Clinical Aphasiology: Future Directions

Clinical Aphasiology This book presents a collection of cutting edge work from leading researchers and clinicians arou...

Author: Ball Damico

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Clinical Aphasiology

This book presents a collection of cutting edge work from leading researchers and clinicians around the world on a range of topics within Clinical Aphasiology. However, more than this, the volume is also a tribute to Chris Code, one of the foremost scholars in the field. Professor Code has made a galvanizing impact on the field: as a savant, a motivator and an impresario of trends which have resulted in several significant developments in the field. In the first chapter of this book the editors outline the considerable contributions Chris Code has made to the area. The remaining contents have been divided into three main approaches to the study of aphasia, reflecting Professor Code’s own interests. First are the contributions that fall under the heading of Conceptual Considerations. These are mainly interdisciplinary in nature, spanning linguistics, phonetics, psychology and neurology, as well as social aspects of communication disorders. The second section of the book deals with Research Considerations, with chapters ranging from how the study of disrupted communication can inform models of normal language processing, through tone production and processing in speakers with aphasia, to anomia and progressive multifocal leukoencephalopathy. Each of these chapters explores different aspects of research methodology, including quantitative and qualitative research. The final section of the collection deals with Clinical Considerations; the chapters here cover counselling, computerized training, cultural and linguistic diversity in aphasia, right hemisphere disorders, and communication problems in the dementias. Clinical Aphasiology will be an invaluable tool for both students and practitioners in speech and language pathology, psychology, neurology, and related fields. Martin J. Ball is Hawthorne-Board of Regents’ Support Fund Endowed Professor, Head of the Department of Communicative Disorders, and Director of the Doris B. Hawthorne Center for Special Education and Communication Disorders at the University of Louisiana at Lafayette. Jack S. Damico holds the Doris B. Hawthorne Eminent Scholar Professorship in Communicative Disorders at the University of Louisiana at Lafayette and is a Fellow of the American Speech-Language-Hearing Association.

Clinical Aphasiology Future directions

Edited by Martin J. Ball and Jack S. Damico

A Festschrift for Chris Code

First published 2007 by Psychology Press 27 Church Road, Hove, East Sussex BN3 2FA Simultaneously published in the USA and Canada by Psychology Press 270 Madison Avenue, New York, NY 10016 Psychology Press is an imprint of the Taylor & Francis Group, an Informa business This edition published in the Taylor & Francis e-Library, 2007. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” © 2007 Psychology Press All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. This publication has been produced with paper manufactured to strict environmental standards and with pulp derived from sustainable forests. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Clinical aphasiology : future directions / edited by Martin J. Ball and Jack S. Damico. p.; cm. Includes bibliographical references and index. ISBN-13: 978–1–84169–670–6 (hardcover) ISBN-10: 1–84169–670–6 (hardcover) 1. Aphasia. 2. Speech disorders. 3. Language disorders. I. Ball, Martin J. (Martin John) II. Damico, Jack Samual. III. Code, Christopher, 1942– [DNLM: 1. Aphasia—Festschrift. WL 340.5 C6386 2007] RC425.C55 2007 616.85′52—dc22 2006032956 ISBN 0-203-96255-9 Master e-book ISBN ISBN: 978–1–84169–670–6

Contents

Professor Chris Code’s publications and presentations Tabula gratulatoria Contributors Preface 1 Chris Code’s contribution to aphasiology

x xx xxiii xxvi 1

MARTIN J. BALL AND JACK S. DAMICO

PART I

Conceptual considerations 2 Investigations in speech and language and related disorders: Crossing the boundaries between disciplines—a tribute to Chris Code

15

17

MANFRED HERRMANN AND THORSTEN FEHR

3 Independent evidence for the unification of explanatory paradigms in the neurosciences

28

HUGH W. BUCKINGHAM AND SARAH S. CHRISTMAN

4 The social and neuropsychological underpinnings of communication disorders after severe traumatic brain injury

42

SKYE McDONALD

5 Social validation of recovery in aphasia

72

LEONARD L. LaPOINTE AND KERRY L. LENIUS

6 Interactional aphasia: Principles and practices oriented to social intervention JACK S. DAMICO, MARTIN J. BALL, NINA N. SIMMONS-MACKIE AND NICOLE MÜLLER

92

vi

Contents

PART II

Research considerations 7 From the study of language dysfunction and handicap to a better understanding of linguistic processing in normality

105

107

JEAN-LUC NESPOULOUS AND JACQUES VIRBEL

8 Production and perception of word tones in patients with brain damage

125

INGER MOEN

9 Subcortical aphasia: Historical perspective and contemporary thinking

136

BRUCE E. MURDOCH

10 Mechanisms of lexical selection and the anomias

156

TOBIAS BORMANN, GERHARD BLANKEN AND CLAUS-W. WALLESCH

11 Repetitive verbal behaviours in PML: An exploratory study of conversation

168

NICOLE MÜLLER, ALANA KOZLOWSKI AND PATTIE DOODY

12 Multiparty interactions in aphasia

181

ALISON FERGUSON

13 Stroke stories: Conveying emotive experiences in aphasia

195

ELIZABETH ARMSTRONG AND HANNA K. ULATOWSKA

PART III

Clinical considerations

211

14 Counseling families and adults with speech and language disorders: The view from a wellness perspective

213

AUDREY L. HOLLAND

15 Cultural dimensions of aphasia: Adding diversity and flexibility to the equation

222

CLAIRE PENN

16 Assessment of aphasia in a multi-lingual world SUSAN EDWARDS AND ROELIEN BASTIAANSE

245

Contents 17 Computerized aphasia treatment outcomes research: The past and a proposal

vii 259

RICHARD C. KATZ AND ROBERT T. WERTZ

18 Traumatic brain injury rehabilitation: Advanced communication training perspectives

270

LEANNE TOGHER

19 The future of our knowledge about communication impairments following a right-hemisphere lesion

284

YVES JOANETTE, MAUD CHAMPAGNE-LAVAU, KARIMA KAHLAOUI AND BERNADETTE SKA

20 Progressive language and speech disorders in dementia

299

MARIA PA˛ CHALSKA

Author index Subject index

325 339

Gabrielle Code

Professor Chris Code’s publications and presentations

Books Müller, D., Munro, S., & Code, C. (1981). Language assessment for remediation. Beckenham, UK: Croom Helm. Code, C., & Müller, D. (Eds.) (1983). Aphasia therapy. London: Edward Arnold. (Translated and published in Italian as Terapia dell’Afasia. Roma: Marrapese Editore, 1984.) Code, C., & Ball, M. (Eds.) (1984). Experimental clinical phonetics. London: Croom Helm. Code, C. (1987). Language, aphasia and the right hemisphere. Chichester, UK: John Wiley. (Translated and published in Japanese, Central Foreign Books, Tokyo, 1990.) Code, C. (Ed.) (1989). The characteristics of aphasia.Brain damage, behaviour and cognition series. Hove, UK: Lawrence Erlbaum Associates Ltd. (Previously published by Taylor & Francis, London.) Code, C., & Müller, D. (Eds.) (1989). Aphasia therapy (2nd ed). London: Cole & Whurr. Code, C., & Müller, D. J. (1992). The Code-Müller protocols: Assessing perceptions of psychosocial adjustment to brain damage. Kibworth: Far Communications. Code, C., & Müller, D. J. (Eds.) (1995). The treatment of aphasia: From theory to practice. London: Whurr. Code, C., & Müller, D. J. (Eds.) (1996). Forums in clinical aphasiology. London: Whurr. Code, C., Wallesch, C.-W., Lecours, A.-R., & Joanette, Y. (Eds.) (1996). Classic cases in neuropsychology. Hove, UK: Lawrence Erlbaum Associates Ltd. Ball, M. J., & Code, C. (Eds.) (1997). Instrumental clinical phonetics. London: Whurr. McDonald, S., Togher, L., & Code, C. (Eds.) (1999). Traumatic brain injury and communication disorders. Hove, UK: Psychology Press. Code, C., Wallesch, C.-W., Lecours, A.-R., & Joanette, Y. (Eds.) (2003). Classic cases in neuropsychology: Volume II. Hove, UK: Lawrence Erlbaum Associates Ltd. O’Halloran, R., Worrall, L., Code, C., Toffolo, D., & Hickson, L. (2004). The inpatient functional communication interview. Bicester, UK: Speechmark Publications. Code, C. (Ed.) (2006). The representation of language in the brain. Hove, UK: Psychology Press. Tesak, J., & Code, C. (in press). Milestones in the history of aphasia: Theories and protagonists. Hove, UK: Psychology Press.

Chris Code’s publications

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Chapters in books Code, C. (1983). Hemispheric specialization retraining in aphasia: Possibilities and problems. In C. Code & D. Müller (Eds.), Aphasia therapy. London: Edward Arnold. Code, C., & Müller, D. (1983). Perspectives in aphasia therapy. In C. Code & D. Müller (Eds.), Aphasia therapy. London: Edward Arnold. Müller, D., & Code, C. (1983). Interpersonal perceptions of psychosocial adjustment in aphasia. In C. Code & D. Müller (Eds.), Aphasia therapy. London: Edward Arnold. Code, C. (1984). Delayed auditory feedback. In C. Code & M. Ball (Eds.), Experimental clinical phonetics. Beckenham, UK: Croom Helm. Code, C., (1984). Dichotic listening. In C. Code & M. Ball (Eds.), Experimental clinical phonetics. Beckenham, UK: Croom Helm. Code, C., & Ball, M. (1988). Apraxia of speech: The case for a cognitive phonetics. In M. Ball (Ed.), Theoretical linguistics and disordered language. Beckenham, UK: Croom Helm. Code, C. (1989). From symptoms to syndromes to models: The nature of aphasia. In C. Code (Ed.), The characteristics of aphasia. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C. (1989). Speech automatisms and recurring utterances. In C. Code (Ed.), The characteristics of aphasia. Hove, UK: Lawrence Erlbaum Associates Ltd. (Previously published by Taylor & Francis, London.) Code, C., & Müller, D. J. (1989). The future history of aphasia therapy. In C. Code & D. Müller (Eds.), Aphasia therapy (2nd ed). London: Cole & Whurr. Code, C. (1994). The role of the right hemisphere in the treatment of aphasia. In R. Chapey (Ed.), Language intervention strategies in adult aphasia. Baltimore, MD: Williams & Wilkins. Code, C., & Müller, D. (1995). Cognitive and neuropsychological approaches. In C. Code & D. J. Müller (Eds.), The treatment of aphasia: From theory to practice. London: Whurr. Code, C., & Müller, D. (1995). Efficacy & effectiveness. In C. Code & D. J. Müller (Eds.), The treatment of aphasia: From theory to practice. London: Whurr. Code, C., & Müller, D. (1995). Pragmatic, linguistic and functional perspectives. In C. Code & D. J. Müller (Eds.), The treatment of aphasia: From theory to practice. London: Whurr. Code, C., & Müller, D. (1995). Psychosocial perspectives. In C. Code & D. J. Müller (Eds.), The treatment of aphasia: From theory to practice. London: Whurr. Code, C. (1996). Aphasia therapy. In J. G. Beaumont & J. Sergent (Eds.), Blackwell dictionary of neuropsychology. Oxford, UK: Blackwell. Code, C. (1996). Auditory techniques. In C. Code & M. Ball (Eds.), Instrumental clinical phonetics (2nd ed). London: Whurr. Code, C. (1996). Classic cases: Ancient and modern milestones in the development of neuropsychological science. In C. Code, C.-W. Wallesch, Y. Joanette, & A.-R. Lecours (Eds.), Classic cases in neuropsychology. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C. (1996). Speech from the isolated right hemisphere? Left hemispherectomy cases E.C. and N.F. In C. Code, C.-W. Wallesch, Y. Joanette, & A.-R. Lecours (Eds.), Classic cases in neuropsychology. Hove, UK: Lawrence Erlbaum Associates Ltd.

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Code, C., & Müller, D. (1996). Assessing for treatment. In C. Code & D. J. Müller (Eds.), Forums in clinical aphasiology. London: Whurr. Code, C., & Müller, D. (1996). Computers in clinical aphasiology. In C. Code & D. J. Müller (Eds.), Forums in clinical aphasiology. London: Whurr. Code, C., & Müller, D. (1996). Issues in clinical aphasiology. In C. Code & D. J. Müller (Eds.), Forums in clinical aphasiology. London: Whurr. Code, C., & Müller, D. (1996). Psychosocial issues. In C. Code & D. J. Müller (Eds.), Forums in clinical aphasiology. London: Whurr. Code, C. (1997). A metamodel for recovery from aphasia. In J. Ponsford, P. Snow, & V. Anderson (Eds.), International perspectives in traumatic brain injury. Melbourne: Australian Academic Press. Code, C. (1997). Aphasia recovery, therapy and psychosocial adjustment. In A. Baum, C. McManus, S. Newman, J. Weinman, & R. West (Eds.), The Cambridge handbook of psychology, health & medicine. Cambridge, UK: Cambridge University Press. Code, C. (1997). Experimental audioperceptual techniques. In M. J. Ball & C. Code (Eds.), Instrumental clinical phonetics. London: Whurr. McDonald, S., Togher, L., & Code, C. (1999). The nature of traumatic brain injury: An overview. In S. McDonald, L. Togher, & C. Code (Eds.), Traumatic brain injury and communication disorders. Hove, UK: Psychology Press. Togher, L., Code, C., & McDonald, S. (1999). Communication problems following traumatic brain injury. In S. McDonald, L. Togher, & C. Code (Eds.), Traumatic brain injury and communication disorders. Hove, UK: Psychology Press. Togher, L., Hand, L., & Code, C. (1999). Exchange of information in the talk of people with traumatic brain injury. In S. McDonald, L. Togher, & C. Code (Eds.), Traumatic brain injury and communication disorders. Hove, UK: Psychology Press. Herrmann, M., Müller, D. J., Ebert, A. D., & Code, C. (2000). Erwartungshaltungen an psychosoziale Anpassung nach Hirnschadigungen. In W. Fries & C. Wendel (Eds.), Ambulante Komplex-Behandlung von Hirnverletzten Patienten. München: W. Zuckschwerdt Verlag. McCooey, R., Toffolo, D., & Code, C. (2000). Assessing and treating functional communication in the acute hospital. In L. Worrall & C. Fratalli (Eds.), Functional communication. New York: Thieme Science. Code, C., & Hogan, A. (2001). Engaging the client in a helping relationship. In A. Hogan (Ed.), Hearing rehabilitation for deafened adults. London: Whurr. Code, C., Eales, C., Pearl, G., Conan, M., Cowin, K., & Hickin, J. (2003). Supported s-help groups for aphasic people: Development and research. In I. Papathanasiou & R. de Bleser (Eds.), The science of aphasia: From therapy to theory. London: Elsevier. Code, C., & Herrmann, M. (2003). The relevance of emotional and psychosocial factors in aphasia to rehabilitation. In W. H. Williams & J. J. Evans (Eds.), Biopsychosocial approaches to neurorehabilitation: Assessment and management of neuropsychiatric mood and behavioural disorders. Hove, UK: Psychology Press. Code, C., & Joanette, Y., (2003). Neural plasticity in the control of language in the adult brain: The role of the separated right hemispheres in cases PS, VP and JW. In C. Code, C.-W. Wallesch, Y. Joanette, & A.-R. Lecours (Eds.), Classic cases in neuropsychology: Volume II. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C., & Müller, D. (2003). Psychosocial and quality of life issues in treatment. In R. Kent (Ed.), The MIT encyclopaedia of communication disorders. Cambridge, MA: MIT Press.


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Kaczmarek, B., Code, C., & Wallesch, C.-W. (2003). ‘Z’. In C. Code, C.-W. Wallesch, Y. Joanette, & A.-R. Lecours (Eds.), Classic cases in neuropsychology: Volume II. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C. (2004). Syllables in the brain. In R. Hartsuiker, R. Bastiaanse, & A. Postma (Eds.), Phonological processing and monitoring. Hove, UK: Psychology Press. Code, C., Müller, N., Tree, J. T., & Ball, M. J. (2006). Syntactic impairments can emerge later: Progressive agrammatic agraphia and syntactic comprehension impairment. In C. Code (Ed.), The representation of language in the brain. Hove, UK: Psychology Press. Code, C., & Wallesch, C.-W. (2006). The form of representation of language in the brain and the influence of John C. Marshall. In C. Code (Ed.), The representation of language in the brain. Hove, UK: Psychology Press. Code, C. (in press). Aphasia recovery, therapy and psychosocial adjustment. In A. Baum, C. McManus, S. Newman, J. Weinman, & R. West (Eds.), The Cambridge handbook of psychology, health & medicine (2nd ed). Cambridge, UK: Cambridge University Press. Code, C. (in press). The operculum syndrome: Foix-Chavany-Marie Syndrome. In M. McNeil (Ed.), Clinical management of sensorimotor speech disorders (2nd ed). New York: Thieme Publishers.

Papers in peer-reviewed journals Code, C. (1979). Genuine and artificial stammering: An EMG comparison. British Journal of Communication Disorders, 14, 5–16. Code, C. (1980). Delayed auditory feedback and auditory-feedback masking with stammerers and normal speakers. Australian Journal of Human Communication Disorders, 8, 40–48. Code, C., & Müller, D. (1980). Is the Edinburgh Masker really successful? British Journal of Disorders of Communication, 15, 141–142. Code, C. (1981). Dichotic listening with the communicatively impaired: Results from trials with a short British-English dichotic word test. Journal of Phonetics, 9, 375–383. Code, C. (1982). Neurolinguistic analysis of recurrent utterances in aphasia. Cortex, 18, 141–152. Code, C. (1982). On the origins of recurrent utterances in aphasia. Cortex, 18, 161–164. Code, C., & Ball, M. (1982). Fricative production in Broca’s aphasia. Journal of Phonetics, 10, 325–331. Müller, D., Code, C., & Mugford, J. (1982). Predicting psychosocial adjustment in aphasia. British Journal of Disorders of Communication, 17, 23–29. Code, C. (1983). On “Neurolinguistic analysis of recurrent utterances in aphasia”: Reply to De Bleser & Poeck. Cortex, 19, 261–264. Code, C. (1986). Catastrophic reaction and anosognosia in anterior–posterior and left–right models of the cerebral control of emotion. Psychological Research, 48, 53–55. Code, C., & Gaunt, C. (1986). Treating aphasia and apraxia with a combined speech and gesture approach: A single case study. British Journal of Disorders of Communication, 21, 11–20.

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Code, C., & Brown, J. W. (1987). Aphasia from the wrong (right) hemisphere: Questions for crossed aphasia. Aphasiology, 1, 401–402. Code, C., & Lodge, B. (1987). Language in dementia of recent referral. Age and Ageing, 16, 366–372. Code, C., & Rowley, D. (1987). Age, sex, handedness and aphasia type. Aphasiology, 1, 339–345. Code, C. (1991). The computerized Boston: Aphasia assessment database with diagnostic features. Computer Users in Speech and Hearing, 7, 314–322. Code, C. (1994). Speech automatism production in aphasia. Journal of Neurolinguistics, 8, 135–148. Code, C., Rowley, D. T., & Kertesz, A. (1994). Predicting recovery from aphasia with connectionist networks: Preliminary comparisons with multiple regression. Cortex, 30, 527–532. Ball, M. J., Code, C., Rahilly, J., & Hazlett, D. (1994). Non-segmental aspects of disordered speech: Developments in transcription. Clinical Linguistics and Phonetics, 8, 67–83. Code, C. (1995). Asymmetries in ear movements and eyebrow raising in men and women and right and left handers. Perceptual and Motor Skills, 80, 1147–1154. Code, C., & Ball, M. J. (1995). Syllabification in aphasic recurring utterances: Contributions of sonority theory. Journal of Neurolinguistics, 8, 257–265. Code, C. (1996). Aphasia therapy. British Journal of Clinical Psychology, 35, 157–159. Code, C., Khanbha, F., Isman, K., & Mattiazzo, V. (1996). Perceptions of emotional and psychosocial state in laryngectomised patients, their significant others and clinicians at three months post-surgery. Asia Pacific Journal of Speech, Language and Hearing, 1, 91–104. Harasty, J., Halliday, G., Code, C., & Brooks, W. (1996). Anatomical evidence for a visual and auditory semantic network in a case of focal dementia. Brain, 119, 181–190. Hemsley, G., & Code, C. (1996). Interactions between recovery in aphasia, emotional and psychosocial factors in subjects with aphasia, their significant others and speech pathologists. Disability and Rehabilitation, 18, 567–584. Herrmann, M., Code, C. (1996). Weighting of items on the Code-Müller protocols: The effects of clinical experience of aphasia therapy. Disability and Rehabilitation, 18, 509–514. Code, C. (1997). Can the right hemisphere speak? Brain and Language, 57, 38–59. Herrmann, M., Hogan, A., Müller, D., & Code, C. (1997). Psychosoziale Anpassungsleistungen und Therapieziele bei Sprach- und Kommunikationsstorungen – Untersuchungen mit den Code-Müller Protokollen. Neurolinguistik, 11, 1–21. Togher, L., Hand, L., & Code, C. (1997). Analyzing discourse in the traumatic brain injury population: Telephone interactions with different communication partners. Brain Injury, 11, 169–189. Togher, L., Hand, L., & Code, C. (1997). Disability following head injury: A new perspective on the relationship between communication impairment and disempowerment. Disability and Rehabilitation, 18, 559–566. Togher, L., Hand, L., & Code, C. (1997). Measuring service encounters with the traumatically brain injured population. Aphasiology, 11, 491–504. Code, C. (1998). Models, theories and heuristics in apraxia of speech. Clinical Linguistics and Phonetics, 12, 47–66.


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Cowell, S. F., & Code, C. (1998). Thinking nuclear medicine: PET activation. Journal of Nuclear Medicine Technology, 26, 17–22. Nespoulous, J.-L., Code, C., Virbel, J., & Lecours, A.-R. (1998). Hypotheses on the dissociation between “referential” and “modalizing” verbal behaviour in aphasia. Applied Psycholinguistics, 19, 311–331. Code, C. (1999). Re-assembling the brain: Are cell assemblies the brain’s language for recovery of function? (Commentary) Behavioural and Brain Sciences, 22, 282. Code, C., Hemsley, G., & Herrmann, M. (1999). Emotional reactions to aphasia. (Special Issue on Psychosocial Issues in Aphasia) Seminars in Speech and Language, 20, 19–31. Code, C., Müller, D. J., & Herrmann, M. (1999). Perceptions of psychosocial adjustment to aphasia: Studies with the CMP. (Special Issue on Psychosocial Issues in Aphasia) Seminars in Speech and Language, 20, 51–63. Code, C., Müller, D., Herrmann, M., & Hogan, A. (1999). Perceptions of psychosocial adjustment to acquired communication disorders: Studies with the Code-Müller protocols. International Journal of Communication Disorders, 34, 193–207. Harasty, J., Halliday, G. M., Kril, J. J., & Code, C. (1999). Specific temperoparietal gyral atrophy reflects the pattern of language dissolution in Alzheimer’s disease. Brain, 122, 675–686. Hogan, A., Code, C., Taylor, A., & Wilson, D. (1999). Employment and economic outcomes for deafened adults with cochlear implants. Australian Journal of Rehabilitation Counselling, 5, 1–8. McCabe, P., Sheard, S., & Code, C. (1999). What do speech pathologists know about HIV? Advances in Speech Language Pathology, 1, 9–18. Code, C. (2000). Not fractionating, converging. Brain and Language: Millennium Issue, 71, 44–45. Cowell, S. F., Egan, G. F., Code, C., Harasty, J., & Watson, J. D. G. (2000). The functional neuroanatomy of simple calculation and number repetition: A parametric PET activation study. NeuroImage, 12, 565–573. Katz, R., Hallowell, B., Code, C., Armstrong, E., Roberts, P., Pound, C., et al. (2000). A multi-national comparison of aphasia management practices. International Journal of Language and Communication Disorders, 35, 303–314. Roger, P., Code, C., & Sheard, C. (2000). Assessment and management of aphasia in a linguistically diverse society. Asia-Pacific Journal of Speech and Language, 5, 21–34. Code, C. (2001). Multifactorial processes in recovery from aphasia: Developing the foundations for a multilevelled framework. Brain and Language, 77, 25–44. McCabe, P., Sheard, C., & Code, C. (2002). Acquired communication impairment in people with HIV. Journal of Medical Speech-Language Pathology, 10, 183–199. Simmons-Mackie, N., Code, C., Armstrong, E., Stiegler, L., & Elman, R. (2002). What is aphasia? Results of an international survey. Aphasiology, 16, 837–848. Code, C. (2003). The quantity of life for people with chronic aphasia. Neuropsychological Rehabilitation, 13, 365–378. Code, C. (2003). Vocalisation and the development of hand preference (Commentary). Behavioural and Brain Sciences, 26 (2), 215–216. Code, C., & Heron, C. (2003). Services for aphasia, other acquired adult neurogenic communication and swallowing disorders in the United Kingdom, 2000. Disability and Rehabilitation, 21, 1231–1237. Code, C., & Herrmann, M. (2003). The relevance of emotional and psychosocial factors in aphasia to rehabilitation. Neuropsychological Rehabilitation, 13, 109–132.

