SPOUSES' UNDERSTANDING OF THE COMMUNICATION DISABILITIES OF APHASIC
PATIENTS
Joseph W. Helmick University o[ Kentucky, Lexington
Toshiko S. Watamori Tokyo Metropolitan Institute of Gerontology, Japan
John M. Palmer University of Washington, Seattle
The language skills of 11 aphasic patients were assessed through the use of the PICA. Spouse's understanding of the aphasic partner's language deficits was measured by rating the aphasic spouse on the Functional Communication Profile. Results indicate that spouses of aphasic patients view the patient's communication to be less impaired than it actually is. Implications for the counseling role of the speech pathologist in language therapy are discussed.
T h e traumatic occurrence of aphasia affects not only the individual patient but the family members as well. In fact, Buck (1969) described aphasia as not just a language problem but a "family illness." Several authors have commented that the family exercises a degree of influence on the language rehabilitation of the aphasic patient (Turnblom and Myers, 1952; Biorn-Hansen, 1957; Buck, 1969; Malone, 1969). Goodkin (1968, 1969) from attempts to modify the spouse's verbal interaction with the aphasic, concluded that the verbal behavior of the spouse may be reflected in the aphasic patient's verbal responses and, therefore, the spouse's verbal behavior can either facilitate or impede the language recovery of the patient. As early as 1951, Wepman commented that the ability of the family to estimate objectively the patient's language contributed to language recovery. Wepman indicated that the family must recognize the importance of its role in language therapy through an understanding of the "aphasic language disturbance and its correlates." Stoicheff (1960) amplified Wepman's perspective by indicating that the clinician's responsibility is not only to work directly with the aphasic but also to extend
;:238
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HELMICK, WATAMORI, PALMER:Aphasics' Spouses 239 his efforts to "making those around the dysphasic patient aware of his problem." Schuell, Jenkins, and Jiminez-Pabon (1967) present a concise yet complete discussion of the objectives of family counseling in which they note that the initial objective "is to help the family to understand and accept the limitations imposed by severe aphasia" (p. 375). The nature of the aphasic language deficit can be very complex and difficult for the family to understand. Yet, as the above comments have indicated, the ability of the family, in particular the spouse, to become informed about the patient's disabilities in language has an important influence on the course of language ilnprovement. Although there has been considerable comment on the importance of the family's understanding of the aphasic's communication, systematic investigations of the problem are lacking. Consequently, the purpose of this study was to investigate spouses' understanding of the communication disability of patients suffering from aphasia as a result of cerebrovascular accidents (CVAs). Specifically, the purpose was to determine if a relationship existed between the aphasic patient's communication disabilities and the degree of understanding of those disabilities by the aphasic's spouse. The study was planned as a broad investigation of the problem area and no attempt was made to manipulate the manner in which spouses received information about aphasic language disabilities. Since, as Schuell et al. (1967) commented, the burden for providing the spouse with information about the aphasic partner's language disability should fall to the speech pathologist, the study also sought to compare the spouse's understanding of the aphasic patient's communication deficit with that of the speech pathologist who had diagnosed the patient as aphasic. METHOD
Subjects The subjects for this study were the spouses of 11 aphasic patients. Each patient was residing with the spouse in the Seattle area. All 11 patients, according to medical evaluation, had suffered a CVA and had been diagnosed as aphasic by a certified speech pathologist. Pertinent subject characteristics for both spouses and aphasics are given in the Appendix. Procedures T h e Porch Index of Communicative Ability (PICA) (Porch, 1967a, b) was administered to the 11 aphasic patients by the same investigator using the standard test conditions described by Porch (1967b). None of the patients had been given the PICA previously. The overall PICA score was taken as a measure of each aphasic patient's communication skill. The Functional Communication Profile (FCP) (Taylor, 1965) was used to measure each spouse's understanding of his partner's aphasic communication.
