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11/15/2010
Managing Aphasia in a
Culturally Diverse World
Luis F. Riquelme, M.S.,CCC-SLP,BRS-S
Joyce L. Harris, Ph.D.,CCC-SLP
Hariklia Proios, Ph.D.,CCC-SLP
Isabella Reichel, Ph.D.,CCC-SLP
Ellayne Ganzfried, M.S.,CCC-SLP
Multicultural Task Force - National Aphasia Association
Managing Aphasia in a Culturally Diverse World
The reality of our caseloads in SLP:
Increasing number of non-monolingual
persons with aphasia
Persons with varying degrees of
multi/bilingualism; dialects of English
Greater racial/ethnic diversity and countries
of origin in the U.S.
Greater variety in social, cultural, educational
and occupational backgrounds
Internal diversity of each group
(heterogeneity)
Managing Aphasia in a Culturally Diverse World
LET’S GET ON THE SAME PAGE…
Culture
Culturally and linguistically diverse (CLD)
Race
Ethnicity
For this presentation:
Racial/Ethnic Diversity
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Introduction: Demographics
The proportion of individuals from ethnic
minority backgrounds has increased from
20% or 57 million people in 1980 to 31%
or 89 million Americans in 2000. Currently,
as of 2008, about 38% of the US
population is of a “minority” background.
These demographic changes profoundly
affect healthcare delivery because “race
and ethnicity correlate with persistent, and
often increasing, health disparities among
U.S. populations” and older adults use a
disproportionate share of healthcare
resources
(US DHHS, Healthy People 2010)
Introduction: Demographics
Language barriers:
There is a large increase in the
number of individuals who speak a
language other than, or in addition
to, English. Today, over 20% of
Americans (48 million people) fall
into this category with half
reporting they speak English “less
than very well.” Interestingly,
almost 60% report Spanish as
their other language
(Davis & Chesbro, 2003 cited in Riquelme, 2006).
Language Diversity in the U.S.
How many languages spoken in the
U.S.?
- English - spoken by 82% of the pop
- Spanish - second most common; 12% pop
- Main immigrant languages: Spanish,
Chinese, French, German, Tagalog,
Vietnamese, Italian
-Main foreign languages: Spanish, French,
German, Italian, Japanese
THE LIKELIHOOD OF AN SLP TO WORK
WITH A BILINGUAL PT WITH APHASIA IS :
EVER INCREASING!
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More relevant Demographics
Stroke in the U.S.:
Third leading cause of death
Leading cause of serious, long-term
disability
About 3/4 occur in 65+
Stroke death: higher for African
Americans than for Whites
Most important risk factor:
hypertension (high blood pressure)
More relevant Demographics
Worldwide figures on Stroke:
WHO: 15 million people suffer a stroke
annually; at least 5 million die and 5 million
permanently disabled
High blood pressure contributes to over
12.7 million strokes worldwide
Europe averages approximately 650,000
stroke deaths each year.
In developed countries, the incidence of
stroke is declining - largely due to efforts to
lower blood pressure and reduce smoking.
However, the overall rate of stroke remains
high due to the aging of the population.
Even more relevant Demographics
Aphasia
Estimate: about 100,000 people
acquire Aphasia every year;
In the U.S., currently about 1 million
persons with Aphasia
Men and women equally affected
TO CONSIDER: Definition of aphasia
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A few more facts…
Blacks, American Indians/Alaska Natives
(AI/ANs), Asians/Pacific Islanders, and
Hispanics die from stroke at younger ages
than Whites
The overall prevalence of stroke among
AI/ANs (6.0%), multiracial persons (4.6%),
and Blacks (4.0%) were higher than the
prevalence among Whites (2.3%).
The prevalence of stroke among
Asians/Pacific Islanders (1.6%) and
Hispanics (2.6%) were similar to the
prevalence among Whites.
Racial/Ethnic Diversity in the U.S.
>30 % of US population is of a
racial/ethnic minority
What is a “minority?”
Ignorance = Fear = Stereotyping
Impact on our professions
Culture in the context of our
professions:
Interpersonal
communication/relationshipbuilding
Clinical decision-making
Misdiagnosis/Mistreatment
Others
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Cultural Humility
“… cultural competence in clinical practice is
best defined not by a discrete endpoint but
as a commitment and acitve engagement in
a lifelong process that individuals enter into
on an ongoing basis with patients,
communities, colleagues and with
themselves. This training outcome is better
described as cultural humility… It is a
process that requires humility as individuals
continually engage in self-reflection and selfcritique as lifelong learners and reflective
practitioners.”
