Are speech-language pathologists good at publicizing the
benefits of aphasia therapy and the results of their aphasia interventions? No.
At least not according to a number of prominent rehabilitation professionals
outside our profession.
One was Jeffrey Metter, a neurologist. Back in 1982 he wrote
in Asha magazine that SLPs' reports of patients' language test scores or
percentages of objects named fail to impress physicians and other stakeholders
in aphasia treatment. More than 30 years later, a physiatrist reviewing the
evidence on aphasia treatment approached us with the same concern. Although a
great champion of rehabilitation for aphasia and highly familiar with aphasia
research, this physician essentially mirrored Metter's comments. He told us
that physicians, policymakers and others rarely understand what SLPs do for
people with aphasia—what SLPs are supposed to do for specific types of patients
or at specific stages along the health care pathway—and many wonder why other
professionals (or even volunteers) cannot do the same thing. He said improved
scores on language tests and other such SLP-reported treatment outcomes mean
little to many stroke professionals.
The physiatrist then challenged us to develop an "elevator
speech" on aphasia and aphasia treatment: a short, clear "lay" description of
what SLPs can deliver and why SLPs should be providing these deliverables. We
are up for the challenge and, through this article, hope to begin shaping such
an elevator pitch with our colleagues.
Communicating our value
In considering how to define the importance of SLPs in
aphasia rehabilitation, we might draw from the field of health economics and
consider the concept of "value" of a service or product. According to health
economist Jeffrey Hoch, in a chapter in the 2013 book "Operations Research and
Health Care Policy", there are three points to
consider regarding value. First, value is the degree to which something is
useful for solving a problem or meeting a goal. Second, showing value involves
considering a problem from the stakeholders' view. And third, if we are not
part of the solution to their problem, we are irrelevant.
Thus, we need to determine what "problems" we are able to
solve from stakeholders' perspectives and describe our solutions in a way that
is understandable and relevant to them.
For example, many of us describe our work as remediating
language deficits in aphasia. However, the impact of a language disability is
not always obvious. While it is apparent to all that physical impairment, such
as hemiparesis, affects mobility and physical access, and that physiotherapy,
walkers and wheelchairs can help, the relationship of language impairment to
reduced life participation is not as easily understood.
Research from the field of knowledge transfer and exchange
tells us that merely informing others via articles or conference papers does
not change practice. Explanations need to make sense to—and take into account
the perspectives of—the stakeholder, whether that be a patient, the patient's
family, our medical colleagues, stroke research funders, administrators, policy
makers or others.
Thus, our elevator speech needs to:
- Describe aphasia in terms of its consequences for activities
involving communication and how it can restrict participation in life.
- Explain that although there is no cure for aphasia, there
are solutions that help patients/families live successfully with this chronic
- Use simple, meaningful language to convince those who
allocate resources, make referrals and fund services of the need for services
for people with aphasia.
- Indicate why aphasia is a problem for health care systems
and society, as well as for patients and their families, in terms of lost
productivity, increased health care costs and reduced adherence to treatment
- Explain the unique contribution of the SLP and relate it to
a broader context—the context of health care, stroke services and society.
When advocating for improved services, consider embedding the
language impairment in descriptions that highlight the impact of aphasia on
essential aspects of daily life—including key relationships, life roles and
activities—and the high cost of resulting social isolation. We typically use the ICF-based A-FROM (Living with
Aphasia: Framework for Outcome Measurement schematic) as a reference point so
that stakeholders can see the effects of aphasia on key life domains.
Proposed elevator speech
We propose that our elevator speech clearly state why
aphasia is a problem, offer solutions to the problem and explain why the SLP is
in a position to provide these solutions. In format, the speech could look
something like this:
Establish the problem for external stakeholders
- Aphasia is a language problem that masks inherent competence
and most dramatically affects conversational interaction (talking and
understanding), as well as the ability to read and write
- Conversational interaction is core to the ability to
participate in virtually every realm of adult life but is not listed as an
essential activity of daily living, as are the more obvious self-care
categories. ADLs are seen as a concrete, practical measurable component in
stroke care. Patients cannot be discharged without support for what is
considered a basic ADL: for example, the ability to care for oneself. However,
stroke patients with aphasia are often discharged without the supports needed
to engage in conversational interaction with significant others.
- Without the ability to participate in conversation, every
relationship, every life role and almost every life activity is at risk. With
additional reading and writing difficulties, the impact is devastating. The
results are not only barriers to accessing stroke/health care services and information,
but also an inevitable loss of self-esteem and a profound sense of social
isolation. Research indicates that social isolation and depression have a
significant negative impact on health. The resulting costs to patients,
families and the health care system are enormous, and the need to pay attention
to secondary prevention should not be underestimated.
Offer solutions to the problem
- Communication and conversational interaction should be seen
as an essential ADL. As part of a comprehensive communication treatment plan,
no patient with aphasia should be discharged without an evaluation of needed
communication supports, including training for key family members and ensured
availability of appropriate communication resources.
- Assessment should, therefore, include the impact of language
impairment on ADLs—including conversational interaction—so that intervention
focuses on key areas and is outcome-driven.
- Appropriate intervention can help minimize costly secondary
problems such as depression, family burden and more costly care. This
intervention needs to begin in acute care and carry through to rehab and
beyond. Intervention may include, but is not limited to, direct work on
language and functional communication.
- Speech-language pathology expertise in communication and
swallowing needs to be recognized and reinstated in order to address the
complex problems outlined above. Further, this inclusive notion must be part of
SLPs' training. Key intervention areas include addressing language impairment;
working directly with families on becoming a good conversation partner;
reading; writing; working with assistants and providing training and resources
to allied health professionals; providing education and psychosocial support to
patients and families; and referring patients to social workers and others with
expertise in aphasia.
Make the case for SLPs
- We need consensus on the skill set SLPs need to treat
patients with aphasia effectively. However, it is important to differentiate an
"approach" from any one single skill. Using a medical analogy, nurse
practitioners perform many tasks previously done by physicians, who now fill a
more holistic problem-solving role. If we want to comply with
cost-effectiveness trends in health care, we also have to ask ourselves what
others, such as occupational therapists, can do, what critical element we bring
to the table, and how to most effectively blend our expertise.
- We must communicate that aphasia treatment requires a
composite of knowledge and skill across areas such as brain and language,
evidence-based language assessment and rehabilitation, partner training and
communication support for others involved with patients, group treatment, and
counseling, including partnering with other professionals in these areas.
As SLPs, we need to communicate these messages effectively
if we want to bolster understanding of the value of our language and
communication services to patients with aphasia. And close work with our
colleagues in allied professions is necessary for this to happen. It would be
the cruelest of ironies if investment in aphasia treatment and care continued
to diminish because of our field's inability to recognize and communicate our
This article is based on Aura Kagan's keynote address at the
2012 International Aphasia Rehab Conference.