the implementation of a learner-centred conversation training...

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The implementation of a learner-centred conversation trainingprogramme for spouses of adults withaphasia in a community settingRiva Sorin-Petersa & Ruth Pattersonb

a Private Practice, Speech-Language Pathology, Toronto,Canadab March of Dimes Canada, York-Durham Aphasia Programs,Richmond Hill, CanadaPublished online: 17 Mar 2014.

To cite this article: Riva Sorin-Peters & Ruth Patterson (2014): The implementation of alearner-centred conversation training programme for spouses of adults with aphasia in acommunity setting, Aphasiology, DOI: 10.1080/02687038.2014.891094

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The implementation of a learner-centred conversationtraining programme for spouses of adults with aphasia in

a community setting

Riva Sorin-Peters1 and Ruth Patterson2

1Private Practice, Speech-Language Pathology, Toronto, Canada2March of Dimes Canada, York-Durham Aphasia Programs, Richmond Hill,Canada

Background: Conversational training programmes are increasingly being reported forpartners of people with aphasia. The approach, formats used and ways in which theseprogrammes have been evaluated vary. The literature to date provides evidence thatconversation partner training can be effective, but it remains unclear as to what specificcomponents contribute to successful outcomes. In this regard, the effectiveness of alearner-centred training programme was demonstrated in the author’s previous workwith five couples living with chronic aphasia. Results of this programme, which wasdelivered in a one-to-one format, included improvements in the quality of conversationfor the couples who participated.Aims: The aim of this study was to determine whether similar results could be obtained ifthe programmes’ original format was modified to include a combination of bothindividual and group sessions. An additional aim was to describe the content andcontribution of both the types of sessions.Methods & Procedures: Four couples living with aphasia participated in this study with acase series descriptive design. The training, delivered by a speech-language pathologist(SLP) and communicative disorders assistant (CDA), consisted of an 8-week commu-nication training programme incorporating content and adult learning strategies similarto the original programme. The modified format included four individual and fourgroup sessions. Couples were seen once a week and were encouraged to practice con-versation strategies at home.Outcomes & Results: Results were consistent with those previously reported using theone-on-one format and included an increase in spouses’ use of supportive conversationstrategies and an increase in the partner with aphasia’s participation in conversation.Couples reported improved ability to discuss more complex topics, increased positivefeelings about conversation and perceived the supportive communication strategies asbeing useful in their interactions at home. Additional positive effects were reported

Address correspondence to: Riva Sorin-Peters, Private Practice, Speech-Language Pathology, 190Winding Lane, Toronto, ON L4J 5J2, Canada. E-mail: [email protected]

The authors gratefully acknowledge the contribution of Anne Hrabi, Communicative DisordersAssistant, March of Dimes Canada, York-Durham Aphasia Programs, who helped implement the pro-gramme and speech-language pathologists Bonnie Moore and Diane Mulholland, who contributed usefulclinical information about clients that helped guide the training. We thank the administrative staff andvolunteers at the March of Dimes Canada Central Region office for their support and assistance. We alsothank the clients, families, staff and volunteers of the March of Dimes Canada, York-Durham AphasiaPrograms, who contributed to the Aphasia Awareness Walk and Roll-a-Thon fundraising campaign whichhelped fund this study, as well as the people with aphasia and their partners who participated in thisprogramme.

Aphasiology, 2014http://dx.doi.org/10.1080/02687038.2014.891094

© 2014 Taylor & Francis

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related to the group experience including the reinforcement of communication strategieslearned in training sessions as well as mutual aid and peer support.Conclusions: The use of a format incorporating both individual and group learner-centred training sessions demonstrated positive changes in attitudes and communicationbehaviours for couples in this study. The group process enhanced the value of theprogramme by promoting mutual aid and the validation of the personal experiences ofeach couple. These results have implications for SLPs’ work with couples living withaphasia in the community and demonstrate the benefits of using an adult learningapproach that includes both individual and group sessions.

Keywords: Communication; Adult learning; Training; Couples; Aphasia.

Family and couple education, training and support programmes have been used tocomplement traditional speech-language therapy (Alarcon, Hickey, Rogers, &Olswang, 1997; Boles & Lewis, 2000, 2003; Hopper, Holland, & Rewega, 2002;Johannsen-Horbach, Crone, & Wallesch, 1999; Lyon, 1998; Lyon et al., 1997;Nichols, Varchevker, & Pring, 1996; Wilkinson et al., 1998). One approach used insuch programmes is to deal with functional conversation in context, as opposed totreating language outside conversational use. These programmes support the role ofthe speech-language pathologist (SLP) in addressing the psychosocial sequelae ofaphasia and demonstrate that communicative participation for adults living withlanguage disabilities can be enhanced by skilled communication partners and appro-priate resources (Hickey, Bourgeois, & Olswang, 2004; Kagan, 2000; Simmons-Mackie, Kagan, O’Neil Christie, Huijbregts, & McEwan, 2007).