Downloaded From: https://jshd.pubs.asha.org/ by a Univ of Auckland User on 04/08/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx
240
JOURNAL OF SPEECH AND HEARING DISORDERS
XLI
238-243
1976
As a comparative measure, the speech pathologist who had diagnosed the individual aphasic independently completed the FCP for the patient(s) with whom he was familiar. For purposes of this study, the nine-point rating continuum developed for the FCP was modified to yield a six-point rating system with categories of " n o change" (from preaphasic language), "lesser efficiency" (compared to preaphasic language), " u n i m p o r t a n t errors," "important errors," "cannot do," and ,unknown." It was felt that the revised categories would alleviate the need for explanation, thus reducing potential experimenter bias, and would not have any differential effect on the two categories of respondents, spouses and speech pathologists. Each of the categories was assigned a numerical value of 5, 4, 3, 2, 1, or 0 respectively. Respondents were to check the category which most nearly described the aphasic patient's behavior for each item on the FCP. Understanding of the aphasic patient's communication skill was represented by mean scores obtained from the FCP. In addition to the mean scores, differences in scoring between the spouses and the speech pathologists were noted through the use of a plus-minus scoring system. While the plus-minus system described the direction in which scoring differences occurred, it did not indicate the extent of differences in scoring between spouses and speech pathologists. If the spouse recorded a higher rating than the speech pathologist on an FCP item, a plus was recorded. Conversely, a minus sign indicated that the spouse gave a lower rating on that item than did the speech pathologist. A frequency count of the pluses and minuses was made for each of the 45 test items. RESULTS
AND
DISCUSSION
A comparison of the FCP scores given by the spouses of the 11 aphasics with the overall PICA scores for the aphasics was made using the Pearson productmoment correlation coefficient. This comparison yielded a significant but negative correlation of --0.66 (p < 0.05). Thus, spouses tended to assign ratings indicating good communication performance in association with poor PICA scores. In contrast to the spouses' ratings, the FCP ratings of the speech pathologists showed a positive and significant relationship to the obtained PICA scores (r = 0.89, p < 0.001). Table 1 contains the mean and standard deviation obtained from administration of the PICA to the 11 aphasic patients and from administration of the TABLE 1. Means and standard deviations PICA and FCP
for
Test
Mean
SD
PICA FCP, spouse FCP, speech pathologist
10.63 3.93 3.07
1.69 0.70 0.87
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HELMICK, WATAMORI, PALMER: Aphasics' Spouses 241
FCP to both the spouses of the aphasics and to the speech pathologists. A comparison of the FCP scores for spouses and speech pathologists indicated significant differences in the rating of the aphasic's communication by the two groups of respondents (t =2.66; df = 20; p < 0.01). In order to assess accurately the direction in which differences in the ratings given by the spouses and those given by the speech pathologists occurred, it was necessary to determine the number of "unknown" responses recorded by each group and to discard these responses from additional analyses. Use of the plus-minus scoring system in which "unknown" responses were omitted indicated that while spouses and speech pathologists agreed on approximately 40% of the test items, differences in rating occurred on 60% of the items. A frequency count of pluses and minuses, representing score differences between speech pathologists and spouses on the FCP items, revealed 194 positive differences (spouse rating higher than speech pathologist) and 56 negative differences in the ratings (spouse rating lower than speech pathologist). This represents a significant tendency for spouses to judge the aphasic's communication as less impaired than do speech pathologists (Z~ = 76.18; d[ = 1; p < 0.001). CONCLUSIONS
The data reported in this study indicate that the aphasic patient's communication efforts are not clearly understood by the patient's spouse. The spouse tends to view the aphasic's communication as less impaired than it actually is. This positive bias on the part of the spouse might well provide some level of emotional support for the aphasic. On the other hand, this lack of understanding might also lead to the establishment of unrealistic expectations for language performance and to the use of inappropriate amount and type of language while interacting with the aphasic. The overall result might well be frustration and depression on the part of the patient. During a brief interview with the spouses, it was noted that most of the spouses reported no alterations in their manner of verbal interaction with their aphasic partner following the CVA. Only a few spouses indicated that they had consciously attempted to "talk in short simple sentences" using step-by-step accounts of "complicated" matters. The general lack of understanding of the aphasic's linguistic impairments, then, can be expected to create some difficulty in the spouse's ability to establish appropriate verbal interactions with the aphasic and can become, therefore, an interfering factor in the language rehabilitation process. T o the extent that the data in this study represent spouses' understanding of their partner's language impairment, it seems reasonable to conclude that the speech pathologist must counsel the spouse of an aphasic patient in order to increase that spouse's understanding of the aphasic's deficits. This counseling role becomes exceedingly important when the aphasic patient is released to an outpatient status or when he is discharged from a formal management
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242
JOURNAL OF SPEECH AND HEARING DISORDERS
XLI
238-243
1976
p r o g r a m to t h e h o m e s i t u a t i o n . U n d e r these c o n d i t i o n s , the spouse a n d all m e m b e r s of the h o u s e h o l d m u s t assume the i m p o r t a n t r o l e of c o n t i n u i n g to p r o v i d e t h e a p h a s i c w i t h a p p r o p r i a t e v e r b a l s t i m u l a t i o n s for m a i n t e n a n c e , if n o t a d d i t i o n a l i m p r o v e m e n t , of his l a n g u a g e skills.
