The use of nonverbal communication and the counselling of significant others as contributing to the functional communication abilities of people with severe aphasia

Pirkko Rautakoski, Speech and language therapist, Assistant in logopedics,

Address: University of Helsinki, Department of Phonetics, Post Box 35,

FIN-00014 University of Helsinki, Finland

pirkko.rautakoski@helsinki.fi

Key words

Aphasia therapy, Communicative Effectiveness Index (CETI), significant others, functional communication, nonverbal and augmentative and alternative communication (AAC).

Aphasia rehabilitation

Aphasia rehabilitation has long centered on the language processes and on speaking. However in the ´80s people began to talk about functional communication and pragmatics became very important. Aphasia was not only a speech disorder anymore, but also a handicap that hindered people from participating in social interaction. Gradually the social interaction aspect has become the guiding principle in rehabilitation (Sorin-Peters & Behrmann, 1995). Recently attention has focused on the important role of the respective communication partners (Kagan 1998; Lyon et al. 1997). The interacting partners in aphasia families need assistance in acquiring new codes to use in their interaction. Some examples of these are Drawing together (Lyon 1995) and Conversational Coaching (Hopper et al. 2002).

Little attention has been focused on combining the use of nonverbal communication and augmentative and alternative communication methods (AAC) with aphasic people, and the counselling of significant others. Doing this especially in group therapy, however, is not so common. The purpose of this study was to examine the change of the functional communication abilities of people with aphasia, during and after the communication course, where they were enabled and encouraged to use nonverbal and AAC methods, and their significant others were likewise counselled to support the interaction.

Method

The Finnish Stroke and Dysphasia Federation arranges adaptation courses both for people with aphasia and for their significant others. The aim of these Communication courses is to encourage people with aphasia to actively use their remaining speech ability and to use different kinds of nonverbal and AAC methods in their interaction. The significant others are guided to support the communication of their aphasic partner. The communication courses last 8 + 4 days with a three-month break in between, where the significant others participate 2 + 4 days. The participants work in groups with speech therapists. The nonverbal and AAC methods that are used in the group conversations are drawing, writing, use of gestures and pantomime, objects, maps, calendars, pictures, wordlists etc. The purpose of this is to help the aphasic people in comprehension and in getting their own messages through.

The subjects were 53 aphasic people and one of each person’s significant others. The sample of aphasic people included 18 women and 35 men, ranging in age from 27 to 72, with a median age of 54. 38 of the subjects had infarcts, nine had haemorrhages, four had traumatic brain damage and two had tumours or intoxication. 38 of the subjects had nonfluent aphasia, five fluent aphasia, nine global aphasia and one had anarthria with mild aphasia. 19 subjects had severe aphasia (severity score 0-1 in accordance with the Boston Diagnostic Aphasia Battery), 30 had moderate aphasia (severity score 2-3) and 4 had mild aphasia (score 4).

The Finnish version (Klippi et al. 1994) of the Communicative Effectiveness Index (CETI) (Lomas et al. 1989) was used to measure the possible change in the functional communication ability of aphasic people. Both the significant others and the people with aphasia filled out the questionnaires. For the aphasic people the CETI questionnaire was revised so that the questions were directed to him/her, and pictures were added to help in the understanding of the questions. The subjects filled out the questionnaires three times: 1. before the first part of the course, 2. before the second part of the course and 3. six months after the intervention as a follow-up assessment.

The data were analysed by using one-way analyses of variance (ANOVA) to determine whether the possible changes in the CETI scores between first and second ratings and between first and third ratings were significant. To avoid the Type II error when measuring the statistical significance of the change in 16 different items of CETI, three summary variables were formed on the basis of the earlier theory and the factor analysis. The summary variables were 1. Understanding (items 3, 5, 13), 2. Conversation (items 2, 6, 7, 10, 12, 14 15, 16) and 3. Many communication methods (items 1, 4, 8, 9, 11).

Results

The trend indicated that people with aphasia estimated their functional communication ability to be a little bit better than the significant others did. This was the case especially in the first assessment (figure 1).

Figure 1. Mean CETI scores of people with aphasia and significant others

In the scores of the summary variables (Table 1) this trend is continuing, but there are two exceptions. The significant others estimated both the Understanding and (in the second estimation) the use of Many communication methods to be better than the aphasic people estimated.

TABLE 1. Mean CETI scores; Index and the summary variables

Group Significant others People with aphasia

Data collection 1. 2. 3. 1. 2. 3.