From: Tervalon, M. & Murray-Garcia, J. (1998)
Language Diversity in the U.S.
Largest racial/ethnic minority in the
U.S. = Latinos
Assimilation/Acculturation
Bilingualism
A continuum?
Is this a problem?
More than half of the world is bilingual!
Using interpreters/translators
Factors to consider
Defining culture
Assimilation is defined as the process
of someone in a new environment
totally embracing the host culture;
Acculturation is the integration of the
host culture with the native culture to
varying degrees.
NATIVE
_________________________________
CULTURE
HOST
CULTURE
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How is Bilingualism viewed in the U.S.?
Language as a Problem.
1950s. Bilingualism viewed as a deficit, low
SES/poverty, disadvantage
Language as Right.
1960s. Civil right. Pamphlets in languages other than
English.
Language as Resource.
Ruiz, 1988, in Goldstein, 2004
Racial/Ethnic Disparities in Healthcare
A problem?
Institutional racism
Provider bias
Cognitive predisposition to
grouping/categorizing
Most powerful tool for SLP: information
To improve cultural sensitivity and
competence in Dx process:
Analyze one’s own assumptions and
values. Expand definition of culture
Use cultural informants and
interpreters
Consider the patient’s needs within
their linguistic community
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MULTICULTURALISM/DIVERSIT
Y in the United States
… at a crossroads
Social/educational/healthcare/
service inequities
vs
The need to acculturate?
Parting Thoughts…
SLPs face many challenges ahead, many
linked to notion of a culture that was intended
to be homogeneous (“melting pot”);
Providing culturally competent services to
clients of all cultural backgrounds should be a
challenge that all clinicians approach with
enthusiasm and passion;
Until misdiagnosis because of cultural
differences is a thing of the past, SLPs cannot
stop learning and challenging their clinical
practices… (Riquelme & Rosas, 2009)
Managing Aphasia in a Culturally Diverse World
Davis, L.A., Chesbro, S.B. (2003). Integrating health promotion, patient
education, and adult education principles with the older adult: A
perspective for rehabilitation professionals. Jnl of Allied Health, 32:
106-109.
Goldstein, B. (2004). Bilingual language development and
disorders in Spanish-English speakers. Paul H. Brookes, Baltimore,
MD.
Riquelme, L.F., Rosas, J. (2009). Multicultural perspectives: The road to
cultural competence. In Shulman, B. and Capone, N. (Eds), Language
Development: Foundations, Processes, and Clinical Applications
(2nd ed). Jonas & Bartlett Publishers, Sudbury, MA.
Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural
competence: A critical distinction in defining physician training outcomes
in multicultural education. Jnl of Health Care for the Poor and
Underserved, 9(2), pp 117-125.
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Managing Aphasia in a Culturally Diverse World
Working with Aphasia:
The Latino Experience
Luis F. Riquelme, M.S.,CCC-SLP,BRS-S
Asst. Professor, New York Medical College
Director, Riquelme & Associates, PC
Director, Center for Swallowing and Speech-Language
Pathology @ New York Methodist Hospital
The Latino Experience
The U.S. Census:
There are “un montón” of us
We are the largest ethnic minority in the U.S.
So, why are we still
a “minority?”
The U.S. Census, 2006:
44.3 million Hispanics in the U.S.
(299 million non-Hispanics in the U.S.)
= 14.8% of the U.S. population
Expected to grow to 17.8% by 2020
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Latinos:
Origin
Mexicans
Puerto iR
cans
Cubans
Dominicans
Centra
l Americans
Where are we from?
2000
2006
58.5%
64%
20.6million
9.6% not on
theIsland
3.4million
+ 3.8millionontheIsland
3.5%
2.2%
4.8%
7.6%
Larges
t: El Salvado
r,
Guatemala
South m
Aericans
3.8%
Larges
t: Colombia
Other aLtinos/Hispanics
17.3%
A few more facts…
Median age: 27.2 years / 36.2
nationwide
Age 65+: 4.8% / 12% nationwide
In 2005:
60% of 1.3 million “new” Hispanics were
U.S. citizens (born here).
Nearly 40% of school-age children
speak a language other than English at
home. Of these 80% speak Spanish.
Why are some people afraid of us?
We tend to retain our native language
more than other bilingual groups
We are bilingual (hmmm…)
We are increasingly becoming
educated
We are influencing the media: TV,
music, trends
We are influencing fashion
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HISPANICITY
Who are we?