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Roberts, P., Code, C., & McNeil, M. (2003). Describing participants in aphasia research. Part 1: Audit of current practice. Aphasiology, 17, 911–932. Ball, M. J., Code, C., Tree, J., Dawe, K., & Kay, J. (2004). Phonetic and phonological analysis of progressive speech degeneration: A case study. Clinical Linguistics and Phonetics, 18, 447–462. Chung, K. K. H., Code, C., & Ball, M. J. (2004). Speech automatisms and recurring utterances from aphasic Cantonese speakers. Multilingual Communication Disorders, 2, 32–42. Togher, L., McDonald, S., Code, C., & Grant, S. (2004). Training communication partners of people with TBI: A randomised controlled trial. Aphasiology, 18, 313–335. Code, C. (2005). First in, last out: The evolution of lexical aphasic speech automatisms to agrammatism and the evolution of language. Interaction Studies, 6 (2), 311–334. Code, C., Lincoln, M., & Dredge, R. (2005). Asymmetries in mouth opening during word generation in male stuttering and non-stuttering participants. Laterality, 10 (5), 471–486. Code, C., Müller, N., Tree, J. T., & Ball, M. J. (2006). Syntactic impairments can emerge later: Progressive agrammatic agraphia and syntactic comprehension impairment. Aphasiology, 20, 1035–1058. Code, C., & Wallesch, C-W. (2006). The form of representation of language in the brain and the influence of John C. Marshall. Aphasiology, 20, 819–822. Power, E., & Code, C. (2006). Waving not drowning: Utilising gesture in the treatment of aphasia (Commentary). Advances in Speech-Language Pathology, 8, 115–119. McCooey-O’Halloran, R., Worrall, L., Code, C., & Hickson, L. (in press). Development of a measure of communication activity for the acute hospital setting Part II: Item analysis, selection and reliability. Journal of Medical Speech-Language Pathology. McCabe, P., Sheard, C., & Code, C. (submitted). Longitudinal communication impairment in the AIDS dementia complex (ADC): A case report. Journal of Communication Disorders. McCabe, P., Sheard, C., & Code, C. (submitted). Pragmatic skills in people with HIV/ AIDS. Disability and Rehabilitation. Packman, A., Code, C., & Onslow, M. (submitted). On the cause of stuttering: Integrating brain and behavioral research. Journal of Neurolinguistics.

Invited presentations Code, C. (1990). Modelling lexical speech automatisms. Invited Paper for Symposium on Repetitive Verbal Behaviour, European Cognitive Neuropsychology Workshop, Bressanone, Italy (January). Code, C. (1990). The right hemisphere and interhemispheric inhibition in aphasia. Invited Paper for the Third National Aphasiology Symposium, Gdansk University, Poland, October. Code, C. (October–November 1990). The role of the right hemisphere in the recovery and treatment of aphasia: A critical appraisal. ‘Lecture tour’ of the USA: University of Texas at Dallas; VA Center Dallas; Arizona State University at Tempe; University of Northern Arizona; VA Center Martinez, California. Code, C. (1990). The role of the right hemisphere in the recovery and treatment of


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aphasia: A critical appraisal. Invited Guest Speaker at Annual Congress of the American Speech and Hearing Associated, Seattle (November). Code, C. (1991). Developments in the Code-Müller protocols: The British studies. Invited Guest Speaker to the Linguistics Society, University of Freiburg, Germany (July). Code, C. (1991). Problems in predicting clinical recovery from aphasia. Invited paper presented at the British Aphasiology Society Conference, University of Sheffield (September). Code, C., & Müller, D. J. (1992). Measuring perceptions to psychosocial adjustment in aphasia. Workshop presented to British Aphasiology Society Meeting, University of Sheffield (June). Code, C. (1992). Psychosocial and emotional reactions to brain damage. Invited Seminar, School of Behavioural Studies, Macquarie University, Sydney (August). Code, C. (1992). Emotional and psychosocial reactions to aphasia. Invited Workshop, Lotte Stewart Hospital, Sydney (September). Code, C. (1993). Examining perceptions to psychosocial adjustment in aphasia. Invited Seminar, University of Queensland (May). Code, C. (1993). Recovery from aphasia. Invited Workshop, University of Queensland (May). Code, C. (1993). Linguistic aspects of speech automatisms in aphasia. Invited Seminar Department of Linguistics, University of Sydney (August). Code, C. (1993). Speech automatisms in aphasia. Invited Seminar, Speech Pathology Department, Prince Alfred’s Hospital Sydney (September). Code, C. (1993). Psychosocial adjustment and emotional reaction to aphasia. Invited Keynote Presentation. First Aphasiology Symposium of Australia, Sydney (October). Code, (1994). The role of the right hemisphere in recovery and treatment of aphasia. Invited Workshop, Flinders University, Adelaide (April). Code, C. (1994). Emotional and psychosocial reactions to aphasia. Invited Workshop, University of Melbourne (September). Code, C. (1994). The linguistics of aphasic speech automatisms. Invited Keynote Presentation at the Fourth Annual Symposium of the International Clinical Linguistics & Phonetics Association, New Orleans (November). Code, C. (1994). Invited discussant. 1st Australian Symposium on the Neuropsychology of Asian Language Processing. University of New South Wales, Sydney (December). Code, C. (1995). Sprache und Gehirn. Invited Workshops. Summer School, University of Freiburg, Germany (August). Code, C. (1995). Aphasic speech automatisms. Invited presentation in the Jacques Lordat Laboratory, University of Toulouse (October). Code, C. (1995). The role of the right hemisphere in recovery and treatment. Invited 4 Hour Workshop: German Neuropsychological Society Conference, Würtzburg, Germany (October). Code, C. (1995). A metamodel of recovery from aphasia. Invited Keynote Paper, German Aphasiology Society Annual Conference, Magdeburg (November). Code, C. (1997). The lateral shift hypothesis: The role of the right hemisphere in the recovery and treatment of aphasia. Invited Workshop, Annual Conference of the Australian Society for the Study of Brain Impairment, Brisbane (November). Code, C. (1997). Speech production from the right hemisphere. Invited Plenary

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Presentation, Annual Conference of the Australian Society for the Study of Brain Impairment, Brisbane (November). Code, C. (1998). Psychosocial adjustment to aphasia. Invited Workshop to College of St Mark and St John, Plymouth. Code, C. (1998). Psychosocial adjustment to aphasia. Invited Presentation to University of Southwestern Louisiana, Lafayette. Code, C. (1998). Recovery from aphasia. Invited presentation at Louisiana State University, Baton Rouge. Code, C. (1998). The role of the right hemisphere in speech production. Invited Seminar, School of Psychology, University of Cardiff. Code, C. (1999). The neural and cognitive representation of syllables and apraxia of speech. Invited Workshop Presentation, Max Planck Institute, University of Nijmegen, Holland. Code, C. (1999). What’s right about speech? Invited Keynote Presentation, Annual Conference of the German Neuropsychological Society, Köln, Germany. Code, C. (2000). Self help for aphasia. Invited presentation, Aphasia, a day of talks, discussions and workshops in memory of Felicity Osborne, July 14, Birkbeck College, London. Code, C. (2000). Calculation and number repetition: PET evidence. Invited Seminar, Cognitive Neuroscience, Birkbeck College, London (July). Code, C. (2000). Brain plasticity and speech control by the right hemisphere: Converging evidence from aphasia, brain imaging, split-brain and hemispherectomy. Keynote Address to the Spanish Neurological Society Conference, Marbella, Spain, October 28. Code, C. (2001). Invited discussant for recovery symposium. European Cognitive Neuropsychology Workshop, Bressanone, Italy (January). Code, C. (2001). Calculation and the brain: PET studies. Invited presentation, Exeter Neuroscience Network (November). Code, C. (2002). Calculation and the brain: Past and prospective PET studies. Invited presentation, University of Bremen. Code, C. (2002). The psychosocial impact of aphasia. Invited presentation, Department of Neuroscience, University of Bremen. Code, C. (2003). Numbers in the brain. Hanse Institute for Advanced Study, Invited Fellowship Lecture, Delmenhorst, Germany (December). Code, C., Ball, M., Tree, J., Dawe, K., Kay, J., & Edwards, M. (2003). Progressive cortical anarthria with apraxias. Invited Visiting Professorship Lecture, University of Louisiana at Lafayette (March). Code, C., Tree, J., Dawe, K., Kay, J., Ball, M., & Edwards, M. (2003). Progressive cortical anarthria with apraxias. Invited Presentation, ‘Vocalise to Localise’ Symposium, University of Grenoble (January). Code, C. (2004). The psychosocial impact of aphasia. Invited Keynote Presentation International Aphasia Rehabilitation Conference, Milos, Greece (August). Code, C. (2004). Disordered communicative interaction: Current and future approaches to analysis and treatment. Invited Discussant, Stirling University Management Centre, Stirling, October 26. Code, C. (2004). Mechanisms of aphasic speech automatism production. Invited Keynote Presentation, Argentinian Aphasia Symposium, November 21–24, Buenos Aires (funded by British Council). Code, C. (2004). Psychosocial life and aphasia. Invited Keynote Presentation,


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Argentinian Aphasia Symposium, November 21–24, Buenos Aires (funded by British Council). Code, C. (2004). Speech production from the left and right hemispheres following brain damage. Invited Keynote Presentation, Argentinian Aphasia Symposium, November 21–24, Buenos Aires (funded by British Council). Code, C. (2005). The recovery of aphasia. Invited Keynote Presentation, Third Congress of Croatian Speech and Language Pathologists, September 28–October 1, Dubrovnik, Croatia. Code, C. (2005). The evolution of aphasic speech automatisms to agrammatism and the evolution of human language. Invited Presentation, Macquarie University, Sydney, October 31. Code, C. (2005). Big writing. Invited Presentation, School of Communication Sciences and Disorders, November 6. Code, C. (2006). Presenting the past and passing the future of clinical aphasia. Invited Keynote Presentation, International Aphasia Rehabilitation Conference, Sheffield, (June). Code, C. (2006). Unfolding the past of aphasia rehabilitation. Invited Keynote Presentation, Nordic Conference on Aphasia: New Knowledge – New Directions, September 14–16, Oslo, Norway. Code, C. (2007). Invited Keynote Speaker, 7th International Scientific Meeting of Faculty of Logopedics, Zagreb, Croatia, July 14–16.

Other public output Unrefereed articles/software Code, C. (1980). The shifting brain. Therapy, 6. Code, C. (1985). Investigating the efficacy of treatment for aphasia with a simple ABA single-case design. Bulletin of the College of Speech Therapists, 394, February. Code, C. (1986). Hearing therapy and the training of speech therapists. Hearing Therapy, 8, October. Code, C., Purser, H., & Rowley, D. (1986). Developing an aphasiology archive. Speech Therapy in Practice, 2. Code, C., Heer, M., & Schofield, M. (1989). The computerized Boston. Far Communications Ltd. (Software Program) Code, C. (1990). Secrets of the brain’s right hemisphere. Therapy Weekly, 16, April 26. Code, C. (1990). An expert prognosis. Therapy Weekly, 16, June 7. Code, C. (1990). Aphasia assessment: The computer meets the Boston. Speech Therapy In Practice. Code, C. (1994). Towards a post-graduate profession. Bulletin of the College of Speech and Language Therapists, January. Code, C. (1999). Meeting expectations. Speech and Language Therapy and Communication in Practice. Code, C. (1999). Profiles of ADA self-help groups. Speaking Up, December. London: ADA. Code, C., & Heron, C. (2001). Aphasia services in the United Kingdom. Therapy Weekly.

Tabula gratulatoria

Apart from the contributors, the following requested to have their names listed as well-wishers. Evelyn Abberton Elise Baker Susan Balandin Kirrie Ballard Marcelo Berthier Maria Black Bronagh Blaney Richard Body Marian Brady Jason Brown Shelagh Brumfitt Sally Byng Stefano Cappa Shula Chiat Kevin Chung Carl Coelho Francesca Cooper Patrick Coppens Alison Crutchley Lucy Dipper Gerry Docherty Patrick Doyle Joe Duffy Martin Edwards Pam Enderby Paul Fletcher Elaine Funnell Jack Gandour Hilary Gardner

University College London, England University of Sydney, Australia University of Sydney, Australia University of Sydney, Australia Hospital Universario Malaga, Spain University College London, England University of Ulster, Northern Ireland University of Sheffield, England Glasgow Caledonian University, Scotland New York University School of Medicine, USA University of Sheffield, England Connect UK Clinica Neurologica dell’Università di Brescia, Italy City University London, England University of Hong Kong, PR China University of Connecticut, Storrs, USA University of Wales Institute, Cardiff, Wales Plattsburgh State University of New York, USA University of Huddersfield, England City University London, England University of Newcastle, England VA Pittsburgh and University of Pittsburgh, USA Mayo Clinic, Rochester, MN, USA University of Birmingham, England University of Sheffield, England University College Cork, Ireland Royal Holloway College London, England Purdue University, USA University of Sheffield, England

Tabula gratulatoria Mike Garman Fiona Gibbon Jackie Guendouzi Jennifer Gurd Brooke Hallowell Linda Hand Jenny Harasty Bill Hardcastle Diane Hazlett Ruth Herbert Anne Hesketh Nigel Hewlett Argye Hillis John Hodges Anthony Hogan Jennifer Horner David Howard Sara Howard Walter Huber Debbie James Janice Kay Kevin Kearns Belinda Kenny Thomas Klee Annu Klippi Herman J. Kolk Matti Laine Margaret Leahy Guylaine Le Dorze Kerrie Lee Eeva Leinonen Carolyn Letts Michelle Lincoln Marjorie Lorch Felice Loverso Jane Maxim Lise Menn

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University of Reading, England Queen Margaret University College, Edinburgh, Scotland University of South Alabama, USA Oxford University, England Ohio University, Athens, USA University of Sydney, Australia University of New South Wales, Australia Queen Margaret University College, Edinburgh, Scotland University of Ulster, Northern Ireland University of Sheffield, England University of Manchester, England Queen Margaret University College, Edinburgh, Scotland Johns Hopkins University, Baltimore, USA University of Cambridge, Addenbrooke’s Hospital, UK University of Sydney, Australia Medical University of South Carolina, Charleston, USA University of Newcastle, England University of Sheffield, England University of Aachen, Germany Flinders University, Adelaide, Australia University of Exeter, England MGH Institute of Health Professions, Boston, USA University of Sydney, Australia University of Newcastle, England University of Helsinki, Finland Nijmegen University, The Netherlands Åbo Akademi University, Finland Trinity College Dublin, Ireland Université de Montréal, Canada University of Sydney, Australia University of Hertfordshire, England; Oulu University, Finland University of Newcastle, England University of Sydney, Australia University College London, England Casa Colina Centers for Rehabilitation, Pomona, CA, USA University College London, England University of Colorado at Boulder, USA

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Tabula gratulatoria

Jane Marshall John Marshall Robert Marshall Nadine Martin Tricia McCabe Sharynne McLeod Malcolm McNeill Mike McTear Kate Morton Dave Müller Siân Munro Penelope Myers Marilyn Newhoff Lyndsey Nickels Mark Onslow Aileen Patterson Mick Perkins Lisa Perkins Brian Petheram Emma Power Friedmann Pulvermüller Alison Purcell Vicki Reed Katherine Ross Dave Rowley Avraham Schweiger Lewis Shapiro Christine Sheard Mark Tatham Jeremy Tree David Trembath Heather Van der Lely Jan Van Doorn Brendan Weekes Bill Wells Klaus Willmes Richard Wise Linda Worrall Wolfram Ziegler

City University London, England University of Oxford, England University of Kentucky, USA Temple University, USA University of Sydney, Australia Charles Sturt University, Australia University of Pittsburgh, USA University of Ulster, Northern Ireland University of Essex, England Suffolk University College, England University of Wales Institute Cardiff, Wales Mayo Clinic, Rochester, MN, USA San Diego State University, San Diego, USA Macquarie University, Australia University of Sydney, Australia University of Ulster, Northern Ireland University of Sheffield, England Jersey Health Authority, Channel Islands, UK Frenchay Hospital, Bristol, England University of Sydney, Australia University of Konstanz, Germany University of Sydney, Australia James Madison University, Virginia, USA Carl T. Hayden VA Medical Center, Phoenix, and Arizona State University, Tempe, USA De Montfort University, England Academic College of Tel Aviv-Yaffo, Israel San Diego State University, San Diego, USA University of Sydney, Australia University of Essex, England University of Exeter, England University of Sydney, Australia University College London, England Umeå University, Sweden; University of Sydney, Australia University of Sussex, England University of Sheffield, England University of Aachen, Germany Imperial College, London, England University of Queensland, Australia Städtisches Klinikum München, Germany

Contributors

Elizabeth Armstrong Department of Linguistics, Macquarie University, Sydney. Martin J. Ball Department of Communicative Disorders, University of Louisiana at Lafayette, USA. Roelien Bastiaanse Center for Language and Cognition, University of Groningen, The Netherlands. Gerhard Blanken Department of Psycholinguistics, University of Erfurt, Germany. Tobias Bormann Department of Psycholinguistics, University of Erfurt, Germany. Hugh W. Buckingham

Louisiana State University, Baton Rouge, USA.

Maud Champagne-Lavau Faculté de médecine, Université de Montréal and Centre de recherche, Hôpital Sacré-Coeur de Montréal, Canada. Sarah S. Christman The University of Oklahoma, Health Sciences Center, Oklahoma City, USA. Jack S. Damico Department of Communicative Disorders, University of Louisiana at Lafayette, USA. Pattie Doody Department of Communicative Disorders, University of Louisiana at Lafayette, USA. Susan Edwards School of Psychology and Clinical Language Sciences, University of Reading, UK. Thorsten Fehr Institute for Cognitive Neuroscience and Center for Advanced Imaging (CAI), Bremen University, Germany. Alison Ferguson Australia.

Speech Pathology Program, University of Newcastle,

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Contributors

Manfred Herrmann Institute for Cognitive Neuroscience and Center for Advanced Imaging (CAI), Bremen University, Germany. Audrey L. Holland Tucson, USA.

Regents’ Professor Emerita, University of Arizona,

Yves Joanette Centre de recherche, Institut universitaire de gériatrie de Montréal and Faculté de médecine, Université de Montréal, Canada. Karima Kahlaoui Centre de recherche, Institut universitaire de gériatrie de Montréal, Canada. Richard C. Katz Veterans Affairs Medical Center, Phoenix, Arizona and Arizona State University, Tempe, USA. Alana Kozlowski Department of Communicative Disorders, University of Louisiana at Lafayette, and Communication Disorders and Deaf Education, Lamar University, Texas, USA. Leonard L. LaPointe Regional Rehabilitation Center, Florida State University, Tallahassee, USA. Kerry L. Lenius Regional Rehabilitation Center, Florida State University, Tallahassee, USA. Skye McDonald School of Psychology, University of New South Wales, Sydney, Australia. Inger Moen Department of Linguistics and Scandinavian Studies, University of Oslo, Norway. Nicole Müller Department of Communicative Disorders, University of Louisiana at Lafayette, USA. Bruce E. Murdoch School of Health and Rehabilitation Sciences, The University of Queensland, Australia. Jean-Luc Nespoulous Laboratoire Jacques-Lordat, University of ToulouseLe Mirail, France. Maria Pa˛chalska Department of Developmental Psychology and Neurolinguistics, Institute of Psychology, Marie Curie-Sklodowska University, Lublin, Poland. Claire Penn School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa. Nina N. Simmons-Mackie Department of Communication Sciences and Disorders, Southeastern Louisiana University, Hammond, USA. Bernadette Ska Centre de recherche, Institut universitaire de gériatrie de Montréal and Faculté de médecine, Université de Montréal, Canada.

Contributors

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Leanne Togher School of Communication Sciences and Disorders, University of Sydney, Australia. Hanna K. Ulatowska School of Behavioral and Brain Sciences, University of Texas, Dallas, USA. Jacques Virbel Institut de Recherche en Informatique de Toulouse, University Paul Sabatier, Toulouse, France. Claus-W. Wallesch Department of University Magdeburg, Germany.

Neurology,

Otto-von-Guericke-

Robert T. Wertz Formerly Veterans’ Administration Medical Center, Nashville, USA.

Preface

This book is a collection of the cutting edge work of many leading researchers and clinicians exploring topics within clinical aphasiology. However, it is more than this; it is also a tribute to our friend and colleague, Chris Code. Chris has been a prime mover in many areas of aphasiology over the years, and we discuss his contribution to the field in some detail in the first chapter of this book. The remaining contents we have divided into three main approaches to the study of aphasia, reflecting Chris’s own interests. First, we have five contributions that fall under the heading of Conceptual considerations. These are mainly interdisciplinary in nature, thus reflecting Chris’s expertise and interests that span linguistics, phonetics, psychology and neurology, as well as social aspects of communication disorders. The second section of the book deals with Research considerations, with seven chapters ranging from how the study of disrupted communication can inform models of normal language processing, through tone production and processing in speakers with aphasia, to anomia and progressive multifocal leukoencephalopathy. Each of these chapters explores different aspects of research methodology, reflecting Chris’s interests in quantitative research (e.g., his work on perceptual psychoacoustics), and qualitative research (e.g., discourse analysis). The final section of the collection deals with Clinical considerations, and the seven chapters here cover counselling, computerized training, cultural and linguistic diversity in aphasia, right hemisphere disorders, and communication problems in the dementias. Again, this part of the collection reflects Chris’s long-term interests in the clinical aspects of aphasiology, as well as the research aspects. The authorship of the chapters in this volume reflects Chris’s strong international ties. We have contributions from the United Kingdom, the United States, Australia, Germany, France, Norway, South Africa, The Netherlands, Canada and Poland. The names in the Tabula Gratulatoria reflect an even wider range of countries. We would like to thank Ben Rutter for compiling the indexes. This collection honours Chris’s contribution to the field, and marks his 65th birthday. However, this is not to suggest that he is about to give up his

Preface

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research into neurological disorders – arguably one of the most fascinating areas within communication disorders. Indeed, we look forward to many more years of interesting and important work emerging from the depths of the Devonshire countryside, with the support of his ‘partner in greatness’ Christine. Martin J. Ball Jack S. Damico Lafayette, Louisiana, August 2006

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Chris Code’s contribution to aphasiology Martin J. Ball and Jack S. Damico

Introduction Chris Code is one of the foremost scholars in aphasiology today, and has advanced the field in many ways. Over a professional career that has spanned nearly 30 years, he has authored or co-authored more than 120 publications and has served as a faculty member or research Fellow in eight institutions of higher learning in the United Kingdom, Australia, and Europe. Importantly, he was the Founding Editor of Aphasiology: An International and Interdisciplinary Journal in 1987 and he has continued to serve as Editor in Chief of that journal. When looking back over the career of a colleague like Chris, there are many achievements that may be highlighted. For example, he has effectively trained scores of students around the world, and he has employed his considerable talents as an editor, editorial board member and reviewer for no less than 16 journals and book series. The measure of Chris Code as a professional, however, must encompass several other areas as well. First, he has produced an impressive list of research and clinical publications that have influenced several fields, but especially clinical aphasiology. His enthusiasm for his work comes through in these publications as he has advanced our understanding of the areas of aphasia, phonetics, the role of the right hemisphere in speech and language, psychosocial adjustments to brain damage, patient rights issues, and traumatic brain injury. Indeed, a survey of his publications shows contributions in at least 18 distinct research areas in the human communication sciences and disorders. Second, he has been an enthusiastic collaborator with a network of colleagues that spans the United Kingdom, North American, Europe, and Australia. Starting with his earliest collaborations with Müller and Ball in the early 1980s until his most recent articles and book projects, Chris Code has worked closely with no fewer than 60 professionals in his research activities. In these collaborations, he has functioned both as a colleague of equal standing and as a mentor for younger colleagues. Finally, Chris Code has had a galvanizing impact on the field of clinical aphasiology as a savant, a motivator, and an impresario of trends that have resulted in several rather significant developments in the discipline. Despite all his other

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accomplishments, this last area may be his most important contribution of all. In this chapter we briefly discuss several areas of achievement that mark Chris Code’s career. We survey the areas within aphasiology that have been his special concern as indicated by his publications, and we discuss his rather considerable influence as an instigator and/or supporter of various developments in clinical aphasiology. Regarding his research and clinical publications, we approach his work under the following broad headings: psychosocial and emotional reaction to brain damage and communication impairment; linguistics and phonetics of aphasia and related disorders; right hemisphere language and speech; and international aspects of aphasiology. The focus on his influence will encompass his role as Editor in Chief of Aphasiology: An International and Interdisciplinary Journal and how he has employed this journal to advance the discipline.