The positive results of education, training and support programmes for familiesand people living with aphasia have been well documented (Fox, Ginley, & Poulsen,2004; Sorin-Peters, 2003). In their review of conversation partner training pro-grammes, Turner and Whitworth (2006a) reported that the main approaches usedinclude (a) conversation analysis-motivated therapy (Booth & Perkins, 1999;Cunningham & Ward, 2003; Lock, Wilkinson, & Bryan, 2001; Wilkinson, Bryan,Lock, & Sage, 2010; Wilkinson et al., 1998), (b) supported conversation for adultswith aphasia (SCA; Kagan, 1998; Kagan, Black, Duchan, Simmons-Mackie, &Square, 2001; Lyon et al., 1997; Rayner & Marshall, 2003; Simmons-Mackie,Kearns, & Potechin, 2005) and (c) conversation coaching (Hopper et al., 2002).These authors suggest that partners’ personalities, attitudes and perceptions as wellas conversational and interactional style may influence the outcomes. However, theyreport a paucity of documented information on the characteristics of conversationpartners and a limited analysis of the impact of the partner’s skills on the interven-tion’s effectiveness (Turner & Whitworth, 2006a, 2006b).

Hopper and Holland (2005) discuss the importance of principles of adult learningin aphasia rehabilitation but state that clinicians cannot easily incorporate principlesof adult learning without evidence to support the practice. They suggest that futureresearch examine the relationship of adult learning principles to learning by adultswith aphasia and the factors of self-concept, readiness to learn, methods to capitaliseon prior experiences, differences between familiar and unfamiliar environments andpatients’ and families’ perspectives on programs based on adult learning principles.In this regard, the effectiveness of learner-centred training programme that incorpo-rates principles of adult learning has been demonstrated in the previous work forspouses of adults with chronic aphasia (Sorin-Peters, 2003, 2004). This programme

2 SORIN-PETERS AND PATTERSON

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was delivered in a one-to-one format with five couples with aphasia. Results includedimproved quality of conversation, improved repair of conversation breakdowns,increased participation in conversation by the person with aphasia, improved abilityto discuss more complex topics, improved spousal and family relations and increasedpositive feelings about conversation.

STUDY AIMS

The aim of this study was to determine whether similar results could be obtainedfrom a learner-centred programme based on the original adult learning model butincorporating both individual and group sessions. The author of the programmecollaborated with clinicians of the York-Durham Aphasia Centre (YDAC)/March ofDimes Canada (MODC), which runs community-based group programmes for peo-ple with chronic aphasia The benefits of group programmes have been documented(Elman, 2007; Ewing, 2007; Kagan, Cohen-Schneider, Sherman, & Podolsky, 2007;Shadden, 2007). The specific aims were to (a) determine the effect of a semi-groupformat of the original learner-centred programme for couples with chronic aphasiaand (b) describe the content and contribution of both individual and group sessions.

For the purposes of this study, adult learning is defined as the process whichindividuals go through as they attempt to change or enrich their knowledge, values,skills or behaviours as a result of experience (Brundage & MacKeracher, 1980). As inthe original study, adult learning principles were explicitly and systematically inte-grated into the programme and all sessions followed the Kolb experiential learningcycle model (Kolb, 1984; Sorin-Peters, 2004). This model includes the cyclical pro-cesses of concrete experience, reflective observation, abstract conceptualisation andactive experimentation (see Figure 1). The Kolb model has been documented topromote “transformational learning” in adults, which is a process of learning throughcritical self-reflection on experience (Boyd & Fales, 1983; Mezirow, 1991).

As in the original study, the Aphasia: Framework for Outcome Measurement(A-FROM; Kagan et al., 2008) provided the conceptual framework for the program.Developed broadly from the International Classification of Functioning, Disability,and Health (ICF; World Health Organization, 2001), the A-FROM model supports

ConcreteExperience

ActiveExperimentation

AbstractConceptualisation

ReflectiveObservation

Figure 1. Kolb’s experiential learning cycle (Kolb, 1984).

COMMUNICATION TRAINING FOR COUPLES 3

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the life participation approach to aphasia (LPAA; Chapey et al., 2000) by providingconstructs for shifting treatment targets toward participation in all aspects of life.Living with communication disability is seen as resulting from the interaction ofseveral components, including participation in life, the communication environment,the severity of the communication impairment, personal characteristics and theexperience of living with communication impairment (see Figure 2). The learner-centred training programme in this study targets the communication and languageenvironment and aims to improve the attitude, knowledge and skills of spouses (i.e.,the communication environment of the person with aphasia.). It involves providingopportunities for genuine conversation (participation in life situations) in order toenhance the well-being (personal attitudes and feelings) of the person living withaphasia.

METHODOLOGY

Design and participants

A descriptive case series design was used. Participants consisted of couples withaphasia who were affiliated with the YDAC/MODC, which provides weeklygroup-based communication programs for adults living with aphasia in southernOntario, Canada.

Participants. Couples affiliated with YDAC programmes in three sites werereferred to this study by their SLPs. Four YDAC partners with aphasia (PWA)

Severity of Communication Impairment (CI)

Communication Environment

Personal identity, attitudes and feelings

Participation in life situations

Living withCI

Figure 2. Aphasia: framework for outcome measurement (Kagan et al., 2008). © Aphasia Institute.Reproduced by permission of the Aphasia Institute.