Sc. Sd Sc. Sd Sc. Sd Sc. Sd Sc. Sd Sc. Sd

CETI Index (Mean score) 42,0 16,3 46,1 14,7 50,2 16,2 49,8 14,3 47,2 15,8 52,1 13,8

Summary variable

Understanding 57,3 17,8 60,4 17,1 63,1 16,9 56,4 16,9 55,8 20,9 57,0 16,2

Conversation 29,5 16,7 35,5 18,0 39,7 19,8 42,1 18,3 40,4 17,8 44,8 16,4

Many comm. methods 52,5 19,3 54,8 14,6 58,9 17,0 58,1 17,3 52,9 17,5 61,0 16,1

Sc. = CETI score, Sd = Standard deviation,

In the estimations of the significant others ANOVA revealed a significant main effect in the CETI Index [F(2,88) = 10,33, p < .001]. The reason for this was the statistically significant differences between the first and second estimation [F(1, 44 = 6.54, p = .028] and the first and third estimation [F(1, 44) = 16,80, p = .002]. When the significance of the possible change of the scores in three summary variables was analysed with ANOVA there was a significant main effect in the Understanding score [F(2,88) = 3,99, p = .022]. The reason for this was the statistically significant difference between the first and the third estimation [F(1, 44) = 7,61, p = .016]. In the summary variable Conversation ANOVA revealed a significant main effect [F(2,88) = 10,34, p < .001]. The reason for this was the statistically significant difference between the first and second estimation [F(1, 44 = 7,87, p = .014] and between the first and third estimation [F(1, 44) = 16,61, p = .002]. In the summary variable Many communication methods ANOVA revealed a significant main effect [F(2,88) = 4,62, p = .012] and the reason was the statistically significant difference between the first and third estimation [F(1, 44 = 6,95, p = .024].

In the estimation of people with aphasia ANOVA revealed a significant main effect in the CETI Index [F(2,88) = 3,63, p = .030], but the reason for this was the statistically significant difference between the second and the third estimation, and so was not included in this analysis. From the summary variables the Many communication methods –variable was the only one where ANOVA revealed a significant main effect [F(2,88) = 5,68, p = .005], but the contrasts between different ratings were not statistically significant. The results between the subjects were independent of age, gender, type of aphasia, severity of aphasia or time post-onset.

Discussion

The reason why aphasic people rated their functional communication ability higher, at first, than the significant others did, and why the estimation decreased in the second rating, could be that, after participating in the course and acquiring experience in communicating with strangers, aphasic people became more aware of their communication problems. Despite this their estimations began to rise again after the second part of the course and the mean CETI score (Index) passed the first rate but did not reach statistical significance.

The significant others estimated that the functional communication ability of their aphasic partners became stronger through the whole intervention. Especially the aphasic people’s communication abilities in conversational situations improved. The reason for this could be either the new communication skills the aphasic people had or the better skills the significant others had in supporting the conversation, or both.

The significant others estimated the aphasic persons´ comprehension to be better than they themselves did. It could be that in natural communication situations at home the context and shared experiences help the aphasic people so much that the significant others do not notice the comprehension problems aphasic people themselves experience.

The subjects of this study were not randomly selected, but rather they were people who had themselves been active enough to send in an application to these courses. They could have been, on average, more motivated than most people in getting help for their communication situations. In spite of this we can draw careful conclusions that even a short intervention like this seems to help aphasia families in their interaction and helps the people with aphasia to participate in their social life. And the indications are that the situation continues to improve after the intervention.

References

Hopper, T., Holland, A., Rewega, M. (2002) Conversational coaching: Treatment outcomes and future directions. Aphasiology, 16, 745-761.

Kagan, A. (1998) Supported conversation for adults with aphasia: methods and resources for training conversation partners. Aphasiology, 12, 816-830.

Lomas, J. Pickard, L., Bester, S., Elbard, H., Finlayson, A. & Zoghaib, C. (1989) The Communicative Effectiveness Index. Development and psychometric evaluation of a functional communicative measure for adult aphasia. Journal of Speech and Hearing Disorders, 54, 113-124.

Lyon. J. G. (1995) Communicative drawing: an augmentative mode of interaction. Aphasiology, 9, 84-94.

Lyon, J. G., Cariski, D., Keisler, L., Rosenbek, J., Levine, R., Kumpula, J., Ryff, C., Coyne, S., Blanc, M. (1997) Communication Partners: enhancing participation in life and communication for adults with aphasia in natural settings. Aphasiology, 7, 693-708.

Sorin-Peters, R. & Behrmann, M. (1995) Change in perception of communication abilities of aphasic patients and their families. Aphasiology, 6, 565-575.

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