Research accomplishments Psychosocial adjustment to brain damage Beginning with some of his earliest research, Chris Code has been interested in documenting and describing the social and emotional changes that often accompany aphasia (Müller & Code, 1983; Müller, Code, & Mugford, 1982) and this focus has been an enduring theme in his published work (e.g., Code, 1997a; Code, Hemsley, & Herrmann, 1999; Code & Herrmann, 2003; Code & Müller, 1989, 1995a, 1996). Taking a more expanded view than was common at the time, Code and colleagues stressed an effective hybrid model of affective issues in aphasia by advocating that emotional issues and experience must always be viewed on an individual basis and within social contexts (e.g., Code, 1986, 1997b; Code & Müller, 1995a; Hemsley & Code, 1996; Müller & Code, 1983). In a series of research studies, he and colleagues have been able to show how the emotional state can have a significant impact on motivation, physical functioning, and cognitive and linguistic processing and that these changes may significantly impact recovery from aphasia (e.g., Code, 1997b, 2001; Code & Herrmann, 2003; Code & Müller, 1992; Code, Müller, & Herrmann, 1999; Hemsley & Code, 1996). Perhaps his most significant achievement regarding psychosocial adjustment has been the development and application of the Code-Müller Protocols. These protocols have developed over time (Code & Müller, 1992; Herrmann & Code, 1996; Müller & Code, 1983; Müller, Code, & Mugford, 1982) and are intended to examine perceptions of psychosocial well-being. By employing these protocols, Code and others have been able to study depression, motivation, and other emotional responses to both the impact of aphasia and how recovery may proceed (e.g., Code, 1986, 1997b; Code & Herrmann, 2003; Code & Müller, 1989). This work has also helped determine how various levels of optimism about recovery across the various players in the rehabilitative

Chris Code’s contribution to aphasiology

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context (i.e., individual with aphasia, significant others linked to these individuals, therapist) may contribute to the complex interaction between perception of potential, psychosocial factors, and recovery in aphasia (e.g., Code, Müller, & Herrmann, 1999; Hemsley & Code, 1996). With additional applications of the protocols using a multiple-attribute utility technique to assign weightings that effectively rank individual priorities of psychosocial adjustment (Herrmann & Code, 1996), it has been shown that different individuals perceive very different priorities during recovery and these may have an important impact on expectations and treatment variables (e.g., Hemsley & Code, 1996; Müller, Code, & Mugford, 1982). In addition to his own work with the Code-Müller Protocols, this procedure has been widely employed in other research and clinical venues (see Code, Müller, & Herrmann, 1999; Code, Müller, Herrmann, & Hogan, 1999), and has been influential in the movement toward consideration of quality of life issues (Code, 2003; Code & Müller, 2003; Worrall & Holland, 2003), the Life Participation Approach to Aphasia (Chapey et al., 2001), and various social models of aphasia (Lyon & Shadden, 2001; Shadden, 2005; SimmonsMackie, 2001). Linguistic investigations: Speech automatisms Another of Chris Code’s main interests has been the study of lexical and nonlexical speech automatisms, also known as real-word and nonmeaningful recurrent utterances (Chung, Code, & Ball, 2004; Code, 1982a, 1982b, 1987, 1989a, 1994a; Code & Ball, 1994). Chris’s work in the 1980s included the first important studies of this area since Alajouanine (1956) and, with colleagues, he has assembled a database of both lexical and nonlexical speech automatisms in English, German, and Cantonese. However, his work in this area is not restricted to simply “butterfly collecting” (important as it is to acquire ample exemplars of a phenomenon, it is also important to investigate it). The main thrust of this analysis has been first, in the area of linguistic analyses of the speech automatisms he and colleagues have collected, and second, on the origins of speech automatisms. One of the first analyses Code conducted on the English data (Code, 1982a) was a phoneme frequency analysis. This was applied to both the real-word and non-meaningful recurrent utterances with interestingly different results. With the real-word tokens, there was a high correlation between the sounds used and the sounds of normal conversational English. Looked at more closely (in terms of place and manner of articulation, and voicing) some differences emerged. These were in respect of manner of articulation with plosives occurring more often in the real-word recurrent utterances than in normal speech (up from 29% to 40%; Code, 1982a, 1989a). Explanations for these findings may be found in terms of sonority theory and we return to this below. Significantly fewer English sounds occurred in the non-meaningful recurrent utterances collected from the English subjects as compared to the

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real-word examples (21 of 44 phonemes as opposed to 40 from 44). There was also a greater consonant to vowel ratio (47% to 53% compared to normal English 62.5% to 37.5%, and in the real-word recurrent utterances 56% to 46%). A place, manner, and voicing analysis again showed that the manner category was the one that deviated most from normal speech, with plosives accounting for 62% of the consonants. In a later study (Code & Ball, 1994, 1995), the authors looked for explanations for the phonotactic patterns and inventory constraints in both the English non-meaningful recurrent utterances, and German data collected by Blanken, Wallesch, and Papagno (1990). The high proportion of plosives partly reflects motorically easier sounds to produce; but also fits into the requirements of the perceptually driven sonority sequencing principle (SSP; Ball, Müller, & Rutter, forthcoming), where (in syllable initial position at least) plosive–vowel sequences are preferred. Interestingly, the SSP also predicts that in syllable final position (where a coda consonant occurs) the consonant will be ranked higher on the sonority hierarchy than are plosives. In the data reported in Code and Ball (1994) we do indeed find in final position a preference for fricatives and nasals over plosives, although open syllables were the dominant pattern (as predicted by universals of syllable structure). The authors use these results to speculate on the nature of sonority, and whether it is a hard-wired feature of phonological processing or simply an artefact of the speech production process. Code (1982a) also undertook a linguistic analysis of the real-word recurrent utterances. As an initial step he examined frequency of occurrence of the words used in the English data. He determined that the majority of the separate words used (proper names and expletives were excluded as not being represented in the normative data) were in the common category: 86% were words occurring 50 times per million or more in normal conversational English. Code then presents a syntactic analysis of the data. The majority of the real-word recurrent utterances were of the form pronoun + verb (often I + modal, e.g., I want to, I can’t, I can try). Expletives were the next most common form, followed by proper names, yes/no, and numbers. Repeated forms were also common, and a range of other syntactic patterns were seen. Chung, Code, and Ball (2004) extended the analysis to Cantonese speech automatisms (both real-word and non-meaningful). Results showed very similar patterns to those found with the English and German examples. As we noted earlier, Chris Code is also interested in the origin of speech automatisms, and Code (1982b) addresses this area. Various attempts to account for real-word forms have been proposed: for example, that the utterance is one the patient intended to produce at the very moment of the stroke, or that it was the last utterance actually produced before the stroke occurred. Alajouanine (1956) felt these two approaches could be combined into the notion that the utterance is the last thought being organized into an utterance before the stroke. However, Code argues convincingly that the origin of realword speech automatisms has more to do with post-onset factors than with


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pre-onset ones. For example, the use of family names, frustration expressed through expletives and pronoun + verb forms can all be accounted for as being the patient’s first attempted utterances on regaining consciousness after a stroke. Code points out that the non-word examples are clearly not propositional speech, but even the real-word ones cannot be so described, as they are invariant and so stereotypical. He notes the view that there is righthemisphere involvement in the production of non-propositional speech, and concludes “that the right hemisphere is subserving the initial and continuing production of RUs [recurrent utterances], perhaps to different degrees in the two linguistically distinct types” (Code, 1982b, p. 163). Phonetic investigations Chris Code has been especially interested in the application of instrumental phonetic techniques to the study of a variety of speech disorders, and his survey of psychoacoustic techniques with stuttering and aphasia can be found in his 1984a, 1984b, and 1997a work. In this section, however, we concentrate on two areas of his research: apraxia of speech and progressive speech deterioration. Apraxia of speech Chris Code’s interest in apraxia of speech was sparked by an early study with Martin Ball (Code & Ball, 1982; see also Code & Ball, 1988). In this study, the subject investigated was able to use voicing appropriately in English sonorant sounds (where contrastive voicing does not play a part), but produced target voiced obstruents mainly without vocal fold vibration. Interestingly, however, the subject was able to distinguish final fortis and lenis obstruents through maintaining the pre-consonantal vowel length difference found in English; indeed, she compensated for the loss of voicing by enhancing the vowel length differences considerably. These findings led to a consideration of how traditional binary divisions of speech (phonetics versus phonology) might account for the apraxia of speech, and discussion of alternative models. Chris Code returned to apraxia of speech in a major review (Code, 1998). In this paper, Code examines a range of multilevel accounts of speech production and discusses where in these models aphasia, apraxia of speech, and dysarthria might fit. Code concludes that as apraxia of speech is a disorder that has both phonetic and phonological implications, work in this area “has contributed significantly to the rethinking of the relationship between phonology and phonetics . . . and highlighted the need for a phonetically derived phonology” (Code, 1998, p. 62). This last point is seen in recent models that posit some kind of phonetic planning component between the phonological organization, and the articulatory implementation levels. It also chimes well with recent approaches to theoretical phonology (such as Government Phonology, Gestural Phonology, and Usage-based Phonology: see

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Ball et al., forthcoming) that emphasize phonetic and cognitive aspects of speech organization. Progressive speech deterioration Recently Chris Code has undertaken investigations of a rare case of progressive speech deterioration (Ball, Code, Tree, Dawe, & Kay, 2004; Code, Müller, Tree, & Ball, 2006). The authors present a range of instrumental analyses of the segmental and suprasegmental characteristics of the client, and it is interesting to note that whereas some of these showed simplifications (e.g., epenthetic vowels in consonant clusters), others showed complicating changes (such as adding /l/ after /u/ in open syllables, and /p/ or /b/ to /r/ initial words). A variety of phonological accounts were discussed that could throw light on the client’s speech patterns and their progressive deterioration over time. The authors conclude that the client’s speech patterns show that his relatively rare progressive speech degeneration “can be captured in terms of a cognitive model of representation, together with a gestural formalism that can show the loss of integration between the various motor systems of speech (and on occasion, total deletion of a gesture)” (Ball et al., 2004, p. 460). The eventual complete loss of intelligibility of the client some months after the data reported were collected shows that the gestural uncoupling and deletion had continued to devastating effect. The important aspect of this study was that Code and his colleagues demonstrated that unusual cases such as the one reported here are amenable to investigation through phonetic description and phonological analysis, and that such studies may throw light on both the case and on theory building itself. The role of the right hemisphere As a result of his commitment to aphasia rehabilitation, Dr Code also has a longstanding interest in the contribution of the right hemisphere of the brain to language and speech processing. There are two likely reasons for this interest. First, as a trained neuropsychologist, Chris Code has not limited his theorizing or his research to the left hemisphere when discussing speech and language processing. His academic and clinical training enabled him to consider the rather substantial contributions that the right hemisphere has to various types of perceptual and cognitive processing and how it may also impact other meaning-making systems (Code, 1989b, 1996, 1997c). Second, because of his belief in the rehabilitative process and the need for defensible models, principles, and approaches to effective rehabilitation (e.g., Code, 1994b, 1999, 2000, 2001; Code & Brown, 1987; Code & Müller, 1989, 1995b, 1995c), he and his colleagues have considered various viable rehabilitation models. In his 1987 text, Language, aphasia, and the right hemisphere, Dr Code effectively discusses the arguments and the data for a fair consideration of


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the role of the right hemisphere in speech and language processing and in aphasia rehabilitation. For example, he presents detailed data from various disciplines that substantiate the role of the right hemisphere in cognitive processing, in some aspects of linguistic comprehension, in the more automatic, non-propositional aspects of speech production, and in some of the extra-linguistic aspects of communication. This text provided timely summaries of the research and served as an effective review on the right hemisphere for a generation of students and professionals in speech-language pathology. This 1987 text also dealt extensively with the “lateral shift hypothesis” as it relates to recovery from aphasia. Taking its simplest variant (“following left brain damage there is a shift to the undamaged right hemisphere for language processing”, p. 110) and several other formulations, Chris discussed several ways that this hypothesis may be applied as a potential recovery mechanism for aphasia and how it relates to other mechanisms of recovery. He then presented a wide range of data from lesion case studies, cerebral blood flow studies, experiments using sodium amytal, electroencephalography, and dichotic listening, and evidence from behavioural studies to assess the evidence for the lateral shift hypothesis. While there was some indication that the right hemisphere does play a role in recovery from aphasia, his findings did not strongly support this hypothesis. Instead, he found that the impact of the right hemisphere on recovery from aphasia was not uniformly demonstrated. While there appeared to be some variation depending on the individual with aphasia, the severity of aphasia, and time post-onset, the right hemisphere does not appear to be a fully equivalent backup system to the left hemisphere, and its impact does not produce effective change in either the quality or quantity of recovery of function. While some aphasic syndromes may be more involved with right hemisphere functioning than previously believed, “right hemisphere involvement in language processing following left hemisphere damage is probably dependent upon a complex interplay of a range of variables” (1987, p. 148). Since the publication of his 1987 book, Code has continued to contribute to the data regarding right hemisphere processing of speech and language. While still uncertain about the contribution of the right hemisphere to language rehabilitation (Code, 1994b; Code & Joanette, 2003), he has presented data suggesting that some preserved utterances (formulaic expressions) noted in severely impaired individuals with aphasia may be processed in the right hemisphere (Code, 1996, 1997c) and that the right hemisphere does play a role in the creation and functioning of some discourse elements (Code, 1996) and in other forms of symbolic processing in individuals with aphasia (Cowell, Egan, Code, Harasty, & Watson, 2000). As he continues to investigate hypotheses regarding language processing and aphasia (e.g., Code, 1997d, 1999, 2001; Code & Joanette, 2003; Harasty, Halliday, Kril, & Code, 1999; Nespoulous, Code, Virbel, & LeCours, 1998), it is expected that this right hemisphere focus will continue.

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International issues As a professional who has worked at universities across the world, Chris Code has also emphasized an international perspective in his work and collaborations. This is evident in his focus on service delivery and research across linguistically diverse populations (e.g., Chung, Code, & Ball, 2004; Roger, Code, & Sheard, 2000) and his work compiling classic cases in neuropsychology across a number of languages and cultures (Code, Wallesch, Lecours, & Joanette, 1996, 2003). He has also collaborated with various colleagues across the world to compare knowledge of aphasia in the public domain (Simmons-Mackie, Code, Armstrong, Steigler, & Elman, 2002), and to investigate and compare aphasia management practices across national boundaries (Katz et al., 2000). In each of these studies there has been an opportunity to demonstrate that although there are some differences regarding institutional and cultural variables, there is also a foundational similarity among those professionals who work in clinical aphasiology throughout the world. To some extent these studies are beneficial in that they emphasize the similarities rather than the differences in our discipline despite ethnocentric beliefs and practices.

Influence as accomplishment In this initial chapter we have attempted to provide a sampling of the many research contributions that Chris Code has made over his 30 years to the area of clinical aphasiology. We have cited studies and provided numbers as objective evidence of his achievements. However, his impressive publication record represents only a fraction of his accomplishment in the field. For even if Chris Code had not published extensively himself, his influence would still be profound. Influence is an interesting phenomenon. One cannot always anticipate how much influence an individual might have in any given field. Often, those with large numbers of publications or other quantifiable indices may have little or no impact on a given field, while an individual with one powerful idea or a galvanizing personality may act as a catalyst for significant change. That is because influence is not so much an indication of one’s productivity but, rather, a measure of one’s impact on others. When viewed from this perspective, Chris Code has had an exceptional career. When he proposed and then served as the instigator and prime motivator for the journal Aphasiology: An International and Interdisciplinary Journal, he provided the first real opportunity to create an international forum for clinical aphasiology and this forum may be his most enduring accomplishment. In the mid-1980s there were venues for the publication of papers in aphasia and the powerful clinical forum created by Bruce Porch, Clinical Aphasiology Conference, was already in its 15th year. However, the published articles in clinical aphasiology were spread across numerous journals and were often


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hard to locate and the Proceedings of the Clinical Aphasiology Conference were privately published with a limited circulation. Within this context, Chris Code saw an opportunity to establish a journal specifically directed toward aphasiology and its treatment. Importantly, he did not squander this opportunity. Rather, he tirelessly worked and networked, travelled and corresponded, encouraged and cajoled professionals in the field – both established researchers and neophytes – to extend their ideas, marshal their data, and prepare manuscripts for his journal. Due to his efforts, Aphasiology: An International and Interdisciplinary Journal has developed from a twiceyearly publication to a monthly publication, and is currently recognized as the leading journal in the field of clinical aphasiology. Over its 20 years of publication, Aphasiology has published 184 issues containing more than 1050 papers and articles. In a recent keynote at the International Aphasia Rehabilitation Conference in Sheffield England, Code provided some interesting data on the content of Aphasiology over its 19 year history (Code, 2006). According to his figures, the journal has published 821 articles that were of direct clinical relevance and 270 of those were reports of treatment studies. These figures do indicate that Aphasiology is the primary venue for aphasia research – especially as it relates to clinical issues. Indeed, even the annual Proceedings of the Clinical Aphasiology Conference is now published in this journal. Impressive as the journal as been in capturing the majority of clinical research in aphasia and in providing a powerful centralized venue for the discipline, it was the way Chris Code has used the journal that has been most influential. With an eye toward a more international perspective, he has used his position as Editor in Chief to encourage more interaction and communication between professionals around the world. He has sought out and encouraged clinical aphasiologists on six continents to publish in the journal, and through the invited Forums section that highlights particular themes discussed by invited participants, he has fostered collaborative interactions across these different countries and across related professional disciplines. This has resulted in greater awareness of the researchers and the theoretical, research, and clinical issues that are of particular concern in various locales. Due to his efforts in Aphasiology and the progressive development of Internet technologies, clinical aphasiology is truly a shared international discipline. Perhaps Chris Code’s greatest accomplishment as Editor in Chief, however, relates to his encouragement and support of various topics, themes, or types of research. Using the Forum format, he has encouraged important research, discussion, and advocacy regarding a number of important clinically related areas. Service delivery issues in aphasia, psychosocial and social issues like sense of self after aphasia, quality of life issues, family therapy, and a focus on types of therapies are areas that Dr Code has effectively influenced through the journal. Additionally, Aphasiology has been the journal most supportive of qualitative research studies. Through his encouragement and care when advocating for this non-experimental research paradigm, Aphasiology is the

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leading journal in the human communication sciences in disorders regarding this powerful research tradition. Consequently, the discipline is richer and has greater understanding of the complexity of language, aphasia, and social action as a result. When Dr Code’s influence on the discipline of aphasia is measured with Aphasiology as one of his instruments of support, advocacy, and change, Chris Code is accomplished indeed. In his book Crowds and Power (1984), the author Elias Canetti discussed the importance of social, political, and intellectual movements and how they were created. He stated that for such movements to occur, there is the need to have effective “crowd crystals”. That is, individuals or small groups of individuals that serve as a seed crystal does in chemistry, to precipitate crowds into action and belief. When looking over Chris Code’s research career and his great influence on the field of clinical aphasiology through his encouragement and advocacy as the Editor in Chief of Aphasiology, we must see him as a “crowd crystal”, a precipitator of the highest order. It is for his efforts and his extensive accomplishments that we dedicate this volume to him.

References Alajouanine, T. (1956). Verbal realization in aphasia. Brain, 79, 1–28. Ball, M. J., Code, C., Tree, J., Dawe, K., & Kay, J. (2004). Phonetic and phonological analysis of progressive speech degeneration: A case study. Clinical Linguistics and Phonetics, 18, 447–462. Ball, M. J., Müller, N., & Rutter, B. (forthcoming). Phonology for communication disorders. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Blanken, G., Wallesch, C. W., & Papagno, C. (1990). Dissociations of language functions in aphasics with speech automatisms (recurring utterances). Cortex, 26, 41–63. Canetti, E. (1984). Crowds and power. New York: Farrar, Straus & Giroux. Chapey, R., Duchan, J., Elman, R., Garcia, L., Kagan, A., Lyon, J., et al. (1994). Life participation approach to aphasia: A statement of values for the future. In R. Chapey (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed., pp. 235–246). Philadelphia: Lippincott, Williams & Wilkins. Chung, K., Code, C., & Ball, M. J. (2004). Speech automatisms and recurring utterances from aphasic Cantonese speakers. Journal of Multilingual Communication Disorders, 2, 32–42. Code, C. (1982a). Neurolinguistic analysis of recurrent utterances in aphasia. Cortex, 18, 141–152. Code, C. (1982b). On the origins of recurrent utterances in aphasia. Cortex, 18, 161–164. Code, C. (1984a). Delayed auditory feedback. In C. Code & M. J. Ball (Eds.), Experimental clinical phonetics. London: Croom Helm. Code, C. (1984b). Dichotic listening. In C. Code & M. J. Ball (Eds.), Experimental clinical phonetics. London: Croom Helm. Code, C. (1986). Catastrophic reaction and anosognosia in anterior–posterior and


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left–right models of the cerebral control of emotion. Psychological Research, 48, 53–55. Code, C. (1987). Language, aphasia and the right hemisphere. Chichester, UK: John Wiley. Code, C. (1989a). The characteristics of aphasia. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C. (1989b). Speech automatisms and recurring utterances. In C. Code (Ed.), The characteristics of aphasia. Hove, UK: Lawrence Erlbaum Associates Ltd. (Previously published by Taylor & Francis, London.) Code, C. (1994a). Speech automatism production in aphasia. Journal of Neurolinguistics, 8, 135–148. Code, C. (1994b). The role of the right hemisphere in the treatment of aphasia. In R. Chapey (Ed.), Language intervention strategies in adult aphasia. Baltimore, MD: Williams & Wilkins. Code, C. (1996). Speech from the isolated right hemisphere? Left hemispherectomy cases E.C. and N.F. In C. Code, C.-W. Wallesch, Y. Joanette, & A.-R. Lecours (Eds.), Classic cases in neuropsychology. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C. (1997a). Experimental audioperceptual techniques. In M. J. Ball & C. Code (Eds.), Instrumental clinical phonetics (pp. 228–261). London: Whurr. Code, C. (1997b). Aphasia recovery, therapy and psychosocial adjustment. In A. Baum, C. McManus, S. Newman, J. Weinman, & R. West (Eds.), The Cambridge handbook of psychology, health & medicine. Cambridge, UK: Cambridge University Press. Code, C. (1997c). Can the right hemisphere speak? Brain and Language, 57, 38–59. Code, C. (1997d). A metamodel for recovery from aphasia. In J. Ponsford, P. Snow, & V. Anderson (Eds.), International perspectives in traumatic brain injury. Melbourne: Australian Academic Press. Code, C. (1998). Models, theories and heuristics in apraxia of speech. Clinical Linguistics and Phonetics, 12, 47–66. Code, C. (1999). Re-assembling the brain: Are cell assemblies the brain’s language for recovery of function? (Commentary) Behavioural and Brain Sciences, 22, 282. Code, C. (2000). Converging not fractionating. Brain and Language: Millennium Issue, 71, 44–45. Code, C. (2001). Multifactorial processes in recovery from aphasia: Developing the foundations for a multilevelled framework. Brain and Language, 77, 25–44. Code, C. (2003). The quantity of life for people with chronic aphasia. Neuropsychological Rehabilitation, 13, 365–378. Code, C. (2006). Back to the future: A recent history of aphasia rehabilitation. A keynote speech at the 12th International Aphasia Rehabilitation Conference, Sheffield, UK, June. Code, C., & Ball, M. J. (1982). Fricative production in Broca’s aphasia: A spectrographic analysis. Journal of Phonetics, 10, 325–331. Code, C., & Ball, M. J. (1988). Apraxia of speech: The case for a cognitive phonetics. In M. J. Ball (Ed.), Theoretical linguistics and disordered language (pp. 152–167). London: Croom Helm. Code, C., & Ball, M. J. (1994). Syllabification in aphasic recurring utterances: Contributions of sonority theory. Journal of Neurolinguistics, 8, 257–265. Code, C., & Ball, M. J. (1995). The status of sonority theory: Evidence from syllabification in aphasic recurring utterances. In K. Elenius & P. Branderud (Eds.),

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Proceedings ICPhS 95 Stockholm (Vol. 4, pp. 480–483). Stockholm: KTH & Stockholm University. Code, C., & Brown, J. W. (1987). Aphasia from the wrong (right) hemisphere: Questions for crossed aphasia. Aphasiology, 1, 401–402. Code, C., Hemsley, G., & Herrmann, M. (1999). Emotional reactions to aphasia. Seminars in Speech and Language, 20, 19–31. Code, C., & Herrmann, M. (2003). The relevance of emotional and psychosocial factors in aphasia to rehabilitation. Neuropsychological Rehabilitation, 13, 109–132. Code, C., & Joanette, Y. (2003). Neural plasticity in the control of language in the adult brain: The role of the separated right hemispheres in cases PS, VP and JW. In C. Code, C.-W. Wallesch, Y. Joanette, & A.-R. Lecours (Eds.), Classic cases in neuropsychology: Volume II. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C., & Müller, D. (Eds.) (1989). Aphasia therapy (2nd ed.). London: Cole & Whurr. Code, C., & Müller, D. J. (1992). The Code-Müller protocols: Assessing perceptions of psychosocial adjustment to brain damage. Kibworth: Far Communications. Code, C., & Müller, D. (1995a). Psychosocial perspectives. In C. Code & D. J. Müller (Eds.), The treatment of aphasia: From theory to practice. London: Whurr. Code, C., & Müller, D. (1995b). Cognitive and neuropsychological approaches. In C. Code & D. J. Müller (Eds.), The treatment of aphasia: From theory to practice. London: Whurr. Code, C., & Müller, D. (1995c). Efficacy and effectiveness. In C. Code & D. J. Muller (Eds.), The treatment of aphasia: From theory to practice. London: Whurr. Code, C., & Müller, D. (1996). Psychosocial issues. In C. Code & D. J. Müller (Eds.), Forums in clinical aphasiology. London: Whurr. Code, C., & Müller, D. (2003). Psychosocial and quality of life issues in treatment. In R. Kent (Ed.), The MIT encyclopaedia of communication disorders. Cambridge, MA: MIT Press. Code, C., Müller, D. J., & Herrmann, M. (1999). Perceptions of psychosocial adjustment to aphasia: Studies with the CMP. Seminars in Speech and Language, 20, 51–63. Code, C., Müller, D., Herrmann, M., & Hogan, A. (1999). Perceptions of psychosocial adjustment to acquired commnication disorders: Studies with the Code-Müller protocols. International Journal of Communication Disorders, 34, 193–207. Code, C., Müller, N., Tree, J. T., & Ball, M. J. (2006). Syntactic impairments can emerge later: Progressive agrammatic agraphia and syntactic comprehension impairment. Aphasiology, 20, 1035–1058. Code, C., Wallesch, C.-W., Lecours, A.-R., & Joanette, Y. (Eds.) (1996). Classic cases in neuropsychology. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C., Wallesch, C.-W., Lecours, A.-R., & Joanette, Y. (Eds.) (2003). Classic cases in neuropsychology: Volume II. Hove, UK: Lawrence Erlbaum Associates Ltd. Cowell, S. F., Egan, G. F., Code, C., Harasty, J., & Watson, J. D. G. (2000). The functional neuroanatomy of simple calculation and number repetition: A parametric PET activation study. NeuroImage, 12, 565–573. Harasty, J., Halliday, G. M., Kril, J. J., & Code, C. (1999). Specific temporoparietal gyral atrophy reflects the pattern of language dissolution in Alzheimer’s disease. Brain, 122, 675–686. Hemsley, G., & Code, C. (1996). Interactions between recovery in aphasia, emotional and psychosocial factors in subjects with aphasia, their significant others and speech pathologists. Disability and Rehabilitation, 18, 567–584.