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participated in the study. Partner selection criteria included (a) diagnosis of stroke, asreported in their file ; (b) exhibiting “difficulty in being understood by others”, asassessed by staff and family; (c) living with the spouse who consented to participate inthe study; (d) using English prior to the stroke and (e) commitment to attend eightweekly sessions.

Table 1 lists the mean characteristics of the four PWA who participated in thisstudy and the specific diagnoses and medical conditions of each. The mean age was68.3 years, with a range of 61–74 years. All PWA who participated were male. Otherdata on ethnic and cultural background were not available. The primary diagnoseswere either stroke or cardiovascular accident. The average number of other medicalconditions was 2.8, with a range of 2–3. Communication diagnoses and severitydeterminations for PWAs were based on the objective assessment reports fromtheir referring SLPs and from YDAC/MODC SLPs’ informal evaluations.

Four spouses participated in the study. Having difficulty communicating withtheir partner with aphasia was the main selection criterion. All spouses affiliatedwith YDAC were invited to participate if they were (a) living with the person withaphasia and (b) committed to attend eight weekly sessions. Mean spouse character-istics are outlined in Table 1. The mean age of spouses was 67.3 years, with a rangefrom 60 to 76 years. All spouses were female. One of them was working full time; onewas working part-time. All couples were married or in common law marriages. Meanyears of marriage was 43.5 years.

Measures

The measures used were similar to those described in the original study (Sorin-Peters,2004) and included the Family intervention for chronic aphasia (FICA) coupleinterview questions, the FICA couple questionnaire and adult learning reflectivequestions. However, unlike the original study, couple conversation was measuredby using the Measure of Skill in Supported Conversation (MSC) and the Measure ofParticipation in Conversation (MPC) developed by Kagan et al. (2004). This was lesstime consuming and more practical than the in-depth qualitative analysis completedin the original study. These complementary measures were designed to captureelements of conversation between adults with aphasia and their conversation partnersand are in line with a social approach to aphasia. The MSC provides an index of theability of a conversation partner (in this case the spouse) to communicate in waysthat acknowledge and reveal the competence of the person with aphasia through theuse of supportive conversation strategies (Kagan & Shumway, 2004). The MPCprovides an index of participation in conversation by the person with aphasia interms of his/her ability to interact with the spouse and to respond to and/or initiatespecific content (Kagan et al., 2004). Categories are scored on a 9-point Likert scalepresented as a range of 0–4 with 0.5 levels for ease of scoring. Rating anchors areprovided. These measures have been shown to be valid and reliable in capturing theconversational interaction and transaction of information with volunteers and peoplewith aphasia. Their usefulness in documenting changes in these skills for a learner-centred couple communication training has not yet been explored.

Two different conversation topics were used pre- and posttraining, as described inSorin-Peters (2004). The SLP and communicative disorders assistant (CDA) trainersobserved videotaped conversations and rated them independently. Ratings were thenshared and discussed until agreement was reached on final ratings. The above


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TABLE1

Characteristicsofpartners

withaphasiaandsp

ouse

s

Participa

nt#

Sex

Age

Years

post

stroke

Medical

conditions

Diagnosison

chart

Com

mun

icationdiag

nosis

Spouseyears

(age

married)

1M

615.8

Atrialfibrillation

Leftcerebrov

ascularaccident,

affectingfron

tal,pa

rietal

and

leftpo

steriorcapsule

Severe

receptivean

dexpressive

60(34)

2M

711.6

Diabetesmellitus

(transient

ischem

icattack

(TIA

)),atrial

fibrillation,

homon

ymou

s,hemiano

psia

Leftfron

talbrainha

emorrhage

Mod

erateto

severe

apha

siaan

dap

raxiaof

speech

76(55)

3M

741

Hyp

ertension,

atrial

fibrillation,

depression

Leftfron

tallobe

brain

haem

orrhage

Cog

nitive

commun

ication

impa

irmentaffectingmem

ory,

plan

ning

andorga

nisation

68(45)

4M

670.6

Myo

cardialinfarction

,surgical

insertionof

twocardiacstents,

resultingin

currentinfarct

Leftmiddlecerebral

artery

infarct

Aph

asia

65(40)

Mean(SD)

68.3

(5.6)

2.3(2.4)

2.8(0.5)

Mean(SD)

67.3

(6.7)

43.5

(8.9)


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measures were completed at the beginning and the end of the programme. All datawere analysed to determine whether there was concurrence across all three measures.In addition to the above measures, each member of the four participating couplescompleted an “aphasia-friendly” evaluation of the programme in the last groupsession to document the perceived value of individual and group sessions. Itemswere explained and assistance via supportive communication strategies was providedto PWA by the CDA trainer, if required.

