Aphasia Therapy Guide

There are two general categories of therapies, and most clinicians utilize both:

 Impairment-based therapies are aimed at improving language functions and consist of

procedures in which the clinician directly stimulates specific listening, speaking, reading
and writing skills.
 Communication-based (also called consequence-based) therapies are intended to
enhance communication by any means and encourage support from caregivers.  These
therapies often consist of more natural interactions involving real life communicative
challenges.

Decisions about approach depend on an individual's needs and wishes.  Therapy for a very
mild impairment is likely to differ from therapy for a very severe impairment.  Also,
therapy changes over time as the person with aphasia improves.

Impairment-based therapies

A person with aphasia initially wants to speak better and make sense of language spoken by
others.  Therefore, speech-language pathologists attempt to repair what is broken. 
Therapies focus an individual's attention on tasks that allow him or her to comprehend and
speak as successfully as possible.  A therapy session may be the only time of the day in
which the mental mechanics of language are exercised with minimal frustration.

Seemingly limited time with a therapist may be supplemented with homework and
computer programs.  Computer software has been designed to exercise word-finding,
comprehension, and real life problems such as exchanging money.  Therapy time can be
extended with professionally guided assistance from caregivers.

Clinical researchers have been developing therapies focused on specific area of language
impairment such as retrieving verbs and formulating sentence structure.  One example of
experimental  treatment includes the use of a virtual therapist speaking from a computer
monitor.  A great deal of clinical research has gone into providing evidence for the
effectiveness of impairment-based therapies.

Communication-based therapies

Although someone with aphasia wants mostly to speak better, communication may still be
frustrating.  Communication oriented treatments, in part, assist the person in conveying
messages and feelings with alternative means of communicating.  This orientation is also
said to involve compensatory strategies.  In addition, an individual is encouraged to use any
remaining language ability that succeeds in conveying messages.  Therefore,
communication-based activities continue to be partly "language-based" and are likely to
incorporate impairment-based objectives simultaneously.
Rehabilitation specialists are attending to the consequences of disability for quality of life. 
Speech-language therapists are enlisting group activities to facilitate a person's participation
in daily life.  We may hear these activities referred to as social approaches or participation-
based approaches.  Methods range from providing meaningful contexts within a
rehabilitation facility to venturing outside  of such facilities.  These methods may
emphasize a return to former activities and interactions, but also there are a few centers
staffed by volunteers which effectively create a new community for people with aphasia.

Examples of Specific Therapies

There are many names for aphasia therapies.  Some represent slight variations of
fundamental procedures, and one could exaggerate by saying that there are as many
methods as there are therapists.  However, certain methods are somewhat unique and well-
known, and clinical researchers are investigating new strategies or new wrinkles for
established strategies.  The following presents a few examples of specific therapies.

Impairment-based

Contstraint-induced therapy (CIT): This therapy is modeled after a physical therapy for
paralysis in which a patient is "forced," for example, to use an impaired side of the body,
because the good side has been restricted or constrained.  In applying this principle to
communication functions, a person with aphasia may be constrained in using intact gesture
in order to direct the individual to use impaired spoken language.

A second, and perhaps more well-known, component of this treatment is that it is more
intensive than typical therapy schedules and it lasts for a relatively short duration.  For
example, the therapy may be administered for three hours daily for two weeks.  Studies of
CIT have been expanding beyond Germany and Houston, but it is not yet covered by
insurance.

Constraint-induced therapy is almost the opposite of compensatory strategies in which the

person with aphasia is encouraged to use intact abilities to communicate.  It is likely that a
therapist will employ both approaches.

Melodic Intonation Therapy (MIT): Developed by Robert Sparks in Boston, MIT is

based on an observation that that some persons with aphasia "sing it better than saying it." 
The method is a series of steps in which an individual practices an artificially melodic
production of sentences.  It has been recommended for people with an expressive type of
aphasia and good comprehension.  We are careful to watch for the individual who speaks
much better with melodic intonation but fails to carry this performance over to natural
conversation.

Tele-rehabilitation: Established procedures are provided over the Internet with web
cameras so that the therapist and person with aphasia can see and hear each other.  Not yet
widely available and not yet covered by Medicare, it is being developed by William
Connors in Pittsburgh.
Specific Communication-based methods

PACE therapy (Promoting Aphasics' Communicative Effectiveness): This procedure is

a slight variation of the basic picture-naming drill, but the adjustments introduce elements
of conversation into the interaction.  These adjustments include the person with aphasia and
the therapist taking turns conveying messages, pictures for messages hidden from the
listener, and a free choice of modalities for conveying messages.  Developed by Jeanne
Wilcox and Albyn Davis in Memphis, it appears to have been popular in Europe where
most studies have been conducted.

Conversational coaching: Developed by Audrey Holland in Arizona, this strategy aims at

increasing commuunicative confidence through the practice of scripted conversations. 
With assistance from Leora Cherney in Chicago, this method has been integrated into a
computer program.  Called "AphasiaScripts," it includes a virtual therapist to provide help
for the person with aphasia.

Supported conversation: Originated by Aura Kagan in Toronto, Canada, supported

conversation is a particular strategy for enhancing communicative confidence that is
commonly found in community support groups.  Volunteers are trained to engage in real
conversations with persons who have aphasia.  Similar therapies have been described,
called "conversation therapy" or "scaffolded conversations."

A General Comment

There are many other therapies, and most of the therapies mentioned are continually being
studied for their effectiveness.  A speech-language pathologist tailors a therapy program to
the wishes and abilities of the individual client, also considering the capacities of the
rehabilitation facility and the availability of caregiver support. 

Screening

Screening does not provide a detailed description of the severity and characteristics of
aphasia, but rather is a procedure for identifying the need for further assessment. Screening
is an invaluable tool in the appropriate referral of persons with aphasia to speech-language
pathology services and is an important first step in determining the need for treatment. It is
conducted in the language(s) used by the person, and with sensitivity to cultural and
linguistic diversity.

Screenings are completed by the SLP or other professional. Standardized and

nonstandardized methods are used to screen oral motor functions, speech production skills,
comprehension and production of spoken and written language, and cognitive aspects of
communication. Screening typically focuses on body structures/functions, but may also
address activities/participation and contextual factors affecting communication (see
International Classification of Functioning, Disability and Health [ICF] framework
proposed by the World Health Organization [WHO], 2001).
Screening may result in recommendations for rescreening; comprehensive speech,
language, swallowing, or cognitive-communication assessments; or referral for other
examinations or services.

