particular contexts
• Script can be a prayer, an explanation about the client’s stroke and
aphasia, a description about a special interest – but in all cases it should
be something that will be very important to the person with aphasia, and
something that can be used across a variety of social contexts or
occasions
• Effective and has been associated with transfer and generalization of
phrases learned within a particular script to other contexts

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Script Themes in Monologues: Examples

• Stories from my life

• Story of my stroke
• Introducing myself to others
• Retelling an event or story
• Prayers or testimonials
• Making plans

(Holland, Halper, & Cherney, 2010)

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 Script Themes in Dialogues: Examples

• Conversations with family

• Seeking or providing information
• Ordering in a restaurant
• Making phone calls
• Talking about hobbies or outside interests

(Holland, Halper, & Cherney, 2010)

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 Best Practice Guidelines: Reminder
• Will the therapy you are offering your client with aphasia
• Have a meaningful impact on communication?
• Have a meaningful impact on life?
• Be culturally appropriate?
• Be personally relevant?
• Do you train communication partners so that the communication of the
person with aphasia is improved?
• Do you provide family members with information?
• Do you train family members to communicate?
• Do you ensure that the person with aphasia has a means to communicate by
discharge?

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My treatment session with Alan - 1

• 5-10 min – warm-up: review homework, review any phone or football

conversations from the last week
• 10 min “Phone-related” RET: Use picture stimuli of different people
on phone

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My treatment session with Alan - 2

• 10 min “Football-related” RET; different plays, different teams,

positions, etc.
• 10 min work on phone script
• “Hello, this is Alan.”
• “One minute, please.”
• “How are you doing?”
• “What’s new?”
• Assign practice.

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A few sessions later…

• Session(s) with spouse • Session(s) with football buddy

• Practice use of phone script with • Use supported conversation
spouse as caller training
• Use conversational coaching • Practice football conversations

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Compare treatment selection and
anticipated outcomes

Additive Model Example Integrative Model Example

Cueing for word-finding Conversation practice

+ Conversation practice + Partner training
Maybe improved word-finding? Improved conversation

Hopefully improved *twice the therapy time for target

conversation? activity*

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Alan’s treatment aims
Phone use (includes partner training)
+ Football conversations (includes partner training)
Participation in important life activities

Increased motivation
Increased persistence
Reduced social isolation
Overall better health

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Thank you!

Please contact me with questions or comments at:

Dr.jjhinckley@gmail.com

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