Hispanic vs Latino
Which generation?
The U.S. Census: on
race/ethnicity
IMMIGRATION
A way to
understanding
who we are…
Time of arrival
Areas of settlement
“Reception
experiences”
DISCRIMINATION / RACISM
A way to understanding who we
are…
“Oh, you are so educated…”
“Gee, you speak English so well…”
He’s blonde, he cannot be “Spanish.”
“They should learn to speak better
English”
“He got that far because they had
quotas to fill.”
“All they do is drink and dance…”
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Latinos/Hispanics:
NOT UNI-DIMENSIONAL
The “Latino +” factor
The super-multiculturals:
Latino + religion
Latino + GLBT
Latino + Golfer
Latinos/Hispanics:
A BILINGUAL PERSPECTIVE
SLPs are increasingly likely to provide
services to bilingual pts with aphasia
(Centeno, 2009; Paradis, 2001).
Goal of language Tx with the bilingual
pt:
To achieve maximum possible level of life
participation;
To improve communication in both
languages
Latinos/Hispanics:
CHALLENGES FROM A BILINGUAL PERSPECTIVE
Access to bilingual Dx/Tx
Availability of materials in both
languages
Availability of bilingual SLPs
Conceptual challenge: Focus on
one language or both in Tx?
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Bilingualism in Aphasia:
NEUROLINGUISTICS
Bilinguals possess an intermixed lexical
and morphosyntactic organization
This “intermixed neurolinguistic
organization” provides support for
bilngual Tx, and also for Tx in a single
language. Transfer via shared neural
networks? (Kohnert, 2009).
Cross-language transfer (CLT): evidence
inconsistent. Are L1 or L2 equipotent for
language/communication gains?
Bilingualism in Aphasia:
EVIDENCE BASE
Effect of treatment for bilingual
individuals with aphasia: A systematic
review of the evidence.
Authors: Faroqui-Shah, Y., Frymark, T.,
Mullen, R., Wang, B.
Journal of Neurolinguistics (2010)
Bilingualism in Aphasia:
EVIDENCE BASE - Findings At-A-Glance
Tx provided in L2 yields (+)
receptive and expressive language
outcomes even in chronic bilingual
aphasia;
CLT does occur in over half of the
participants
Age of acquisition of L2 has little
differential effect on outcomes
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The Latino experience: Assessment
Essential elements:
A good interview
current/ future communication needs
level of bilingualism PTA
level of education
Formal tools
What’s available in other languages?
Informal tools
Automatisms, Abstract Language
Communicative Competence
Grammatical competence
phonological, syntactic, lexical
Sociolinguistic/Sociocultural
competence
Discourse competence
Strategic competence
Culturally Competent Assessment:
Ethnographic Interviewing
Essential elements:
good listening skills
select appropriate types of questions
skill in presenting open-ended
questions
skill at looking for patterns and
common themes
(Westby, 1990)
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Culturally Competent Assessment:
Ethnographic Interviewing
Outcomes:
conveys empathy/acceptance of the world
as defined by informant;
collects necessary information
helps equalize power differential
allows examiner to discover the family
culture
helps reduce potential bias
(Wesby, 1990)
Bilingual Assessment:
Test Modifications
Reword instructions as needed;
Allow additional response time;
Record all responses for later analysis;
Accept culturally appropriate
responses;
Repeat stimuli as needed;
Use culturally approp. materials
Kayser, H. (1995)
Bilingual Assessment/Treatment:
Use of Interpreters
Definitions:
INTERPRETER: transposes oral or signed
text from one language to another;
TRANSLATOR: transposes written text
from one language to another;
Training
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Bilingual Assessment/Treatment:
Use of Interpreters
Not every bilingual person has the ability to
be an interpreter
In addition to proficiency in two languages,
other needed skills are:
Ability to say the same thing in different
ways
Ability to shift styles
Ability to retain chunks of information
while interpreting
Familiarity with medical, educational and
professional terminology
(Langdon, 2002)
The Latino experience: Treatment
Essential elements:
Language of choice for Tx
Pre-morbid language history
Strengths/weaknesses in each language
Environmental factors
Other factors to consider (e.g., code
switching, patient’s desire)
Materials for Tx
The Latino Experience
Parting thoughts…
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The Latino Experience
Centeno, J. (2009). Issues and principles in service delivery to
communicatively impaired minority bilingual adults in neurorehabilitation.
Seminars in Speech and Language, 139-152.
Kohnert, K. (2009). Cross-language generalization following treatment in
bilingual speakers with aphasia: a review. Seminars in Speech and
Langauge, 30, 174-186.