About evidence and expert opinion

Expert Opinion

 Persons with suspected aphasia should be screened using a valid (sensitive and
specific) and reliable screening tool (National Stroke Foundation, 2010; Stroke
Foundation of New Zealand and New Zealand Guidelines Group, 2010).

See the Screening section of the aphasia evidence map for pertinent scientific evidence,
expert opinion and client/caregiver perspective.

Comprehensive Assessment

Individuals identified with aphasia through screening are referred to an SLP for a more
comprehensive assessment of language and communication.

Assessment is conducted to identify and describe

 underlying strengths and deficits related to spoken and written language that affect
communication performance
 effects of the language disorder on the individual's activities and participation in
ideal settings, everyday contexts, and employment settings
 contextual factors that serve as barriers to or facilitators of successful
communication and participation for individuals with spoken and written language
disorders
 the impact on quality of life for the individual and the impact on his or her family.

Assessment may result in

 diagnosis of a language disorder

 description of the characteristics and severity of the language disorder
 prognosis for change (in the individual or relevant contexts)
 recommendations for intervention and support
 identification of the effectiveness of intervention and supports
 referral for other assessments or services.

Prior to assessment, consider the influence of cultural and linguistic factors on the
individual's communication style and discuss the potential impact of the impairment on
quality of life and participation in daily activities with the person with aphasia, their family,
and the treatment team in order to customize the assessment. In addition, evaluate sensory
functions to identify deficits (e.g., auditory and visual acuity deficits, auditory and visual
agnosia, and visual field cuts) that can potentially impede assessment and treatment
procedures (Murray & Chapey, 2001). Also consider cognitive functions (e.g., executive
function) prior to assessment.

A comprehensive assessment is sensitive to cultural and linguistic diversity and addresses

the components within the WHO framework (see ASHA's Scope of Practice in Speech-
Language Pathology), including body structures/functions, activities/participation, and
contextual factors. Assessment should occur in the language(s) used by the person with
aphasia.

Assessment can be static (i.e., using procedures designed to describe current levels of
functioning within relevant domains) and/or dynamic (i.e., ongoing process using
hypothesis-testing procedures to identify potentially successful intervention and support
procedures). Assessment typically includes

 relevant case history, including medical status, education, occupation, and

socioeconomic, cultural, and linguistic backgrounds
 review of auditory, visual, motor, cognitive, and emotional status
 standardized and nonstandardized methods, selected with consideration of
ecological validity:
o client's report of areas of concern (listening, speaking, reading, writing),
contexts of concern (e.g., social interactions, work activities) and
language(s) used in those contexts, and goals and preferences;
o administration of standardized assessment tools and/or nonstandardized
sampling or observational methods to assess and describe the individual's
knowledge and skills in the areas of language form (phonology and
alphabetic symbols, morphology and orthographic patterns, and syntax),
content (lexicon and semantics), and use (pragmatics) across spoken and
written modalities;
o analysis of natural communication samples gathered in modalities (listening,
speaking, reading, or writing) and specific contexts (social, educational, or
vocational) identified as problematic;
o assessment of oral, speech, and motor (e.g., hemiparesis, limb apraxia,
apraxia of speech) function;
o identification of contextual barriers and facilitators and potential for
effective compensatory techniques and strategies, including the use of
augmentative and alternative communication (AAC)
 follow-up services to monitor spoken and written language status and ensure
appropriate intervention and support in individuals with identified language
disorders.

About evidence and expert opinion

Expert Opinion

 Individuals with aphasia should receive a comprehensive assessment by a

specialized clinician with expertise in aphasia (National Stroke Foundation, 2010;
 Intercollegiate Stroke Working Party, 2012; Stroke Foundation of New Zealand and
New Zealand Guidelines Group, 2010).
 The nature and extent of aphasia should be documented and discussed with the
person with aphasia and his or her family, and individual goals and a treatment plan
should be developed and reassessed at appropriate intervals (National Stroke
Foundation, 2010; Intercollegiate Stroke Working Party, 2012; Stroke Foundation
of New Zealand and New Zealand Guidelines Group, 2010; Taylor-Goh, 2005).

 Assessment areas should consider the individual's cultural background, their ability
to use strategies to compensate for communication impairments in real-life
environments, and the communication partner's ability to facilitate strategies
(Taylor-Goh, 2005).
 Assessment should consider an individual's speech production abilities in various
conditions, including narrative, conversation, and constrained conditions (e.g.,
picture description) (Taylor-Goh, 2005).

See the Comprehensive Assessment section of the aphasia evidence map for pertinent
scientific evidence, expert opinion and client/caregiver perspective.

Assessment Measures

A number of valid and reliable aphasia screening tools and comprehensive assessment
batteries are available to assist SLPs. These measures may be helpful in assessing basic
communication difficulties or may provide a more detailed description of the type and
severity of aphasia.

Comprehensive Standardized Test Battery Versus Nonstandardized Testing

Assessment of individuals with aphasia is completed in a number of ways and incorporates

a range of assessment measures. In some cases, an entire standardized test battery is
administered. In other cases, the clinician may give selected subtests from standardized test
batteries, recognizing the impact on the psychometric properties when using subtests in this
manner. This impact includes understanding that when tools are not administered according
to standardized procedures, scores cannot be reported; only subjective descriptions of a
person's functioning can be made. In other cases, nonstandardized tools developed by the
clinician are used to probe aspects of speech, language, and cognition. The decision to use
standardized or nonstandardized assessment procedures is determined by the clinician
based upon a variety of factors, including the needs of the person with aphasia, the
complexity of impairment, payer rules, facility policy, and other considerations.

About evidence and expert opinion

Expert Opinion

 The speech and language evaluation may incorporate a range of assessment

measures including the use of formal and informal measures (Taylor-Goh, 2005).
  Conversation analysis should be considered to assess the conversation/interaction
patterns of the individual with aphasia with their caregiver (Taylor-Goh, 2005).

See the Assessment Measures section of the aphasia evidence map for pertinent scientific
evidence, expert opinion and client/caregiver perspective.
Aphasia treatment is individualized to address the specific areas of need identified during
assessment as well as the specific goals identified by the person with aphasia and his or her
family. Additionally, treatment occurs in the language(s) used by the person with aphasia
either by a bilingual SLP or with the use of trained interpreters, when necessary. In general,
the aim of aphasia treatment includes

 restoring language abilities by addressing all impaired communication modalities

and focusing on training in those areas in which a person makes errors
 strengthening intact modalities and behaviors to support and augment
communication
 compensating for language impairments by teaching strategies and by incorporating
augmentative and alternative methods of communication if they help to improve
communication
 training family and caregivers to effectively communicate with persons with aphasia
using communication supports and strategies, in order to maximize communication
competence
 facilitating generalization of skills and strategies in all communicative contexts
 educating persons with aphasia, their families, caregivers, and other significant
persons about the nature of spoken and/or written language disorders, the course of
treatment, and prognosis for recovery.