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Herrmann, M., & Code, C. (1996). Weighting of items on the Code-Müller protocols: The effects of clinical experience of aphasia therapy. Disability and Rehabilitation, 18, 509–514. Katz, R., Hallowell, B., Code, C., Armstrong, E., Roberts, P. M., Pound, C., et al. (2000). A multi-national comparison of aphasia management practices. International Journal of Language and Communication Disorders, 35, 303–314. Lyon, J. G., & Shadden, B. (2001). Treating life consequences of aphasia’s chronicity. In R. Chapey (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed., pp. 297–314). Baltimore, MD: Williams & Wilkins. Müller, D., & Code, C. (1983). Interpersonal perceptions of psychosocial adjustment in aphasia. In C. Code & D. Müller (Eds.), Aphasia therapy. London: Edward Arnold. Müller, D., Code, C., & Mugford, J. (1982). Predicting psychosocial adjustment in aphasia. British Journal of Disorders of Communication, 17, 23–29. Nespoulous, J.-L., Code, C., Virbel, J., & Lecours, A.-R. (1998). Hypotheses on the dissociation between “referential” and “modalizing” verbal behaviour in aphasia. Applied Psycholinguistics, 19, 311–331. Roger, P., Code, C., & Sheard, C. (2000). Assessment and management of aphasia in a linguistically diverse society. Asia-Pacific Journal of Speech and Language, 5, 21–34. Shadden, B. B. (2005). Aphasia as identity theft: Theory and practice. Aphasiology, 19, 211–223. Simmons-Mackie, N. (2001). Social approaches to aphasia intervention. In R. Chapey (Ed.), Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed., pp. 246–268). Baltimore, MD: Williams & Wilkins. Simmons-Mackie, N., Code, C., Armstrong, E., Stiegler, L., & Elman, R. (2002). What is aphasia? Results of an international survey. Aphasiology, 12, 837–848. Worrall, L. E., & Holland, A. (2003). Editorial: Quality of life in aphasia. Aphasiology, 17, 329–332.

Part I

Conceptual considerations

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Investigations in speech and language and related disorders Crossing the boundaries between disciplines—a tribute to Chris Code Manfred Herrmann and Thorsten Fehr

Sydney University, 1997

Introduction Our research in speech and language started in the early 1980s and focused primarily on topics in the field of aphasia rehabilitation. Nonverbal communication as a compensatory means of communication in severe aphasia, psychosocial alterations following aphasia and psychosocial adjustment to aphasia, the neuronal basis of depressive disorders in aphasic patients, and the investigation of specific goals of aphasia rehabilitation are just some of the topics that were originally influenced by Chris Code. Chris not only initiated part of our research but he also participated in several investigations. Even when we expanded the scope of our investigations into basic research (such as molecular neurobiology or the spatiotemporal analysis of neuronal correlates of number processing) Chris was with us – not only in a theoretical sense but also in person (i.e., spending sabbaticals in our labs or as a scientific fellow invited by the Hanse Institute for Advanced Studies). In this chapter, we try to delineate part of this cooperation between Chris and ourselves, which up to now has not only survived more than two decades but also bridged research on different continents.

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Nonverbal communication in severe nonfluent aphasia About 25 years ago, our research group, formerly located at Freiburg University, started investigations in the field of aphasia and related disorders. Our first studies focused on the issue of communication and communication strategies in people with severe and chronic aphasia. We tried to analyze nonverbal communication as a compensatory behavioral strategy in severely nonfluent aphasia. Based on videotaped conversation sequences we investigated the use of nonverbal communication between aphasic patients and their communication partners. The data derived from that study show that aphasic patients used nonverbal channels of communication significantly more often, and for a significantly longer period of time, than their healthy partners. We concluded that severe aphasic patients use nonverbal communication strategies in natural conversation settings as a means of compensation for verbal deficits, and that these spontaneously used communication strategies should extend the scope of speech therapy towards communication therapy (Herrmann, Reichle, Lucius-Hoene, Wallesch, & Johannsen-Horbach, 1988). In a follow-up study with 20 chronically nonfluent aphasic patients with moderate or severe language deficits we could demonstrate that communicative and neurolinguistic deficits did not correlate and that non- and paralinguistic communication accounted for the communicative efficiency in nonfluent aphasia (Herrmann, Koch, Johannsen-Horbach, & Wallesch, 1989). These preliminary data also gave a first indication of communicative efficiency in nonfluent aphasia being strongly affected by both the psychosocial status of the patient and his family and emotional disorders resulting from stroke. At that time (the early 1980s), there were only few aphasia therapists and speech pathologists who were engaged in investigating psychosocial changes and emotional disorders following stroke and aphasia. We, by chance, became acquainted with a young lecturer from the Leicester Polytechnic, UK, who presented a research instrument and some data on expectations concerning psychosocial adaptation in chronic aphasia. Chris Code was one of the authors of the Code-Müller Scale of Psychosocial Adjustment (SPA; Müller, Code, & Mugford, 1983; Müller & Code, 1983) nowadays known as the Code-Müller Protocols (CMP; Code & Müller, 1992). Since then, we have established a long-lasting friendship and fruitful scientific cooperation bridging continents and covering a variety of research topics in the field of speech and language and related disorders.

Psychosocial alterations following aphasia In 1985 we started with a number of studies investigating psychosocial changes resulting from communicative impairment in chronic aphasic patients and their relatives. We found that aphasic patients and relatives suffer from a considerable amount of professional, social, familial, and psychological stress

Investigations in speech and language and related disorders

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(Herrmann, Bartels, & Wallesch, 1993a; Herrmann, Johannsen-Horbach, & Wallesch, 1992; Herrmann & Wallesch, 1989; Johannsen-Horbach, Wenz, Fünfgeld, Herrmann, & Wallesch, 1993), which in turn seems to be a limiting factor in patients’ rehabilitation (Herrmann, 1997; Herrmann, JohannsenHorbach, & Wallesch, 1993b). In a longitudinal study with 58 stroke patients and their relatives we were able to demonstrate that aphasic patients and relatives experience significantly more severe professional and social changes than subjects without aphasia and their families. Aphasia itself, however, seems to have no substantial effect on adaptive or maladaptive coping strategies or activities of daily living (Herrmann, Bartels, Britz, & Wallesch, 1995b). In a small pilot study we investigated ten chronically aphasic patients and their relatives with respect to the emotional experience of psychosocial changes and the individually perceived stresses and burdens posed by different stroke symptoms (Wenz & Herrmann, 1990). The most striking result from that study was that the respective speech therapists expected the patients to be most severely stressed by speech and language disorders, while the patients’ relatives thought that both aphasia and hemiparesis contribute equally to the patient’s stresses. The patients themselves, however, reported to be most severely affected by motor symptoms (see Figure 2.1). Based on these findings we decided to dedicate part of our research on interpersonal perceptions of psychosocial adjustment to aphasia.

Figure 2.1 Stresses and burdens in chronic aphasic patients as perceived by the patients, their respective relatives and speech therapists (modified from Wenz & Herrmann, 1990).

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Psychosocial adjustment to aphasia: Applications of the Code-Müller protocols (CMP) The CMP (formerly known as the Scale of Psychosocial Adjustment, SPA) were introduced by Chris Code and colleagues in 1983 (Code & Müller, 1992; Müller & Code, 1983; Müller et al., 1983) and originally aimed to compare perceptions of psychosocial adjustment to aphasia from the separate perspectives of patients, relatives, and speech therapists. The CMP consisted of ten items on psychosocial expectations derived from an expert rating, which covered the following topics: (1) the ability to work, (2) receiving speech therapy, (3) independence of others, (4) meeting friends socially, (5) coping with depression, (6) following interests and hobbies, (7) speaking to strangers, (8) coping with frustration, (9) making new personal relationships, and (10) coping with embarrassment. In a first study (Herrmann & Wallesch, 1989), we found that aphasic patients and relatives significantly overestimated the patient’s ability to cope with psychosocial stresses when compared to the assessment of their respective speech therapists. This study replicated the original findings by Chris Code and colleagues, and the findings of our first study were also corroborated by a series of future studies. In our view, these data showed that a considerable number of patients and relatives expected – even after years of limited progress – that the premorbid status might eventually be restored. This “unhealthy attitude” (Helmick, Watamori, & Palmer, 1976), on the other hand, could lead to significant emotional and psychosocial crises on the part of the relatives and of the patients. Apart from the above described use of the CMP as an instrument that targeted the expectations of psychosocial adjustment to aphasia, we also introduced the CMP items as a scale reflecting particular objectives of aphasia rehabilitation (Herrmann & Wallesch, 1990). By means of the multi-attribute utility technique (MAUT; Edwards & Newman, 1982), we investigated the therapeutic staff of a Neurological Rehabilitation Center (occupational therapists, physiotherapists, neuropsychologists, neurologists, and speech therapists) with respect to the relative importance of CMP items / topics as specific goals of aphasia rehabilitation. The data of this study indicated that the specific demands of different therapeutic methods and approaches clearly influence the appraisal of abilities for psychosocial adaptation and aphasia rehabilitation. In 1995, when Chris came over from Sydney to Germany to spend part of his sabbatical in our lab at Freiburg University, we conducted a bigger study with 122 professionals engaged in aphasia therapy (Herrmann & Code, 1996). These aphasia therapists participated in a summer academy on “Language and Brain” that was held at Freiburg University and was organized by Gerhard Blanken. The participants were asked to rank and weight the relevance of the items of the CMP for assessing the expectations of psychosocial adjustment to aphasia as a general target of aphasia rehabilitation. The data show two major results: (1) for professionals working in aphasia


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rehabilitation independence from others and emotional adaptation emerge as the most important domains on the CMP (see Figure 2.2), and (2), the relevance of CMP items as potential targets in aphasia therapy changes with duration of clinical experience. In 1997, when the first author of the present chapter spent part of his sabbatical at Sydney University, we worked up our studies on the CMP in two review papers (Code, Müller, Hogan, & Herrmann, 1999b; Code, Müller, & Herrmann, 1999c). During the last couple of years we have also started to use the CMP as teaching material in courses on neurological and neuropsychological rehabilitation. Within a special education program in clinical neuroscience, fourth year psychology students are expected to participate as visiting students in speech and language therapy, occupational therapy, physiotherapy, and neuropsychological therapy. Before starting the practical courses we always introduce the CMP (and the respective results derived from the ranking and weighting procedure) as a common starting point for discussing the relative importance of different goals of aphasia rehabilitation. Interestingly, the relative weightings of the CMP items in naïve or untrained students do not differ significantly from the weightings given by experienced aphasia therapists (see Figure 2.2). Disagreement in the assessment of the relative

Figure 2.2 Distribution of relative item weightings of the Code-Müller Protocols (CMP; mean scores). Weightings are standardized to a mean weight of .10. Dark bars show the weightings of experienced aphasia therapists (N = 60) and bright bars indicate the weightings of 4th year psychology students (N = 78). Error bars represent ± 1 SEM, p values refer to t-tests (two-sided).

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importance of rehabilitation goals was only found with respect to the ability to work, following interests and hobbies, and coping with frustration. And only the ability to work (again) was judged a significantly more important rehabilitation goal by untrained psychology students.

Emotional disorders in aphasia: Post-stroke depression and neuropathological correlates As already mentioned above, our experience with the use of nonverbal behavior as a compensatory means of communication in severe aphasia seemed to be highly influenced by both the psychosocial and the emotional status of the patients and relatives. We, therefore, also started to investigate depressive mood changes following brain lesions in aphasic and non-aphasic stroke patients. In a first study conducted from 1987 to 1991 we investigated depressive alterations in acute and chronic aphasic patients with first-ever single left-sided stroke lesions (Herrmann et al., 1993a). Patients with major depression were only found in the acute group, and only among those with nonfluent aphasias. Brain imaging data showed that it was not the volume of the lesion but only the lesion location that had a major impact on the type and severity of depressive symptoms. Superimposition of brain lesions of aphasic patients with major depressive disorders demonstrated a common subcortical lesion area involving putaminal and external pallidal structures, which we interpreted to account for the pathogenesis of post-stroke depression. We were able to replicate these findings in two broader studies (Herrmann, Bartels, Schumacher, & Wallesch, 1995a, and Beblo, Wallesch, & Herrmann, 1999), both of which supported the hypotheses that (1) brain lesions of the left hemisphere basal ganglia and surrounding white matter tend to play a decisive role in the development of major depression in the early stage after stroke, and (2) (functional) disruption of frontostriatal circuits seems to contribute to the underlying pathophysiology of post-stroke depression. These data, however, only account for the development of severe depressive disorder (major depression) in aphasic patients during the post-acute stage after stroke onset, but obviously do not contribute to the pathophysiology of depressive disorders emerging in the later course of stroke and aphasia. Based on data from our own studies (Herrmann et al., 1995b; Herrmann et al., 1992; as well as studies from other colleagues) we argued that during the course of aphasia rehabilitation there are different stages during which the patients exhibit a specific vulnerability to developing depressive disorders. In a first approach we classified these stages as “primary,” “secondary,” and “tertiary” (Herrmann & Wallesch, 1993). These terms, however, mainly reflect the time of occurrence of depression in aphasia rehabilitation and do not specify the underlying pathophysiology of different types of depression. At that point of our studies in speech and language and related disorders, Chris again joined our group and helped us to characterize and differentiate the


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distinct sub-types of depressive disorders during long-term aphasia rehabilitation (Code, Hemsley, & Herrmann, 1999a; Code & Herrmann, 2003).

The neuronal basis of number representation and mental calculation During the sabbatical stay of the first author of the present chapter at Sydney University in 1997, Chris Code was heavily engaged in disentangling the mystery of number processing and mental calculation by the use of positron emission tomography (Cowell & Code, 1998; Cowell, Egan, Code, Harasty, & Watson, 2000). While these very first investigations on number processing were based on simple calculation tasks, we decided to use a more complex paradigm and advanced methods of spatiotemporal analysis of brain activity in future studies. From 2002 to 2004, Chris was invited to Bremen University for several research stays as a fellow of the Hanse Institute for Advanced Studies, and we decided to resume investigations on the neuronal basis of mental calculation. During the last couple of years, a huge volume of studies have been published, which investigated “mental calculation” or “number processing” by using different study designs including different operators, different stimulation modalities, and different complexities of mental calculation tasks. Our combined UK (Exeter)–Germany (Bremen) approach aimed at spatiotemporal analysis of neuronal correlates of different stimulation modalities (auditory versus visual), task complexities (e.g., “simple tasks” with results in the number domain below 10 or “complex tasks” with results in the number domain between 10 and 100), and basic operations (+, −, ×, /) during mental calculation. Prior to fMRI and MEG examinations we started with a German pilot study on a behavioral data level (reaction times (RTs), error rates) followed by a parallel study with British students at Exeter University. Surprisingly, students from Bremen University presented faster RTs than the age-matched British group (see Figure 2.3), while error rates did not differ significantly between groups. So far, we do not have a strong explanation for how these differences originate, and how Chris might have contributed to this result. In both groups, participants showed longer RTs for complex tasks in comparison to simple tasks. The auditory presentation mode produced longer RTs than the visual presentation mode. In a further study combining functional magnetic resonance imaging (fMRI) and magnetencephalography (MEG), 11 German subjects were scanned with both methods while they performed the same tasks evaluated in the pilot study. Data derived from event-related fMRI showed a network of activated areas for complex tasks in contrast to simple tasks in prominently right frontal, parietal and central regions. A preliminary finding demonstrated different task-related and task modality specific spatiotemporal characteristics of source space activity as revealed by seeded dipoles based on the fMRI regions of interest (ROI) and minimum-norm (L2) estimates (see Figure 2.4).

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Figure 2.3 Reaction times for complex mental calculation tasks (/: division; −: subtraction; ×: multiplication; +: addition) with auditory (left) and visual (right) stimulation modes for two age-matched groups of German (Bremen University; dark bars) and British (Exeter University; bright bars) students. Error bars represent ± 1 SEM, p values refer to t-tests (two-sided).

At the present point of analysis our data show that different arithmetic operations should be analyzed independently of each other. Furthermore, the present data indicate that there is no empirical basis for the comparison of studies using different presentation modalities.

Conclusions Most of the studies presented in this chapter were initiated or motivated by the research or research interests of Chris Code. These areas reflect a very broad range of scientific interest, with respect to both research topics and research methods. The bracket, however, that encloses these diversified activities is always the issue of speech and language and related disorders. Although our studies in the periphery of “aphasiology proper” always remained low-budget research, a great number of PhD students and postdocs participated in the series of investigations as described before. Furthermore, part of the research methods originally developed by Chris and colleagues were also taken into teaching modules in universities and further education in neurological and neuropsychological rehabilitation. So we are quite sure that our cooperation with Chris Code will continue for the next decades and that Chris will also accompany our next projects on the molecular basics of brain disorders (Herrmann & Ehrenreich, 2003) and neuroprotection (Ehrenreich et al., 2004).


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Figure 2.4 Left: data from mental calculation processes after auditory stimulation; right: data from mental calculation processes after visual task presentation (both columns represent the contrast “complex” vs. “simple” tasks). The upper row shows MEG signal space averaged responses and the corresponding global field power (GFP) time courses with the respective maxima. The middle row shows minimum-norm (L2) estimates according to marked GFP maxima. The lower row shows fMRI contrasts and illustrates corresponding dipole positions seeded into a standard brain volume (Talairach Space).

References Beblo, Th., Wallesch, C. W., & Herrmann, M. (1999). The crucial role of frontostriatal circuits for depressive disorders in the post-acute stage after stroke. Neuropsychiatry, Neuropsychology, and Behavioral Neurology, 12, 234–246. Code, C., Hemsley, G., & Herrmann, M. (1999a). The emotional impact of aphasia. Seminars in Speech & Language, 20, 19–31.

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Code, C., & Herrmann, M. (2003). The relevance of emotional and psychosocial factors in aphasia to rehabilitation. Neuropsychological Rehabilitation, 13, 109–132. Code, C., & Müller, D. J. (1992). The Code-Muller protocols: Assessing perceptions of psychosocial adjustment to brain damage. Kibworth: Far Communications. Code, C., Müller, D. J., & Herrmann, M. (1999c). Perceptions of psychosocial adjustment to aphasia. Seminars in Speech & Language, 20, 51–62. Code, C., Müller, D. J., Hogan, A., & Herrmann, M. (1999b). Perceptions of psychosocial adjustment to acquired communication disorder: Applications of the Code-Müller protocols. International Journal of Language and Communication Disorders, 34, 193–207. Cowell, S. F., & Code, C. (1998). Thinking nuclear medicine – PET activation. Journal of Nuclear Medicine Technology, 26, 17–22. Cowell, S. F., Egan, G. F., Code, C., Harasty, J., & Watson, J. D. (2000). The functional neuroanatomy of simple calculation and number repetition: A parametric PET activation study. NeuroImage, 12, 565–573. Edwards, W., & Newman, J. R. (1982). Multiattribute evaluation. Beverly Hills, CA: Sage Publications. Ehrenreich, H., Aust, C., Krampe, H., Jahn, H., Jacob, S., Herrmann, M., et al. (2004). Erythropoietin: Novel approaches to neuroprotection in human brain disease. Metabolic Brain Disease, 19, 195–206. Helmick, J. W., Watamori, T. S., & Palmer, J. M. (1976). Spouses’ understanding of the communication disabilities of aphasic patients. Journal of Speech and Hearing Disorders, 41, 238–243. Herrmann, M. (1997). Studying psychosocial problems in aphasia: Some conceptual and methodological considerations, Aphasiology, 11, 717–726. Herrmann, M., Bartels, C., Britz, A., & Wallesch, C. W. (1995b). The impact of aphasia on the patient and family in the first year post-stroke. Topics in Stroke Rehabilitation, 2, 5–19. Herrmann, M., Bartels, C., Schumacher, M., & Wallesch, C. W. (1995a). Poststroke depression: Is there a patho-anatomical correlate for depression following the post-acute stage of stroke? Stroke, 26, 850–856. Herrmann, M., Bartels, C., & Wallesch, C. W. (1993a). Depression in acute and chronic aphasia: Symptoms, pathoanatomical–clinical correlations, and functional implications. Journal of Neurology, Neurosurgery, and Psychiatry, 56, 672–678. Herrmann, M., & Code, C. (1996). Weightings of items on the Code-Müller protocols: The effects of clinical experience on aphasia therapy. Disability and Rehabilitation, 18, 509–514. Herrmann, M., & Ehrenreich, H. (2003). Brain derived proteins as markers of acute stroke: Their relation to pathophysiology, outcome prediction and neuroprotective drug monitoring. Restorative Neurology and Neuroscience, 21, 177–190. Herrmann, M., Johannsen-Horbach, H., & Wallesch, C. W. (1992). Psychosocial aspects of aphasia. In D. Lafond, Y. Joanette, J. Ponzio, R. Degiovani, & M. Taylor-Sarno (Eds.), Living with aphasia: Psychosocial issues (pp. 187–206). San Diego, CA: Singular. Herrmann, M., Johannsen-Horbach, H., & Wallesch, C. W. (1993b). Empathy and aphasia rehabilitation: Are there contradictory requirements of treatment and psychological support? Aphasiology, 7, 575–579


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Herrmann, M., Koch, U., Johannsen-Horbach, H., & Wallesch, C. W. (1989). Communicative skills in chronic and severe nonfluent aphasia. Brain and Language, 37, 339–352. Herrmann, M., Reichle, T., Lucius-Hoene, G., Wallesch, C. W., & JohannsenHorbach, H. (1988). Nonverbal communication as a compensative strategy for severely nonfluent aphasics: A quantitative approach. Brain and Language, 33, 41–54. Herrmann, M., & Wallesch, C. W. (1989). Psychosocial changes and psychosocial adjustment with chronic and severe nonfluent aphasia. Aphasiology, 3, 513–526. Herrmann, M., & Wallesch, C. W. (1990). Expectations of psychosocial adjustment in aphasia: A MAUT study with the Code-Müller scale of psychosocial adjustment. Aphasiology, 4, 527–538. Herrmann, M., & Wallesch, C. W. (1993). Depressive changes in stroke patients. Disability and Rehabilitation, 15, 55–66. Johannsen-Horbach, H., Wenz, C., Fünfgeld, M., Herrmann, M., & Wallesch, C. W. (1993). Psychosocial aspects in the treatment of adult aphasics and their families: A group approach. In A. Holland, & M. Forbes (Eds.), Aphasia therapy today: World perspectives (pp. 319–334). San Diego, CA: Singular. Müller, D. J., & Code, C. (1983). Interpersonal perceptions of psychosocial adjustment to aphasia. In C. Code, & D. J. Müller (Eds.), Aphasia therapy (pp. 101–112). London: Edward Arnold. Müller, D., Code, C., & Mugford, J. (1983). Predicting psychosocial adjustment in aphasia. British Journal of Disorders of Communication, 18, 23–29. Wenz, C., & Herrmann, M. (1990). Subjective perception and the emotional experience of psychosocial changes: A comparison between patients and their relatives. Psychotherapie, Psychosomatik, Medizinische Psychologie, 40, 488–495.