Kohnert, K. (2004). Cognitive and cognate-based treatments for bilingual
aphasia: a case study. Brain and Language, 91, 294-302.
Langdon, H. (2002). Interpreters and translators in communication
disorders: A practitioner’s handbook. Thinking Publications, WI.
Riquelme, L.F. (2006). Working with limited English speaking adults with
neurological impairment. Perspectives in Gerontology, 11(2), 3-8.
Westby, C. (1990). Ethnographic interviewing: Asking the right questions
to the right people in the right ways. Jnl of Childhood Communication
Disorders, 13(1), 101-111.
Managing Aphasia in a
Culturally Diverse World:
African Americans with Aphasia
Panel Member: Joyce L. Harris, Ph.D., CCC-SLP
The University of Texas at Austin
American Speech-Language-Hearing Association National
Convention
Philadelphia, PA
November 2010
Evidence-Based Practice
The road to EBP
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International Classification for Functioning
and Disability (ICF)
Short Shrift
Body structure and Function
Research-based evidence
Clinical Expertise
Client preference
Activities and participation
Client Preferences
Culturally-influenced activities and participation
Contextual factors
Aphasia in African Americans
Large population segment
Higher incidence of morbidity and chronic
disability1, 2
Higher risk for medical conditions
associated with aphasia1, 2
Least likely to volunteer as participants in
research investigations3
Underrepresentation in the full range of
rehabilitative and supportive services
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The challenges of managing
aphasia in African Americans
Relatively low number of African
American SLP/Aud professionals
Lack of confidence in their educational
preparation to serve African American
adults
The challenges of managing
aphasia in African Americans
The challenges of managing
aphasia in African Americans
Lack of population-specific assessment
and treatment protocols
Lack of evidence-based interventions
for African American adults
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The challenges of managing
aphasia in African Americans
Large population segment
Higher incidence of morbidity and chronic
disability1, 2
Higher risk for medical conditions
associated with aphasia1, 2
Least likely to volunteer as participants in
research investigations3
What we need to know
Incidence and prevalence of aphasia in African
Americans
Culturally-influenced thresholds for “normalcy” in
cognition, language, and communication
Extent of knowledge regarding the prevention
and treatment of acquired communicative
disorders
What we need to know
Which, if any, social and cultural
distinctions are critical to effective
interventions?
In what ways are social and cultural
distinctions modified by an individual’s
acculturation status?
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Basic Assumptions
African Americans have a culture that is
qualitatively different from the
mainstream U.S. culture.
The professions of audiology and
speech-language pathology are
entrenched in mainstream culture.
There is a likelihood of cultural
mismatch.
Basic Assumptions
Human communication cannot be fully understood
without considering the cultural context in which it
develops and the social context in which it is used.
Socially and culturally congruent clinical services are
inherently more effective.
SLPs are obligated to serve as cultural mediators
between mainstream rehabilitative and medical
institutions and adults from diverse backgrounds.
The Great Migration:7The Source
of African American Culture
The Great Migration lasted for over 60 years
Six million Americans of African descent left the agriculturallybased South for urban centers in the North.
They left to escape the caste system imposed by so-called Jim
Crow laws—legally sanctioned segregation and oppression.
The magnitude of this social upheaval surpassed that of the
Gold Rush or that of the Dust Bowl.
These immigrants brought with them remnants of their culture
and infused their culture into the every aspect of American
culture. food, music, worship, language, etc.
The culture of these early immigrants is the substance of
African American culture, the ethnocultural identity of many
African Americans.
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Variability in African American
Culture
Traditional: immersed in culture of
origin
Bicultural: Immersed in culture of origin
as well as in mainstream culture
Acculturated: Immersed mostly in the
dominant (mainstream) culture.
African American Acculturation Scale-R
Landrine, H., & Klonoff, E. A. (1996)
Cultural Adapted Intervention
Consider communicative roles and contexts
Vocational
Social interactions
Community affiliations
Role-maintenance and communicative needs
Culturally Adapted Assessment
Mainstream Identity
Social identity
Corporate worker
Middle-class values
Blood kinships
Religious affiliation
Ethnocultural Identity
Social identity
Protestant
Working professional
Geographic identification
Blood and fictive kinships
Religious affiliation
African American Church
Communication Style
Standard American
English
Low context style
Choir member
Usher Board
Bereavement Committee
Women’s/Men’s Ministry
Communication style
Code switiching
High context style
Verbal play
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Some Core African American
Values
Resilience
Resourcefulness
Religiosity
Expressiveness
Transcendence
In-group/out-group distinctions
What We Need to Know
Incidence and prevalence of language
impairing disorders in adults from CLD
backgrounds
Culturally defined thresholds for
“disordered” in cognition, language, and
communication
What We Need to Know
Extent of knowledge regarding the
prevention and treatment of acquired
communicative disorders
Relative effectiveness of culturallyadapted therapeutic and supportive
communication interventions
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Selected References
1. Nyenhuis DL, Gorelick PB, Freels S, Garron DC. Cognitive and functional decline in
African Americans with VaD, AD, and stroke without dementia. Neurology.