About evidence and expert opinion

Evidence Highlights

 Evidence indicates that speech and language treatment is effective in improving

functional communication, as well as receptive and expressive language skills in
individuals with stroke-induced aphasia (Brady, Kelly, Godwin, & Enderby, 2012).

Expert Opinion

 Individuals with aphasia should receive treatment and periodic assessments as long
as there are identifiable objectives and measurable progress (Scottish Intercollegiate
Guidelines Network, 2010; Catalan Agency for Health Technology Assessment and
Research, 2007; Management of Stroke Rehabilitation Working Group, 2010).

See the Treatment:  General Findings section of the aphasia evidence map for pertinent
scientific evidence, expert opinion and client/caregiver perspective.

Because of the complexity and nature of aphasia, and based on the individual's language
profile and values, interventions vary. There are many ways to organize treatment options,
including by aphasia type or by primary signs and symptoms. However, since most
individuals with aphasia present with a variety of communication deficits and bring
different backgrounds and unique needs to the treatment situation, treatments here are
organized using the framework proposed in the WHO's ICF framework (2001).

This framework considers two overarching components: health conditions and contextual
factors. The health conditions component is most relevant to the treatment descriptions
below, while the contextual factors must be considered for all patients throughout the
treatment process. Health conditions include body functions and structures and activity and
participation.

Copyright 2008 by Aphasia Institute. Adapted with permission.

In the section below, some of the aphasia treatments described directly address body
function impairments (e.g., difficulty formulating syntactically correct sentences, finding
words, comprehending words or sentences), while others focus on communication activity
and participation (e.g., working directly on functional tasks or situations in everyday
activities such as answering the phone, completing paperwork, or ordering food).
Regardless of the approach used, the ultimate goal of aphasia treatment is to maximize the
individual's quality of life and communication success, using whichever approach or
combination of approaches meets the needs and values of that individual.

The following are brief descriptions of both general and specific treatments for persons
with aphasia. It is important to note that while the interventions below are categorized by a
specific ICF domain (e.g., impairment-based treatment), the outcomes of treatment may
extend across domains (Simmons-Mackie & Kagan, 2007). Where available, links to
evidence and expert opinion regarding the intervention are provided. This list is not
exhaustive nor does inclusion of any specific treatment approach imply endorsement from
ASHA.

Language Impairment-Based Treatment

A treatment approach that addresses all communication modalities (spoken, written, and
gestures) and focuses on training those areas in which a person makes errors.

About evidence and expert opinion

Evidence Highlights

Evidence indicates

 task-specific semantic therapy and task-specific phonological therapy improves

semantic and phonological language activities, respectively, in aphasia (Teasell,
Foley, & Salter, 2011)
 cognitive linguistic treatment with both semantic and phonological elements may
improve semantic and letter fluency (Teasell et al., 2011).

Expert Opinion

 For individuals with expressive language difficulties, treatment may include tasks
involving semantic processing (e.g., semantic cueing, semantic judgments,
categorization and word-to-picture matching) (Taylor-Goh, 2005).
 Intervention should include tasks that focus on spoken output or accessing
phonological word forms such as phonemic cueing, cueing spoken output with
written letters, repetition, rhyme judgment, and reading aloud (Taylor-Goh, 2005).

See the Language-Oriented Therapy ection of the aphasia evidence map for pertinent
scientific evidence, expert opinion and client/caregiver perspective.

Computer-Based Treatment

Treatment involving the use of software programs targeting various language modalities.

About evidence and expert opinion

Evidence Highlights

 Evidence indicates computer-based aphasia treatment can improve language skills

at the impairment level and generalize to functional communication (Teasell et al.,
2011).
See the Computer-Based Treatment section of the aphasia evidence map for pertinent
scientific evidence, expert opinion and client/caregiver perspective.

Constraint Induced Language Therapy (CILT)

Intensive treatment approach focused on increasing verbal output. In contrast to many other
approaches, CILT discourages the use of compensatory communication strategies, such as
gestures or writing.

About evidence and expert opinion

Evidence Highlights

Evidence indicates

 the use of CILT is recommended for individuals with aphasia (National Stroke
Foundation, 2010; ).
 CILT is specifically beneficial for Stroke Foundation of Stroke Foundation of New
Zealand and New Zealand Guidelines Group, 2010
 individuals with stroke-induced aphasia, although results are considered preliminary
(Cherney, Patterson, Raymer, Frymark, & Schooling, 2010)
 individuals with chronic aphasia, with evidence indicating improved language
function and everyday communication over a short period of time (Teasell et al.,
2011).

See the CILT section of the aphasia evidence map for pertinent scientific evidence, expert
opinion and client/caregiver perspective.

Melodic Intonation Therapy (MIT)

Treatment using intonation patterns (melody, rhythm, and stress) to increase the length of
phrases and sentences. Reliance on intonation is gradually decreased over time. MIT targets
improvement in spoken language expression.

About evidence and expert opinion

Evidence Highlights

 Evidence indicates that MIT may be beneficial for individuals with aphasia
(Hurkmans et al., 2012).

See the Melodic Intonation Therapy section of the aphasia evidence map for pertinent
scientific evidence, expert opinion and client/caregiver perspective.

Reading Treatment
Treatment designed to improve decoding and comprehension of written language.

About evidence and expert opinion

Expert Opinion

 For individuals with reading impairments, treatment should focus on training the
impaired component or incorporating strategies to compensate for impairment (e.g.,
semantic approach, improving speed and efficiency of letter identification) (Taylor-
Goh, 2005).

See the Reading Treatment section of the aphasia evidence map for pertinent scientific
evidence, expert opinion and client/caregiver perspective.

Syntax Treatment

Treatments designed to improve the grammatical structure of utterances, including

Treatment of Underlying Forms

An approach, grounded in linguistic theory, designed to improve sentence production for

people with agrammatism that starts with training more complex sentence structures.

Verb Network Strengthening Treatment

A verb treatment approach designed to improve word retrieval in simple active sentences.
Verbs are trained with pairs of related nouns to improve sentence production.

Chaining (Forward and Reverse)—an approach that breaks tasks/words/sentences into

small parts and teaches the beginning (or end) part first.

Sentence Production Program for Aphasia—a prescribed treatment program designed to aid
the production of specific sentence types.