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Independent evidence for the unification of explanatory paradigms in the neurosciences Hugh W. Buckingham and Sarah S. Christman

Introduction In this chapter we propose to trace the recent history of a counterintuitive observation in the neurosciences that comprises descriptions of active processing whereby strong stimulus forces evoke weak or insignificant associations, and where weak forces evoke stronger associates. This phenomenon has been labeled “paradoxical,” since it is opposed to the normal situation whereby strong elements in a network associate with their most frequent associates, and weak elements in a network associate with less frequent associates. We chart the trajectory of the notion as it weaves its way from the Pavlovian physiology of conditioned reflexes and stimulus–response motorsensory reflexes of vegetative and alimentary levels to the neuropsychology of Sigmund Freud, Alexander Luria, and the connectionist modeling of late twentieth-century neuropsychological science. Our purpose is to highlight the fact that the threads of this paradoxical phase of stimulus–response balance, or rather imbalance, have been cast at three distinct levels of explanation in the neurosciences: Pavlovian physiology; Luria’s concomitant neuropsychology of language; and Trevor Harley’s connectionist modeling. We emphasize that the situation is one that argues for a unification or alignment rather than any reduction of Luria’s neurolinguistics or Harley’s connectionism to Pavlov’s physiology. Independent findings of similar phenomena from distinct scientific methodologies in the neuropsychology of language serve to strengthen each paradigm, and rather than fractionating the neurosciences, there is a growing convergence, alignment, or unification of information (Code, 2000). Scientific investigation is often driven by: (1) the (frequently unstated null hypothesis) search for evidence for one or another hypothesis or model previously proposed in the literature, (2) a straightforward and unbiased search for possible evidence for a deductive prediction, and (3) the search for further occurrence of inductively predicted correlations between events. Often, different explanatory methodologies and paradigms will uncover a similar set of observations in nature, all of which are in “alignment” (Gotts & Plaut, 2004, p. 332) in some way or another. Compatible findings from distinct

Unification of explanatory paradigms in the neurosciences

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methodological inquiries are extremely important in accessing the contributions of the respective explanatory accounts. The position we adopt in this preliminary study is that the “unification” of the sciences avoids the metaphysical trappings of a “reductionist” stand, which would have us believe that ultimately our understanding of the physical universe will itself reduce to the physical – whence the word “physics” is derived. That is, all sciences will eventually come to be explained in the terms of that science. Once we abandon the fear or lingering doubts that mental objects can be understood as objects in nature nevertheless (see Chomsky, 2000, 2002, on language as a natural object) and therefore studied as such, the eschewing of reductionism and the embracing of a unification view of the sciences is a great deal easier to tolerate. Buckingham and Christman (2004a, p. 292) adopted this view in unifying the heterogeneous methodologies on the issue of perseveration written for a special journal volume collection of papers: neuropharmacological, connectionist, neuropsychological, linguistic and rehabilitative. We carefully resisted the ancient tendency to imply that ultimately all will reduce to the biochemistry of the synapse, only to wait around for physics to explain that. The topic for our chapter is an outgrowth of an essay by one of us (Buckingham, forthcoming) on Alexander Luria, which made reference to a special issue project of Chris Code in the journal Aphasiology, edited by the Polish neuropsychologist Bozydar Kaczmarek in 1995. Chris’s contributions as a scientist as well as an editor of books and journals have influenced us all in one or another way. The present chapter draws from connectionist modeling in a historical framework. Here, again, we note Chris’s research contributions in stochastic predictions of recovery from aphasia with connectionist networks (Code, Rowley, & Kertesz, 1994) and yet another special editorial project with Harley’s (1993) detailed overview and assessment for Aphasiology on connectionism. Chris, the scholar-researcher, has contributed both as principal editor of two recent volumes of classical cases in neuropsychology (Code, Lecours, Joanette, & Wallesch, 1996; Code, Wallesch, Joanette, & Lecours, 2003) for Psychology Press, and has chapters in these volumes as well. The marks of Chris’s editorial scholarship and scientific research are accordingly implicit through our contribution to his Festschrift.

Ivan Pavlov – physiology Ivan Pavlov (1962) originally worked out physical principles that he labeled as “laws of strength” or “rules of force.” He was a physiologist, and his explanatory idiom was the development of conditioned reflexes of sensory-motor nerve physiology. Most undergraduates in psychology have studied at least the rudiments of Pavlov’s investigations “of the dog, this friend of man since pre-historic times” (Pavlov, 1962, p. 87). His commitment to physiology was straightforward from the beginning. He wrote that he was trying to comprehend the totality of the dog’s nervous system, “purely physiologically without

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using any psychological ideas or terms” (Pavlov, 1962, p. 87). He conditioned the alimentary functions of the dog through the “coupling,” as he writes, of various kinds of outside stimuli (whistles, metronomes, lights, bells, and the like) with presentations of food. As we all recall, he therefore could elicit many gustatory motor secretions of saliva with one or another of these sensory stimuli. Reflecting on his work in a paper delivered at the Sorbonne, Paris, in December 1925, he claimed in French that, “At the present time we have facts which warrant the assumption that the act of coupling is even an elementary physiological process” (Pavlov, 1962, p. 88). Unfortunately, there is no evidence at all that Pavlov was aware of the early suggestions of David Hartley (1746, 1749; Buckingham & Finger, 1997) to the same effect. In his study of canine physiology, Pavlov found that the repeated administration of coupled sensory stimuli led simultaneously to the easy activation of specific (conditioned) motor responses and the thorough inhibition of competing responses. He believed that this natural phenomenon also characterized the activity underlying many of the aspects of consciousness that he studied, such as narcolepsy, hypnotic states, severe psychotic and neurotic states, the “oneiroid” phases of pre-sleep, and the deeper phases of slumber. For Pavlov, the continuum from wakefulness to complete sleep mirrored in an important sense a continuum from total consciousness to unconsciousness. He conceived of a multitude of difference “phases” along this continuum, each characterized by different admixtures of activation and inhibition levels of associated conditioned couplings between elements. All phases were tied to the interplay, or stasis, of activation and inhibition, inhibition becoming stronger and stronger in phases that approached sleep. Phases were differentiated by Pavlov in terms of the behavioral consequences of the many shifts in the balance of strong and weak stimuli, their activations and inhibitions. The conditioned reflex was the sine qua non of Pavlovian physiology. For Pavlov, “The idea of reflex in physiology, the gift of Descartes’ genius, is, of course, a purely natural-science idea” (Pavlov, 1962, p. 87).

Pavlov’s paradoxical state Pavlov’s experiments indicated that not all states of full physiological (or mental) conditioning were instantly achieved; rather the course of the conditioning process moved behavioral responses through a series of behavioral phases. Of interest is the phase that Pavlov labeled “paradoxical.” For an illustration, we look at the work in Pavlov’s laboratory by one of his collaborators, Dr. Razenkov. The experimental paradigm provided a subject (e.g., a dog) with coupled presentations of whistles, metronome beats, and rhythmic mechanical stimulations of the skin, the flashing of an electric bulb and the delivery of food. Razenkov brought about “the normal effect of the positive conditioned stimuli” (Pavlov, 1962, p. 132) when the stimulus strength yielded 30 drops of salivation. At first presentation, it turned out that the whistle evoked 5 drops of saliva, the metronome 3.5 drops, the tactile


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stimulations 3 drops, and the bulb flashes 2 drops. Pavlov writes that “the stimuli ranged in strength, from the strong to the weak, thus: whistle, metronome beats, mechanical stimulation of the skin and flashing of the bulb” (Pavlov, 1962, p. 133). Clearly, not all stimuli appeared equally strong, forceful, or efficient at eliciting a desired response. This observation led to a crucial follow-up investigation with the same experimental subject. We first note that in the above original set of stimuli, the tactile mechanical stimuli included 24 contacts within the 30 second introduction of the stimulus, and again it elicited 3 drops of saliva. The second experiment was one in which, along with the other positive stimuli of the first experiment, a differentiated tactile stimulus of 12 per minute was applied during 30 seconds and followed without any interval by the positively conditioned tactile stimulus of 24 per minute, which was also continued for 30 seconds and then reinforced in the typical fashion. The next day the dog was subjected to another experiment where he was tested with the original set of stimuli from experiment 1. One English translation of this paper has Pavlov claiming that the small factor of introducing the 12 per minute tactile stimulus “produced an extraordinary effect” (Green, 2006, p. 4). Pavlov, in another translation of this paper, writes, “The day after this experiment [the second one, HB/SC] and during the subsequent nine days all the conditioned reflexes disappeared and were manifested only very rarely and to a minimal extent. This period was followed by a very special period” (Pavlov, 1962, p. 133). Experiments in this special period, which lasted 14 days showed “extremely peculiar changes” (Green, 2006, p. 4). The peculiar and extraordinary effects were that the mechanical stimulation now elicited 5.5 drops of salivation, the bulb flashing 3 drops, the metronome beats 1 drop, and the whistle 0 to 0.3 drops. Crucial for our chapter is the following statement by Pavlov (1962, p. 133): The result, as you see, is quite the reverse of what formerly occurred normally: strong stimuli either failed to act or barely acted, while the weak stimuli produced an effect even greater than normal. Following the example of N. Vvedensky, we named this state of the hemispheres the paradoxical phase. The 14-day paradoxical phase slowly shifted to a phase where all previous stimuli seemed to have returned to their original strength or force, since the whistle (4 drops) and the metronome (4.5 drops) again elicited strong responses. This phase of response strength overlap came to be called the phase of “equalization,” where strong and weak stimuli had an equal likelihood of eliciting the same response. We do not consider this phase in the present chapter, although it, too, comprises an intriguing alternative to normal stasis where strong evokes strong and weak evokes weak. The effect of the second experiment was an inhibitory one, and it was this inhibition that brought about the counterintuitive switch in the rule of force. In any event,

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for Pavlov, its outcome pointed to a physiology that eschewed all psychology. Our goal now is to show how the explanatory account of this paradoxical phase was lifted from the neuronal level to the neuropsychological level and from there, through Hebbian learning, to modern connectionist modeling.

Alexander Luria – neuropsychology Luria (e.g., 1962/1980, 1973) borrowed the so-called laws of strength/rules of force from Pavlov in his explanations of paraphasia within his neuropsychological model of language and its related accounts of linguistic breakdown secondary to neurological damage. Luria accounted for the normal and abnormal evocation of different linguistic constituents such as phonemes and words within the physiological idiom of Pavlov’s nervous laws. Phonemic and lexical access were captured by the same laws. Luria’s neuropsychology at the very least pointed to a certain compatibility of the explanatory accounts of physiology and the burgeoning field of the neuropsychology of language – often referred to as “neurolinguistics” by Luria. Luria, however, was not a reductionist and resisted at all costs a complete reduction of his explanatory paradigm to the domain of physiology. Homskaya (2001) charts Luria’s initial attraction to Sigmund Freud’s work at the psychological level, and his psychophysical accounts of human language and its breakdown in aphasia. Freud’s “software” approach to the functionality of language and cognition influenced Lev Vygotsky as well, and both Vygotsky and Luria developed theories of how society and culture were tightly interwoven with the complexities of human cognition. Later, as a medical student of neurology and subsequently a physician who worked with all aspects of the neuropsychology of brain and behavior, Luria consistently kept the physical and the psychological apart. His take on the mind– brain issue was that of Freud, and as a consequence, he was indebted to John Hughlings-Jackson, whose influence on Freud was marked throughout Freud’s (1891) book on aphasia. Luria’s philosophy, accordingly, took the form of a “psychophysical parallelism,” a kind of dualist “identity theory,” not unlike Hughlings-Jackson’s theory of “concomitance,” defined as a togetherness of mind and brain running concurrently and bringing about a “coin-like” single effect, where both are considered as the respective sides of that coin. Nevertheless, when it came to accounting for paraphasias, Luria continually gave credit to Pavlov for notions such as the paradoxical phase (e.g., Luria, 1973, pp. 44, 157, 317; and 1962/1980, pp. 513–518). Luria’s (1973, 1962/1980) neurolinguistic descriptions of lexical or phonemic paraphasias were couched in terms of selection errors, wherein target words or sounds were thought to be erroneously chosen from among their (inappropriately) highly activated competitors. In the normal case, highly activated competitors would naturally be those with strong associations (as per Pavlov’s law of strength) to intended targets. For example, if a speaker were trying to access the word “college,” he would have a statistically greater


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likelihood of activating (and then inhibiting) strong associates, such as “school” or “university,” than weakly related associates such as “kindergarten,” “hospital,” or “gymnasium.” The same principles were thought to apply to phonological as well as lexico-semantic processing. Luria believed that a certain amount of cortical tone and mobility were necessary for efficient linguistic processing, and he suggested that these requisites became impaired as a consequence of neurological pathology. For Luria, physiological paradoxical and equalization states induced by brain damage were completely compatible with concomitant linguistic outcomes, such as semantic paraphasias, given his predisposition toward psychophysical parallelism. In his view, a system driven to the paradoxical activation of weak rather than strong associates for a stimulus would be statistically more likely to produce weakly related semantic paraphasias such as “kindergarten,” “hospital,” or “gymnasium” than strongly related associates (such as “school” or “university”) when attempting the target word “college” during a naming task. In an equalization state of processing, Luria predicted that strong and weak associates for a target would have a statistically equal chance of being activated, since a reduction of cortical tone would cause normal mechanisms of competitor inhibition to fail. This was thought to be the most likely neurolinguistic (and, indeed, connectionistic) characterization of severe anomia, where a likely outcome of the equalization phase would be no output at all. The paradoxical stage, on the other hand, would reveal statistically greater probabilities of weaker associates – a greater likelihood for error.

D. O. Hebbian learning The link between a neural associationism and modern connectionism revolves around the ideas of D. O. Hebb (1949). The notion that couplings are strengthened between neurons that act in synchrony is most often referred to as “Hebbian learning.” A large number of theoretical rules that mediate this learning in domains referred to as “neural” networks have been proposed in the last several decades. The notions go back to William James (1890) and to the summation idea that brain activity is governed by the sum of concurrent inputs to a given single neuron as long as there are (1) a high frequency of simultaneous synaptic connections, (2) intense firings, and (3) no other leaks of the firings into other neurons. All must converge on a single neuron unit. At this point, the Aristotelian notions of strength of associative force can be quantified into mathematical summation. Also needed are the mathematical transformations of inhibition and the formulae of change so that activated forces can return to their original values “at rest” (resting levels). These “neural” networks typically support three levels of linguistic processing: semantic/conceptual, lexical, and phonological. Others have been added, but for our purposes a three-level system will be all that is needed. In language, frequency of usage often determines the physiological resting values of neurolinguistic units in many models. Furthermore, just as the

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setting of initial “weight” values may vary, the nature of the spread of neural activation through the system may also vary. Some view the spread of activation as going from level to level more or less instantaneously, while others incorporate a cascading spread, where subsequent levels may start their activation before all activations at the earlier levels are finished. Most systems have feedback between and among levels, and some are set up so that elements at their tactic levels may send inhibitory volleys to others at that level. Many models that are organized in the ways indicated above and that have cascading spread are referred to as models of interactive activation (Dell, 1986). The connectionist model we are drawing from, which unwittingly simulated the paradoxical phase, is one proposed by Trevor Harley and his colleague, Siobhan MacAndrew (1992).

Harley’s connectionist model of lexicalization This model was created to account for substitution errors among whole words. It can handle phonemic substitutions as well, but Harley and MacAndrew (1992) concentrated on lexical retrieval processes. Theirs was an interactive activation model, closely related to those constructed by Gary Dell (1986) and more recently by Dell, Schwartz, Martin, Saffran, and Gagnon (1997). There is a three-layer architecture containing 26 nodes at the semantic level, 70 nodes at the lexical level, and 21 nodes at the phoneme level. That is, there are 26 conceptual categories, 70 words, and 21 phonemes. As is the case with most of the connectionist models that have been constructed to date, the linguistic nodes have limited domains at each level. There are feedback connections between the phonological and lexical levels. Unlike many other models of this type, the authors built in semantic representations that would allow for a “richness” component to concepts with a high degree of imageability. At the lexical and phonological strata, inhibitory links were established, which highlight the effects of intra-level “competition,” but which when operating normally serve to speed up processing by inhibiting inappropriate competitors – phonemes competing with phonemes and words competing with words. Inhibitory intra-level connections, when working, provide accounts of lexical priming in naming, while when inhibition falters, effects such as the “phonological blocking” of tip-of-the-tongue (TOT) effects are nicely illustrated. Clusters of plan-external competing phonologically related word forms can severely interfere with lexical access. Harley and MacAndrew (1992) tested four hypotheses with this model: that (1) altered decay rates would interfere with word finding; (2) loss of intra-level inhibition would interfere with word finding; (3) increased random “noise” would interfere with word finding; and (4) reduction in connection weights between the semantic level and the lexical level (i.e., reduced flow of activation from the semantic to the lexical level) would interfere with word finding. As with many models of its type, this system can account for aspects of recovery in aphasia as well as the influence of frequency of usage and


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imageability effects in paraphasic errors. The model computes the input summation formulae for activation spreading through the system, and it computes formulae for return rates for each cycle (“processing epoch”) to resting levels. Whether returning from higher activation levels or from lower levels due to inhibition, processing nodes must reset to their resting stages in normal fashion for the system to work normally for each cycle. Needless to say, slowed decay rates from recent activation and weakened weight connections between levels would lead to perseveration of words as well as of phonemes (Buckingham & Christman, 2004b). This model has parameters as well for processing lateral inhibition among nodes at the same level. Here, the authors manipulate intra-tactic inhibition at the lexical level only. As mentioned earlier, the focus of the Harley and MacAndrew (1992) study was on lexical access and substitution. Suffice it to say that the lexical level sends outputs to the phonological level and, for production, five-slot serially ordered phonological templates serving as output frames must be filled. The production level is left in a rather primitive form, allowing for no phonotactic constraints, and specification of all input features is characterized simply as “on–off” binary units. Harley and MacAndrew motivate many of these shortcomings with arguments for simplicity. The simulations of connectionist models for pathology come from different arrays of alterations of weights, decays, and the addition of inhibition by “noise” at different locations in the system. Harley and MacAndrew (1992) “lesion” their system in varying ways in order to evaluate their impact (re: the above four hypotheses) on lexical access failure. All other parameters distinct from weight values are considered to be “control parameters.” These include post-activation decay, amounts of random “noise,” the effect of lexical frequency, and the time the external semantic input is received by the semantic units. The investigators search for any errors the model may produce in response to some external semantic input. They are specifically testing for inductively based predictions from the aphasia literature on the origin of paraphasias – words in English, and words that could be but are not in English. Some of the non-words produced by the model bear a form transparency to the external semantic input (called the “target”), whereas others do not. Some call all non-word productions “neologisms” (e.g., Butterworth, 1979), while others reserve the term “neologism” for non-words whose form is opaque to any likely target word in the context of the utterance (Buckingham & Kertesz, 1976). An example of this model’s activity may be illustrative at this point. Suppose that an external semantic input (the so-called “jolt”) to the processing model is the word “cow.” In a normal cycle, that word would send a jolt of activation to, say, five semantic categories: animal, dairy related, fourlegged, adult, female. Those categories would converge onto the lexical item , which would in turn send activation to the phonemes /k/ and /aw/ (a diphthong counts as one phonemic unit). The normal output would be the CV word /kaw/. In Harley and MacAndrew’s study, the word “cow” is the

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input target for each hypothesis-testing. For comparison, they plotted not only the activations of the target against the processing cycle time, but also those parameters for “calf” (semantically and phonologically related associate), for “dart” (unrelated), for the onset /k/ phoneme (of “cow” and of “calf ”) and for the onset phoneme /d/ of “dart.” The test of hypothesis 1 did not show much effect in the Harley and MacAndrew (1992) study. With increases in the rate of decay alone, the response “cow” was significantly favored. They then combined decay rate with a time delay of the external semantic input to the semantic level. They observed that doing this reduces the target activation to near zero, but it reduces all possible word competitors as well. In effect, little if anything is produced – somewhat akin to the “equalization” phase of Pavlov, but we are not charting that phase abnormality in this chapter. This simulation is not without interest, however. The authors rather doubt that decay rate alteration alone is likely to be a good explanatory account of paraphasia. In any event, as they point out, connectionist theory would actually predict that decay rate lesions should only give rise to “smart” errors, whereby inter-level connectivity is still apparent. This would not be the case at least for jargon or complex neologisms, or for the error: “cow” → “dart.” Harley and MacAndrew next tested for loss of intra-level inhibitory connections, leaving vertical connections and decay rates unaltered mathematically (e.g., “unlesioned”). Even though logic seemed to predict that lowered levels of inhibition at the word level would serve to promote many similar competitors with the target, in this study, the target word was still significantly more likely to be produced over all other possible candidates. Even when the authors added random noise under this condition, there was no noticeable increase in errors – and certainly no production of jargon neologisms. Research is still ongoing to try to find accounts for lexical priming and TOT errors, but Harley and MacAndrew found no help in these domains when altering intra-level word inhibition, even with added noise to the system. Hypothesis 3 was then tested. Random initial noise was added to the system but it failed to evoke much effect for severe paraphasia. Hypothesis 4 was tested last, with a method involving the weakening of the connection strengths between concept nodes and lexical nodes, resulting in weaker lexical activations from the semantic level. Previous studies (e.g., Miller & Ellis, 1987) had indicated that interferences in the normal connectivity between the semantic and lexical level set the stage for neologistic production, where underlying targets would be accordingly blocked in the production line, but where other processes would come to bear on the production of surrogate forms that would in turn effectively mask the access block. Those “abstruse” neologisms (Lecours, 1982) would appear bizarre and opaque as to some underlying target. This account of neology was first labeled “the anomia theory” by Brian Butterworth (1979). Harley and MacAndrew, however, observed that weakened weights alone between the semantic and the lexical level did not have much of a dilatory effect on word


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finding. Continually weakening the connections over time still showed that the target was more likely to be activated, but eventually other semantic competitors would decrease even more rapidly, still being distinguished from the target, but waning in appearance so that semantic paraphasias fade away from the picture, leaving other types of lexical substitutions to be occasionally produced. These are then likely to be only form related and not semantically related. Also, since frequency and imageability result in higher resting levels of activation, they may play a role in word selection such that their potency may counterbalance the overall weakening of the semantic to lexical connections. With respect to the outcome of the test for hypothesis 4, Harley and MacAndrew (1992, p. 382) state that, “Although this gives a more satisfying distribution of lexical activations than the other accounts, it still fails to satisfy the criterion that, on some occasions, the activation of competitors should be above that of the target.” They then introduced some random variation into the weakening of the semantic–lexical connections. Accordingly, they could increase the severity of lesioning “by adding an amount of normally distributed random noise to each connection and increasing the standard deviation of that noise distribution” (Harley & MacAndrew, 1992, p. 382). In this way, without being aware of the long history of the “paradoxical phase,” they ended up simulating the extraordinary, very special, and counterintuitive phenomenon of Pavlov’s famous inhibitory phase. The other astounding outcome was that Harley and MacAndrew actually had to add increased inhibition with the random noise to the already weakened connections. Recall that Pavlov’s abnormal phases were largely due to increased inhibition in one way or another. Harley and MacAndrew (1992, p. 382) wrote: Random lesioning of alphasl [“alpha semantic lexical” – the name of their parameter that governed the rate of spread of activation between the semantic and lexical levels – HB/SC] affects the target lexical unit such that the greater the severity of the lesioning, the lower the probability of the target unit being highly activated. Further, the greater the lesioning, the higher the probability of other lexical units being highly activated. In other words, the greater the severity of the lesioning, the more likely it is that weak associates will be activated where strong ones should be produced. Harley and MacAndrew (1992) thus describe precisely the paradoxical effect captured by the different scientific paradigms of Pavlov and Luria before them. Figure 3.1 (Harley & MacAndrew’s Figure 9, 1992, p. 382) shows that for input target “cow,” the weaker associate “calf” is more highly activated throughout increasing time in cycles, although activation levels begin to decrease after 10 time in cycles. The paradox continues nevertheless to the 40 time in cycles, where “cow” almost approaches “dart,” which is practically

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Figure 3.1 The effects of introducing some random variation (noise) into the weakened weight connections of the semantic to lexical levels. Normally distributed random noise was added to each connection. The severity of lesioning is mimicked by increasing the standard deviation of the noise distribution. Only moderate damage (standard deviation = 0.05) was applied for the effects shown in this figure, which was Figure 9 in Harley and MacAndrew (1992, p. 382). The random lesioning into the weakening was such that the more severe the noise, the lower the probability of producing the target input (“cow” in these cases). Further, the more severe the noise, the higher the probability of producing other lexical items. This is the essence of the paradoxical phase suggested by Pavlov and Luria, although admittedly, the weaker element was “calf,” and not “dart.” The paradoxical nature of the phenomenon still holds. (Reproduced from Harley & MacAndrew, 1992, with permission to use the figure given by T. Harley, June 13, 2006).

off the map for all processing epochs. Note that /k/ has a much greater set of activation levels than /d/, for the obvious reason that both “cow” and “calf ” share that onset phoneme. The /d/ is actually more highly activated throughout the cyclings than is the word “dart.” This is most likely to be because a small number of occasionally activated unrelated words with /d/ onset were produced as well as “dart.”

