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Tuesday, August 4, 2009

Second in a series of free, innovative treatment protocols

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Free Treatment Protocol:  Say What You Mean-Speech Acts
Second in a series of newsletters devoted to presenting innovative treatment techniques based in evidence, clinical experience, patient needs, and commonsense.
Conversation.  People with  aphasia (PWA) want to converse. They want to read stories to their grandchildren; they want to chat about politics and sports over coffee with friends.  Moreover, they want to converse independently, generating their own linguistic propositions. Results of focus group interviews conducted by us over the past 20+ yearsindicate that 85% of PWA consider the loss of conversational abilities to be the most devastating of stroke effects. Linda Albright and colleagues offered that conversation depends upon the speaker making, “… specific statements that are intended to accomplish some particular social action (e.g., to praise, criticize or sympathize)” and for the listener to, “… consensually perceive the intentions of each other’s messages.” ( .  Effective normal conversation,according to Mary Jo Asmus at Aspire Collaborative Services, LLC, involves,“…examining your intent before starting the conversation.” ( )
Although we have known about the significance and importance of intent in conversation for more than 30 years thanks to Albyn Davis and Jeannie Wilcox ( ), there seems to be scant literature that specifically and effectively addresses this conversationally decisive mental operation in aphasia rehabilitation.  PWA need assistance in being able to mentally focus on athought, ACTIVATE AN INTENT, select lexical items, prosodic features and syntactic structure based on that intent, and then, move that information forward mentally in order to autonomously generate a proposition.  Given what we know about the detrimental effects of learned non-use, we need to help PWA aggressively engage in lots and lots of practice that facilitates these mental processes and reconnects the normal pathways and brain circuits ( see: ). 
In this issue, we present one of our treatment protocols that focuses on the patient formulating sentences based on specific intents in as independent a manner as possible.  The focus inon the patient’s understanding of the mental process ( metaphasia ); independent thought, and correlated word and syntax selection.  Speech/language pathologists and practice coaches can address prosodic features (intonation, rhythm) and incorporation into conversational contexts once the patient speaks and/or writes the sentence.  Remember the key is to have the patient doing the thinking. 

Protocol – Self-help exercise guideline:  Say What You Mean-Speech Acts – 1.35 
Use the Speech Acts Associated Words Materials and the stimuli on the Aphasia Sight Reader with this protocol. This activity may seem daunting at first but it actually consists of talking activities that we all do everyday in our conversations. The goal is for the person with aphasia to begin to reconnect the vocabulary to say sentences that do things like: request; thank; ask; command, etc.
Easy Step-By-Step Directions:
  1. Make eye contact with the patient and say the topic or big idea, “Wash the dishes.”
  2. The patient repeats the original big idea several times to place it clearly in his/her working memory, (“Wash the dishes.”)
  3. Present to the patient a word or phrase that offers an intent, “Request. Think about making a request to wash the dishes.”  
  4. Tell the patient to mentally select a word or short phrase ( lemmas ) to make such a request.
  5. Tell the patient to mentally organize a short sentence using those words to make a request to wash the dishes.
  6. Tell the patient to say the sentence, (“Please wash the dishes” for example).
  7. Type or have the patient type the sentence (“Please wash the dishes” for example) for mulit-modality practice.
  8. The patient again repeats the original big idea several times to place it clearly in his/her working memory, (“Wash the dishes.”)
  9. Repeat 3-8 above for additional, various intents.
The Aphasia Sight Reader is especially well-suited for this exercise as it presents varies topic and intent stimuli, provides the opportunity to type/record responses, summarizes for record keeping and later practice, and is easily sent to another (SLP or coach) vie email.
Be prepared to assist the patient as needed particularly in providing words/verbs that relate to the intent. 
ü  How to make this activity a little easier:  Provide and practice in print or  verbally  ‘intent words’ separate from the sentence drill; there are thousands of words related to speech acts (see:   Use more common intent words at first.  
ü  How to make this activity a little harder: Increase patient independence.  Have the patient practice with various coaches/others. 
ü  How to expand this activity:  Combine with Conversational Perfection Practice protocol.
ü  How to get extra practice for this activity:  Use the Sentence list for Speech Acts on our Aphasia Sight Reader Software Program. 
Horizontal Tweaking and Vertical Stepping are simply more advanced ways to expand the basic activities or tomake them easier or harder.  Effective use of the basic procedures above and the advanced ideas below will expand and grow the activities as the patient makes progress and will help to avoid patient plateau. 
Horizontal Tweaking for this protocol – exercise activity:  Drill individual word/verb selection for various intents; expand into less typical intents; adjust for individual patient issues (perseveration;initiation); drill in cumulative cyclical manner;  work within basic speech act types such as those proposed by David Crytal in his book, How LanguageWorks : Representatives [ affirm; believe; conclude;]; Directives [command; insist; request ] ; Commissives [promise; pledge; vow ]; Expressives [apologize; thank; welcome; congratulate ] ; Declarations [ I resign; I baptize; War is declared 1] ;  
Vertical Stepping for this protocol – exercise activity:  Advance to Social Engagement activates; advance through sentence pattern types from less to more difficult for the individual patient; conjugate or vary tense; vary subject;
Behavioral Objective for this protocol – exercise activity: The patient will self-generate verbally (say aloud) a fluently produced sentence given an intent by the coach/speech therapist that includes a real-life interaction on a topic/idea with       % accuracy over      sessions. 
Targeted Mental Processes for this protocol – exercise activity: Lemma and lexeme activation; lexical to semantic area interaction; task focus to task shift; verbal working memory; turn taking; truly listening;anchoring; sentence generation; complexity training; pragmatics; 
This protocol is part of the Simply Smart Aphasia Therapy program.
To learn how to make optimal use of this protocol, call 724.494.2534 or email  
1 Crystal, David, 2006, How Language Works, The OverlookPress, New York
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