Outcome evaluation in aphasia therapy: a participants' perspective

Evaluating the outcomes of aphasia therapy is a clinical activity which today probably is getting as common as assessing a person with aphasia prior to the intervention. In Denmark, the Act of Special Needs Education for Adults, emphasises that any given intervention provided under this Act must be evaluated.

A great number of tests, questionnaires and other outcome evaluation tools both for research and clinical purposes are identified in the aphasia literature, but new and better ways of assessing outcomes of aphasia therapy are still sought. Until now, research into clinical outcome evaluation has focused primarily on the number of therapists who assess outcomes, and the various methods that are employed. In-depth descriptions of current practice amongst clinicians is underresearched in terms of investigating the interactional process of outcome evaluation since making outcome evaluations is multifaceted and require more than choosing and using tools. Moreover, interaction has not previously been studied as a substantial method or mean by which outcome evaluations can be made, regardless of the involvement of formal or informal outcome measures. Interaction between the professional and the person with aphasia is the most significant instrument no matter if an assessment battery, a specific outcome measure, an informal scale, or merely dialogue is used. 

The aim of this thesis was therefore to investigate, which self-reported motives and interactional conditions are present in current practices of outcome evaluation amongst the researched population of Danish speech-language therapists and their clients with aphasia. It was directed by four research questions:

Why are speech-language therapists conducting outcome evaluation according to themselves?
What role does outcome evaluation – and the action of making it – play in aphasia therapy according to the speech-language therapists?
How is outcome evaluation constituted in and through interactional sequences with speechlanguage therapists and people living with aphasia?
How does the involvement of people living with aphasia take place in outcome evaluation according to the speech-language therapists and their actions?

The study was done by means of ethnographic exploration, and included studying speech-language therapists’ views of why outcome evaluation is made and the role it plays in therapy as well as describing, at a micro level, outcome evaluations as interactional activities between speechlanguage therapists and people living with aphasia. Data included 33 video recordings of outcome evaluation sessions and interviews with speech-language therapists, in total 12, participating in the videos. The findings were presented in three separate studies.

The first study sought to identify the demands for outcome evaluation as well as the role outcome evaluation plays in aphasia therapy in the clinic reported by the participating speech-language therapists in qualitative research interviews. Six themes corresponding with the aims of this study were identified, showing that the speech-language therapists initially evaluated outcomes because of external demands and interests. However, they also describe it as a necessary activity inherent to therapy and state that they would not want to be without it. Outcome evaluation is seen as an interactive process between clinicians, clients and, possibly, significant others. It is seen not only as a product in which outcome and/or client satisfaction is documented, but also as a dynamic process that benefits the clients, significant others, the therapy process and the clinicians themselves, in various ways. This role of outcome evaluation ranges from enhancement of insight and promotion of acceptance for the clients and significant others, to planning the next step in therapy or in life with aphasia after therapy. The results suggested an interesting relationship between treatment policy and treatment practice, where an initial administrative initiative is adopted by the speechlanguage therapists and made into a meaningful part of therapy. 

The second study focuses on how outcomes of aphasia therapy in Denmark are documented in evaluation sessions in which both the person with aphasia and the speech-language therapist take part. The participants negotiate agreements on the results of therapy. How agreements on therapy outcome are reached interactionally was investigated by using the principles and practices of the research method conversation analysis. Sequential analysis of video recordings of outcome evaluation sessions demonstrated a recurrent method for reaching agreements in these sessions. In and through a special sequence of conversational assessment it is claimed that the person with aphasia has certain communicative skills. Such claims are systematically substantiated by invoking examples of the person with aphasia performing this skill either outside or inside the therapeutic setting. Substantiation can be seen as a form of validation of the claim and thereby a basis is set for agreement. The findings suggest that in this type of evaluation, the requirements of producing a valid account in which the person with aphasia has been heard, are being met. 

The last study aimed to explore and describe speech-language therapists’ views of involving clients in decision-making in aphasia therapy, more precisely in decisions to be taken during outcome evaluation about continuation or discharge of therapy. Furthermore, the study investigated, how such involving activities were carried out in interaction between speech-language therapists, their clients with aphasia, and possibly significant others. The analytic process was accomplished in two steps, as a sequential mixed-methods study with two qualitative methods. Firstly, thematic analysis of interviews with the 12 speech-language therapists was done which resulted in two themes. Secondly, the findings from the interviews directed applied conversation analysis of video-recorded sessions with the same 12 speech-language therapists and their clients when evaluating outcomes of aphasia rehabilitation. The findings showed that all speech-language therapists in the study had a wish to involve their clients with aphasia despite recognition of language difficulties and other person-related barriers in all interlocutors. Through the interactional organisation of shared decision making processes, the clinicians took the lead, often by proposing suggestions. The clients got an opportunity to accept these suggestions or otherwise express their opinion within a limited provided context, also serving as communicative support due to aphasia. The shared decision making practice by the participants did not let the clients decide, whatever they wanted. Instead, it let the clients have choices within a particular framework. In some cases it meant that the only real option a client had was to accept choices suggested by the speech-language therapist. This finding suggests that genuine decision making between equal parties is not present and possible within a clinical context, additionally challenged by aphasia.

The three studies in the dissertation show, how the therapists navigate between standardised and individual therapy by using outcome evaluation as a method for involving people with aphasia. The studies therefore contribute to, how speech-language therapists become better decision-makers in clinical practice for the benefit of and together with their clients with aphasia. The findings in the studies are in accordance with the field of medical historians' description of medical education and development: the nineteenth century was a diagnosis era; the twentieth century was an era of interventions where methods for assessment and intervention were generated, whereas they predict the twenty-first century to be an era of decision-making. The challenge will be to offer research based knowledge to practitioners by which decisions for selecting and sequencing treatment can be made.