Concluding remarks Here, we witness the final link in the Pavlov to Luria to Harley/MacAndrew phenomenon of an inhibitory phase in pathology whereby normal laws of strength are reversed and strong and weak activation levels operate counterintuitively. The paradox has been shown to exist at distinct levels of “neural”


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description. Pavlov’s descriptions of the paradox were cast in the vocabulary of his physiological paradigm. This notion then was transferred to words and phonemes in the neuropsychological descriptive idiom of Alexander Luria, an idiom firmly implanted in the psychology of Hughlings-Jackson and Sigmund Freud (1891) and rather incongruous with the materialism of the Russian revolution and the Union of Soviet Socialist Republics (Homskaya, 2001). We now have witnessed how the phenomenon of the paradoxical state has unwittingly been simulated in a modern connectionist model, and therefore has been aligned with yet another level of neuroscientific description. Modern connectionism has provided the field of neuropsychology with numerous computational simulations of both normal and abnormal human cognitive behavior. Before the advent of modern connectionism, Luria had borrowed much of the cortical neurodynamics of Pavlovian physiology. Luria, however, was incorporating the Pavlovian paradigm at a substantial remove from Pavlov, since Luria’s units were phonemes and words. Luria’s scientific descriptors drew heavily not only from Pavlov, but also from association psychology. By weakening connection strengths between the conceptual (semantic) level and the lexical level, and adding some random noise to the system, Harley and MacAndrew independently simulated a phase intriguingly similar to the paradoxical states of Pavlov and Luria. The independence of this simulation is all the more powerful, since at best they only tweaked the network so as to have it produce paraphasias. The paradox, as illustrated in their Figure 9, shows that the input target word “cow” strangely enough evoked “calf” and rarely if ever evoked “cow.” We note, however, that “dart” (totally unrelated) was almost never produced. But, there is nevertheless something puzzling about the surfeit of productions of “calf” for the target “cow.” One might suggest that “calf” was perseverated, in which case the argument for a paradoxical phase as it is described would be weakened. Harley and MacAndrew’s paradox-producing lesions did not involve slowing decay rates, or hampering with any cleanup units in the spirit of Plaut’s original suggestion for simulating perseveration (see Gotts & Plaut, 2004). In fact, the only alteration to decay rates they tested was speeding them up – not slowing them down. Harley and MacAndrew’s paradox lesions importantly involved weakening connections between the conceptual and the lexical levels plus the addition of random noise. More recent connectionist thinking has suggested that in fact decay rates need not be damaged to simulate perseverative production. Gotts and Plaut (2004) and Basso (2004) have suggested that weakened weight levels in one modality may indeed lead to perseveration, where the onus is on the weakened connectivity. Local weakened connections in a certain modality may be such that normal decay rates would in a sense not operate fast enough to avoid normal post-activation rebound, resulting in perseveration. Harley and MacAndrew did not have architectures such that they could set up simulations specifically for reading aloud, repeating, or naming, although these networks tend to extend more easily to the naming

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situation, where the spreading activation begins at the semantic level. Many questions, however, remain in the interpretation of simulation correlations between normal and abnormal linguistic processing (e.g., Ruml, Caramazza, Capaso, & Miceli, 2005). Nevertheless, we have presented what we feel are some extremely interesting descriptions of inverted stimulus–response contingencies across three different investigative paradigms in the neural sciences. Our view is again that we should resist any tendency to claim that the neuropsychological or the modern connectionistic theories should in any way reduce to Pavlov’s physiology. Rather we suggest that each explanatory account unifies or comes more closely into alignment with the others in obvious ways, but each with its separate scientific methodologies and distinct vocabularies, cast as they are at different levels of human cognition.

References Basso, A. (2004). Perseveration or the Tower of Babel. Seminars in Speech and Language, 25, 375–389. Buckingham, H. W. (forthcoming). Alexander Romanovich Luria: The man and his science. In N. Koertge (Ed.), New dictionary of scientific biography. Farmington Hills, MI: Charles Scribner’s Sons. Buckingham, H. W., & Christman, S. (2004a). Preface. Seminars in Speech and Language, 25, 291–293. Buckingham, H. W., & Christman, S. (2004b). Phonemic carryover perseveration: Word blends. Seminars in Speech and Language, 25, 363–373. Buckingham, H. W., & Finger, S. (1997). David Hartley’s psychobiological associationism and the legacy of Aristotle. Journal of the History of the Neurosciences, 6, 21–37. Buckingham, H. W., & Kertesz, A. (1976). Neologistic jargon aphasia. Amsterdam: Swets & Zeitlinger. Butterworth, B. (1979). Hesitation and the production of verbal paraphasias and neologisms in jargon aphasia. Brain and Language, 18, 133–161. Chomsky, A. N. (1994/2000). Language as a natural object. In A. N. Chomsky, New horizons in the study of language and mind (pp. 106–133). Cambridge, UK: Cambridge University Press. Chomsky, A. N. (2002). On nature and language. Cambridge, UK: Cambridge University Press. Code, C. (2000). Converging not fractionating. Brain and Language: Millennium Issue, 71, 44–45. Code, C., Lecours, A. R., Joanette, Y., & Wallesch, C.-W. (Eds.) (1996). Classical cases in neuropsychology (Vol. 1). Hove, UK: Psychology Press. Code, C., Rowley, D., & Kertesz, A. (1994). Predicting recovery from aphasia with connectionist networks: Preliminary comparisons with multiple regression. Cortex, 30, 527–532. Code, C., Wallesch, C.-W., Joanette, Y., & Lecours, A. R. (Eds.) (2003). Classical cases in neuropsychology (Vol. 2). Hove, UK: Psychology Press. Dell, G. S. (1986). A spreading-activation theory of retrieval in sentence production. Psychological Review, 93, 604–616.


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Dell, G. S., Schwartz, M. F., Martin, N., Saffran, E. M., & Gagnon, D. A. (1997). Lexical access in aphasic and non-aphasic speakers. Psychological Review, 104, 801–838. Freud, S. (1891/1953). On aphasia: A critical study (Trans. and introduction by E. Stengel). London: Image. Gotts, S. J., & Plaut, D. C. (2004). Connectionist approaches to understanding aphasic perseveration. Seminars in Speech and Language, 25, 323–334. Green, C. D. (2006). Classics in the history of psychology: “Conditioned reflexes: An investigation of the physiological activity of the cerebral cortex – Lecture XVI: Transition stages between the alert state and complete sleep: hypnotic stages.” Internet resource developed by Christopher D. Green, York University, Toronto, Ontario, Canada. Harley, T. A. (1993). Connectionist approaches to language disorders. Aphasiology, 7, 221–249. Harley, T. A., & MacAndrew, S. B. G. (1992). Modelling paraphasias in normal and aphasic speech. In Proceedings of the 14th Annual Conference of the Cognitive Science Society (pp. 378–383). Bloomington, Indiana. Hartley, D. (1746/1959). Various conjectures on the perception, motion, and generation of ideas (Trans. from the Latin by R. E. A. Palmer, and introduction with notes by M. Kallich). Los Angeles, CA: The Augustan Reprint Society, Publication No. 77–78. William A. Clark Memorial Library, University of California. Hartley, D. (1749). Observations on man, his frame, his duties and his expectations. London: S. Richardson. Hebb, D. O. (1949). The organization of behavior. New York: John Wiley. Homskaya, E. D. (2001). Alexander Romanovich Luria: A scientific biography (Trans. from the Russian by Daria Krotova. Ed., with a foreword, by D. E. Tupper). New York: Kluwer Academic/Plenum Publishers. James, W. (1890/1950). The principles of psychology. New York: Dover Publications. Kaczmarek, Bozydar L. J. (Ed.) (1995). Special Issue on Alexander R. Luria. Aphasiology, 9 (Mar–Apr). Lecours, A. R. (1982). On neologisms. In J. Mehler, E. Walker, & M. Garrett (Eds.), Perspectives on mental representations. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Luria, A. R. (1962/1980). Higher cortical functions in man. New York: Basic Books. Luria, A. R. (1973). The working brain: An introduction to neuropsychology. New York: Basic Books. Miller, D., & Ellis, A. (1987). Speech and writing errors in “neologistic jargonaphasia”: A lexical activation hypothesis. In M. Coltheart, G. Sartori, & R. Job (Eds.), The cognitive neuropsychology of language. Hove, UK: Lawrence Erlbaum Associates Ltd. Pavlov, I. (1962). I. P. Pavlov: Psychopathology and psychiatry – Selected works (Trans. from the Russian by D. Myshne & S. Belsky. Compiled by Y. Popov & L. Rokhlin). Moscow: Foreign Languages Publishing House. Ruml, W., Caramazza, A., Capaso, R., & Miceli, G. (2005). Interactivity and continuity in normal and aphasic language production. Cognitive Neuropsychology, 22, 131–168.

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The social and neuropsychological underpinnings of communication disorders after severe traumatic brain injury Skye McDonald

Preamble Chris Code has had a wide and varied research career. While well known for his research publications, Chis’s role as a mentor is possibly less acknowledged. With his innate curiosity, generosity and enthusiasm, Chris has a remarkable capacity to motivate his colleagues into the pursuit of collaborative projects. In my case these have led to significant inroads into communication research, ongoing collaborations and enduring friendships. Furthermore, although Chris may be best known for his aphasia work, his interests have been more wide-ranging than this, delving into other kinds of communication disorders that are characterized less by problems of language, and more by problems of language use. When Chris Code first arrived in Australia to take up the inaugural Chair of Communication Sciences and Disorders at the University of Sydney, he encouraged me to submit a review to Aphasiology, outlining the similarities and differences between communication disorders arising from damage to the frontal lobes of the brain as opposed to the right hemisphere (McDonald, 1993a). Not long after, he embarked on a collaboration with Leanne Togher examining communication patterns after traumatic brain injury, the result of which has been many innovative and influential published studies. In 1995 Chris initiated a meeting in which he proposed that the three of us join forces to produce an edited book entailing a comprehensive overview of the nature of communication disorders after traumatic brain injury from neuropsychological, linguistic, and social orientations. The book (McDonald, Togher, & Code, 1999) had contributions from many of the leading authorities of the time, all good friends of Chris’s. It is now a standard text in Psychology and Speech Pathology departments in over 20 universities across the USA, the UK and Australia. Research has moved on since that time and some fascinating new directions are emerging. It is timely, therefore, that in this tribute to Chris, the following chapter continues on from the themes of that text, to review some of the earlier work and to overview more recent innovations.

Underpinnings of communication disorders after TBI 43

Introduction The notion of communication disorders in people with severe traumatic brain injury (TBI) has developed significantly over the past few decades and has been the impetus for a variety of innovative approaches to the way in which such disorders have been conceptualized and subsequently assessed. Such approaches were originally stimulated by important observational studies (Levin, Grossman, Rose, & Teasdale, 1979; Thomsen, 1975) that alerted the research community to the unique difficulties that people with TBI experienced when communicating. While aphasic disorders were found, these were clearly apparent in only the minority of cases (estimated between 2% and 30%; Heilman, Safran, & Geschwind, 1971; Sarno, 1980; Sarno & Levita, 1986). Far more prevalent were difficulties with communication, including problems of slowness, hesitancy, lack of initiative, reliance on set expressions, tangentiality, inappropriateness and over-talkativeness (Levin et al., 1979; Thomsen, 1975). These characteristics could not be clearly defined as aphasia, although some were considered to represent a sub-clinical aphasic language disorder (e.g., Sarno, 1980; Sarno & Levita, 1986). In the ensuing decades, evidence has gradually accrued to suggest that such communication disturbances reflect underlying cognitive impairment rather than language per se. As such, they have represented an unparalleled opportunity to examine the intertwining of language and cognition that is inherent in any act of communication. More recently, the potential role of affect in communication has begun to be addressed. Broadly speaking, problems in communication that emerge after traumatic brain injury have been conceptualized using three theoretical orientations: pragmatics and specifically speech act theory (Searle, 1975); discourse analyses, especially systemic functional linguistics (Halliday, 1985); and models of social skills (e.g., McFall, 1982). This chapter reviews advances in each of these and where possible, considers the neuropsychological underpinnings of communication difficulties as exposed by these approaches, as well as social and cultural implications.

Conceptualizing communicative ability using pragmatic theory Pragmatic theory addresses the role that contextual factors play in establishing the meanings associated with any given utterance. For example, it is argued that any utterance represents behaviour; that is, a speech act that is motivated by the desire to have some impact on the listener. Speech acts may be direct, in that the speaker states what is on his or her mind directly, as in “Please open the window”, or indirect although clearly transparent, as in “Can you please open the window”, whereby the speaker asks about the listener’s ability rather than making a direct request. The motivation to use indirect rather than direct speech acts is often the desire to be polite or to be otherwise thought well of by the listener (Brown & Levinson, 1978). Different forms of

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politeness may be appropriate depending on the familiarity and status of the co-conversant as well as the import of the message. When high degrees of diplomacy are required, speech acts may be so indirect as to be opaque in their meaning (“It is hot in here!”). The idea that the speaker’s attitude towards the listener motivates their choice of utterance (e.g., the level of indirectness) suggests that, conversely, their attitude is revealed to the listener by that choice. Indeed, normal speakers have been shown to be sensitive to the relative politeness of various surface forms of the same underlying request (“Do you know where Jordan Hall is?” “Could you tell me where I might find Jordon Hall?”, etc.) which varied systematically with the degree of indirectness and hesitancy they signalled (Clark & Schunk, 1980). Several issues arise from this conceptualization of speech acts. First, it suggests that, in order to be adept at understanding the social nuances of language, listeners must be able to comprehend and use politeness signals such as hesitancy. Second, it suggests that there must be some means by which opaque indirect speech acts (“It is hot in here!”) are decoded for the speaker’s intended meaning. Conversely, speakers must have the means to produce speech acts that convey their intended meanings via inference. There is clearly scope to examine pragmatic language competence in people with severe TBI, as they have often been described as both blunt and insensitive in their language use and concrete and literal in their general responses and understanding of information (Crosson, 1987; Milton & Wertz, 1986; Prigatano, 1986). Pragmatic understanding The comprehension of indirect language after TBI has been the focus of a number of studies in recent years, with a particular interest in sarcasm and irony. When being sarcastic, the speaker commonly says something that is literally the reverse, or at least different from, what they mean, such as “What a great haircut” spoken to suggest the reverse. It is now well established that, in the absence of language deficits, many adults and children with severe traumatic brain injury have great difficulty comprehending irony and sarcasm (Bara, Tirassa, & Zettin, 1997; Channon, Pellijeff, & Rule, 2005; Channon & Watts, 2003; Dennis, Purvis, Barnes, Wilkinson, & Winner, 2001b; McDonald, 1992; McDonald & Flanagan, 2004; McDonald, Flanagan, Rollins, & Kinch, 2003; McDonald & Pearce, 1996; Turkstra, McDonald, & Kaufmann, 1996). This raises the question as to what deficit is responsible for this difficulty. In 1975 Grice explained the conveyance of sarcasm within his broader conceptualization of the communication of conversational inference. According to Grice, conversational inferences are possible due to implicit agreements between speakers regarding the rules of conversation. It is assumed that, first, speakers will cooperate with each other in the act of communication and, second, they will observe certain conventions (maxims) in speech by saying only as much as is required, saying this as clearly as possible, and saying only

Underpinnings of communication disorders after TBI 45 what is true and relevant to the context. These commonly shared assumptions can be exploited to vary the manner in which communication occurs. A blatant disregard of a conversational maxim will be noticed by the listener and will cause him or her to reconsider the utterance to make sense of why it was said in this manner. In doing so, he or she will inevitably take into account other contextual information, and the final interpretation of the conversational meaning will be an inference drawn from both the utterance and the context in which it was said. By transgressing conversational maxims, speakers can thus communicate indirectly in the service of politeness or other social and cultural requirements (Brown & Levinson, 1978). Sarcastic statements transgress the maxim of quality (truthfulness). The listener, recognizing from the context that the literal truth of the remark contrasts with known facts, but assuming that the speaker said this for a reason (i.e., is attempting to communicate), reinterprets the statement to make it consistent with the context and thus derives the implied meaning, which is frequently opposite to that asserted. The process by which the listener comprehends the intended meaning was considered by Grice (1975, 1978) to be similar to that proposed for the interpretation of other indirect speech acts (Gordon & Lakoff, 1975; Searle, 1975): (1) the literal meaning is comprehended; (2) some cue indicates this is not sufficient (e.g., the literal meaning is contradicted by the context); (3) inferential rules are implemented in order to derive the intended meaning from the literal meaning and from the context in which it occurred. Given that the majority of people with TBI do not suffer from basic language impairment, failure to understand sarcasm is unlikely to reflect an inability to comprehend the literal meaning, hence step 1 is unlikely to be problematic. Consequently deficits must reside in other processes, either step 2 or step 3. In order to understand how these stages might be affected it is necessary to consider the nature of neuropsychological disorders following traumatic brain injury. Neuropsychological underpinnings of pragmatic understanding 1. Common cognitive deficits arising from traumatic brain injury While extremely variable, severe traumatic brain injuries typically produce lesions concentrated in the frontal and temporal lobes of the brain (Adams et al., 1985; Levin et al., 1987) with attendant diffuse axonal damage (Adams, Doyle, Ford, Gennarelli, Graham, & McLellan, 1989). Consistent with this, disorders of executive functioning (reflecting frontal system dysfunction), disorders of new learning (reflecting temporal and frontal dysfunction), and slowed information processing (reflecting diffuse axonal injury) are well documented sequelae of TBI (e.g., Tate, Fenelon, Manning, & Hunter, 1991). Executive functions are those that mediate and regulate other cognitive activities and behaviour in a purposeful and goal directed fashion, and are

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often conceptualized as representing either a loss of drive or a loss of control, although both may co-exist in the single individual with frontal system impairment (Tate et al., 1991). Disorders of drive will result in apathy and inertia, rigidity, inflexibility and perseveration. Disorders of control lead to impulsivity, disinhibition and distractiblity. In general, executive dysfunction significantly impairs problem-solving capacity. Individuals may experience reduced attention and working memory capacity, fail to reason at an abstract level (draw inferences) and to develop effective plans, and fail to monitor problem-solving behaviour effectively or learn from mistakes (Darby & Walsh, 2005). Slowed information processing speed exacerbates these difficulties. Executive dysfunction is clearly implicated in the process of decoding indirect speech acts, as outlined by Gordon and Lakoff and others. The integration of (verbal) information with the context (step 2) and the application of inferential rules (step 3) are processes that demand both working memory and abstract reasoning. INFERENTIAL REASONING

The extent to which individuals with TBI experience executive dysfunction varies enormously in both severity and kind. Nevertheless, there is a strong link between frontal injury after TBI and poor inferential reasoning (Dennis, Guger, Roncadin, Barnes, & Schachar, 2001a; Ferstl, Guthke, & von Cramon, 2002; MacDonald & Johnson, 2005) and also frontal injury and sarcasm comprehension (Shamay-Tsoory, Tomer, & Aharon-Peretz, 2005). It is possible, therefore, that pragmatic inferential reasoning represents a particular application of generic inferential reasoning skills. In support of this, measures of general inference making have been linked to poor pragmatic understanding in people with TBI (Martin & McDonald, 2005; McDonald, Bornhofen, Shum, Long, Saunders, & Neulinger, 2006). WORKING MEMORY

At a more refined level, it is interesting to question what particular aspects of executive dysfunction contribute to poor inferential reasoning. Barnes and Dennis (2001) have argued that the problem with inferential reasoning may lie less in the computational aspects of inferencing (step 3 above) than in the working memory demands of integrating discourse meaning and world knowledge in real time (step 2). By a careful reduction of working memory demands, they demonstrated that deficits in inferential reasoning could be correspondingly reduced in children with TBI. Independent studies have also reported correlations between poor working memory capacity and poor inferential reasoning (Dennis & Barnes, 1990) including the ability to understand sarcasm (Martin & McDonald, 2005; McDonald et al., 2006). Slowed information processing is linked to working memory deficits and has, similarly, been associated with poor pragmatic understanding (McDonald et al., 2006).

Underpinnings of communication disorders after TBI 47 FLEXIBILITY

Inferential reasoning deficits are not, however, likely to be completely explained by a disorder of working memory. Other executive deficits may also play a role. For example, inflexible, perseverative thinking will impact on the ability to resolve pragmatic inference because rigid fixation on the literal meaning will impede the capacity to understand the implied meaning, even if working memory demands are low. Empirical evidence for a link between pragmatic understanding and measures of flexibility on standard neuropsychological measures is mixed. A relationship between the ability to understand sarcasm and performance on specific concept formation/shift tasks has been found in one study (McDonald & Pearce, 1996) but not in others (Martin & McDonald, 2005; McDonald et al., 2006; Turkstra et al., 1996). A specific measure of rigidity (i.e., perseverative errors) was found to be share a small amount of variance with scores on a sarcasm task (Martin & McDonald, 2005). IMPULSIVITY

Impulsivity (poor control) is also likely to impact on inferential reasoning because the participant reacts to initial meanings of conversational comments. There is even less research regarding this relationship, although a correlation between sarcasm and impulsivity has been found in the one study to examine this to date (Channon & Watts, 2003). NEW LEARNING

The capacity to learn is also likely to affect pragmatic understanding as contextual information that is relevant to the conversational exchange may have occurred some time earlier. There is surprisingly little research that has been conducted into the effects of poor new learning on pragmatic understanding following TBI (or indeed any clinical population). However, in one study it has been found that standard measures of new learning (taken from the Wechsler Memory Scale III) were correlated with poor understanding of sarcastic inference (McDonald et al., 2006). In sum, common cognitive sequelae of severe traumatic brain injury, including slowed information speed and working memory, rigidity and impulsivity, and poor new learning may each undermine the ability to understand pragmatic inferences. The impact of these executive abilities on inferential reasoning is consistent with the psycholinguistic account of how indirect speech acts are processed, suggesting that failure to recognize the conversational implicature occurs as a result of a failure to process and integrate language and the context in which it occurs in order to reject the literal meaning for another, inferred, meaning. Despite this, the three-stage model as advocated by Grice and others has

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been criticized as an inadequate explanation for how indirect speech acts are decoded. For example, some sarcastic comments can be both literally true and ironic. The mother who states “I love children who keep their rooms clean!” (Gibbs & O’Brien, 1991) may believe this to be true, but may also be speaking ironically (depending on the state of the bedroom). Sarcasm may also be manifested in the excessive politeness of the utterance “Oh I do beg your pardon most exalted one!” As a means to reconcile these issues it has been argued that sarcasm and irony may be better understood in terms of the (in)sincerity of the utterance rather than its truth value (Haverkate, 1990). This suggests that, in order to interpret such utterances, the hearer does not reject the literal meaning at all, but understands it in the context of the speaker’s attitude. Other kinds of pragmatic inference (e.g., hints) may also allude to issues that are on the speaker’s mind rather than in the patent context. These considerations suggest a different kind of inference is required on the part of the listener; that is, an inference needs to be formed regarding the speaker’s intentions. 2. Theory of Mind The capacity to attribute mental states, such as thoughts, beliefs, desires and intentions, is considered pivotal to the ability to make sense of communication. This type of ability is known as having “Theory of Mind” (ToM) and has been thought to cause the communicative disorders seen in autism. Many individuals with high functioning autism or Asperger’s syndrome and normal IQ have fluent and articulate speech but are, nonetheless, pedantic and overliteral (Happé & Frith, 1996), fail to interact normally in conversation, often talk at length on obscure or inappropriate topics (Ozonoff & Miller, 1996), have inappropriate non-verbal communication and poor adherence to social rules (Bowler, 1992). They also fail to appreciate how utterances are used to convey information in a socially appropriate manner (Surian, BaronCohen, & Van der Lely, 1996) and misinterpret both metaphor and irony (Happé, 1993). Similar deficits in social reasoning and social communication as seen in autism have also been reported in adults with TBI who have been reported as egocentric, self-focused, lacking interest in other people, displaying inappropriate humour, frequent interruptions, a blunt manner, overly familiar and disinhibited remarks or advances, and inappropriate levels of self-disclosure (Crosson, 1987; Flanagan et al., 1995; Levin et al., 1979; McDonald, Flanagan, Martin, & Saunders, 2004; McDonald & Pearce, 1998; McDonald & van Sommers, 1992). More particular reasoning deficits that implicate ToM have also been found in people with TBI. For example, adults with TBI have difficulty filling in a questionnaire as though they were somebody else (Spiers, Pouk, & Santoro, 1994), find it difficult to identify the source of interpersonal conflict (Kendall, Shum, Halson, Bunning, & Teh, 1997) or otherwise interpret non-verbal interpersonal interactions (Bara, Cutica, &

Underpinnings of communication disorders after TBI 49 Tirassa, 2001; Cicerone & Tanenbaum, 1997). Deficits on explicit ToM tasks have also been found in people with TBI, both adult and child (Bibby & McDonald, 2004; Dennis et al., 2001b; Milders, Fuchs, & Crawford, 2003; Santoro & Spiers, 1994; Stone, Baron-Cohen, & Knight, 1998). Furthermore, ToM performance has been linked to sarcasm comprehension. Specifically, those who experience difficulties understanding second order ToM inferences (i.e., what one person wants another person to believe) are also those most likely to experience problems understanding the meaning of sarcastic exchanges (Channon et al., 2005; McDonald & Flanagan, 2004). It is possible that problems with general inference-making secondary to executive deficits in TBI affect both non-social inferences and ToM. Studies that have examined this have reported a relationship between the two (Bibby & McDonald, 2004; Martin & McDonald, 2005). Working memory may also play a role. For example, a number of studies have shown that young children’s performances on false belief tasks are influenced by working memory capacity (Davis & Pratt, 1995; Gordon & Olson, 1998; Hughes, 1998; Keenan, 1998), although the evidence suggests that it is not the sole contributing factor (Tager-Flusberg, Sullivan, & Boshart, 1997). In acquired brain injury, working memory deficits have been found to contribute to poor ToM performance (Bibby & McDonald, 2004; Stone et al., 1998) although it does not totally explain the difficulties seen (Bibby & McDonald, 2004). Performances on laboratory-based sarcasm tasks and conventional executive tests probably do have some underlying processes in common, but this does not exclude the possibility that inference-making such as ToM also calls on specialized systems for processing social information. Indeed, there is growing speculation (e.g., Adolphs, 2001, 2003; Bechara, 2002) that social problem solving may engage distinct neural systems. Social, interpersonal problems focus on quite different information from the lists of words, numbers and simple figures that so often represent neuropsychological problemsolving tasks. For example, social information emphasizes individual rather than categorical differences and is dynamic, changing in response to the observer (Corrigan & Toomey, 1995). When relationships between executive measures and communication tasks requiring ToM are reported, these do not appear to represent exclusive relations. Correlations between pragmatic comprehension and indices of working memory, information processing speed, abstract reasoning and inhibition are modest at best (Channon & Watts, 2003; McDonald et al., 2006). Consequently, while there may be common processes required for social and non-social tasks, depending on the medium and response requirements (spoken, written, etc.), there may also be unique requirements called into play when solving social inferential tasks such as understanding sarcasm. Whether ToM represents a modular function that is differentially impaired in TBI, or a higher order ability reliant on generic executive skills, it is clearly related to impaired pragmatic understanding.