Word Finding Treatment

Treatments designed to improve word finding in spontaneous utterances, including

Word Retrieval Cueing Strategies (semantic and cueing verbs)—an approach that provides
additional information, such as the beginning sound of a word or contextual cues, to prompt
word recall.

Gestural Facilitation of Naming—an approach that uses gestural interventions to facilitate

verbalization.
Response Elaboration Training—a treatment approach designed to improve word finding
and increase the number of content words used by a person with aphasia. The clinician
elaborates on the person with aphasia's utterances to improve conversational abilities.

Semantic Feature Analysis Treatment—a word retrieval treatment where the person with
aphasia identies important semantic features of a target word (e.g., building, books, quiet
for "library"); this is thought to activate the semantic network and possibly aid in retrieval
of nontargeted but related words.

About evidence and expert opinion

Evidence Highlights

 Evidence indicates that phonological and semantic cueing strategies improve

naming accuracy and word retrieval skills (Teasell et al., 2011).

See the Word Finding Treatment section of the aphasia evidence map for pertinent
scientific evidence, expert opinion and client/caregiver perspective.

Writing Treatment

An intervention designed to improve expression via written language.

About evidence and expert opinion

Evidence Highlights

 Evidence indicates that writing treatment in a group setting is less beneficial

compared to individual treatment (Teasell et al., 2011).

Expert Opinion

 For individuals with writing impairments, treatment should focus on the impaired
component or incorporating strategies to compensate for impairment such as
grapheme-to-phoneme training, use of anagrams, pictorial or first letters cues, or
oral spelling (Taylor-Goh, 2005).

See the Writing Treatment section of the aphasia evidence map for pertinent scientific
evidence, expert opinion and client/caregiver perspective.

Activities/Participation-Based Treatment

Multimodal Treatment

Treatment approaches focusing on the use of effective and efficient communication

strategies via nonverbal and alternative means, including
Augmentative and Alternative Communication (AAC)—treatment involving the use of
augmentative aids, such as picture and symbol communication boards and electronic
devices, to help individuals with aphasia express themselves.

Visual Action Therapy—treatment used with individuals with global aphasia. This
nonvocal approach trains persons with aphasia to use hand gestures to indicate specific
items.

Promoting Aphasics' Communication Effectiveness (PACE)—treatment designed to

improve conversational skills using any modality to communicate messages. Both the
person with aphasia and the clinician take turns as message sender or receiver, promoting
active participation from the person with aphasia.

Oral Reading for Language in Aphasia (ORLA)—treatment using auditory, visual, and
written cues to assist the person with aphasia in reading sentences aloud.

About evidence and expert opinion

Expert Opinion

 For individuals with aphasia, the use of alternate means of communication (e.g.,
AAC, gestures, drawing) should be considered (National Stroke Foundation, 2010;
Stroke Foundation of New Zealand and New Zealand Guidelines Group, 2010;
Taylor-Goh, 2005; Catalan Agency for Health Technology Assessment and
Research , 2007).
 Spared language capacities should be considered to improve communication
effectiveness. This includes the use of writing to bypass spoken production and the
use of spoken output to compensate for writing difficulties (Taylor-Goh, 2005).

See the Multimodal Treatment section of the aphasia evidence map for pertinent scientific
evidence, expert opinion and client/caregiver perspective.

Partner Approaches

Treatment approaches engaging communication partners to facilitate improved

communication in persons with aphasia, including

Conversational Coaching—treatment designed to improve communication between the

person with aphasia and primary communication partners. The SLP serves as the "coach"
for both partners.

Supported Communication Intervention (SCI)—an approach to aphasia rehabilitation that

emphasizes the need for multimodal communication, partner training, and opportunities for
social interaction. The three essential elements of SCI are incorporating augmentative and
alternative communication, training communication partners, and promoting social
communication, including participation in an aphasia group.
Social and Life Participation Effectiveness—an approach that focuses on the real-life goals
of the person with aphasia, considering what the person can do with and without support.
Intervention may also focus on others affected by aphasia, such as family members. Learn
more.

About evidence and expert opinion

Evidence Highlights

Evidence indicates

 supported conversation for adults with aphasia (SCA) can enhance conversational
skills and increase social participation for individuals with aphasia (Teasell et al.,
2011).
 Conversation partner training can improve communication activities/participation
for individuals with chronic aphasia, with improvements maintained over time
(Simmons-Mackie, Raymer, Armstrong, Holland, & Cherney, 2010).

Expert Opinion

 Conversation partner training should address environmental barriers of individuals

with aphasia and promote access and inclusion through aphasia-friendly formats and
other environmental adaptions (National Stroke Foundation, 2010; Stroke
Foundation of New Zealand and New Zealand Guidelines Group, 2010).
 Treatment should focus on training the conversation partner on verbal and
nonverbal strategies to improve communication interactions and functional
communication abilities of individuals with aphasia (Taylor-Goh, 2005).

See the Conversation Partner Training Approaches section of the aphasia evidence map for
pertinent scientific evidence, expert opinion and client/caregiver perspective.

Pragmatic Treatment

Treatment designed to address social communication deficits, such as appropriate word

choice, nonverbal communication, and understanding the rules of conversation.

Reciprocal Scaffolding

Treatment approach in which communication skills are addressed in natural, relevant

situations where the person with aphasia takes on the role of instructor to "novices" during
conversations about topics of interest to the person with aphasia. The relationship allows
both parties to demonstrate and reinforce communication strategies.

Script Training
Treatment approach in which the clinician and person with aphasia construct a monologue
or dialogue that is practiced intensely so that the person with aphasia can communicate
about a topic of interest to them.

Service Delivery

In addition to determining the type of speech and language treatment that is optimal for the
person with aphasia, consider other service delivery variables that may have an impact on
treatment outcomes such as format, provider, dosage, and timing.

See the Service Delivery section of the aphasia evidence map for pertinent scientific
evidence, expert opinion and client/caregiver perspective.

Format

Format refers to the structure of the treatment session (e.g., group vs. individual) provided
to the person with aphasia.

About evidence and expert opinion

Evidence Highlights

 Evidence indicates that participation in group therapy may result in communicative

and linguistic improvements for individuals with chronic aphasia (Teasell et al.,
2011).

Expert Opinion

 In addition to receiving individual speech and language treatment, individuals with

aphasia should have the opportunity to participate in group treatment (National
Stroke Foundation, 2010; Stroke Foundation of New Zealand and New Zealand
Guidelines Group, 2010; Taylor-Goh, 2005; Catalan Agency for Health Technology
Assessment and Research , 2007).
 For individuals with chronic aphasia, group treatment should be recommended for
longer durations (National Stroke Foundation, 2010;  Stroke Foundation of New
Zealand and New Zealand Guidelines Group, 2010).