2002;58(1):56-61.
2. US Department of Health and Human Services. A Statistical Profile of Black Older
Americans Aged 65+. Washington, DC: Author; 2006.
3. Harris JL. Issues in recruiting African American participants for research. In: Kamhi AG,
Pollock KE, Harris JL, eds. Communication development and disorders in African
American children: Research, assessment, and intervention. Baltimore: Paul H. Brookes
Publishing Co.; 1996:19-33.
4.Robey R, Apel K, Dollaghan C, et al. Report on the Joint Committee on Evidence-Based
Practice: American Speech-Language-Hearing Association; 2004.
5. Jandt FE. An introduction to intercultural communication: Identities in a global
community (5th ed.). Thousand Oaks, CA: Sage; 2007.
6. Landrine H, Klonoff EA. African American Acculturation: Deconstructing race and
reviving culture. Thousand Oaks, CA: Sage; 1996.
7. Wilkerson, Isabel (2010). The warmth of other suns: The epic story of America’s greatest
migration. New York: Random House.
Managing Aphasia in a
Culturally Diverse World:
an international perspective on the impact
of diversity on aphasia intervention
Hariklia Proios, PhD, CCC-SLP
Human Resources
All European countries have imbalances in supply
of speech therapists and other health care
professionals
WHO promotes integrated development of health
systems and human resources to ensure a supply
of personnel with competencies relevant to the
country needs and balanced according to
occupation, specialty and institution.
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European perspective
Much of what is normally considered a part of
therapist role in other countries is undertaken
by doctors including neurologists, or
neuropsychologists and linguists.
Caring for clients from many different cultural
backgrounds; also speech therapists may
come from various cultures (common in
Greece)
SLP can give preventative, curative and
rehabilitative care but in practice most do not
have a proper job description and are
subordinate to doctors.
CPLOL
only the permanent coordinating committee
for speech language therapists or logopedics
in the European Union and consists of 31
organizations in 28 countries. It represents
60.000 employees
http://europa.eu/abc/european_countries/eu_members
Annual statistics of initial education data in Europe, CPLOL, 2009
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CPLOL
IS THIS APHASIA ??-video
Communication confusion in a “title”
In US-Canada,Australia
“Speech Language Pathologist “
Europe….
In Germany, Belgium as well as Balkan countries
the term used is Logopaedic
In the UK the term used is Speech-Language
Therapist
In the Czech Republic the term used is
Phoniatrist
In France the term is Orthophonist
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National organizations in Greece
20-25 speech therapists began practicing earlier but it wasn’t
until 1982 various organizations were founded..
in 1996 the first Technological Educational Institutes (TEI 4year programs) were established, not at university level.
Their graduates formed an organization called SELLE.gr but
ASHA only lists one organization, the Panhellenic
Association of Logopedics…WHY?
over 5 organizations with over 50 members each claiming to
service communication impairments!
Tsoukala M., Tziorvas R., (1995) The development of a new era of SLP in Greece,
American Journal of Speech Language Pathology, Vol. 4 No 1.
Resources in Greece
Today there are three speech-language
departments in state run Technological
Educational Institutes and few private colleges
providing SLT degrees
Thus, practitioners have training from various
countries with very different backgrounds
(speech therapists, linguists, psychologists,
special educators, doctors, etc) providing speech
language and swallowing services, including
aphasia.
2010
• Akmi Metropolitan College: approved
program for a BSc in Speech-Language
Therapy running in Thessaloniki Greece
• currently only two BSc offered in Athens
and one in Thessaloniki
• Degree is from the University of Wales
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Speech services and insurance
IKA – the main health insurance
provider of Socialized Health Care for
employees of state and private
organizations has been cut substantially
when approved, which is becoming
more difficult, services are performed
privately by private practitioners others
do not get services, perhaps occasional
consultations with therapist.
