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Therapeutic Outcomes for RET and How They are Achieved

Hannah Searls

Marshall University
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Therapeutic Outcomes for RET and How They are Achieved

Effective communication relies heavily on the ability to retrieve words. When expressing

our thoughts, we unconsciously retrieve words from our lexicon (mental dictionary) to say what

we need to say. Although this may appear to be a simple process, word retrieval can be difficult

for individuals who experience non-fluent aphasia or fluent aphasia. According to Rohrer,

Knight, Warren, et al. (2008), people who have fluent or non-fluent aphasia, such as Broca’s

aphasia, Wernicke’s aphasia, transcortical motor aphasia, transcortical sensory aphasia, and

conduction aphasia have the potential of developing word finding deficits. To assist with such

deficits, several word finding strategies, including Gestural Facilitation of Naming (GES),

Response Elaboration Training (RET) and cueing strategies have been established. This paper

will focus specifically on RET and will attempt to answer the question, “What therapeutic

outcomes are associated with the use of RET and how are they achieved?”

RET is a word finding strategy that is intended to regain a client’s flexible and creative

use of language. It is common for people with various types of aphasia to use only nouns, single

words and/or short phrases when communicating. RET attempts to increase an individual’s

variety of words and phrases by utilizing a loosely structured treatment protocol. Instead of

trying to elicit a specific response or grammatical form, RET focuses on the amount and type of

information that is being conveyed to the listener (Roth & Worthington, 2016).

Since its appearance in the late 1900’s, RET has shown positive results in increasing the

number of content words in people with aphasia. Kearns (1985), the developer of RET,

conducted a single subject study to examine the effectiveness and generality of RET in people

with chronic Broca’s aphasia. The participant was a 50-year-old man approximately three years

post onset of aphasia secondary to a left cerebral vascular attack (CVA). The participant was
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presented with 30 picture cards, divided into three sets of 10 cards each, that depicted transitive

and intratransitive verbs. Two of the sets were utilized as training items while the third set was

used to examine generalization. After twice-weekly intervention for 12 weeks, the participant

demonstrated improvements in the overall number of content words produced. When presented

with the first set of picture cards, the participant increased his amount of content words from one

to two responses to five or more, while eliciting more than five responses during the second set.

Additionally, during the third set, the participant demonstrated approximately 50% of

generalization for untrained items. These results suggest that RET is beneficial for increasing the

amount of content words used and shows promising results for generalization.

Since Kearns initial study, several modern studies have been conducted to evaluate the

effects of RET. For example, a selective meta-analysis conducted by Husak and Marshall (2013)

evaluated the effect size of an increase in content words by examining 12 individual research

studies, resulting in a total of 30 participants with various degrees and types of aphasia. All

evaluated studies followed a similar protocol to Kearns, including two training sets and one

generalization set. Out of the 30 participants, positive effects were virtually seen in all

participants with severe non-fluent aphasia. Larger effect sizes were noted in participants with

severe fluent aphasia for both trained (two training sets) and untrained (generalization set) items.

The results of this metanalysis concluded that RET provides promising positive effects in

increasing the total number of content words for individuals with various types of aphasia.

Around 15 years after RET was established, Wambaugh and Martinez (2000) modified

the approach to account for typical co-occurring apraxia of speech (AOS). Researchers suggested

that the traditional approach did not consider that many individuals with aphasia also experience

sensorimotor speech difficulties. To accommodate for these issues, researchers included

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additional opportunities for clinician modeling, options for providing integral stimulation, and

incorporated repeated practice and delayed production of elaborated utterances to promote motor

learning.

After an establishment of M-RET, Wambaugh and Martinez (2000) conducted a study to

determine the effects of the newly revised treatment. Individuals with Broca’s aphasia and

moderate to severe AOS took part in a multiple baseline design across behaviors study. The

format of treatment was similar to Kearns initial study as there were two training sets and one

generalization set; however, the previous discussed modifications were made. Researchers

focused on examining informativeness and efficacy in participation by utilizing the Correct

Information Unit (CIU) analysis. According to Oelschlaenger and Thorne (1999), CIU

determines the degree in which a person’s speech conveys the intended message and the rate at

which the message is produced. The results of the study indicated that two participants

demonstrated large gains in the production of CIU, while one participant only displayed a

modest increase (Wambaugh & Martinez, 2000).

Using RET to promote an increase in the total number of content words for people with

aphasia can essentially impact how they participate in daily activities. Papathanasiou and

Coppens (2017) describes activities as tasks or actions involving four language modalities:

listening, speaking reading, and writing – along with daily functional communication tasks, such

as conversation with family members and friends or writing an email. Many individuals with

word finding difficulties display challenges in participating in daily activities. Things such as

having an intimate conversation with their partner at dinner or even describing their symptoms to

their physicians becomes difficult. Through the use of models and opportunities to practice
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elaborating utterances, RET can increase a patient’s ability to successfully communicate his/her

thoughts, leading to an increase in activity participation.