See the Format section of the aphasia evidence map for pertinent scientific evidence, expert
opinion and client/caregiver perspective.

Provider

Provider refers to the person providing the treatment (e.g., SLP, trained volunteer,
caregiver).

About evidence and expert opinion

Evidence Highlights

Evidence indicates that volunteers can serve as an effective adjunct to aphasia treatment for
speech and language, provided that the volunteers are trained by a qualified professional
and given access to relevant therapy materials and a therapeutic intervention plan
developed by or under the direction of the professional therapist (Brady et al., 2012; Teasell
et al., 2011).

Expert Opinion

 SLPs should be involved in training volunteers working with individuals with

aphasia. Training should focus on increasing volunteers' understanding of aphasia
and use of communication techniques (Taylor-Goh, 2005).

See the Provider section of the aphasia evidence map for pertinent scientific evidence,
expert opinion and client/caregiver perspective.

Dosage

Dosage refers to the frequency, intensity, and duration of service.

About evidence and expert opinion

Evidence Highlights

Evidence indicates

 an advantage of intensive speech and language treatment over less intensive,

conventional speech and language therapy. Intensive treatment produced more
significant benefits than conventional speech and language therapy (Bhogal,
Teasell, & Speechley, 2003; Teasell et al., 2011).
 mixed findings in support of more intensive language treatment for individuals with
stroke-induced aphasia (Cherney et al., 2010).
 support for more-intensive treatment over less-intensive treatment for improving
language impairment outcomes for individuals with chronic aphasia. Findings
remain mixed for communication outcomes at the level of activity/participation for
individuals with chronic aphasia (Cherney, Patterson, & Raymer, 2011).

See the Dosage section of the aphasia evidence map for pertinent scientific evidence, expert
opinion and client/caregiver perspective.

Timing

Timing refers to the timing of rehabilitation relative to the onset of aphasia.

About evidence and expert opinion

Evidence Highlights

 Evidence indicates that aphasia treatment should be initiated as early as possible and
as can be tolerated (National Stroke Foundation, 2010; Stroke Foundation of New
Zealand and New Zealand Guidelines Group, 2010).

Expert Opinion

 Individuals with persistent aphasia at 6 months should be referred for further speech
and language treatment in a group or one-to-one setting (Taylor-Goh, 2005).

See the Timing section of the aphasia evidence map for pertinent scientific evidence, expert
opinion and client/caregiver perspective.

Setting

Setting refers to the location of treatment (e.g., home, community-based).

About evidence and expert opinion

Evidence Highlights

Evidence indicates

 community-based aphasia programs improve language outcomes (Teasell et al.,

2011)
 aphasia assessment delivered via telehealth is comparable to face-to-face
assessment (Teasell et al., 2011).

See the Setting section of the aphasia evidence map for pertinent scientific evidence, expert
opinion and client/caregiver perspective.

Bilingual Considerations

In addition to the service delivery variables mentioned above, it is important to consider a

person's language needs when selecting the language of intervention. Damage to the
language center of the brain in bilingual individuals may produce aphasia across languages.
Recovery of language may vary depending on the type of aphasia, how languages were
acquired-simultaneously or sequentially-and the degree of proficiency and demands for the
use of each language.

The goal of intervention might not be a full recovery of all language(s) used. For example,
consider the patient/client with severe global aphasia who spoke English at work and
Spanish at home and in the community. Return to work may not be feasible. English might
be incorporated into treatment at a minimum; however, Spanish might be the primary focus
to return the person to daily activities. It is essential to consider the linguistic demands on
the patient/client.

Questions to consider when treating bilingual individuals with aphasia include the
following:

 How many languages does the person speak?

 At what point did he or she learn English or a secondary language?
 When and with whom does he or she use each language? For example, what
language(s) are spoken at work, at home, and with family or friends?
 What is the prognosis? How will that impact language(s) that are needed to
communicate?

In addition to considering these questions, clinicians may need to consult with another
professional, such as a bilingual SLP, a cultural/language broker (a person trained to help
the clinician understand the person's cultural and linguistic background to optimize
treatment), and/or an interpreter. An SLP will need to determine the language of treatment
and its impact on cross-language generalization (i.e., improvement in the nontreated
language). The language of intervention must involve the language that the person uses in
the home. Demands for services in additional languages will depend on the person's ability
to return to premorbid levels of functioning.

About evidence and expert opinion

Evidence Highlights

 Evidence from exploratory studies indicates that aphasia treatment provided in the
secondary language (L2) yields positive results. Bilingual individuals with aphasia
receiving unilingual services in L2 demonstrated improved receptive and expressive
language outcomes. Mixed results were found for cross-linguistic transfer to the
untreated language (Faroqi-Shah, Frymark, Mullen, & Wang, 2010).

 EXPERT OPINION

 According to the Intercollegiate Stroke Work Party, individuals with aphasia whose
first language is not English should be offered treatment and assessment in their
primary language (Intercollegiate Stroke Working Party, 2012).

See the Bilingual Considerations section of the aphasia evidence map for pertinent
scientific evidence, expert opinion and client/caregiver perspective.

Legal Requirements

In the United States, Title VI of the Civil Rights Act of 1964 (Title VI of the Civil Rights
Act, 42 U.S.C §§ 2000 et seq.) ensures equal access to services regardless of language
spoken. Therefore, health care organizations are required to seek the assistance of an
interpreter for provision of service when there is not a client-clinician language match.

Executive Order 13166, issued by President Clinton on August 11, 2000, clarifies that all
federal agencies shall develop and implement a system by which persons with limited
English proficiency (LEP) can access services and shall ensure that persons with LEP have
the opportunity to provide input to federally funded agencies (Moxley, 2002). Federal
agencies that fail to meet these guidelines are at risk of facing a number of potential
consequences, including losing federal funding if they are found to be discriminatory in
practice (Limited English Proficiency, 2013).

Cultural Considerations

Views of the natural aging process and acceptance of disability vary by culture. Cultural
views and preferences may not be consistent with medical approaches typically used in the
U.S. health care system. It is essential that the clinician demonstrate sensitivity to family
wishes when sharing potential treatment recommendations and outcomes. Clinical
interactions should be approached with cultural humility.