Speech services and definition
no Quality Control for services
provided at a hospital or private level
Lack of clear role and definition of the
profession
Boundaries between and within
professionals with some degrees but may
even be 2-year programs (as young as
20 years of age servicing aphasics
independently)
Role of Rehab is diverse
The list of specialists is endless
Terms such as “specialist” and
“advanced” are still controversial and
definitions are not universally accepted
Advanced practice is generally
supported by higher education
resources
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Greek Aphasia Group Website (1)
http://www.aphasia-group.gr
Greek Aphasia Group Website (2)
http://www.aphasia-group.gr
Aphasic support groups
Part of our clinical activity in the area
of rehabilitation, is also a support
group
to establish a therapy efficacy group
(problems included: Drop-out rates,
No good control group etc.)
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Acknowledgements
Thanks to the:
• National Aphasia Association
Prof. Luis F. Riquelme, M.S.,CCC-SLP, BRS-S
Ellayne S. Ganzfried, M.S., CCC-SLP
• We would like to gratefully acknowledge
the AKMI Metropolitan College
Touro College Russian-Speaking Aphasia Group
: Considerations and Participants’ Feedback
By Isabella K. Reichel, Ed.D., SLP/A
Board-Recognized Fluency Specialist
Associate Professor, Touro College
Graduate Program in Speech Pathology
Living in a Multicultural World
In countries world over, the word multicultural
is becoming more relevant to most people
Immigrants contribute their culture to their new
country, and the culture of the host country
influences the lives of immigrants
Regardless of culture, a communication
disorder can interfere with a person’s
performance in all areas of life
(Threats, 2010)
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Goals for this Presentation
This presentation will address the
clinical linguistic and cultural
considerations in the process of
development of the aphasia group for
Russian-speaking stroke survivors
Participants’ perceptions of their
communication skills and their quality of
life as a result of attending the aphasia
group will also be discussed
Immigrants from Russia
Russians are the biggest Slavic community in the
USA, after immigrants from Poland
Nearly 2,000,000 Americans are of Russian origin,
per U.S. census, 2000.
433,000 Russians received permanent resident
status in the U.S.A. during the 1990s
Although Russian immigrants are well assimilated
into American life, they maintain their own
identity, the Russian language and culture in their
new country
2009)
(Anders,
Challenges of RussianSpeaking PWA
Russian immigrants who suffer from aphasia, living
in a country with cultural and language differences,
face more barriers and stresses that interfere with
their quality of life and their communication skills
Usually, people with aphasia (PWA) try to deal with
these issues by seeking a Russian-speaking speech
pathologist and books in their native language, so
they can practice with family members.
They face a dearth of speech-language
pathologists and materials in Russian
This leaves them frustrated, hopeless, and
depressed
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Creation of the RussianSpeaking Aphasia Group
Considering the great importance of culture and
language for successful treatment of PWA, a
Russian-speaking group was created by this
presenter at Touro College in the Spring of 2009
I extend my appreciation to the strong support of
Professors Hindy Lubinsky, Rosalie Unterman, and
Felicia Gironda, of the Touro graduate program in
Speech-Language Pathology, and Dr. Dorothy Roth
from AphasiaNYC who has been encouraging me to
create a Russian-speaking group for about a
decade.
Clinical Considerations for the
Aphasia Group
Research as to benefits of group treatment over
individual therapy:
Facilitates the transfer of functional communication
skills to outside situations by improving turn-taking,
conversation initiation, and increasing other
communicative functions, as well as more natural
activities and a variety of partners.
May increase the participation in community life,
increase psychosocial functioning and adjustment to
life.
A cost effective model for the participants.
(Elman, 1999)
Linguistic, Sociopolitical, and
Cultural Considerations
Using space
Touch
Eye contact
Silence
Posture
Movements
Dress
Objects
Artifacts
(Samovar & de Porter,
1991)
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Language of Instruction
Clients with abnormal code-mixing and codeswitching, and those who live in mostly
monolingual environment will benefit from
unilingual therapy
When clients speak in their native language
at home, they feel safe and in control, even
though they are living in a world where a
different language is spoken all around them
(Faroqi-Shah et al, 2010)
CLT Depends on
Structural language differences
Pre-stroke language proficiency
Lexical retrieval and syntax
Type of aphasia
Severity of the aphasia in each
language
Size of the lesion
(Faroqi-
Other Variables Influencing the
Choice of Language of Instruction
Word frequency
Imageability
Age of language acquisition
Cognate status (words with similar form
and meaning in different languages)
There are differences in the processes
of L1 and L2 when L2 is restored after
L1
(Weekes,
2010)
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Difficulties Assessing the Outcome
of Aphasia Treatment
There is a correlation between the quality of life
and communication disorders
The quality of life was not widely measured in
aphasia patients since the responses rely on
understanding, speaking, and writing language
(Bose et al.,
2009)
An aphasia-friendly survey entitled “Self-Rating of
Communication Skills and Quality of Life by
Russian-Speaking Aphasia Group Participants” was
created and presented to the group participants.