Intervention

The training programme included eight weekly sessions. Each session was 2 hr longwith a 15-min break. All sessions were delivered by the SLP trainer and a CDAaffiliated with YDAC, who was experienced in the use of supportive communicationstrategies, within a mutual aid group format. The training incorporated the contentof the original one-on-one programme across individual and group sessions (seeTable 2). Prior to the training, information was obtained about the communicationabilities and supportive communication strategies specific to each partner withaphasia from standardised and nonstandardised communication assessments intheir files. This information was confirmed and elaborated on during phone con-versations between the SLP trainer and the SLPs affiliated with the YDAC pro-gramme and was used to provide a basis for supportive conversation

TABLE 2Training programme

Session Format Content

1 and 2 Individual Couple “tells their story”Completion of FICA Interview, FICA Questionnaire and reflective learning

questions (privately with each member of couple)Review results (couple together)

3 Individual Videotape couple conversationCouple reviews and self-rates video clipCollaborate regarding couple’s goalsTrial of supportive conversation strategies

4 Group Introductions, icebreaker activityConversation practiceAgreement regarding: home activity to practice for the week

5 Group Group discussion “what is aphasia”, concept of communicative competence;learning styles; how learning styles impact couple communication (beforeand after stroke)

Conversation practiceHome activity6 Group Supporting each other; changes in roles, participant experiences, successes,

challengesReview of supportive conversation strategiesConversation practiceHome activity

7 Group Conversation practiceFeedback about programme

8 Individual FICA interview and questionnaire and reflective learning questionsVideotaped conversationLong-term goals, strategies


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recommendations for each couple. In addition, before the programme began,resource kits were developed for each couple which included a white board andmarker/eraser, maps, numbers, calendars and conversation topics. A list of familiarnames was added by the trainers for each couple after the first session.

The first two sessions of the programme were individual sessions where eachcouple had the opportunity to “tell their stroke story”, answer reflective learningquestions and rate their communication with each other. Each member of the couplewas seen privately to answer the reflective learning questions and complete thecommunication rating scale. Summary information was shared with the coupletogether upon their consent. The information was obtained from the PWA throughthe use of supportive communication materials and strategies.

The third session was also an individual session in which results of the interview,learning questions and the rating scale responses of each member of the couple weresummarised and discussed with the couple. Couples were also videotaped duringconversation. They were invited to observe their videotaped conversations andencouraged to rate themselves, using the MSC and MPC guidelines. Individualgoals were developed for each couple in an “aphasia-friendly” written format. Thissession also included a conversation trial in which the SLP trainer demonstrated andcoached each spouse in the use of individualised conversation strategies. A list ofindividualised goals and communication strategies were included in each couple’sresource kit.

The subsequent four sessions were group sessions and included all the fourcouples. These sessions were facilitated by the SLP and CDA trainers. The goalsand content of the group sessions were similar to the goals of the original one-on-one programme (Sorin-Peters, 2004). The following topics were discussed: aphasiaand communicative competence, common poststroke communication disorders andtheir relevance to participants, participant learning styles and the impact of learningstyles on couple communication, ways to work out learning style differences,spouses’ new roles in conversation and supportive conversation strategies (SCA)(Kagan, 1998). Aphasia-friendly communication strategies were used in groupsessions including use of flip chart key words, gesture, pictographic materials aswell as demonstrations and videotaped examples of supportive communicationstrategies. Couples practiced using their individualised supportive conversationstrategies with their partners in the second half of each group session. The SLPand CDA trainers provided coaching and feedback during practice time and rein-forced spouses’ successful use of communication strategies. As the group sessionsprogressed, less trainer support was required. As mentioned in Sorin-Peters (2004),the Kolb’s experiential learning cycle was used to guide all the session activities.Participants were encouraged to draw on their concrete experience, reflect on theirexperiences communicating with each other, develop concepts about effective com-munication with each other and then collaborate with the SLP trainer to determineways to apply the strategies.

The last session was an individual session with the SLP trainer in which coupleswere asked reflective learning questions, rated their communication with each otherand were also videotaped in conversation with each other. As with the pretrainingmeasures, each member of the couple was first seen privately, and then results wereshared with the couple together. Changes compared to pretraining were discussed.The last session also included the development of long-term goals of each couple.


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RESULTS

Couples’ perception of communication: FICA interview with spouses

Spouses’ interview comments about couple communication before and after trainingrevealed a similar pattern across couples. This pattern was also similar to the resultsobtained in the original study. Before training, all the four spouses spoke at lengthabout the stroke and aphasia and its negative impact on communication. Spouseseither expressed sadness or cried when they spoke about the changes in their lives asa result of the stroke. After training, when asked about conversation with theirPWA, all the four spouses listed specific strategies they were using to facilitateconversation. For example, after training Spouse 1 reported “Well, I do have thepen and paper always on the kitchen table”; Spouse 2 reported “I use yes/no withthumb up/down”; Spouse 3 reported “We sit at the kitchen table. It’s the best spotwith no distractions” and Spouse 4 reported “If he gets stuck and I can’t figure itout, I ask questions about the context and topic or I ask for clues and cue wordsfrom him”.