ACKNOWLEDGMENT At the time this research was conducted all authors were affiliated with the program in speech pathology and audiology, University of Washington, Seattle. Requests for reprints should be addressed to Joseph W. Helmick, 224 Taylor Education Building, University of Kentucky, Lexington, Kentucky 40506.
REFERENCES BIORN-HANSEN,V., Social and emotional aspects of aphasia. J. Speech Hearing Dis., 22, 53-59 (1957). BucK, M., Expressive language problems of the aphasic patient which interfere with vocational rehabilitation. The Vocational Rehabilitation Problems o] the Patient with Aphasia. U.S. Department of Health, Education, and Welfare, Social and Rehabilitation Service, Rehabilitation Services Administration, Washington, D.C.: Government Printing Office (1969). GooomN, R., Use of concurrent response categories in evaluating talking behavior in aphasic. patients. Percep. Mot. Skills, 26, 1035-1040 (1968). GOODKIN, R., A procedure for training spouses to improve functional speech of aphasic patients. Proc. 77th A. Cony. Am. psychoI. Ass., 4, 765-766 (1969). MALONE, R. L., Expressed attitudes of families of aphasics. J. Speech Hearing Dis., 34, 146151 (1969). PORCH, B. E., Porch Index of Communicative Ability: Theory and Development. Vol. I. Palo Alto: Consulting Psychologists (1967a). PORCH, B. E., Porch Index o] Communicative Ability: Administration, Scoring, and Interpretation. Vol. II. Palo Alto: Consulting Psychologists (1967b). ScnuELL, H., JENKINS, j. j., and J]MINm-PABoN, E., Aphasia in Adults. New York: Harper and Row (1967). STOmHEn% M., Motivating instructions and language performance of dysphasic subjects. J. Speech Hearing Res., 3, 75-85 (1960). TAYLOR, M. L., A measurement of functional communication in aphasia. Archs phys. Med. Rehabil., 46, 101-107 (1965). TURNBLOM, M., and MYERS, J. S., A group discussion with families of aphasic patients. J. Speech Hearing Dis., 17, 393-396 (1952). WEPMAN, j., Recovery Irom Aphasia. New York: Ronald (1951). Received June 6, 1975. Accepted August 31, 1975.
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HELMICK, WATAMORI, PALMER: Aphasics' Spouses 243
APPENDIX
Selected Characteristics of Aphasic Patients and Spouses
Group
.4ge
Sex
Education (years)
Aphasics
70 6O 40 53 57 57 63 34 77 61 65
M F F M M M M F F M F
12 8 13 12 12 12 12 17 12 12 8
Mean
58
Spouses
69 65 48 48 52 51 62 30 77 61 63
Mean
57
Months post-eVA
.4 mount o[ Therapy (months)
9 11 11 12 3 6 2 3 7 2 5
6 6 11 12 1 6 1 3 2 2 4
11.8 F M M F F F F M M F M
12 12 12 12 12 12 8 12 11 12 12 11.5
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6.5
5
PATIENTS
Joseph W. Helmick University o[ Kentucky, Lexington
Toshiko S. Watamori Tokyo Metropolitan Institute of Gerontology, Japan
John M. Palmer University of Washington, Seattle
The language skills of 11 aphasic patients were assessed through the use of the PICA. Spouse's understanding of the aphasic partner's language deficits was measured by rating the aphasic spouse on the Functional Communication Profile. Results indicate that spouses of aphasic patients view the patient's communication to be less impaired than it actually is. Implications for the counseling role of the speech pathologist in language therapy are discussed.