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3. Emotion A potential source of information when interpreting pragmatic inference is the emotional stance of the speaker. This is especially salient in the recognition of sarcasm, which is almost universally associated with a particular attitude of derision or scorn. Indeed a major criticism of the serial stage model of speech act comprehension as advocated by Grice is that such a model fails to account for the integral role that speaker attitude plays in the sarcastic retort. Nor does it specify how one inferential meaning is determined rather than another (Sperber & Wilson, 1986). As an alternative, Sperber and Wilson postulated a theory of irony within their larger thesis regarding the role of relevance in communication. They argued that every utterance has at most a single interpretation, which is a product of the listener’s search for the relevance the utterance has to the context, and therefore, unlike Grice’s proposition, Sperber and Wilson argued that there are no successive stages of interpretation. According to this position it is the recognition of the affective stance of the speaker that alerts the listener to the sarcastic meaning of the comment. The potential role played by emotion recognition in pragmatic understanding in people with TBI needs to be considered. Over the past two decades there has been a surge of interest in emotion recognition. There is now a considerable body of evidence to suggest that emotion processing deficits are prevelant in a substantial proportion of adults suffering from severe TBI. People with severe TBI have been found to have difficulties with emotion recognition across a range of media including photographs (Croker & McDonald, 2005; Green, Turner, & Thompson, 2004; Jackson & Moffat, 1987; Milders et al., 2003; Prigatano & Pribram, 1982; Spell & Frank, 2000), audiotaped remarks (Marquardt, Rios-Brown, Richburg, Seibert, & Cannito, 2001; McDonald & Pearce, 1996; Milders et al., 2003; Spell & Frank, 2000) and audiovisual displays (McDonald & Flanagan, 2004; McDonald et al., 2003). Interestingly, there appears to be relatively little association between the ability to recognize emotions and the ability to understand sarcasm (McDonald & Flanagan, 2004; McDonald & Pearce, 1996). Thus, despite the fact that sarcasm is usually associated with affective states, the problems that people with TBI have in understanding sarcasm predominantly arise from their inability to make inferences, whether these are specifically about the non-literal meanings of the comment or the beliefs and attitudes of the speaker (McDonald & Flanagan, 2004). This is not to say that emotion deficits have no role in communication difficulties after TBI. Sarcasm, after all, is only one example of the rich repertoire of subtle meanings and innuendos available to speakers. Emotional cues may well play an important, possibly pivotal, role in many other communication contexts. But there is virtually no research in this area to date.

Underpinnings of communication disorders after TBI 51 Pragmatic language production: Politeness theory Disorders in the production of effective communication have also been examined from a pragmatic theoretical perspective. First, the notion of politeness has proven useful to elucidate difficulties that arise following TBI in the use of diplomatic language to negotiate social situations. While adults with TBI appear to have an intact repertoire of strategies to moderate the politeness of their utterances (McDonald, 1993b) they are less flexible than matched control speakers in their ability to use these across different contexts (Togher & Hand, 1998). When faced with diplomatically challenging communication tasks such as hinting, or making requests to overcome a perceived reluctance on the part of the listener, adults with TBI have been found to have difficulty refraining from stating their desires directly (McDonald, 1993b) and making comments that were counter-productive to their desired outcome (McDonald & Pearce, 1998). These studies of politeness suggest that adults with TBI have difficulties producing language that utilizes pragmatic inference as a means of communication. A study of children with TBI suggests that younger speakers also have difficulties producing appropriate speech acts to meet contextual constraints (Dennis & Barnes, 2000). Neuropsychological underpinnings of politeness useage According to the pragmatic approaches outlined, certain predictions may be made concerning the contributions of co-existing cognitive impairments. Specifically, according to politeness theory, speakers need to appraise their conversational partners in order to determine their social and cultural standing (in relation to the speaker) as well as their particular attitude and sensitivities. Speakers need to have a repertoire of different devices for moderating the politeness of their remarks, and they need to choose flexibly between these in order to adapt to different situational and inter-personal contexts. Finally, they need to be able to refrain from making their intentions explicit in the service of diplomacy and saving face. Deficits in flexibility, inhibition, theory of mind judgements and emotion perception are, therefore, likely to impact on the use of appropriately moderated, polite communication. Failure of restraint, or disinhibition, has already been discussed as a common sequel of frontal lobe injury secondary to TBI. Further, poor performance in the production of effective requests has been found to be correlated with indices of disinhibition on formal neuropsychological tests (McDonald & Pearce, 1998) suggesting that more general disorders of control will impact on the ability to use language diplomatically. Although inflexibility with politeness has been documented (Togher & Hand, 1998) there has been no independent research linking politeness in discourse to other measures of rigidity in people with TBI. Similarly, there has been no research to date that links ToM and emotion recognition deficits to failure to moderate politeness appropriately in either the TBI or other clinical populations. So, despite the potential

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contribution these deficits make to the ability to use socially appropriate language, we await empirical confirmation of this. Social knowledge An additional consideration is the role of social knowledge in communication. The notion that people with TBI have reduced access to social knowledge has been barely considered to date. Indeed, it is widely believed that people with circumscribed deficits in either memory (learning) or executive function have relatively preserved access to knowledge and skills that were acquired premorbidly (Darby & Walsh, 2005). However, recent research challenges this belief in the area of social knowledge. Functional imaging of normal individuals suggests that ventromedial portions of the frontal lobes, in conjunction with the amygdalae, are involved in judgements concerning “trustworthiness” based on facial characteristics (Winston, Strange, O’Doherty, & Dolan, 2002). Patients with amygdala damage lose this ability (Adolphs, Tranel, & Damasio, 1998). Other social attributes also appear to be mediated by frontal–amygdala circuits. For example, personality judgements of extraversion, warmth, neuroticism, reliability and adventurousness that are based on the movements of light points on a walking figure are impaired in people with focal brain lesions (not TBI), with the relevant cortical region localized to the left frontal opercular cortices (Heberlein, Adolphs, Tranel, & Damasio, 2004). Similarly, adults with medial frontal damage appear to be less regulated by implicit gender stereotypes on a reaction time task than are people with dorsolateral frontal lesions and non-brain-injured controls (Milne & Grafman, 2001). Adults with focal ventromedial frontal lesions also appear to be less sensitive to dominance cues (based on gender, age, friendly facial expression and clothing) than adults with brain damage outside this region or without brain damage at all (Karafin, Tranel, & Adolphs, 2004). Finally, preference judgements related to the visual attractiveness of faces activate the ventral striatum (Kampe, Frith, Dolan, & Frith, 2001) and the orbitofrontal cortex (O’Doherty, Winston, Critchley, Perrett, Burt, & Dolan, 2003), once again suggesting that the frontal, especially medial frontal, systems of the brain are involved in such social judgements. The orbitofrontal and medial temporal lobes are specifically vulnerable to the acceleration–deceleration forces of high impact TBI because of their proximity to the bony shelves of the anterior and middle fossa (Darby & Walsh, 2005). Consequently, disorders in social appraisal may accompany TBI. The relationship between such disorders and poor modulation of politeness is unknown. Pragmatic language production: Grice’s maxims As another means of utilizing pragmatic theory, the expressive communication of people with TBI has been characterized according to Grice’s maxims.

Underpinnings of communication disorders after TBI 53 Thus, in principle, language production should adhere to the maxims of quantity, quality, manner and relevance; that is, speakers should be precise, accurate, organized and relevant in their language production. Planned deviations from these maxims may be effective in order to be diplomatic or dramatic in the right circumstances (as discussed with regard to politeness). Conversely, haphazard failures to adhere to these maxims will result in chaotic, socially unacceptable or ineffective language. Descriptions of discourse problems following TBI include lack of initiative, reliance on set expressions and general impoverishment in the amount and variety of language produced (Chapman et al., 1992; Erlich, 1988; Hartley & Jensen, 1991, 1992) or else over-talkativeness (Hagan, 1984; Milton, Prutting, & Binder, 1984), tangentiality and inappropriateness (e.g., Prigatano, Roueche, & Fordyce, 1986). These suggest that people with TBI do have problems adhering to implicit conversational maxims as outlined by Grice. A number of measures of communication have been developed using Grice’s maxims as a guide. In a study of two adults with TBI, “blind” raters evaluated how well two adults with severe TBI were able to explain how to play a game to a naive listener (i.e., a procedural narrative). Their productions were rated on scales that equated to the maxim of quantity (specifically “repetitiveness” and “amount of detail”) and manner (“clarity, “organization” and “effectiveness”) and compared to those of demographically matched controls (McDonald, 1993b). The blind raters were able to clearly distinguish the productions of the participants with TBI from the control participants on these dimensions. A second study of a larger group of adults with TBI confirmed problems with the demands of the procedural narrative. Typically, they failed to mention essential information, included irrelevant and therefore misleading information, repeated information and failed to sequence important steps in their correct chronological sequence (McDonald & Pearce, 1995). Similar problems with the orderly transfer of information have been reported when adults with TBI have been presented with different procedural tasks (Galski, Tompkins, & Johnston, 1998; Prince, Haynes, & Haak, 2002; Snow, Douglas, & Ponsford, 1999). Other discourse genres have also been analyzed for characteristics that equate to the maxims of quantity and manner. Thus conversational topics have been reported as repetitive (Body & Parker, 2005), and as narratives insufficient or inaccurate with respect to communicating essential content (Body & Perkins, 1998; Brookshire, Chapman, Song, & Levin, 2000; Snow et al., 1999). Grice’s maxims have also guided the development of checklists and questionnaires regarding communicative ability for people with TBI (Prutting & Kirchner, 1987). The Latrobe Communication Questionnaire (LCQ; Douglas, O’Flaherty, & Snow, 2000), for example, consists of 30 questions based on Grice’s maxims, as well as some additional questions tapping particular communication problems arising from cognitive deficits (such as word retrieval, distractibility and impulsivity). The questionnaire has been found

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to be sensitive to discourse difficulties in people with TBI (Douglas, Bracy, & Snow, in press). Neuropsychological underpinnings of maxim violation Similar deficits to those that are surmised to underpin pragmatic understanding may play a role in disrupting effective expressive communication that meets Grice’s maxims. An individual with slow information processing, poor working memory, rigidity with associated loss of conceptual thought and/or disinhibition, as well as memory problems is likely to have difficulty planning an effective communication strategy that enables information to be transferred in an orderly and efficient manner. Interestingly, a factor analytic examination of the LCQ revealed that, while originally conceptualized along the lines of Grice’s maxims, the self-report questionaire appeared to cluster somewhat differently (Douglas et al., in press). Thus two factors seemed to represent “quantity”. On the one hand there appeared to be a constellation reflecting “too much”, suggesting the impact of disinhibition. On the other there was too little; that is, dysfluencies such as word-finding problems, hesitancies and failure to provide sufficient information, so suggesting a role for loss of drive and initiative. Another factor that emerged reflected attentional difficulties; that is, losing track when conversing and getting sidetracked. Yet another reflected the problem-solving, planning and monitoring aspect of executive function; that is, the ability to manage the task of communication, by selecting accurate information to meet the listener’s needs, keeping track of main details, putting ideas together logically, self-monitoring, adapting conversational style to different situations and knowing when to talk and when to listen. These results suggest that Grice’s maxims, while useful for highlighting the role of speaker expectations in communication, do not map directly onto psychological processes involved in effective discourse. On the other hand, discourse difficulties do appear to correspond to common neuropsychological deficits after TBI. Empirical evidence for a link between discourse errors and independent neuropsychological indices will be discussed in the following sections. Aspects of social cognition are also likely to have an impact on the ability to produce effective communication that meets the listener’s needs. The ability to see the situation from the other’s perspective (ToM) is clearly important in order to formulate utterances that are meaningful for them. So, too, being able to read the emotional demeanour of others will be important in order to “pitch” one’s utterance at the right level. There has been no research, to date, examining these relationships.

Conceptualizing communication using discourse analysis Sophisticated linguistic frameworks have been applied in the field of TBI to reveal discourse regularities by close examination of text (either written by

Underpinnings of communication disorders after TBI 55 the participant or transcribed from their speech) produced in response to specific communication tasks. A number of overviews of discourse analytic approaches in TBI have been written in recent years (e.g., Coelho, 1999; McDonald, 1998; Togher, Hand, & Code, 1999), which the interested reader should pursue. In general, discourse analyses are concerned with the discourse as a whole, its continuity, organization and the relation between structure and function. Thus discourse analytic methods provide the means to analyse meanings inherent in text across the conventional boundaries of sentences and clauses. Monologues such as telling a story or relating a procedure have been useful vehicles for analysing discourse. Two attributes of discourse that have been a major focus of investigation are efficiency and coherence. Efficiency Efficiency of discourse can be conceptualized as the rate of speech, or otherwise the amount of information imparted in the words produced. Early observational accounts of the communicative characteristics of people with TBI emphasized slow, hesitant, or conversely, over-talkative communication patterns. Analyses along the lines of Grice’s notion of “quantity” have similar revealed inefficient information delivery. Analysis of the rate and nature of language produced has confirmed these impressions. Adult and adolescent TBI patients have been found to speak more slowly (Hartley & Jensen, 1991; Stout, Yorkston, & Pimentel, 2000), produce fewer meaningful words (Brookshire et al., 2000; Chapman et al., 1992; Chapman, Levin, Matejka, Harward, & Kufera, 1995; Hartley & Jensen, 1991), more incomplete, ambiguous or uninterpretable utterances (Body & Perkins, 2004; Hartley & Jensen, 1991; Stout et al., 2000), as well as shorter information units (C-units) (Hartley & Jensen, 1991) and less information overall (Biddle, McCabe, & Bliss, 1996), per minute (Erlich, 1988; Stout et al., 2000) or, alternatively, per informational unit, expressed as either C-units (Wilson & Proctor, 2002) or T-units; that is, each independent clause plus associated subordinate clauses (Coelho, 2002; Coelho, Grela, Corso, Gamble, & Feinn, 2005) across both narrative and procedural discourse tasks. Coherence The coherence of discourse relies on the semantic continuity of the text (Patry & Nespoulous, 1990) and may reflect local or global coherence. At a “local” level there must be appropriate relations between adjacent propositions for coherence to occur. At a “global” or macrostructure level there is development and maintenance of an underlying discourse plan (Coelho, Liles, & Duffy, 1991b; Patry & Nespoulous, 1990). Both notions of coherence have been investigated in TBI subjects.

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1. Local coherence One measure of local coherence is provided by an estimate of textual cohesion created by the interdependence of linguistic items occurring in separate clauses in a text. A cohesive tie occurs wherever one linguistic item relies on another for its interpretation, via reiteration of semantically linked items “he brought the bag of apples in, placing the fruit in front of her”, or grammatical links such as that formed via pronominal reference “he had an apple but would not share it” (Halliday, 1985; Halliday & Hasan, 1985; Hasan, 1984, 1985). As noted in the earlier section, adults with TBI are frequently insufficiently informative, or else overtalkative, as well tangential and disorganized. The question arises, therefore, as to whether they have difficulties developing and maintaining textual cohesion. Despite the sophistication in (local) cohesion analyses that has developed in the past 10–15 years, results have produced a somewhat mixed picture. In general, adults with TBI remain sensitive to the demands of different discourse requirements, such as procedural versus narrative discourse, varying the amount and type of lexicogrammatical cohesion accordingly (Coelho, 2002; Davis & Coelho, 2004; Hartley & Jensen, 1991; Liles, Coelho, Duffy, & Zalagens, 1989; Mentis & Prutting, 1987). However, whether the quality of cohesion is affected is disputed. In some studies TBI speakers have been found to use less cohesive ties than non-brain-damaged control subjects (Davis & Coelho, 2004; Hartley & Jensen, 1991; Mentis & Prutting, 1987), but other studies have not found this (e.g., Coelho, 2002; Galski et al., 1998; Hough, 1990; Jordan, Murdoch, & Buttsworth, 1991; Leer & Turkstra, 1999; Wilson & Proctor, 2002). Similarly, there is disagreement as to whether or not TBI speakers produce more incomplete references where the source for interpretation of a given linguistic unit is missing or ambiguous (Hartley & Jensen, 1991; Hough & Barrow, 2003; Leer & Turkstra, 1999; Liles et al., 1989; McDonald, 1993b; Mentis & Prutting, 1987). This variability in study results may reflect the heterogeneity of the population under examination. After all, not all adults or children with TBI are expected to have deficits in communication. There may also be differences in the way in which local coherence is calculated from one study to the next (see Davis & Coelho, 2004, for further discussion). An important additional issue is the need to carefully select the comparison group with respect to both socioeconomic status (see Snow & Douglas, 2000; Snow, Douglas, & Ponsford, 1997b, for discussion) and premorbid verbal abilities for any kind of discourse examination. Verbal ability and socioeconomic status have been clearly shown to influence the ability to produce coherent text (Brookshire et al., 2000; Coelho, 2002). But, in addition, it is not entirely clear that linguistic cohesion, thus measured, corresponds to subjective impressions concerning the coherence of the discourse (Glosser & Deser, 1991; McDonald, 1993b).

Underpinnings of communication disorders after TBI 57 2. Global coherence Global coherence has been gauged by identifying the nature and sequence of the propositional content, propositions being roughly equivalent to a predicate (i.e., verbs, modifiers and connectors) with one or more arguments (Kintsch & van Dijk, 1978; van Dijk & Kintsch, 1983). In story-telling tasks the propositional structure of TBI discourse has been characterized according to its organization into episodes defined as sequences of events with specific beginnings, middles and ends (Brookshire et al., 2000; Chapman et al., 1992; Jordan et al., 1991; Liles et al., 1989; Mortensen, 2005). In procedural narratives, propositions are identified as to whether they represent essential, non-essential, ambiguous or irrelevant information, and whether they are positioned appropriately according to the sequence of the procedure (Galski et al., 1998; McDonald, 1993b; McDonald & Pearce, 1995; Snow, Douglas, & Ponsford, 1995, 1997b; Turkstra et al., 1996). Measures of global cohesion have also produced a rather mixed picture. Some studies suggest that, when relating a story, TBI speakers (child and adult) produce as many complete episodes and essential propositions as control speakers (Jordan et al., 1991; Liles et al., 1989; Snow et al., 1997b) while others suggest that they provide fewer episodes, less complex episodes and generally less essential information (Brookshire et al., 2000; Chapman et al., 1992; Coelho, 2002; Coelho, Liles, & Duffy, 1995; Liles et al., 1989). Arguably, propositional analyses of procedural narratives have been a bit more consistent. People with TBI, both adult and adolescent, have been reported to omit essential information, provide a disrupted sequence of explanation and include irrelevant and ambiguous material when explaining how to play a simple game (McDonald, 1993b; McDonald & Pearce, 1995; Turkstra et al., 1996) (although see Snow et al., 1997b). Raters’ impressions of procedural texts produced by TBI speakers support notions of disrupted global coherence by suggesting they are confused and disorganized (McDonald, 1993b). Neuropsychological contributions to failed efficiency and coherence after TBI Discourse analytic approaches arise from linguistic rather than psychological accounts of communication. As such, like Grice’s maxims, they would not necessarily directly address the role of cognitive or neuropsychological abilities in discourse production. Even so, the detailed characterization of language that such discourse analyses yield suggests a role for several important cognitive abilities, some of which have been examined empirically. Clearly word finding and word retrieval problems will impede the efficient production of effective discourse, and a link between the two has been reported within the child TBI literature (Brookshire et al., 2000). Second, coherent discourse

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requires continuous monitoring of verbal output in order to, for example, ensure that each pronominal reference used has an unambiguous source, and that ideas are inserted logically and effectively into the language flow. This is an on-line processing task that depends on good working memory capacity. Consistent with this there is empirical evidence for a relationship between impaired working memory and estimates of low efficiency and cohesion (Hartley & Jensen, 1991) and complexity of clauses within T-units (Youse & Coelho, 2005). The global coherence of text is likely to be affected by executive disorders that impair the ability to plan and sequence behaviour to meet specified goals. In studies of adults and children with TBI (including mild and severe injuries) (Brookshire et al., 2000) the amount of essential information provided was associated with measures of conceptual thought, generativity and problem solving (Brookshire et al., 2000; McDonald & Pearce, 1995). Likewise, inability to transform the gist of written text was correlated with poor problem solving (Chapman et al., 2004). These results strongly suggest that deficits in the ability to reason flexibly and readily interfere with the orderly transmission of information. Furthermore, certain kinds of tasks may be more taxing of executive abilities than others. Story generation tasks, for example, wherein the speaker has no template for the structure and flow of information, are likely to be more challenging for those with executive disorders than story recall based on prior exposure to an oral or pictorial story. In general, it appears that story generation tasks are more demanding for adult speakers, be they normal or suffering from TBI (Coelho, 2002). The ability to relate a narrative in a sensible sequence will also depend on the ability to recall the events to be narrated, as well as the events of the narration that have already unfolded. Thus, while story generation tasks may be more taxing of executive abilities, story recall tasks may rely more on intact memory capacity. Indeed, it appears that various indices of linguistic cohesion and coherence are more affected by poor new learning capacity when the task requires someone retelling a previously heard story rather than generating one on the basis of a stimulus that remains in front of them (Brookshire et al., 2000; Youse & Coelho, 2005). Although it is less clear how social cognition (e.g., theory of mind and social knowledge) might be relevant to these particular dimensions of discourse production, emotion may represent a different case. The finding of Leer and Turkstra (1999) that emotionally salient experiences are related by adolescents with and without TBI (and probably adults although this has not been examined) with better informational structure and coherence than less engaging tasks, raises the question as to whether emotional engagement facilitates coherent discourse and, if so, how. This is another fascinating avenue of exploration that awaits empirical research.