In addition, spouses appeared to be more accepting of communicating in adifferent way with their partners at the end of the programme. This is similar tothe results observed in the original study (Sorin-Peters, 2004). For example, Spouse 1commented “I’m trying to do stuff for myself … I look at life differently now”;Spouse 2 said “Sometimes it’s difficult, but it’s easier—that’s the progress we did”;Spouse 3 commented “I’m always encouraging him … How can he do it and let himthink for himself … It’s different” and Spouse 4 said “Oh boy. I don’t know. It justchanges your whole world upside down … I believe there’s a light at the end of thetunnel”. Spouses subjectively commented that the training was extremely helpful.They liked the individual and group sessions, especially the information aboutlearning styles and the discussion about role changes after the stroke. Spousescommented that they learned new communication techniques and that the trainingpromoted enhanced communication with their partners. Spouses also reported thatthe group sessions helped them feel less isolated with their challenges. Regardingspouses’ impressions of what it must be like for their partners, before training, allspouses reported that their partners were frustrated, angry or scared. After training,their comments suggested that their partners’ frustration was still present butdecreased.

During the training sessions, spouses had an opportunity to use the specificstrategies recommended for each of them and make modifications. Spouses reportedthat the one-on-one coaching by the SLP and CDA in the groups was extremelyhelpful as well as the feedback and reinforcement from other spouses in the group.For example, when Partner 2 got frustrated in conversation practice, other spousesand partners in the group acknowledged his frustration and encouraged Couple 2 touse the specific communication strategies in order to facilitate more effectivecommunication.

Couples’ perception of communication: FICA interview with PWA

PWA’s interview responses about couple communication before and after trainingrevealed a similar pattern across partners. This pattern was also similar to theresults obtained in the original study. Before training, all the four PWA expressedthat their aphasia had significantly impacted their family. PWA1 expressed


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sadness about the changes in his life as a result of the stroke while PWA3expressed anger and frustration regarding decreased control of his everyday lifeand conversation. After training, all the four partners expressed that their spouseswere using more specific strategies to facilitate conversation. They appeared to bemore understanding of their spouses’ new role in conversation and were moreaccepting of communication with their partners. When PWA were asked how theyfelt about their communication abilities, they were asked to rate their satisfactionwith their communication out of 10. The results to this interview question aredisplayed in Table 3, showing that all of the PWA’s self-ratings improved aftertraining.

Couples’ perception of communication: FICA questionnaire withspouses

FICA questionnaire results for spouses are displayed in Table 4. For item 1, “I enjoytalking with my partner”, spouses’ ratings were higher after training for all thespouses except Spouse 2, who rated this item at ceiling, i.e., 4 out of 4, both beforeand after training. No changes were observed for any spouse on items 2, 3, 4 or 5,except for small changes for Spouse 1. For item 7, “My partner initiates commu-nication with me”, ratings for Spouses 1 and 4 increased, while ratings for the othertwo spouses remained the same after training. This corresponds to the observationthat Spouses 1 and 4 needed to initiate and use supportive communication strategiesmore. On item 8, “I look forward to communicating with my partner”, ratingsdecreased after training for Spouses 1 and 4, while ratings for the other two spousesremained the same. Only Spouse 3 rated item 9, “My partner is responsive tocommunicating with me”, higher after training. However, both Spouse 2 and 4rated this item a 4 out of 4 both before and after training, reaching a ceiling effect.Spouse 1 rated this item lower after training. There was no change in ratings on item10, “Communication ends successfully or positively”, for Spouses 1, 3 and 4. Spouse2 rated this item lower after training.

Couples’ perception of communication: FICA questionnaire with PWA

FICA questionnaire results for PWA are displayed in Table 5. All PWA rated item 1,“I enjoy talking with my spouse”, higher after training, except for PWA3, whoseratings decreased slightly after training. For item 5, “my spouse works hard to

TABLE 3FICA interview: PWA’s ratings of their communication abilities

Partner with aphasia (PWA) Pre Post

PWA1 5 8PWA2 2 9PWA3 4 5.5PWA4 4.5 6.5

Ratings are out of 10. 1 = not satisfied at all; 10 = extremely satisfied.


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communicate with me”, ratings for all partners increased after training, except forPWA3 whose ratings were at ceiling level both before and after training. Thiscorresponds with PWA’s comments in group sessions that the training programmehelped them become more aware of how difficult it was for their spouses to commu-nicate with them. Partners’ ratings for item 6, “my spouse uses many different waysto communicate with me”, increased for PWA1 and PWA3, stayed the same forPWA2 and decreased for PWA4. Ratings for item 7, “my spouse initiates commu-nication with me”, decreased after training for PWA3 and PWA4. All partners rateditem 8, “I look forward to communicating with my spouse”, higher after training,except for PWA4, whose scores were at ceiling before and after training. PWA1 andPWA3 rated item 10 higher after training, i.e., “communication ends successfully orpositively”, while ratings on this item were rated positively both before and aftertraining for PWA2 and PWA4.