Note: This section is under construction and will be developed in full detail based on the
work of ASHA's Cultural Competence Practice Portal team.

philosophies on Aphasia

-Some therapies have a process vs. product orientation

-Some have a programmed (clinician centered) vs. Loose (client centered) orientation
(RET)
-Some have a linguistic vs. communication focus (PACE)

Linguistic Treatment

"Treatments with a linguistic focus try to help patients successfully comprehend and
produce specific language forms to achieve language success whereas those with a
communication focus try to help patients express themselves and understand others during
conversational speech interactions to achieve communication success despite linguistic
imperfections"

Combinations in Therapy

Every aphasia therapy can be described with a combination of charcteristics

-Stimulation: process, programmed, linguistic
-MIT/VAT/SPPA: process, programmed, linguistic
-RET: process, loose, communication
-PACE: process, loose, communication
-PICA: Process, programmed, linguistics
Combination thoughts

"even then however, most therapies are implemented in less than pure form as we modify
them in accordance with our patient's needs. Further, each dichotomy (process vs product
for ex) should really be understood as a continuum, since most therapies are delivered in a
"relatively more process-oriented" way or a "relatively more product-oriented" way

PACE Therapy

Promoting Aphasic's Communicative Effectiveness

-Wilcox and Davis, 1981
"aphasia treatment approach that is both process oriented and loosely structured (client
centered) with emphasis on improving client's abilities to send and receive communicative
messages"

PACE Therapy II

Does not mean that specific linguistic structures or content words can't be targeted (shaped,
and practiced as well) within conversational activities, but it means that their production is
not the main goal of therapy

Improvement in PACE

"improvement comes when 1-a patient comprehends what another person

says/write/gestures with increasing accuracy and independence and 2-when a pt expresses
him/herself via speech/writing/gesture/drawing, etc with increasing accuracy and
independence
-comprehension and production do not have to be linguistically perfect, the goal is
successful exchange (send/receive) of messages

PACE Therapy Sequence

Sequence of Events for Production

-Message Level
-Linguistic Level
-Planning Level
-Execution Level

Message Level

Thinking
Ideation
Higher Cognition

Linguistic Level
Semantics
Syntax
Phonology
Morphology
Pragmatics

Planning Level

Allomorphs
Allophones
Allographs
Motor Planning

Execution Level

Speech
Writing
Gesture/Pantomime
Sign Language

PACE etc.

Most therapies discussed previously work to help clients translate their message into a most
complete and accurate linguistic code.
-PACE is structured to help clients translate their message into any linguistic or non
linguistic symbols that will help them to express (send) their message successfully to
communication partners

Comprehension Goals

Goal is to help patients decode any linguistic or non-linguistic symbols that will help them
to understand (receive) the meaning of another person's message.

PACE etc. cont.

Whereas most aphasia therapies focus directly on improving linguistic content and form in
order to improve communication, PACE uses relatively intact pragmatic abilities found in
most Pts with aphasia to improve communication and hopefully improve linguistic content
and form

Pragmatics in Aphasia: Linguistic Contextual Strengths

-knowledge and use of discourse macrostructures

-ability to maintain referential coherence in spite of article omissions and overuse of
pronouns
-semantic plausibility facilitates comprehension
Pragmatics in Aphasia: Paralinguistic Contextual Strengths

-Comprehension and use of prosody expressing emotion

-production of prosody in fluent aphasias
-exaggerated stress facilitates comprehension of lexical items

Pragmatics in Aphasia: Extralinguistic Contextual Strengths

-recognition of auditory and other nonverbal components of a setting

-conceptual knowledge pertaining to topic of conversation
-appropriate emotional states
-Knowledge and recognition of roles of conversational participants
-some movement including facial expression (usually unilateral in NF aphasias and
Bilateral in F aphasias)

Pragmatics in Aphasia: Conversational Strengths

-appropriate use of turn-taking

-sensitivity to conversational cooperative principle
-sensitivity to given and new information distinctions
-comprehension of speaker intentions and meaning (nonliteral interpretation, indirect
request, metaphor, etc)

Pragmatics in Aphasia: Contextual and Conversational Limitations

-occasional failure to comprehend pronoun coreference

-agrammatic omission of articles to distinguish given and new info
-incoherent semantic shifts in jargon of Wernicke's aphasia
-moderate difficulty comprehending emotional prosody in severe aphasia
-impaired comprehension of semantic and syntactic uses of prosody
-some auditory agnosia for environmental sounds in patients with severe lang
comprehension deficits
-possible disorganization of conceptual knowledge in sever aphasia
-difficulty in using symbolic movement patterns

PACE Principles

4 Principles
1. Clinician and client participate equally as senders and receivers of messages
2. Treatment interactions consist of the exchange of new information between clinician and
client.
3. Client is allowed free choice of the modality with which to send and receive messages
4. Feedback from the clinician is based on the client's success in communicating the
message successfully, much the same as natural conversation

PRAGMATIC APPROACH TO REHABILITATION OF APHASIA

 Intervention for pragmatic impairments can be potentially successful
when the clinical activities include all of the conversational functions and
rules that normally underlie communicative interactions. Generally, the most
efficient strategy for targeting pragmatic impairments in intervention involves
two simple steps.
1.     The clinician should determine situations or contexts in which the impaired
skills are normally used in a client’s daily conversations.  
2.     Similar settings should be constructed and/or made available in intervention to
approximate the same context(s).
 For example, if the person has shown impairment in the ability to request
information during a conversational breakdown, then the first step in
intervention might be to determine contexts in which most speakers provide
requests for clarification. Examples of contexts in which this skill is used
could include asking for directions to a new restaurant in town or participating
in telephone conversations with grandchildren. Once several contexts are
determined, the clinician can begin to incorporate and/or simulate these same
contexts for intervention purposes. The intervention is pragmatic not only in
the sense of incorporating the linguistic and non linguistic aspects of
communication, but also in that the activities are of functional use.
Cummings in 2007 reviewed pragmatics and adult language disorders:
past achievements and future directions. Specifically, pragmatic deficits were
examined in adults with left-hemisphere damage, often resulting in aphasia,
and in adults with right-hemisphere damage, traumatic brain injury,
schizophrenia, and neurodegenerative disorders (principally, Alzheimer's
disease). Although many pragmatic phenomena had been examined in these
clinical populations, studies had also tended to neglect important areas of
pragmatic functioning in adults with these disorders. Several such areas are
identified within a wider discussion of how researchers and clinicians can best
pursue future investigations of pragmatics in adults with language impairment.

