each of the scenarios below. Take turns in playing three roles: per-son with a communication disorder, caregiver or partner of that person, and clinician. Clinicians, for each sce¬nario, convey information about the condition and its severity, the limi¬tations of your assessment findings, your best guess at prognosis, and limitations to guessing about progno¬sis. Others, ask questions and respond to the clinician in ways you think would be likely in such scenarios.
- The clinician conveys that the person has global aphasia due to a stroke that occurred 5 days ago.
- The clinician conveys that the person has a mild posterior form of aphasia due to a stroke that occurred 1 year ago.
- The clinician confirms that findings are consistent with a
diagnosis of cognitive-linguistic deficits due to MCI.
- The clinician summarizes findings suggesting that the person has PPA.
Be sure to practice suggestions for information sharing and making prognostic statements given in your readings.
- Describe important strategies for using in an assessment information¬sharing session to empower a person with a language disorder and focus on strengths while remaining realistic about challenges.
- Describe how the contents of a writ¬ten assessment report to be sent to an insurance company as part of a billing procedure may differ from a written report shared with the family.
- Review the abbreviations in Table 22-1. How might each be relevant to your own reading and writing of docu¬ments in medical and rehabilitation settings?
More materials to foster teaching and learning on this chapter’s content may be found on the companion website.
Theories and Best Practices
This section addresses best practices and theories of intervention for adults with acquired cognitive-linguistic disorders. In Chapter 23, we focus on what we mean by “best practices,” what we need to know about them, and how to find informa¬tion about the evidence base in our field to support our work as clinicians. You are encouraged to reflect on how you will implement evidence-based practice in your own professional work. In Chapter 24, we consider the theories that support the wide range of treatment methods (and components of those methods) used in clinical practice serving people with cog-nitive-linguistic challenges. This content serves as an important foundation for the final two sections of the book regarding treatment methods.
The excellent clinician is a dedicated vehi-cle for fostering brain changes and help¬ing people compensate for and cope with chronic challenges. As we discussed in the context of best practices in assessment (Chapter 17), honing in on the people with whom we are in an empowering, affirm¬ing clinical role is paramount in serving as that vehicle. So is grounding our work in evidence-based practice. In this chapter, we consider wisdom about intervention best practices offered by clinical aphasiol- ogists over many decades. We also review means of determining levels of evidence for methods of intervention.
After reading and reflecting on the content in this chapter, you will ideally be able to answer, in your own words, the following queries:
- What are the best practices in the treatment of neurogenic language disorders?
- What does the excellent clinical apha- siologist know about evidence-based practice?
- Where can we find pertinent infor-mation to support evidence-based practice?
- How does the excellent clinician apply evidence-based practice?
What Are the Best Practices in
the Treatment of Neurogenic
Below is a list of best practices for engag¬ing in clinical excellence in treatment of neurogenic language disorders. All of the best practices recommended for assess-ment in Chapter 17 also apply to treat¬ment, although some noted here have a special nature that is important to con¬sider in the treatment context. Of course, there are additional best practices that are particular to treatment itself.
as a Human Right
The ability to communicate is a funda-mental human right. Advocate vigorously for the people you serve. Be sure to review the strategies for advocacy to boost access
to services and supports for people with neurogenic communication disorders in Chapter 14.
Recognize Assessment as an
Ongoing Intervention Process
We noted in Chapter 17 that, although we might be expected to document that we are engaged in a formal assessment session prior to initiating treatment, we must continue to ask and answer ques¬tions about a particular person’s commu¬nication abilities throughout the entire time that he or she is seen for professional services. Every treatment session entails assessment of some type. For example, how much has been retained from one clinical interaction to the next? Is there carryover of progress from one area to another? How is he or she progressing toward his or her goals? We constantly learn new information about a person’s life context that might influence our goals, the content and location of our sessions, and who might be included in any of our interactions.
Monitoring of progress through¬out intervention fits into the single-case hypothesis-testing scheme akin to the assessment-focused research process illustrated in Chapter 17. With an indi¬vidual person, we may apply a specific approach for which there is empirical support detailed in the literature based on individual cases or groups. Then, as we assess its effects with a particular individ¬ual, we may continuously tweak the pro¬cess to best suit that individual’s needs (Turkstra, 2010). Ylvisaker (e.g., in Ylvi- saker, Shaughnessy, & Greathouse, 2002) referred to this as patient-specific hypothesis testing and case-based decision making.