TABLE 4FICA questionnaire results for spouses

Spouse 1 Spouse 2 Spouse 3 Spouse 4

Item Pre Post Pre Post Pre Post Pre Post

1. I enjoy talking with my PWA 0 1 4 4 2 4 1 32. I have strategies to be successful in talking with PWA 4 3 2 2 2 3 2 33. I initiate communication with PWA 3 4 2 2 3 4 4 24. PWA enjoys communicating with me 1 2 3 4 3 3 2 35. PWA works hard to communicate with me 2 2 4 4 3 4 2 36. PWA uses many different ways to communicate 2 2 2 4 1 2 3 17. PWA initiates communication with me 2 3 2 2 2 2 1 28. I look forward to communicating with my PWA 2 0 4 4 3 4 4 39. PWA is responsive to communicating with me 4 3 4 4 2 3 4 410. Communication ends successfully or positively 2 3 4 2 2 2 3 3

FICA = Family intervention for chronic aphasia questionnaire, Olswang et al. (1998). PWA = partner withaphasia, 4 = always, 3 = usually, 2 = sometimes, 1 = rarely, 0 = never.

TABLE 5FICA questionnaire results for partners with aphasia (PWA)

PWA1 PWA1 PWA1 PWA1


1. I enjoy talking with my S 1 2 3 4 4 3 3 42. I have strategies to be successful in talking with S 2 3 2 3 3 3 4 43. I initiate communication with S 2 3 2 2 3 4 2 34. S enjoys communicating with me 2 3 2 3 3 3 3 35. S works hard to communicate with me 1 3 2 3 4 4 3 46. S uses many different ways to communicate 1 2 3 3 2 3 4 17. S initiates communication with me 2 2 3 3 4 3 3 28. I look forward to communicating with my S 2 3 2 3 3 4 4 49. S is responsive to communicating with me 2 2 3 4 3 3 3 410. Communication ends successfully or positively 2 3 3 3 2 3 3 3

FICA = Family intervention for chronic aphasia questionnaire, Olswang et al. (1998). S = spouse,4 = always. 3 = usually. 2 = sometimes. 1 = rarely. 0 = never.


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Couple conversation: MSC and MPC

Results for measures of couple conversation for each couple are displayed in Table 6.For the MSC, all spouses were rated as acknowledging competence more aftertraining, except for a slight decrease for Spouse 2. In addition, all spouses wererated as revealing their partners’ competence more after training on one or more ofthe submeasures. For the MPC, ratings for interaction increased for all PWA, exceptfor PWA2 for whom the interaction score remained the same. For transaction, onlyPWA1 was rated higher after training. This corresponds with the observation thatSpouse 1 used more supportive conversation strategies after training, thus promotingher partner with aphasia’s increased ability to convey information.

Group evaluation of the training programme

Results of group members’ evaluation of the training programme are displayed inTable 7. Items rated the highest by participants included: met the objectives, appro-priate length, group sessions helpful, materials and resource kit useful and practice insessions helpful. All three items related to the trainer were rated excellent or verygood. Overall ratings of the training programme were either excellent or very good.Several participants gave low ratings regarding the duration of the group. This wasrelated to their comments stating that they would have appreciated more sessions tomaintain and/or further improve their conversation skills.

TREATMENT FIDELITY

Methods to enhance treatment fidelity were implemented in the design, training,delivery, receipt and implementation of the intervention. The design of this studyexplicitly incorporated the Kolb’s theoretical model and the life participationapproach to intervention, and the length and number of sessions were the same foreach participant. The SLP trainer had experience in delivering the training contentand administering the pre- and posttraining evaluation protocols, as well as informal

TABLE 6Results of MSC and MPC for each couple

Couple 1 Couple 2 Couple 3 Couple 4


MSCAck comp 0 3 2 1.5 2 3 1 2.5Reveal compMsg IN 1 3 1 1.5 1 3 1 2Msg OUT 1 3 1 1.5 2 3 1 1Verifying 1 2 1 1 1.5 3.5 1 2MPCInteraction 1 3 2 2.5 2 2 2.5 3Transaction 5 3 1 1 3 2 2 1

MSC = Measure of Skill in Supported Conversation, MPC = Measure of Participation in Communication,Kagan et al. (2004). Ack comp = acknowledging competence, reveal comp = revealing competence, MsgIN = message in, Msg OUT = message out.


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experience using the MSC and MPC measures. In order to ensure that the SLPtrainer and CDA ratings of the MSC and MPC were reliable, two half-day sessionswere conducted with the CDA to review the study design and content as well as theMSC and MPC measures. Videotaped conversations of couples who did not partici-pate in the study were used for rating practice until reliability was reached betweenthe SLP trainer and CDA. A training manual was used in the original study, and thesame manual was used to guide the content of all sessions using the semi-groupformat. Aphasia-friendly strategies were used to ensure that PWAs understood thetraining material delivered and opportunities were given to all participants to requestclarification or further explanation of content, if necessary, during all the sessions.Participants’ ability to implement the strategies learned was observed informally inall the sessions, and the SLP trainer and CDA provided support and demonstration,as necessary. Skill acquisition was further assessed by videotaping couples in con-versation before and after the training.