T h e traumatic occurrence of aphasia affects not only the individual patient but the family members as well. In fact, Buck (1969) described aphasia as not just a language problem but a "family illness." Several authors have commented that the family exercises a degree of influence on the language rehabilitation of the aphasic patient (Turnblom and Myers, 1952; Biorn-Hansen, 1957; Buck, 1969; Malone, 1969). Goodkin (1968, 1969) from attempts to modify the spouse's verbal interaction with the aphasic, concluded that the verbal behavior of the spouse may be reflected in the aphasic patient's verbal responses and, therefore, the spouse's verbal behavior can either facilitate or impede the language recovery of the patient. As early as 1951, Wepman commented that the ability of the family to estimate objectively the patient's language contributed to language recovery. Wepman indicated that the family must recognize the importance of its role in language therapy through an understanding of the "aphasic language disturbance and its correlates." Stoicheff (1960) amplified Wepman's perspective by indicating that the clinician's responsibility is not only to work directly with the aphasic but also to extend
;:238
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HELMICK, WATAMORI, PALMER:Aphasics' Spouses 239 his efforts to "making those around the dysphasic patient aware of his problem." Schuell, Jenkins, and Jiminez-Pabon (1967) present a concise yet complete discussion of the objectives of family counseling in which they note that the initial objective "is to help the family to understand and accept the limitations imposed by severe aphasia" (p. 375). The nature of the aphasic language deficit can be very complex and difficult for the family to understand. Yet, as the above comments have indicated, the ability of the family, in particular the spouse, to become informed about the patient's disabilities in language has an important influence on the course of language ilnprovement. Although there has been considerable comment on the importance of the family's understanding of the aphasic's communication, systematic investigations of the problem are lacking. Consequently, the purpose of this study was to investigate spouses' understanding of the communication disability of patients suffering from aphasia as a result of cerebrovascular accidents (CVAs). Specifically, the purpose was to determine if a relationship existed between the aphasic patient's communication disabilities and the degree of understanding of those disabilities by the aphasic's spouse. The study was planned as a broad investigation of the problem area and no attempt was made to manipulate the manner in which spouses received information about aphasic language disabilities. Since, as Schuell et al. (1967) commented, the burden for providing the spouse with information about the aphasic partner's language disability should fall to the speech pathologist, the study also sought to compare the spouse's understanding of the aphasic patient's communication deficit with that of the speech pathologist who had diagnosed the patient as aphasic. METHOD
Subjects The subjects for this study were the spouses of 11 aphasic patients. Each patient was residing with the spouse in the Seattle area. All 11 patients, according to medical evaluation, had suffered a CVA and had been diagnosed as aphasic by a certified speech pathologist. Pertinent subject characteristics for both spouses and aphasics are given in the Appendix. Procedures T h e Porch Index of Communicative Ability (PICA) (Porch, 1967a, b) was administered to the 11 aphasic patients by the same investigator using the standard test conditions described by Porch (1967b). None of the patients had been given the PICA previously. The overall PICA score was taken as a measure of each aphasic patient's communication skill. The Functional Communication Profile (FCP) (Taylor, 1965) was used to measure each spouse's understanding of his partner's aphasic communication.
