“I can’t hear it!” This was said by Mrs. A, a 67-year-old woman with aphasia, who actually hears fine. What she meant to say is that she can’t recall the sequence of sounds to express a particular word or idea. When we have that tip-of-the-tongue loss of a name, how do we try to remember it? What strategies are we using to get to that word that we can’t remember?
Our success depends on our ability to hunt and gather—and on the number of neural connections we can tap into to access the information. These skills are cognitive, not simply learned operantly.
In my last blog post, I talked about establishing cueing hierarchies and functional activities for our adult clients. This post looks at using the cueing hierarchy to stimulate the rewiring process. Sometimes I think that I am a sort of electrician rather than an SLP. I work on finding the connections based on observed behavior from evaluations or activities (like writing, gesturing or drawing) that require least intervention.
How do we develop these skills? How can we teach strategies for short and long-term functional success?
Sometimes, we spend the therapy session working on the most disabled aspects of the communication disorder: comprehension, word retrieval, writing and reading. But if we don’t tap clients’ best abilities to foster some success, and if we don’t address whether they are continuing to practice these skills outside the therapy room, how will compensatory skills, adaptive skills and new connections work for them?
Let’s look at Mrs. A, who said, “I can’t hear it.” She was telling me about the very connection that she lacks due to her aphasia: re-auditorization. She can’t hear the words or the phonemes that make up the words in what I call “her mind’s ear.” If given the first phoneme, or a carrier phrase, she almost always names the word. She is able to write the word about 75 percent of the time but can only read it aloud about 30 percent of the time. She will often be able to speak complex multisyllabic words or a short phrase when discussing a topic. Auditory and reading comprehension is 75 percent for paragraphs. She is very intact cognitively, but her affect varies emotionally from congenially engaged to depressed and angry.
She is about two years post-stroke and has an all-in-one AAC that she doesn’t use. Our goals must address her frustration by establishing immediate successful compensatory strategies for communication. Then we need to build skills that will help in the rewiring, so that she begins to cue herself. The rewiring will be difficult here because she doesn’t link the phoneme to the letters she is able to write. But if she can write the word and then read it aloud more often, she can develop a clear strategy for verbalization that will reduce her frustration.
We will begin by simply reviewing phonetic placement in monosyllabic words. I like to use real words—which have semantic value—rather than nonsense syllables. Consonant-vowels alone don’t work as well as consonant-vowel-consonants that mean something. Mrs. A started relearning that a /b/ means that the lips come together when starting a whole word like “beer.” We chose beer for the visceral, emotional connection it has for many people. We talked about when she might drink beer, such as at a baseball game, which lends itself to picture assistance to boost cognitive links. We initially used a mirror to model the placement while sitting next to her. We highlighted the first letter and said it with her. She saw the picture, then wrote the word.
Mrs. A can now produce the whole word “beer” after seeing a picture of it. Looking at the Cueing Hierarchy, we have moved from most clinician involvement to independent self-cueing for this phoneme. She is moving on to more phonemes rapidly so that we may not need to review every letter after a period of time. Mrs. A. is beginning to generalize the link to other sounds. New neuro-behavioral links and relinks are helping her associate the orthographic letter with a physical movement and the sound that is produced. New cognitive links and self-cueing has begun!
Next, she will need to use the strategy in controlled conversation and small groups to increase her comfort level and functional use outside of treatment. This is a big hurdle. Families and caregivers are crucial players and need to be instructed how to encourage communication without frustration. When possible, teach the caregivers and families how the strategy works. They will use it more readily at home and will see how it can work in a variety of situations, such as in restaurants.
Another client, Mrs. C, had a similar functional ability to write but not verbalize. With time, she was able to trace the first letter in the air to cue herself to say a word.
In both cases, skills that had been present were improved, then used to create a compensatory strategy for functional communication. We must teach our clients strategies for improving the scope of their communication without our cues, using their own strategies, thereby making them more independently functional. While available strategies are unique to each client, they usually take the form of low tech gesturing, drawing, writing, even circumlocution.
We want our clients to be learning and improving communication dynamically. If we always fill in all of the sentences or speak for them, they cannot make their own connections. When allowed to use strategies independently, they then blossom, not only communicatively but socially.
Betsy C. Schreiber, MMS, CCC-SLP, is a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders, and 18, Telepractice.