DISCUSSION

The aim of this study was to modify and evaluate a learner-centred communicationtraining programme for couples with aphasia using a format that included bothindividual and group sessions. Results showed positive outcomes similar to thoseobserved in a previous study where training was provided individually and sepa-rately to each couple (Sorin-Peters, 2004). In general, posttraining results observedon the interview, rating questionnaire and videotape clips corroborated with eachother and showed improvements posttraining. The decreases in spouses’ FICAratings on items 8–10 after training may also reflect improvements because thedecreases suggest that spouses were more aware of the skill and difficulty involvedin facilitating conversation with their partners. Similarly, the decreases in partners’FICA ratings on items 1, 6 and 7 may also reflect improvements because partners

TABLE 7Training evaluation—number of responses in each rating category (n = 8)

Ratings 5 4 3 2 1

Training sessionsMet the stated learning objectives 1 5 2Was useful to me 1 4 3Was of appropriate length (i.e., 2 hr) 3 3 2Was of appropriate duration (i.e., 10 week) 3 2 1 1Individual sessions were helpful 5 3Group sessions were helpful 3 3 2Materials and resource packs were adequate and useful 2 5 1Videos were helpful 1 3 3 1Practice sessions were helpful 1 5 2Home practice was helpful 1 4 3The trainerKnowledgeable about subject matter 3 5Effectively presented the material (i.e., clear and organised) 3 5Enthusiastic throughout sessions 1 7Overall rating 1 6 1

1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent.


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were taking more responsibility for communication and initiating more so that theirspouses needed to initiate less. The training and the opportunities to practiceindividualised communication strategies improved both spouses’ and PWA’s per-ceptions of communicating with each other. Couples also felt they could transferthis learning to improve the way they communicated with each other at home. It isinteresting to note that PWA1 had the most severe communication impairmentwhile PWA3 had the mildest difficulty and yet both rated communication as endingmore successfully after training. This suggests that individuals with both severe andmild communication disabilities can perceive positive changes in communication asa result of learner-centred training.

This study expands on previous research in two important ways. First, it suggeststhat at least two possible formats can achieve similar results when an adult learningapproach is explicitly incorporated in all training sessions. Similar to the resultsobtained using the original individual format, the use of an adult learning approachand the focus on the learning needs of participants in the semi-group format offereda means of investigating and addressing complex communication behaviours incouples. It offered insights that expanded the knowledge about communication toinclude couple’s experiences with aphasia and their emotions related to commu-nication with each other. The explicit discussion of participants’ learning styles andhow this impacted couples’ conversation allowed the SLP trainer to modify herapproach to accommodate these learning needs and differences. As a result, train-ing was effective for clients with both severe and mild aphasia. This suggests thatSLPs need to understand that individuals, including couples and clients withaphasia, learn differently. Therefore, we may need to address these differences bymodifying our own teaching and training styles, as opposed to claiming that certainclients or families are noncompliant or resistant.

In their review of communication training programmes, Turner and Whitworth(2006a) outlined the criteria used by SLPs to recruit spouses of people with aphasiainto conversation training programmes. Using these criteria, they developed the“Profile of Partner Candidacy for Conversation Training” which suggests that a“high candidacy” conversation partner has a motivation to change, views conversa-tion as a collaborative act, values the social function of conversation, recognises thatcommunication has the potential to change and accepts multi-modal communicationover speech. The results of this study suggest that the learning style of each memberof the couple and how this affects their conversation and conversation style shouldalso be considered so that couples who might otherwise not be offered training areseen as potential candidates.

Both spouses and PWA reported benefits from both individual and group ses-sions. Individual sessions allowed for the individualisation of supportive conversa-tion strategies and for one-on-one coaching when couples first learned to use thesestrategies in conversation with each other. These individualised communicationstrategies incorporated speech-language assessment data as well as clinically impor-tant information gleaned from couples’ interviews. It is interesting that beforetraining all spouses reported they used some generic communication strategieswith their partners. (e.g. being patient with their partner). However, these genericstrategies were not reported as being as effective in promoting successful commu-nication as the specific, individualised couple communication strategies combinedwith education, training and support. Spouses also liked the individualised coach-ing within the group sessions because it gave them specific guidance when they were


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“stuck.” Couples reported that the list of individualised communication goals andstrategies in their resource kits was easily accessible and encouraged them to use thestrategies with the enclosed resources. These results suggest that future trainingshould include not only generic communication strategies but also individualisedgoals and strategies similar to those described by Sorin-Peters (2004) and those thatwere implemented in this study. The benefits of individualising communicationstrategies has also been documented in relation to nursing communication trainingprogrammes for nurses working with long-term care residents with aphasia as aresult of stroke (Généreux, Julien, Larfeuil, Lavoie, & Soucy, 2004; McGilton,Sorin-Peters, Sidani, Rochon, & Boscart, 2010; Sorin-Peters, McGilton, &Rochon, 2010). Moreover, it is interesting to note that all spouses found thecommunication strategies useful in practice or learned additional informationabout communication with their partners, although they had been living withaphasia anywhere from 6 months to 5 years. This suggests that effectively usingsupportive conversation strategies is a learned skill and requires education, trainingand support and that although a caring and patient spouse is beneficial, it may notbe enough.