An enhancement in the participation of daily activities has the potential to increase a

patient’s social network. According to Northcott, Marshall, and Hilari (2016), many factors exist

in predicting strong social networks following a stroke. Within their study, 87 participants with

various severities of expressive aphasia and mild to moderate expressive aphasia were evaluated.

The result of the study concluded that there are several factors affecting a patient’s social

network with one of the most relevant being fewer activity limitations. Researchers reported that

participants who experienced a decline in activity participation post-stroke reported a weaker

social network. Since word finding difficulties pose a potential for a decrease in activity

participation, many patients with aphasia may exhibit weak social networks. However, utilizing

RET in therapy can allow patients to say more of what they want to say, leading to a potential

increase in activity participation and social networking.

Although the utilization of RET in therapy can result in the discussed therapeutic effects,

it is important to note that not all patients will experience the same effects. The type of aphasia,

severity of aphasia, personal factors, and environmental factors all play a role in treatment

outcomes. For example, an individual with no support system may not see as strong of results as

someone who has a strong support system. Additionally, as seen in the previously discussed

study by Husak and Marshall (2013), a patient with severe fluent aphasia may display greater

results than one with severe non-fluent aphasia. In addition to different factors affecting

treatment, it is important to note that RET alone may not always result in positive therapeutic

effects. Beneficial therapy often involves more than one strategy. An increase in activity

participation and social networking is likely to occur when more than one strategy is used.
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In order to achieve the discussed therapeutic effects, a patient must first retrieve words

from his/her lexicon (mental dictionary). According to Papathanasiou and Coppens (2017), this

is achieved by the creation of concepts through sensory input, such as looking at a stimulus

picture. This input causes an activation of the semantic features of several words. The patient

must then select words in his/her lexicon that is associated with the semantic features of each

concept. This semantic activation contacts other words that overlap in meaning with each target

word, requiring a correct selection of target words. Once the patient selects his/her target words,

phonological encoding occurs which requires a correct selection of phonemes to form the word.

One the patient achieves the above steps and describes the picture (often through nouns and/or

short phrases), the clinician provides a model to expand or elaborate the response. The clinician

will also ask a wh- question to further prompt the patient for word retrieval. After the patient’s

response, the clinician reiterates what the patient says and adds any additional information. The

patient is then instructed to repeat the model to reinforce the expanded utterance. Finally, the

clinician repeats the utterance to provide a final reinforcement. This process is repeated with

various stimuli to promote elaboration of spoken utterances.

In conclusion, positive therapeutic effects have been reported with RET. Based on

literature reviews, RET has shown positive results in increasing the total number of content

words in people with various types of aphasia. Additionally, M-RET has demonstrated positive

results in increasing informativeness, the degree in which a person’s speech conveys the intended

message, and efficacy, the rate at which the message is produced for those with co-occurring

AOS. Increasing these areas can also improve participation in daily activities, potentially leading

to an enhancement of positive social networking. To achieve these effects, the patient must pull
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words from his/her lexicon and must practice elaborating their utterances. Overall, past and

modern literature has shown promising results in the use of RET for word retrieval therapy.
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References

Husak, R. S. & Marshall, R. C. (2013). Assessing responsiveness to RET by individuals with

chronic non-fluent aphasia: A clinical perspective. [Clinical Aphasiology Paper].

Kearns, K. P. (1985). Response elaboration training for patient initiated utterances. Clinical

Aphasiology, 15, 196-204.

Northcott, S., Marshall, J., & Hilari, K. (2016). What factors predict who will have a strong

social network following a stroke? Journal of Speech, Language, and Hearing Research,

59(4), 772-783.

Oelschlaeger, M. L., & Thorne, J. C. (1999). Application of the correct information unit analysis

to the naturally occurring conversation of a person with aphasia. Journal of Speech,

Language, and Hearing Research, 42(3), 636-648.

Papathanasiou, I. & Coppens, P. (2017). Aphasia and related neurogenic communication

disorders (2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Rohrer, J. D., Knight, W. D., Warren, J. E., Fox, N. C., Rossor, M. N., & Warren, J. D. (2008).

Word-finding difficulty: A clinical analysis of the progressive aphasias. Brain, 131(1), 8-

38. doi:10.1093/brain/awm251

Roth, F. P. & Worthington, C. K. (2016). Treatment resource manual for speech-language

pathology (5th ed). Clifton Park, NY: Centage Learning.

Wambaugh, J. L., & Martinez, A. L. (2000). Effects of modified response elaboration training

with apraxic and aphasic speakers. Aphasiology, 14(5-6), 603-617.