Why should discourse be considered in aphasia rehabilitation?
Discourse is language that is beyond the boundaries of isolated sentences. It is the manner through which sentences are combined to form meaningful wholes. We can look at discourse as connected language. This concept developed from the field of sociolinguistics when Labov, in the 1960s, looked at speech styles in New York. It was also used in interactional sociolinguistics and was studied by several fields, including anthropology, history, sociology, linguistics, psychology, education, and, in the 1990s, speech-language pathology.
There are different discourse genres. The most popular one used in speech-language pathology is narrative discourse. Simply put, narratives are stories. We use these when we ask our patients to describe picture sequences, or have them read a paragraph and then recall the story later. We can also look at this by asking them to tell the story of their stroke, or a memorable experience, or a frightening experience. Another type of discourse is procedural discourse. One of the more popular elicitation methods used in research is, "Tell me how to make a peanut butter sandwich"; and the patient is asked to give the steps. Conversational discourse is when the person with aphasia is conversing with another person. There is also expository discourse, wherein there is one subject, with details that are logically related to that subject and that may not necessarily be in chronological order. For example, we ask a patient to talk about their stroke. They can discuss the symptoms of the stroke, the causes of the stroke, and the risk factors behind the stroke. These are not chronologically related - unlike a story - but they all revolve around one topic.
Why is it important that we consider discourse in aphasia rehab? From the patient's perspective, patients with aphasia choose to speak about their life experiences. They want to reconnect with their families and focus on communication that helps them with activities of daily living. If you were to put yourself in your patients' shoes and you only had very limited language, where would you want to put all your effort? This idea was underscored in the 1970s by the work of Holland and Sarno, wherein they would emphasize functional communication rather than linguistic accuracy for persons with aphasia. Persons with aphasia “communicate better than they talk,” in that there is very little relationship between the severity of the language impairment and the ability to communicate in daily life.
Also, from a clinical perspective, we want to get a comprehensive analysis of what our patients can and cannot do by examining how they perform in social contexts. Another important reason to consider discourse is that discourse allows us to examine the cognitive and linguistic aspects of expressive language via natural forms of communication.
Consider the following question. What are the various cognitive tasks that are required for engaging in our patients in discourse? Discourse is a complex task that involves executive skills, working memory, and long-term memory. For example, if you asked a patient to talk about his wedding day, he would need to recall information from his memory. He would need to select what to include and what not to include. He would need to remember what has been said and try to organize what he is about to say while accounting for what the listener may or may not know and also while maintaining that same topic.
Finally, it is important to consider discourse because it can be used to identify meaningful changes in communication that may not be detected on standardized battery tests.
Please refer to the SpeechPathology.com course, Discourse Intervention in Aphasia: The Clinical Value of Stories and Conversation, for more in-depth information on the importance of discourse in patient-centered care and various approaches to incorporating discourse in aphasia rehabilitation.