Be Person Centered
Person-centered care is reflected in our demonstrating that the individuals we serve are the core of our purpose as clini¬cal professionals (DiLollo & Favreau, 2010; Kitwood, 1997; Kitwood & Bredin, 1994; Leach et al., 2010; Lewin, Skea, Entwistle, Zwarenstein, & Dick, 2001; Peri, Kerse, & Halliwell, 2004; Worrall, 2006). At the heart of person-centered care is the direct inclusion of the indi¬vidual with a communication disorder in decisions about all aspects of assessment, treatment planning, and decisions about intervention alternatives and follow-up after direct intervention (Hinckley, Boyle, Lombard, & Bartels-Tobin, 2014; Lund, Tamm, & Branholm, 2001). This may seem obvious when considered in the abstract. However, in our everyday busy clinical and research environments, we have con¬stant time and fiscal pressures. We have many demands that do not involve direct contact with the people we serve. Thus, the goal of person-centered care can easily be undermined (Rohde, Townley-O’Neill, Trendall, Worrall, & Cornwell, 2012). No matter how stressed we may be, who is observing or not observing us, how much confidence we may lack . . . when we are in gear as clinicians, we ideally focus pri¬marily on those we serve and not on our¬selves or our own performance.
Include Family Members, Caregivers, and Others Whose Roles Are Relevant
Communication is not typically an activity that we carry out alone. It relies on inter-action with and engagement of others. Achieving communicative success with a person who has a communication disor¬der depends not only on the abilities and strategies of the person with the disorder but also on the abilities and strategies of the people with whom she communicates.
Include caregivers and significant others to enhance and expand the net¬work of supportive people in a person’s environment to continue recovery and ensure maximal generalization of prog¬ress to everyday use in naturalistic envi-ronments. Authors of several studies have demonstrated that training of partners in the use of supportive communication strategies improves short- and long¬term treatment outcomes (see Simmons- Mackie, Raymer, Armstrong, Holland, & Cherney, 2010). We explore this notion further in Chapter 24.
Have a Clear Sense of
Purpose and Goals
A key tenet of Covey’s (2013) strategies for “highly effective people” is to begin with the end in mind. It is unlikely that we will reach a goal if we don’t know what the goal is, let alone how to get there. As noted above and throughout this book, our ultimate goal is to help people with neurogenic language disorders foster the most successful and fulfilling lives possi¬ble. The way toward that goal is shaped by the people we serve—their strengths and weaknesses, their support systems, and their own sense of what is “successful” and what is “fulfilling.” As mentioned in our discussion of assessment best prac¬tices, the excellent clinician knows what he or she is doing with a person and why at any given time. He or she begins with the end in mind. If we don’t know our cli¬ents’ own personal goals—what defines the “end” for them—then we cannot possibly have the end in mind. At least not the right end. Kagan and Simmons- Mackie (2007) eloquently declare that the concept of beginning with the end in mind is central to outcomes-focused treatment planning.
Unfortunately, stories of unprepared SLPs demonstrating their ignorance of the literature on treatment methods are not uncommon. For some, it seems that completing photocopied workbook sheets from a book of language exercises or hav¬ing a person name objects depicted on a stock set of cards constitutes a treatment approach. Practices without sound theo-retical foundations and evidence of effec-tiveness are unethical and unworthy of the skills and abilities of a qualified SLP.
Directly tied to having a clear pur¬pose and goals is having a strong basis supporting the methods we use and the activities in which we engage in through¬out intervention. As we discuss through¬out this book, the excellent clinician typi¬cally does not champion one theoretical framework at the cost of recognizing the validity or utility of others. He or she knows about multiple approaches and frameworks, integrates multiple theories, evaluates critically the results of pub¬lished research results in light of what is most relevant to specific people with language disorders, and remains open to modifying theoretical perspectives based on new learning.
Engage Communication Partners
Outside of the Client’s Immediate
Circle of Friends and Family
In cases where there are not sufficient numbers of truly supportive people, find ways to enlist volunteers who may be helpful. Members of community service organizations, students in clinical or pre-clinical academic programs, and retired people can become wonderful commu-nication partners to assist in supporting social communication in general and carryover of specific communication goals in particular.
Embrace Cultural and
Treatment content and goals must take into account each individual’s unique background. This is essential to our focus on the person, on “functional” communi-cation, and on life participation.
Ylvisaker, well known for person-centered approaches that promote emotional self-regulation in TBI survivors, preferred the metaphor of “self-coaching” to self-regulation to enhance the relevance of the notion to clients. Most of us would probably rather be coached than regulated (Ylvisaker, 2006). Let’s keep this in mind as we work with people who have execu¬tive function problems, lack of awareness of deficits, and needs for improved self-monitoring or self-cuing.
Consider Optimal Timing
We must make every effort to time treat-ment sessions to minimize negative influ-ences of pain, illness, fatigue, distraction, and so on. Additionally, there is important research emerging indicating that the tim-ing of intervention in terms of stages of recovery from stroke or brain injury is of vital importance. We discuss this fur¬ther in Chapter 24, under queries about optimal times in recovery to initiate treat¬ment, and about intensity and duration of treatment