Participants
6 people with aphasia and 1 person with dysarthria
participated in the group
4 males and 3 females
Ages ranged from 62 to 83
Education level ranged from high school to Ph.D. & M.D.
Russian was the native language of 5 participants; 2
people were early simultaneous bilingual Yiddish and
Russian speakers
4 spoke English as a 2nd language; 2 had some proficiency
in German or French; & 1 had some proficiency in
Ukranian, Polish, Hebrew, Italian, and Spanish
Participants (Continued)
Residence in USA ranged from 16 to 21
years for 5 participants, and 32 years for 1
participant
Time after stroke ranged from 1½ to 7
years
Time people attended the group ranged
from 5 months to 1 year
6 preferred Russian as the language of
instruction; 1 preferred English but could
not speak or understand it
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Group Therapy
All participants attended group
treatment for 2 hours per week,
conducted by a Russian-speaking
speech-language pathologist and 2
Russian-speaking graduate students
All participants had a history of
traditional didactic therapy before
attending the group
4 participants received individual or
small group therapy at Touro during
Group Therapy (Continued)
The group considered the collectivistic culture typical for Russia,
including 1 participant representing the whole group
Activities included: sharing personal stories, engaging in
personal interactions, singing Russian songs together, playing
jeopardy games, etc.
Topics of discussions focused on participants’ interests and
strengths, including recovery, positive attitudes, family, former
professions, politics, historic events, literature, food, travel, etc.
The group atmosphere was optimistic, enthusiastic, and cheerful
Participants inspired each other, joked, laughed, and reacted
with joy to every success in the group
Positive emotions and positive thinking were consistent
components of the group activities and interactions
10 Cognitive and Affective
Transformations
Slavery to freedom;
Fear to courage;
Doubts to trust;
Anger to empathy;
Helplessness to
control;
Shame to
confidence
Frustration to
happiness;
Avoidance to
assertiveness;
Struggle to victory;
Withdrawal to joy of
communication.
(Reichel,
2007)
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Self-Rating of Communication Skills and
Quality of Life by Russian-Speaking
Aphasia Group Participants
SELF-RATING OF QUALITY OF
LIFE (Pre-Treatment / PostTreatment)
SELF-RATING OF
COMMUNICATION SKILLS (PreTreatment / Post-Treatment)
1 to 8 (2 people)
1 to 5 (3 people)
1 to 5 ( 2 people)
1 to 7 (1 person)
2 to 9 (2 people)
3 to 8 (2 people)
1 to 6 (1 person)
3 to 1 (1 person)
Participants’ Feedback
in Their Own Words
“The group is a miracle in our lives.”
“The group is a blessing from God.”
“Every meeting is a return to life.”
“The group gives a sense of recovery.”
“The group is a continuation of life.”
“The group is a victory and hope.”
“I used 1-word; now I use 5-6 word sentences.”
“I speak on the phone now.”
“Every member of the group made fantastic progress.”
“The group is a great stimulus, giving confidence and
support to each other.”
References
Anders, J. (2009). New immigrants live Russian and American
lives. For retrieval, http://www.america.gov/st/peopleplaceenglish/2009/June/20090617175234ZJsrednA0.6852075.html
Bose, A., McHugh, T., Schollenberger, H., & Buchanan, L.
(2009). Measuring quality of life in aphasia: Results from two
scales. Aphasiology, 23, 797--808
Elman, R. J., & Bernstein-Ellis, E. (1999). The efficacy of group
communication treatment in adults with chronic aphasia.
Journal of Speech, Language, and Hearing Research 42, 411—
419.
Faroqi-Shah, Y., Frymark, T., Mullen, R., & Wang, B. (2010).
Effect of treatment for bilingual individuals with aphasia: A
systematic review of the evidence Journal of
Neurolinguistics,(23)4, 319-341
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References (Continued
Reichel, I. (2007). Emotional intelligence and stuttering
intervention. 10th International Stuttering Awareness Day
Online Conference [Minnesota State University, Mankato.