Specific Treatment Tasks

Promoting Aphasics’ Communicative Effectiveness[PACE]

The notion of a naturalistic intervention setting served as the theoretical basis

for the intervention protocol devised by Davis and Wilcox (1985), Promoting
Aphasics’ Communicative Effectiveness (PACE). PACE was developed from
the recognition that traditional intervention techniques do not duplicate the
structure of natural conversation. With PACE the client and clinician are
focused on ideas to be conveyed rather than on the struggle for linguistic
 accuracy; divergent linguistic behavior is inherent in the interaction; and
active listening (i.e. listening for the intent of the speaker) is required by both
conversational partners. The four principles of PACE are as follows –

1.     The clinician and client participate equally as senders and receivers of
messages.
2.     There is an exchange of new information between the clinician and the client.
3.     The speaker has free choice as to which modality is used to convey a message.
4.     Feedback to the listener focuses on the adequacy of the message, that is, the
degree to which it was communicated successfully.

PACE intervention frequently centers on the process of the clinician and

client taking turns describing unknown pictures to each other. Typically, the
clinician and the client sit across from each other. A large stack of picture
cards is placed face down on the table between them. The clinician and the
client then take turns choosing a card and describing the contents. For
example, clients with problems in providing informative messages may
describe pictures of simple objects or actions.
 If a client has difficulty in providing information in a logically ordered
sequence of actions or events, the card may contain a series of pictures that
represent a simple story line or common event or procedure. The goal of the
activity is to convey adequate information to the listener. The client’s message
is judged on how well the clinician is able to understand what’s on the card
being described. As a speaker, the clinician models the type of appropriate
pragmatic behaviors that are being targeted for change in the activity. The
important feature of this intervention protocol is that the use of conversational
functions and rules is required of the client and modeled by the clinician.

ROLE PLAYING

A second useful intervention technique that can be used for pragmatic

intervention is role playing, which provides opportunities to practice
communication in situations that arise in everyday experiences, and enables
the clinician to discuss and implement possible strategies useful outside the
clinical environment. Role playing also allows for free exchange of
information between the participants, thus emphasizing the use of language in
context.

A role-playing activity typically involves three phases (Webster, 1977).

During the first phase, the clinician and the client discuss the goal of the role-
playing activity as well as possible responses and behaviors that can be used
during the activity. For example, if the goal is to initiate and maintain a topic
across several conversational turns, one possible role-play situation might be
the meeting of an old friend for the first time in several years. The clinician
and the client first discuss possible “opening lines” that the client might use as
well as possible statements or questions that can serve to continue the topic.

After the clinician and the client have discussed the situation, role
playing commences. The emphasis during this phase of role playing changes
from practice and discussion of target pragmatic behaviors to using these
skills in a “spontaneous” conversational setting. Its is essential that the
clinician retain his or her role throughout the role play so as to best represent a
situation in which the client must use the target skills. If the clinician steps out
of his or her role during this phase, he or she risks the chance of turning a
functional, communicative setting into a nonfunctional, instructional setting.

The third intervention phase follows completion of the role play. After
the role playing is completed, the clinician and the client discuss and evaluate
the adequacy of the information exchanged. This last phase is particularly
important because it enables the clinician and client to reflect on specific
communicative behaviors. Additionally, it allows the clinician to reinforce
those behaviors that contributed to the adequacy of the message conveyed,
while providing possible alternative strategies for remediating inappropriate
pragmatic skills. Although it is not a requirement, videotape playback
enhances the evaluation of these communicative behaviors that have been
targeted.

A role playing treatment approach specifically designed for use with

adults with neurogenic communication disorders is conversational coaching
(Holland, 1991). It is an interactive approach consisting of practicing
strategies in conversational simulations that were learned in treatment. The
clinician prepares a script that is meaningful and relevant to the client, and that
the client and clinician can follow. The script is just beyond the client’s
productive ability, thus encouraging use of strategies he or she has previously
practiced. First, the clinician and client practice the script and the client is
encouraged to use previously practiced strategies to convey the information.
Then, the client communicates the script to others (i.e. family members or
close friends) with the clinician coaching the client. Optimally, the coaching
sessions are videotaped for late review. To promote generalization, the script
is attempted with an unfamiliar communication partner.
 Situations for role playing are many and varied and should be guided by
the specific pragmatic goal of remediation, as well as by usefulness of the
content of the role play to the client’s everyday living. Role playing may be
useful in developing several pragmatic skills including making ambiguous
messages understood, producing different speech acts, and practicing
appropriate eye gaze and proximity. The main point is that role playing is a
viable activity, not only for encouraging spontaneous communication, but also
for providing a means of discussing and building pragmatic skills for effective
communication.

BARRIER ACTIVITIES

The principles underlying PACE also can be easily be incorporated into

other types of intervention activities. Originally devised by researchers to
examine children’s ability to convey new versus old information (Glucksberg
& Krauss, 1967), barrier games are communication settings that share with the
PACE protocol the same underlying principle of creating a functional
communicative setting. These activities, as the name implies, involve placing
an opaque barrier between the clinician and the client so as to create a need for
each individual to communicate. For most barrier activities, each participant
has the same materials on his or her side of the barrier. The task usually
requires each conversational partner to take a turn describing a move or
change in the materials, and /or commanding the other partner to move the
materials. After a message is conveyed, the barrier is removed so that the two
participants may judge the effectiveness of the speaker’s message. As does
PACE, these activities stress the importance of conveying new information
adequately to a conversational partner that often continues to be ignored in
clinical intervention.

Barrier activities are general enough to use in remediation for a variety

of pragmatic impairments (Busch et al., 1988). These activities provide
numerous avenues for comprehending and producing various speech acts as
well as conversational rules that serve to maintain the communication
interaction. For example, in the manipulation of common objects on each side
of the barrier, a client practices making and understanding requests for
information, indirect requests for action, comments on actions, requests for
clarifications, and revisions of prior utterances.
Other pragmatic goals can be targeted and accomplished through
changes in the materials. For example, one commonly used barrier activity
involves giving directions from one destination to another along a simple map.
 Clinicians can use this activity to work on client’s skills in providing adequate
information to their listeners. To increase the quantity and quality of a client’s
conversational turn, a barrier activity might involve a description of the
arrangement of similarly shaped objects that vary in size and color. This type
of activity increases the need to provide more descriptive information to a
listener. Whatever the activity, the use of a barrier between the speaker and
the listener forces a conversational dialogue. These activities also remove
emphasis on his or her role as an equal partner in the communicative event.
This minimizes some of the problems inherent in a traditional didactic format.

Although most barrier activities require actual barriers to create a need

for communicating, not all such activities require a physical barrier. Because
the basic premise of the activity is to provide a reason to communicate, other
physical settings can also be used. When available, a third person can act as
the recipient of information that is known to the client and the clinician. For
example, a client and clinician could view a photo album and then relate
information about the photos to a third person who is not in visual range of the
album. In this situation, then, distance alone is the barrier. Such an approach
can be particularly useful because the clinician is free to cue the client as he or
she provides information about a topic to a “naïve” listener.