Downloaded From: https://jshd.pubs.asha.org/ by a Univ of Auckland User on 04/08/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx
240
JOURNAL OF SPEECH AND HEARING DISORDERS
XLI
238-243
1976
As a comparative measure, the speech pathologist who had diagnosed the individual aphasic independently completed the FCP for the patient(s) with whom he was familiar. For purposes of this study, the nine-point rating continuum developed for the FCP was modified to yield a six-point rating system with categories of " n o change" (from preaphasic language), "lesser efficiency" (compared to preaphasic language), " u n i m p o r t a n t errors," "important errors," "cannot do," and ,unknown." It was felt that the revised categories would alleviate the need for explanation, thus reducing potential experimenter bias, and would not have any differential effect on the two categories of respondents, spouses and speech pathologists. Each of the categories was assigned a numerical value of 5, 4, 3, 2, 1, or 0 respectively. Respondents were to check the category which most nearly described the aphasic patient's behavior for each item on the FCP. Understanding of the aphasic patient's communication skill was represented by mean scores obtained from the FCP. In addition to the mean scores, differences in scoring between the spouses and the speech pathologists were noted through the use of a plus-minus scoring system. While the plus-minus system described the direction in which scoring differences occurred, it did not indicate the extent of differences in scoring between spouses and speech pathologists. If the spouse recorded a higher rating than the speech pathologist on an FCP item, a plus was recorded. Conversely, a minus sign indicated that the spouse gave a lower rating on that item than did the speech pathologist. A frequency count of the pluses and minuses was made for each of the 45 test items. RESULTS
AND
DISCUSSION
A comparison of the FCP scores given by the spouses of the 11 aphasics with the overall PICA scores for the aphasics was made using the Pearson productmoment correlation coefficient. This comparison yielded a significant but negative correlation of --0.66 (p < 0.05). Thus, spouses tended to assign ratings indicating good communication performance in association with poor PICA scores. In contrast to the spouses' ratings, the FCP ratings of the speech pathologists showed a positive and significant relationship to the obtained PICA scores (r = 0.89, p < 0.001). Table 1 contains the mean and standard deviation obtained from administration of the PICA to the 11 aphasic patients and from administration of the TABLE 1. Means and standard deviations PICA and FCP
for
Test
Mean
SD
PICA FCP, spouse FCP, speech pathologist
10.63 3.93 3.07
1.69 0.70 0.87
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HELMICK, WATAMORI, PALMER: Aphasics' Spouses 241
FCP to both the spouses of the aphasics and to the speech pathologists. A comparison of the FCP scores for spouses and speech pathologists indicated significant differences in the rating of the aphasic's communication by the two groups of respondents (t =2.66; df = 20; p < 0.01). In order to assess accurately the direction in which differences in the ratings given by the spouses and those given by the speech pathologists occurred, it was necessary to determine the number of "unknown" responses recorded by each group and to discard these responses from additional analyses. Use of the plus-minus scoring system in which "unknown" responses were omitted indicated that while spouses and speech pathologists agreed on approximately 40% of the test items, differences in rating occurred on 60% of the items. A frequency count of pluses and minuses, representing score differences between speech pathologists and spouses on the FCP items, revealed 194 positive differences (spouse rating higher than speech pathologist) and 56 negative differences in the ratings (spouse rating lower than speech pathologist). This represents a significant tendency for spouses to judge the aphasic's communication as less impaired than do speech pathologists (Z~ = 76.18; d[ = 1; p < 0.001). CONCLUSIONS
The data reported in this study indicate that the aphasic patient's communication efforts are not clearly understood by the patient's spouse. The spouse tends to view the aphasic's communication as less impaired than it actually is. This positive bias on the part of the spouse might well provide some level of emotional support for the aphasic. On the other hand, this lack of understanding might also lead to the establishment of unrealistic expectations for language performance and to the use of inappropriate amount and type of language while interacting with the aphasic. The overall result might well be frustration and depression on the part of the patient. During a brief interview with the spouses, it was noted that most of the spouses reported no alterations in their manner of verbal interaction with their aphasic partner following the CVA. Only a few spouses indicated that they had consciously attempted to "talk in short simple sentences" using step-by-step accounts of "complicated" matters. The general lack of understanding of the aphasic's linguistic impairments, then, can be expected to create some difficulty in the spouse's ability to establish appropriate verbal interactions with the aphasic and can become, therefore, an interfering factor in the language rehabilitation process. T o the extent that the data in this study represent spouses' understanding of their partner's language impairment, it seems reasonable to conclude that the speech pathologist must counsel the spouse of an aphasic patient in order to increase that spouse's understanding of the aphasic's deficits. This counseling role becomes exceedingly important when the aphasic patient is released to an outpatient status or when he is discharged from a formal management
Downloaded From: https://jshd.pubs.asha.org/ by a Univ of Auckland User on 04/08/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx
242
JOURNAL OF SPEECH AND HEARING DISORDERS
XLI
238-243
1976
p r o g r a m to t h e h o m e s i t u a t i o n . U n d e r these c o n d i t i o n s , the spouse a n d all m e m b e r s of the h o u s e h o l d m u s t assume the i m p o r t a n t r o l e of c o n t i n u i n g to p r o v i d e t h e a p h a s i c w i t h a p p r o p r i a t e v e r b a l s t i m u l a t i o n s for m a i n t e n a n c e , if n o t a d d i t i o n a l i m p r o v e m e n t , of his l a n g u a g e skills.