The additional specific benefits reported by participants about group sessionsincluded mutual support, the acknowledgement of the level of difficulty involved incommunicating with each other and encouragement and reinforcement from othersin the group in the use of recommended supportive communication strategies. Thesetypes of benefits have been documented in other studies using a group format(Elman, 2007). Future research needs to determine what factors influence couples’candidacy for one type of format over another, i.e. more in-depth one-on-onetraining versus a semi-group or group-only format.

Results of spouse and partner interview comments, questionnaire ratings andvideotape observations suggest that formal language assessments may not be theonly indicators of which couples will have difficulty communicating with each other.Partners 1 and 2 had more severe language difficulties while Partners 3 and 4 hadrelatively mild impairments. However, Spouses 3 and 4 commented about the frus-tration and difficulty involved in communicating with their partners as much asSpouses 1 and 2, and they rated several items of the questionnaire as low or lowerthan the other two spouses. This suggests that SLPs could explore couples’ percep-tions of communication to obtain a more accurate impression of whether they couldbenefit from training. Interview and rating scales such as those used in this studycould be used for this purpose. In addition, comparing spouses’ and PWA’s percep-tions of couple communication would also be important to determine the difficultiesperceived by each.

Studies evaluating training programmes to facilitate communication betweenpeople with aphasia and their partners have used various measurement tools, includ-ing qualitative ratings on tests such as the Visual Assessment for Self-Esteem Scale(VASES) (Cunningham & Ward, 2003), Stroke-Aphasia Quality of Life Scale(SAQOL) (Hilari, Owen, & Farrelly, 2007), the Psychosocial Well-Being Index(Lyon et al., 1997), the Burden of Stroke Scale (BOSS) (Doyle, McNeil, Hula, &Mikolic, 2003) as well as informal ratings of transactional and interactional commu-nication (Purdy & Hindenlang, 2005). Others have used a more quantitativeapproach using conversational analysis (Beek, Maxim, & Wilkinson, 2007;Cunningham & Ward, 2003). In this study, couple conversation was measured withthe MSC and the MPC developed by Kagan et al. (2004). This measurement was


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used because it was in line with the philosophy and strategies used in the trainingprogramme. The MSC ratings showed spouses improvements in acknowledgingcompetence and in revealing their PWA’s competence after training on one ormore of the submeasures. The largest changes in ratings were for Couple 1, whichcorroborated with Spouse1 and PWA1’s interview comments and questionnaireratings. The MPC ratings showed improvements in PWA’s interaction in conversa-tion and some improvement in the transaction of information in conversation. It maybe that couples were just beginning to learn new communication behaviours and thatthese would have been reflected in higher ratings on this measure with more time andpractice. This measure has clinical utility in that it is relatively quick and easy to usecompared to in-depth qualitative analyses of conversation as well as conversationanalysis. It is based on a sound theoretical model and is philosophically in line withthe learner-centred approach and intervention strategies used in this training pro-gramme. However, its validity and reliability to document changes in couple con-versation after this type of training need to be determined with larger numbers ofcouples.

A final issue raised by this study is related to the skills required to implement theadult learning approach in couple communication training. Clinicians attemptingsuch an approach may need formal education on adult learning and guidance on howto apply the principles and strategies to aphasia intervention. Additional courseworkon counselling and family systems may also be beneficial. These skills could helpSLPs more effectively implement the adult learning approach to promote life parti-cipation for couples with aphasia.

The major limitation of this study is that a small number of couples were studied,and couples represented a select group of couples with aphasia because they demon-strated a high degree of commitment to improve their communication with eachother. In addition, there is a potential bias of results, because interviews, question-naires and videotape data were collected by the SLP trainer. Similarly, although theCDA trainer had extensive experience in the use of supportive communicationstrategies to facilitate the person with aphasia’s sharing of opinions in the groupevaluation, she may have biased the group evaluation results. An objective persontrained in supportive communication techniques may be a future choice. The use ofthe FICA rating questionnaire as an outcome measure would need to be reevaluated,as scores on this questionnaire ceilinged out on pretraining. Additional treatmentfidelity checks would also need to be done in future research to ensure that theintervention is delivered according to the steps outlined in the manual. For example,sessions could be videotaped and observed by an independent examiner to ensurethat it is delivered properly. In addition, although a communication kit was devel-oped and used for each couple, future interventions could include the use of low-techaugmentative and alternative communication (AAC) devices for partners with com-munication impairments, if appropriate. Finally, more long-term effects of this typeof training need to be studied, and methods to ensure the clinical sustainability of theprogramme need to be developed.

In conclusion, the results reported here on the use of a modified format todeliver a learner-centred communication training programme demonstrate thatthe programme enhanced both spouses’ and PWA’s perception of their commu-nication and their communication skills. Benefits of both individual and groupsessions were observed and are consistent with those reported in previous litera-ture. These findings support the role of the SLP in conversational partner training


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and suggest the benefits of varied formats of a learner-centred approach in theimplementation of a communication training programme for couples living withaphasia as a result of stroke.

Manuscript received 15 August 2013Manuscript accepted 1 February 2014First published online 17 March 2014

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