CONVERSATIONAL ANALYSIS
WHAT IS CA?
CA is a systematic procedure for the analysis of recorded, naturally occurring
talk produced in everyday human interaction. The principle aim is to discover
how participants understand and respond to one another in their turns at talk
and how such turns are organized into sequences of interaction.

A CA approach makes use of recordings of naturally occurring conversations,

which would have taken place even if they had not been recorded. There is a
preference in the study of communication disorders for video rather than audio
recording.

Principles of CA
          The methodology that underpines CA are a qualitative one, and thus its
approach to language is quite distinct from others within
aphasiology.Wilkinson summarizes the four main principles of CA as follows.
1.     Analysis is data-and participant-driven.
2.     Conversation is orderly.
3.     Sequential context is important.
4.     There is a wariness of quantification.

Principle1
Analysis is data-and participant-driven
An analysis begins with actual utterances in real contexts and is not
constrained by prior theoretical assumptions, it is a bottom up, data –driven
approach. It aims to describe and explain how the participants display their
interpretations of each others talk. Evidence about what a speakers intention
is, or whether an utterance is communicatively adequate, is sought by
observing the reaction of the other participants in the conversation. Thus, the
conversation analyst attempts to avoid putting his or her own interpretations or
judgments onto the data. This approach is different from the more “Analyst-
driven” methods prevalent in aphasiology, where the clinician is used to
making interpretations about
1.     How an aspect of language should be coded, using a theoretically driven
categorization scheme.
2.     Whether an utterance is successful or adequate in terms of communication.
Principle2
Conversation is orderly.
A Ca methodology treats conversation as the orderly and organized
product of the participant’s systematic methods of talking to and making sense
of each other on an utterance -by-utterance basis. The analysis therefore pays
attention the intricate details of conversation, focusing on features such as
pausing, overlapping, talk, eye gaze, gesture, and the repair of interactional
“trouble” in addition to addressing lexis and grammar. In this way, CA differs
from many linguistic approaches to aphasia, where features such as
overlapping talk and cut-off or recycled utterances are judged to be messy and
disorderly parts of language that will not reward scientific study and are
therefore omitted from the analysis.

Principle3
Sequential context is important
Analysis of conversation has shown that, for the participants, one of the
most important aspects of any interactional contribution is the point in the
conversation at which it occurs, that is, its sequential context. Each turn at talk
is constructed within a sequential context of prior turns and itself creates the
sequential context for upcoming turns. This contextualization is something
that recipients use as a resource for interpreting conversational contributions
and speakers use when designing turns, to make them understood by
recipients. Rather than assessing the language of conversation in terms of
words , sentences, or speech acts , conversation analysis assess how language
functions in the environment of sequentially ordered turns at talk.
Principle4
There is a wariness of quantification.
A CA methodology makes use of two main forms of analysis. One
involves the investigation of a particular phenomenon across various parts of
the data, in an attempt to uncover a pattern of occurrences within similar
sequential contexts. Another take the form of a “single” case analysis, where
the focus is the explication of conversational practices in a single extended
sequence of talk. Both use the findings of previous CA studies to illuminate
what is happening in a piece of talk.

CA AS AN INTERVENTION TOOL
CA can be applied to support the person with aphasia in talking to the
persons everyday conversational partners.CA intervention begins with the
premise that changing the conversational behavior of either partner (the
aphasic or non aphasic speaker) may provide an opportunity for change in the
conversational behavior of the other speaker.CA intervention requires the
clinician to put aside the concepts of impairment and compensatory or
functional interventions and to focus on the conversational resources and
troubles of a conversational partnership. An important aspect of intervention is
sensitively highlighting conversational patterns in a partnership to facilitate
discussion about the usefulness of these patterns for the couple and they
perceive a need to change them. The clinicians role is to provide the couple
with options for change and an environment in which to try out new
conversational patterns. The clinician, aphasic speaker, and partner work
together to facilitate the couple in developing new methods of talking that
work for them.
This type of intervention for people with aphasia is still developing.CA
has been used to provide individualized advice to people (family members and
formal careers) interacting with the aphasic person, either verbally or in the
form of booklets, and to deliver CA-based intervention in a group setting.

In 1998 Luise Springer, Nick Miller and Frauke Burk did a cross
language analysis of conversation in a trilingual speaker with aphasia to
explore the relationships between formal and functional language
performance. Free conversations and semi structures interviews were video
recorded, transcribed and analyzed for nature of breakdowns, sources of
trouble, properties of self repairs, resolution patterns, code switching,
circumlocution, MLU etc.With this analysis we view communication
 functionally and can pin point where the errors are taking place, how and why.
The possible reasons for divergence across settings and languages can also be
studies.

WORKING WITH COUPLES-SOLUTION FOCUSED APHASIA

THERAPY(SFAT)
The principles of SFT are (Walter & Peller 1992) are:
1.     Determine what the client wants,
2.     Look for what is working and do more of that and
3.     Identify what is not working and do something different.
Exceptions to problems are emphasized rather than persueing the “cause”
(Berg&Miller 1992).
 SFAT
          SFAT abides by the following criteria for social approaches (Simmons-
Mackie &Damico 1995, 1996).
1.     Conversation is the focus, rather than discrete linguistic units.
2.     Social interaction and information exchange are both worthy goals for
therapy.
3.     Address communication within authentic , relevant, natural contexts
4.     View communication as a dynamic, flexible, multidimensional activity.
5.     The collaborative nature of communication is the focal point, rather the
individual with aphasia.
6.     Focus on the social and personal consequences of aphasia,
7.     Focus on adaptations to impairment.

PACE (Promoting Aphasic's Communicative Effectiveness):

This is one of the best-known forms of pragmatic therapy, a form of aphasia therapy that
promotes improvements in communication by using conversation as a tool for learning. PACE
therapy sessions typically involve an enacted conversation between the therapist and the patient.
In order to stimulate spontaneous communication, this type of therapy uses drawings, pictures,
and other visually-stimulating items which are used by the patient to generate ideas to be
communicated during the conversation. The therapist and the patient take turns to convey their
ideas.

The difficulty of the materials used to generate conversation is increased in a gradual

fashion. Patients are encouraged to use any means of communication during the session,
which allows the therapist to discover communication skills that should be reinforced in the
patient. The therapist communicates with the patient by imitating the means of
communication with which the patient feels most comfortable.