For retrieval,
http://www.mnsu.edu/comdis/isad10/isadcon.html; for
international dialogue,
http://www.mnsu.edu/comdis/isad10/papers/reichel10.ht
ml].
Samovar, L. A., & Porter, R. E. (1991): Basic Principles of
Intercultural Communication. In Larry A. Samovar and
Richard E. Porter: Intercultural Communication: A Reader.
CA: U.S.A.: Wadsworth, Inc.
Weekes, B. S. (2010). Issues in bilingual aphasia: An
introduction. Aphasiology, 23(2), 797--808
Managing Aphasia in a
Culturally Diverse World
Education and Community Outreach
in Multicultural Aphasia Contexts
Ellayne S. Ganzfried, M.S., CCC-SLP
ASHA Fellow
Executive Director
National Aphasia Association
ASHA 2010
National Aphasia Association
(NAA)
NAA is a consumer-focused, not-for-profit organization
that was founded in 1987 as the first national
organization dedicated to advocating for persons with
aphasia and their families. Resources include:
NAA Hotline (800-922-4622) helps over 4,000
families a year.
NAA National Registry links to over 440 US and
International aphasia support groups and 220 state
representatives
www.aphasia.org receives over 30,000 hits per
month, potentially helping over 150,000 families a
year.
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NAA Resources, cont’d
The Aphasia Handbook: A Guide for
Stroke and Brain Injury Survivors and
Their Families -- with its simple, illustrated
design and practical, non-technical content –
this award-winning, internationally acclaimed
book is a user-friendly, easy-to-understand
resource.
Aphasia Bill of Rights adopted in 2006,
available on www.aphasia.org
News Bulletin
Multicultural Task Force (MTF)
Formed in September 2007
Members reflect various settings;
variety of languages/cultural
experiences and expertise
Monthly conference calls
Mission and Goals
The mission of the NAA’s Multicultural
Task Force ( MTF) is to enhance the
understanding and intervention of
aphasia and its consequences in
different linguistic and sociocultural
environments
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Mission and Goals
The MTF’s mission includes the following
goals:
1. To bring together the input from a multidisciplinary
cohort of researchers and practitioners as well as
people with aphasia to clinical practices.
2. To link research on aphasia in different languages
and in individuals from different cultures to clinical
practices.
Mission and Goals
3. To bring together the input from both national and
international researchers and practitioners.
4. To collect and disseminate literature on aphasia in
different languages and in individuals from different
cultures among researchers, practitioners, and
people with aphasia.
5. To be an active resource center for the national and
international public.
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MTF Accomplishments
Creation of MTF web page
Recruitment of multicultural state
representatives
Fostering the creation of multicultural
support groups
Press release on MTF and issues
MTF Accomplishments
Newsletter articles on multicultural
topics
Translation of NAA brochure into
Spanish, Greek, Chinese, Tamil,
Portuguese, Hebrew, Korean , Russian,
French, Arabic and German
Revision of NAA Mission and Bill of
Rights
MTF Accomplishments
Received 2010 ASHA Multicultural
Project Grant for Todavia Soy Yo! Aphasia
Film Project for Hispanic Persons with
Aphasia
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MTF Accomplishments
Collaboration with related organizations
and outreach to international aphasia
community
http://issuu.com/latinonewyorkmagazine/docs/april_2010
http://issuu.com/latinonewyorkmagazine/docs/marchissue
Sub-Committees
Language Bank/Availability
To find ways to access professionals
around the country( and internationally)
that provide professional services, in
languages other than English, to
persons with aphasia
These persons should be vetted and
recommended
Sub-Committees
Outreach Plan
To develop an outline/plan for reaching
out to other professional groups.
Plan includes outreach to organizations,
hospitals , etc.
Use of NAA state representatives to
facilitate project
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Next Steps
Expand MTF membership and
multicultural state representative
network
Brochure translation into additional
languages
Creation of DVD and/or on line video
about aphasia in other languages
Next Steps
Formalize Outreach Plan
Expand Language Bank/ Availability
Survey of constituents to determine
current and future needs; access to
resources and availability of
multicultural services
National Aphasia Association
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11/15/2010
National Aphasia Association
350 Seventh Avenue-suite 902
New York, NY 10001
(212) 267-2814
(212) 267-2812 (fax)
(800) 922-4622
www.aphasia.org
[email protected]
For More Information
Ellayne Ganzfried, M.S., CCC-SLP
Executive Director
[email protected]
Amy Coble
Information/Administrative Coordinator
[email protected]
42