ACKNOWLEDGMENT At the time this research was conducted all authors were affiliated with the program in speech pathology and audiology, University of Washington, Seattle. Requests for reprints should be addressed to Joseph W. Helmick, 224 Taylor Education Building, University of Kentucky, Lexington, Kentucky 40506.
REFERENCES BIORN-HANSEN,V., Social and emotional aspects of aphasia. J. Speech Hearing Dis., 22, 53-59 (1957). BucK, M., Expressive language problems of the aphasic patient which interfere with vocational rehabilitation. The Vocational Rehabilitation Problems o] the Patient with Aphasia. U.S. Department of Health, Education, and Welfare, Social and Rehabilitation Service, Rehabilitation Services Administration, Washington, D.C.: Government Printing Office (1969). GooomN, R., Use of concurrent response categories in evaluating talking behavior in aphasic. patients. Percep. Mot. Skills, 26, 1035-1040 (1968). GOODKIN, R., A procedure for training spouses to improve functional speech of aphasic patients. Proc. 77th A. Cony. Am. psychoI. Ass., 4, 765-766 (1969). MALONE, R. L., Expressed attitudes of families of aphasics. J. Speech Hearing Dis., 34, 146151 (1969). PORCH, B. E., Porch Index of Communicative Ability: Theory and Development. Vol. I. Palo Alto: Consulting Psychologists (1967a). PORCH, B. E., Porch Index o] Communicative Ability: Administration, Scoring, and Interpretation. Vol. II. Palo Alto: Consulting Psychologists (1967b). ScnuELL, H., JENKINS, j. j., and J]MINm-PABoN, E., Aphasia in Adults. New York: Harper and Row (1967). STOmHEn% M., Motivating instructions and language performance of dysphasic subjects. J. Speech Hearing Res., 3, 75-85 (1960). TAYLOR, M. L., A measurement of functional communication in aphasia. Archs phys. Med. Rehabil., 46, 101-107 (1965). TURNBLOM, M., and MYERS, J. S., A group discussion with families of aphasic patients. J. Speech Hearing Dis., 17, 393-396 (1952). WEPMAN, j., Recovery Irom Aphasia. New York: Ronald (1951). Received June 6, 1975. Accepted August 31, 1975.
Downloaded From: https://jshd.pubs.asha.org/ by a Univ of Auckland User on 04/08/2018 Terms of Use: https://pubs.asha.org/ss/rights_and_permissions.aspx
HELMICK, WATAMORI, PALMER: Aphasics' Spouses 243
APPENDIX
Selected Characteristics of Aphasic Patients and Spouses
Group
.4ge
Sex
Education (years)
Aphasics
70 6O 40 53 57 57 63 34 77 61 65
M F F M M M M F F M F
12 8 13 12 12 12 12 17 12 12 8
Mean
58
Spouses
69 65 48 48 52 51 62 30 77 61 63
Mean
57
Months post-eVA
.4 mount o[ Therapy (months)
9 11 11 12 3 6 2 3 7 2 5
6 6 11 12 1 6 1 3 2 2 4
11.8 F M M F F F F M M F M
12 12 12 12 12 12 8 12 11 12 12 11.5
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6.5
5
