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>> Amy Natho: Welcome to our SpeechPathology.com e-learning Expert Seminar titled, “Developing and Using Scripts in the Treatment of Aphasia, Apraxia of Speech and TBI.” We're very honored to have Dr. Audrey Holland here today to present for us. My name is Amy Natho. I will be your moderator for this online course. At this time it is my great pleasure and quite an honor to introduce Dr. Audrey Holland. Audrey Holland, Ph.D., has had a long and productive career in working with people with neurogenic communication disorders and developing innovative treatment techniques in aphasia. She also has conducted research aimed both at increasing understanding aphasia and related disorders, and in evaluating the efficacy of treatment. So welcome, Audrey. We're very pleased to have you here with us today.
>> Dr. Audrey Holland: Thank you very, very much. It is really an interesting experience to be here. I don't think I have ever spoken so much to my computer in my life as I was getting ready for this. I want you to know that I really don't believe you can't see me. I really want you to know that I got dressed up for it and I cleaned my office. So I hope that you appreciate all of those little touches that I did for you!
I'm going to be talking about developing and using scripts in the treatment of aphasia and apraxia of speech and TBI (traumatic brain injury), and to some extent with PPA (primary progressive aphasia) as well. I think I better start by telling you what I mean by scripts. It is pretty much what most of you had some experience with in your high school days when you were in the senior class play. And since I know the background of many speech pathologists is in theater, maybe you might have had it later. It simply is a matter of learning an appropriate script and doing all of the techniques that you did and do in learning a script, but as that might apply to the treatment of aphasia.
One other comment I do want to make. I just realized that missing from my handouts is a reference to Aphasia Corner. I just want to get you to add that if you wish. It is www.AphasiaCorner.com on the Internet or email them at email@example.com. The reason I'm mentioning that is that they're developing some training materials and testing out some materials in which they're using scripting techniques to teach phrases. I'm going to talk about longer units, but it is a really good thing to point out at the beginning, that often just simply practicing with phrases is a really nice activity for some people with aphasia. Scripts don't have to be the long kind of things I'm talking about today. They can actually be started with phrases in many cases, or continued for people with more severe aphasias, as a way to get into scripting. So if you're interested in participating in those trials, you might want for contact Aphasia Corner.
Scripting Relies on Two Disparate Theoretical Underpinnings
So let me begin. I think scripting really relies on two rather disparate underpinnings. The first is the importance of scripts and stories in everyday communication. Way back in 1980, in one of his nifty novels, Tom Robbins pointed out that “We are the stars of our own movies,” and I think that is a useful way to think about this. Or, as David Krieger (2001) pointed out, “You are the author of your own story.” So the scripts are important in everyday communication, and that's one of the underpinnings.
The second is previous work that's been done on “whole task training” in aphasia. I'm going to be explaining that probably ad nauseum as we go on.
We Are Our Stories
In terms of our stories, we are our stories in some degree. My sense is that it is quite likely that stories get lost with aphasia. Many of our stories carry our own sense of identity, and they have a tie to our self-confidence and to our sense of safety. Both of those issues seem to me to be things that fall out pretty hard on people who have communication disorders. So I think the loss of identity is one major underpinning for why scripts and stories are important.
The second is illness narratives. There are powerful palliative and curative effects of illness narratives. I think that's probably pretty easy to justify if you just look at how many psychoanalysts would be out of work were it not for the importance of illness narratives. Comfort also lies in the repetition of stories, and repetition of illness narratives particularly. I ran aphasia groups for years at the University of Arizona and one of the things that happened in our group pretty consistently was that a new person would enter the group. These were people who had milder aphasias. People would enter the group and immediately someone would say, “Tell us about you. Tell us your stroke story.” That story would be told and everybody listened very, very intently to the story, and then everybody shared their stories with the person who had just told his for the first time. The thing that always amazed me about that was that some of these people had been in the group for two or three years, and still sat there listening entranced to other people whose stories they had heard maybe once a month for those two years that they had been in the group! So comfort not only is in the repetition of your own story, but in hearing repetition of those stories from someone else. So stories are part of this.
But then also there are much more straightforward scripts. For the purpose of the talk here, they're predictable verbal responses in interaction or routines. They’re not all that different from learning your part in a play from the script. But in normal life, they're more like things that you might say to the person who says he's not a solicitor when he calls once again on the telephone. I have three or four choice scripts that I use in kind of a random order for dealing with those kinds of things at my house. Another predictable verbal response might be what you say when someone says, “How do you get to your house?” Those are some examples of predictable verbal responses.
Then there are initiations and responses in canonical interactional routines. One of my examples is what I call the “Meeting Adrian” example. Adrian is one of my grandchildren, and Adrian was visiting at our house at a time when I had to go to a memorial service for the mother of a friend of mine who had died. I said, “Adrian, I'll be back in an hour or so.” He said, “Couldn't I go with you?” I said, “Well, certainly. But why would you want to do this?” Well, it never was clear to me until we were on our way there that what Adrian wanted to do was, as he put it, “to practice adult conversation.” What happened to Adrian as at this memorial service was that at the reception afterwards, tons of people came up to him and they all did the same thing. They said, “Are you visiting your Grandma?” “Where do you live?” “How old are you?” (Which you never ask to another adult, so that was not really practicing any form of adult conversation.) “Do you like to come to Tucson?” “How long are you staying?” And invariably, they ended with, “Your Grandma must be very proud of you.” So Adrian got very adept at running through this little bit of canonical interaction in which he was the respondent, not the initiator. I'm not sure that that actually counts as practicing adult conversation, because that sounds pretty child-like to me. But, anyway, there it was. It was an experience for him.
Two Sources Justify Scripting
So two sources that justify scripting are the importance of stories in everyday life and communication. That source comes to us through the study of social communication and discourse, and provides the rationale for this participation-based approach to treatment. I mean “participation-based” in terms of the ICF. We'll get into that a little bit later. Behavioral science provides the rationale for this contextual training approach and we're going to talk now at some length about that source.