Underpinnings of communication disorders after TBI 59 Conversation The vast bulk of communication occurs as part of an interaction with one or more other speakers. Furthermore, it is in the social milieu that the problems experienced by speakers with TBI become most apparent. Consequently, methodologies are required that can characterize how verbal interaction between two or more participants is managed during spontaneous conversation. Broadly speaking, useful approaches for examining conversational skills following TBI have emerged from either linguistic (conversational) analyses (Patry & Nespoulous, 1990) or behavioural classification based on models of social skills (McFall, 1982). 1. Linguistic approaches to analysing conversation Using a variety of linguistic approaches it has been found that TBI speakers elicit greater numbers of questions and prompts from their partners (Coelho, Liles, & Duffy, 1991a; Godfrey, Knight, Marsh, Monory, & Bishara, 1989). They have been rated as having poor topic maintenance (Drummond & Boss, 2004; Erlich, 1988; Milton et al., 1984), poor initiation (Drummond & Boss, 2004; Ehrlich & Barry, 1989) and providing information in an inefficient and disorganized manner (Mentis & Prutting, 1987; Snow, Douglas, & Ponsford, 1997a, 1998). A particular theoretical approach that has been applied to interactive discourse in TBI has been Systemic Functional Linguistics (SFL). SFL is a theoretical approach developed by Halliday (1985) that addresses the relationship between the purpose and context of communication and its structure. According to this approach there are several levels of meanings within any discourse. Ideational meanings reflect the nature of the social interaction (shopping enquiry, social chit-chat, etc.) and are apparent in the vocabulary of the interaction. Interpersonal meanings reflect the nature of the social relationship between the speakers such as familiarity, power, and so on, and are realized in the choice of speech act. Thus speakers who have higher status may hold (and impart) more information, be in a position to make requests of their conversational partner and be able to be more direct in their communication (i.e., be less reliant on indirect politeness strategies). Finally, there are textual characteristics, that is, the connectedness of the discourse that reflects the mode of the language (e.g., spoken versus written). Cohesion analyses, for example, are based on Halliday and Hasan’s notion of textual coherence (Hasan, 1985). SFL, particularly as it pertains to interpersonal meanings, has been useful for examining conversation because it takes into account the discourse of the speaker with TBI in relation to their interlocutor as well as how that interlocutor behaves towards the speaker with TBI. Using this approach some similar patterns of discourse production to that already described have been revealed. For example, people with TBI tend to provide more information, including inappropriate information, to their

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conversational partner (Togher, Hand, & Code, 1997a, 1997b). But of potentially greater import, analyses have emphasized the role that conversational partners have in influencing the opportunities and choices that TBI speakers have when conversing. In general, it has been revealed that conversational partners often converse with speakers identified as having a TBI in a manner that has the effect of disempowering them. Thus, compared to carefully matched control speakers, people with TBI were asked more questions for which the speaker already knew the answer, were subjected to repeated checking of the veracity of their responses, were given more information and were asked for less. (Togher et al., 1997a, 1997b). Togher and colleagues also demonstrated that, placed in an empowering situation, such as educating school children on the circumstances of their injury, speakers with TBI conversed in a manner that was indistinguishable from control speakers (with spinal injuries) (Togher, 2000; Togher & Hand, 1999). 2. Behavioural approaches to conversation Finally, communication disorders following TBI have been addressed from within the rubric of social skills (McFall, 1982). Notions of social skills have emerged primarily from a behavioural rather than a linguistic analysis. Checklists and rating scales based on this framework have ranged in focus from global measures of verbal and non-verbal behaviour such as “social performance” (Newton & Johnson, 1985; Spence, Godfrey, Knight, & Bishara, 1993) to intermediary measures such as “partner-directed behaviour” (Flanagan, McDonald, & Togher, 1995; McDonald et al., 2004) and “turntaking” (Drummond & Boss, 2004), to measures of specific and discrete attributes of communication such as “frequency of questions” (Godfrey et al., 1989). Using this behavioural approach, severe TBI speakers have been found to be generally less interesting, less rewarding and more effortful to interact with than control speakers (Bond & Godfrey, 1997; Godfrey, Knight, & Bishara, 1991). They are reported to elicit higher rates of verbal facilitation from their conversational partner (Godfrey et al., 1989) and to be generally unskilled in their response to their partner’s questions (Spence et al., 1993). They have also been noted to be egocentric in their discussion and fail to actively involve their conversational partner, such as by asking questions or supporting them with the use of verbal reinforcers (Flanagan et al., 1995; Marsh & Knight, 1991; McDonald et al., 2004). Neuropsychological underpinnings of social skills Theoretical frameworks of social skills typically encompass three basic categories of social skills: (1) Encoding; that is, execution of behaviour including speech content, paralinguistic elements (e.g., voice volume), and non-verbal behaviour (e.g., facial expression), (2) decoding components such as attention, perception and interpretation of social cues, and “social intelligence”; that is,

Underpinnings of communication disorders after TBI 61 the identification of problems and/or goals, and (3) decision making; that is, the generation of alternative plans of action and decisions concerning these (McFall, 1982). These relate very clearly to neuropsychological deficits that have already been discussed in relation to communication disturbances after TBI as evaluated using other models. Thus executive dyscontrol and impulsivity will impact on the ability to formulate appropriate behavioural (including verbal) responses, and to monitor and regulate behavioural output. Attention to, processing and interpretation of social signals will be affected by deficits in emotion recognition, theory of mind, social knowledge and ability to think at a conceptual level and plan. Finally, executive dysfunction will also impede the ability to generate alternate plans and decisions. Once again, there has been little research to empirically test these hypothetical relationships.

Conclusions In conclusion, research into communication disorders after traumatic brain injury has advanced significantly since the early observational studies of the 1970s. The use of linguistic theoretical approaches, such as pragmatics and systemic functional linguistics, as well as behavioural approaches emanating from a social skills perspective, has provided a sensitive means to elucidate disorders of communication. Although primary disorders of language are relatively infrequent after brain injury, it is apparent that for many people with severe TBI the task of communicating with others in a way that is clear and effective, and sensitive to their conversational partner’s needs, is often compromised. The analytic approaches discussed in this chapter emphasize the social nature of communication. As such they represent an important advance over the “context-free” assessments of standard language batteries of the past. Social theories of communication expand notions of communicative competence to encompass the ability to use language in context and all that this entails. In doing so they have been shown to be sensitive to subtle but pervasive disorders of communication wherein basic language abilities remain intact but the ability to apply these sensitively and adaptively is impaired. Socially orientated theoretical approaches have also heightened awareness of cultural differences and refined our notions of normality. For example, research by Togher, Snow, Body and colleagues (e.g., Body & Perkins, 1998; Snow et al., 1995; Snow & Douglas, 2000; Togher, 2000; Togher & Hand, 1999) highlights the importance of cohort effects in what is considered normal and effective conversational style. Studies such as these seriously challenge the assumption that professionally trained therapists can judge the competence of their clients’ communication skills by their own interactions (Ylvisaker, 2000). Socially oriented theories of language have provided the means to evaluate regularities in language use that may transcend conventional notions of “proper” talk and may vary from one context to the

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next, from one cohort to the next. They also reveal how important conversational partners are in terms of providing the speaker with TBI with adequate and/or normal opportunities to demonstrate communicative competence. Importantly, socially oriented theories of communication have also provided the means to consider how cognitive and emotional abilities interact with the language system to produce normal communicative ability. In the case of speech act theory (pragmatics), a psychologically based account of how indirect speech acts are understood emerged in the 1970s. This provided the impetus for a number of studies aimed at evaluating the model’s veracity in explaining disorders in the comprehension of irony relative to other competing notions (e.g., relevance theory, Sperber & Wilson, 1986). It has also pointed to a variety of potential mechanisms that align with our growing understanding of neuropsychological impairments commonly seen after traumatic brain injury. Other linguistic approaches have been less concerned with the psychological mechanisms underlying discourse ability but have, nonetheless, characterized communication disturbances in sufficient detail to enable clear speculation as to the underlying neuropsychological cause. As a result of these different approaches it is possible to hypothesize about systematic relationships between a variety of neuropsychological impairments and communicative ability and to test these empirically. Thus deficits in attention, working memory, information processing speed and learning have each been found to contribute to communication disorders as operationalized by these different theoretical frameworks. So too, problems in conceptual reasoning and problem solving as well as the ability to monitor and regulate behavioural responses have been clearly implicated in both the ability to understand subtle communicative meanings and the ability to produce social skilled discourse. Despite this, not all studies have been able to demonstrate significant associations between aspects of discourse and performance on standard neuropsychological tests, even when the constructs are clearly relevant (Brookshire et al., 2000; McDonald & Pearce, 1995; Turkstra et al., 1996). It is quite possible that discourse tasks represent ecologically valid tasks that are complex and unstructured relative to standard neuropsychological measures. The ecological validity of standard tests has often been criticized (Silver, 2000). It is also possible that discourse falls into the domain of social information processing and is therefore more relevantly compared to performance on other social problem-solving tasks. There are, however, few standard instruments in this domain – an issue that is increasingly recognized. But, in addition, recent advances in our understanding of social cognition identify entirely different neuropsychological constructs that may be highly relevant to communication. The possibility that emotion recognition, theory of mind judgements and social attitudes are uniquely represented in the frontal systems of the brain and processed differently from non-social information opens a whole new avenue of research. The prevalence of psychosocial dysfunction following severe TBI is well known. It is becoming increasingly apparent that many

Underpinnings of communication disorders after TBI 63 people with TBI experience various deficits in social information processing. New advances in our understanding of social cognition and how this becomes disordered following TBI, combined with sophisticated developments in characterizing discourse and communication as detailed in this chapter, thus provide us with exciting new directions for characterizing the neuropsychology of communication difficulties seen following brain injury.

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Spell, L. A., & Frank, E. (2000). Recognition of nonverbal communication of affect following traumatic brain injury. Journal of Nonverbal Behavior, 24 (4), 285–300. Spence, S. E., Godfrey, H. P., Knight, R. T., & Bishara, S. (1993). First impressions count: A controlled investigation of social skill following closed head injury. British Journal of Clinical Psychology, 32, 309–318. Sperber, D., & Wilson, D. (1986). Relevance: Communication and cognition. Oxford, UK: Basil Blackwell. Spiers, M. V., Pouk, J. A., & Santoro, J. M. (1994). Examining perspective-taking in the severely head injured. Brain Injury, 8, 463–473. Stone, V. E., Baron-Cohen, S., & Knight, R. T. (1998). Frontal lobe contributions to theory of mind. Journal of Cognitive Neuroscience, 10 (5), 640–656. Stout, C. E., Yorkston, K. M., & Pimentel, J. I. (2000). Discourse production following mild, moderate, and severe traumatic brain injury: A comparison of two tasks. Journal of Medical Speech Language Pathology, 8 (1), 15–25. Surian, L., Baron-Cohen, S., & Van der Lely, H. (1996). Are children with autism deaf to Gricean maxims? Cognitive Neuropsychiatry, 1 (1), 55–71. Tager-Flusberg, H., Sullivan, K., & Boshart, J. (1997). Executive functions and performance on false belief tasks. Developmental Neuropsychology, 13, 487–493. Tate, R. L., Fenelon, B., Manning, M. L., & Hunter, M. (1991). Patterns of neuropsychological impairment after severe blunt head injury. Journal of Nervous and Mental Disease, 179, 117–126. Thomsen, I. V. (1975). Evaluation and outcome of aphasia in patients with severe closed head trauma. Journal of Neurology, Neurosurgery and Psychiatry, 38, 713–718. Togher, L. (2000). Giving information: The importance of context on communicative opportunity for people with traumatic brain injury. Aphasiology, 14 (4), 365–390. Togher, L., & Hand, L. (1998). Use of politeness markers with different communication partners: An investigation of five subjects with traumatic brain injury. Aphasiology, 12 (7–8), 755–770. Togher, L., & Hand, L. (1999). The macrostructure of the interview: Are traumatic brain injury interactions structured differently to control interactions? Aphasiology, 13 (9–11), 709–723. Togher, L., Hand, L., & Code, C. (1997a). Analysing discourse in the traumatic brain injury population: Telephone interactions with different communication partners. Brain Injury, 11 (3), 169–189. Togher, L., Hand, L., & Code, C. (1997b). Measuring service encounters with the traumatic brain injury population. Aphasiology, 11 (4–5), 491–504. Togher, L., Hand, L., & Code, C. (1999). Exchanges of information in the talk of people with traumatic brain injury. In S. McDonald, L. Togher, & C. Code (Eds.), Communication disorders after traumatic brain injury. Hove, UK: Psychology Press. Turkstra, L. S., McDonald, S., & Kaufmann, P. M. (1996). Assessment of pragmatic communication skills in adolescents after traumatic brain injury. Brain Injury, 10 (5), 329–345. van Dijk, T., & Kintsch, W. (1983). Strategies of discourse comprehension. New York: Academic Press. Wilson, B. M., & Proctor, A. (2002). Written discourse of adolescents with closed head injury. Brain Injury, 16 (11), 1011–1024. Winston, J. S., Strange, B. A., O’Doherty, J., & Dolan, R. J. (2002). Automatic and

Underpinnings of communication disorders after TBI 71 intentional brain responses during evaluation of trustworthiness of faces. Nature Neuroscience, 5 (3), 277–283. Ylvisaker, M. (2000). Reflections on dobermanns, poodles, and social rehabilitation for difficult to serve individuals with traumatic brain injury. Aphasiology, 14 (4), 407–431. Youse, K. M., & Coelho, C. A. (2005). Working memory and discourse production abilities following closed-head injury. Brain Injury, 19 (12), 1001–1009.

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Social validation of recovery in aphasia Leonard L. LaPointe and Kerry L. Lenius

Introduction Social validation of an outcome is achieved by assessing the social significance of the goals, the social appropriateness of the procedures, and the social importance of the behavioral change (Kazdin, 1977; Wolf, 1978). This is essential if we are to generate meaningful conclusions regarding rehabilitation therapy. This chapter provides insights into the origins of social validation of change in the literature, and the application of this concept in aphasia therapy today. An excerpt from Talking about aphasia (Parr, Byng, Gilpin, & Ireland, 1997, p. 82) illustrates the frustration experienced by a person with aphasia while working on treatment goals. It aptly speaks to the need for social validation of therapeutic targets and strategies: Weekly group therapy involved quizzes and language games. At the time he [Vincent, the person with aphasia] was consumed with a desire to return to work and was extremely anxious about his financial and home situation. While not being at all critical, Vincent points out that the weekly activities in speech and language therapy did not touch on these issues: “I personally had got a bit bored – I learned a lot of things that I didn’t know when I had the stroke, like the history of the Royals – The speech therapy didn’t give me information about help. The help they give me is to try and get better.” Vincent eventually left the group, but stays in touch with some of the people he met there. In this example, the consumer was less than satisfied with the services he received. If Vincent’s therapist had simply asked him, “What would you like to work toward in therapy? What is important to you?” Vincent’s statement might have gone something like this: Working in group therapy really helped me learn to socialize with others in a new way. I learned communication skills that I really needed to try to return to work. Despite the aphasia, I was able to use words, gestures, and drawings to make myself understood. This prepared me

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for the communicative interactions I would be facing when I returned home. Social validation of the goals and outcomes of treatment can provide the framework for planning and implementing intervention that is salient and relevant to each of the individuals with whom we work.

Emergence of social validity in the literature As early as the 1950s social validation was present in a meager number of articles in medicine, psychotherapy, and business. It wasn’t until the 1970s that the term was more clearly defined by behavioral therapists (Kazdin, 1977; Wolf, 1978). Wolf, the first editor of the Journal of Applied Behavior Analysis (JABA), provided an entertaining description of the process and the perceived reluctance of the journal in coming to terms with the need to incorporate social importance with subjective assessments of social validity. He provided a delicate example of the need for this type of assessment by describing a manuscript submitted by Jones and Azrin (1969), who researched synchronized speech to reduce stuttering. Despite the reduction of the stuttering behavior, the speech sounded artificial. Jones and Azrin dealt with this problem by having judges rate the speech on the dimension of naturalness. Thus the researchers used social validation by having raters assess the social appropriateness of speech. If social validation was ignored and clients who stuttered were all instructed to use a regular beat pattern for speech, the stuttering might be extinguished; but the stigma of “abnormal” speech would remain. So what? This is the basis for testing social validity. If the changes we make in therapy are not impacting our clients at home and in the community, did we provide adequate service? If scores on standardized tests increase one standard deviation but consumers are unable to perceive a change, did we make a difference? When does a difference make a difference is an important question about any attempt to intervene and facilitate a change in behavior. Who cares? If we as professionals only use our own expertise and experience in setting up criteria for success, thereby neglecting the values and opinions of the other experts involved (the clients), we are implying that consumer opinions do not matter. This can be a serious flaw in the successful realization of treatment goals. Wolf (1978, p. 210) states that “Behavioral treatment programs are designed to help someone with a problem. Whether or not the program is helpful can be evaluated only by the consumer.” This may be a little overstated, as the opinions of professionals and others in the community might indeed contribute to the determination of adequate outcomes, but certainly the opinion of the consumer should be paramount. Wolf also poses questions that might well be retained by every clinician during the phases and stages of treatment.

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Are the specific behavioral goals that have been generated really what society wants? Does the end justify the means? That is, do the participants, caregivers and other consumers consider the treatment procedure acceptable? Are the consumers satisfied with the results? This includes all results, even unpredicted ones.

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Despite this growl by Wolf, trends in the use of social validity in behavioral modification research remained flat and low. Kennedy (1992) reviewed articles for inclusion of social validity in JABA from 1968 to 1990 and the journal Behavior Modification from 1977 to 1990. His graphs show a sluggish trend toward increased use of social validity. Despite improvement, by 1990 social validation procedures were reported in only about 20 percent of the articles surveyed.

Implementing socially valid treatment Three main targets exist for the appropriate integration of social validation procedures in aphasia treatment. These are: • • •

developing socially valid goals using valid methods, and validating the outcomes.

Each of these areas needs to be addressed in order to achieve the result of providing treatment that is appropriate, meaningful, and effective in enabling successful communication. Socially valid goals Traditionally a clinician may use a standardized test such as the Western Aphasia Battery (WAB) (Kertesz, 1982) to determine areas of impairment, select therapy goals, and possibly to document change. This focus on impairment is consistent with traditional approaches to disease characteristic of the medical model, but may not be the most efficient way to determine socially relevant goals. The seemingly ever-changing terminology of the World Health Organization is being integrated into models of aphasia treatment (Rogers, Alarcon, & Olswang, 1999; Threats, 2002), but the concepts involved are important. Changes in social activities and participation are emerging as more relevant goals of treatment and are eroding the stone face of impairment-based approaches to intervention. The Life Participation Approach to Aphasia is having an impact on approaches to aphasia intervention and shaping the very core of the aphasia treatment model (LPAA Project Group, 2000). Most standardized tests of aphasia are predominantly impairment-based. Recently, some efforts have been made to incorporate the


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social model of aphasia into assessment procedures. The latest edition of Eisenson’s classic Examining for aphasia (LaPointe, 2006) incorporates principles of the social model of aphasia into the assessment in an effort to guide clinicians in the quest to develop relevant participation-based treatment goals. This approach does not suggest that we discard the baby with the bathwater, as impairments and cognitive-linguistic processes also may need to be targeted for treatment; but for far too long it has been impairment or nothing, with little emphasis on reintegration of the person into an active, participating milieu. The traditional biographic standardized test interview needs to be supplemented or indeed replaced with specific information gathering as to the goals, values, hobbies, likes, dislikes, hopes, fears, anticipations, and motivations of each unique individual for whom we are planning treatment. This will assist the informed clinician with planning, delivering, and evaluating services (Pound, Parr, & Duchan, 2001). Lubinski (2001), Elman (2005), Simmons-Mackie (2001), Lyon and Shadden (2001), LaPointe (2002), and Worrall and her associates (Cruice, Worrall, Hickson, & Murison, 2005) all provide social model flesh and humanity to the skeleton of treatment planning in aphasia. This entire movement, of course, harkens back to the birth and upbringing of language in context and person-centered concepts of aphasia intervention nurtured and influenced so thoroughly by Audrey Holland (Holland, 1982a, 1982b). Interview questions appropriate to determining and creating socially relevant and valid treatment goals can be gleaned, inferred, or directly created from all of the above sources and particularly from Lubinski (2001) and Simmons-Mackie (2001), and Elman (2005). The interview allows the client and any others present to express what life was like before the onset of aphasia, how life is impacted now, and what areas of communication breakdown generate the most stress on relationships. In an effort to define socially valid aphasia therapy goals Ross and Wertz (2003) set out to determine the difference in quality of life as rated by people with and without aphasia. Two groups (people with aphasia for at least six months and non-brain-damaged individuals) completed quality of life measures. The greatest difference between the groups was evident in areas of activities of daily living, opportunities to acquire new information and skills, social support, mobility, and sexual activity. Of course it is imperative to customize treatment planning and weave specific treatment goals around the idiosyncracies of each person, but this study shows support for language therapy focusing on enhancing communication for specific functional situations and expanding participation in society. Sometimes we tend to err on the side of overzealous treatment planning and implementation. One of the authors of this chapter (LLL) remembers well an early treatment planning faux pas when a full court press of intervention (twice per day; intensive reading comprehension strategies integrated into the treatment schedule) was probably not in keeping with the personal goals of the person with

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aphasia. After two weeks of rather intensive treatment, I remember his words well: Doc, I thank you for all you’re trying to do here, but, you know, I never have completely read through a whole book. I don’t really care if I ever do. I just want to go up on the St. Johns River and live with my brother in the trailer there, and maybe sit out on the dock and fish a little. I know you’re trying real hard Doc, and I appreciate it, but I really don’t care if I can’t read very good. If the treatment goals of the person with aphasia are not built into the treatment plan, misguided expenditures of time, effort, and money can be the result. This clinical lesson made it abundantly clear that precise activity and participation therapy must be harmonious with the expectations and needs of the person in therapy. Sometimes the people with whom we work are content to fish or plant cumquats. Socially valid methods In addition to determining goals that are vital to clients’ lives it is imperative to ensure the methods used to achieve the outcome are acceptable. Socially valid procedures can be facilitated by verifying that the materials being used are consistent with the patient’s expectations. An example of this is reported by Lustig and Tompkins (2002, p. 510), They state: “LG was presented with a list of possible conversation topics prior to the study and her preferences were taken into account when the final stimulus sets were created.” By allowing the person with aphasia to aid in the selection of stimuli that are most relevant to him or her, we facilitate participation and ownership in the therapy. Validating the importance of the materials to each person can only help motivation and participation in rehabilitation. A fly fisherman probably would not respond as well to retelling the story of Cinderella as to creating instructions on how to match the insect hatch. A cake decorator may be more motivated to work on divorce cake designs than on conjugating the verb “to be.” Materials need to be not only age appropriate but person appropriate. Treatment procedures are another important consideration in generating socially valid intervention. Are the selected treatment procedures within the social or cultural norms or expectations of the person with aphasia? Working on paralinguistic nuances such as improving conversational eye contact may not be within the cultural norms of a young adult stroke victim who happens to be a Navajo American Indian. In the Navajo culture direct eye contact, particularly with an authority figure or older person, is considered bad manners. Naming the edible cuts of meat from a pig may not be a palatable activity for a Muslim or Orthodox Jew. Writing the stanzas of “What a friend we have in Jesus,” may be less appropriate for a Sri Lankan Buddhist than a

Social validation of recovery in aphasia 77 retired Baptist preacher from Dothan, Alabama. Reading statistics on comparative handgun violence in America and Australia may not sit well with a former officer of the National Rifle Association. Acceptable interventions that are socially appropriate also may take less time, are less unsettling, have fewer adverse or apathetic reactions, and are cost efficient according to some research (Reimers, Wacker, Cooper, & DeRaad, 1992). Consumers of aphasia therapy have voiced dissatisfaction with treatment procedures that are not client centered or age appropriate. Clowns, balloons, circus animals, fluffy puppies and kittens should be banished to the pediatric wards, unless of course one is working with a former clown or fluffy puppy lover. We also need to explain why we are doing certain assessments or working on certain communication tasks. Explaining that we are evaluating coordination and control of the speech articulators (lips, front of the tongue, back of the tongue) fosters understanding; as opposed to the unexplained request to say “pa-ta-ka” over and over. Sometimes we assume too much and our clients wonder what we could possibly learn from the requests “smile; stick out your tongue; wiggle it from side to side; point to these pictures.” Possible client reactions are illustrated in the following observation: When asked about what speech and language therapy entails, people who have aphasia describe a number of different activities . . . therapists seem to be poor at conveying information about what is being done in therapy, and why. As a result, to some aphasic people the rituals of therapy seem demeaning and made them feel stupid. Many people point out that therapy can feel like returning to the classroom. The association with school can sometimes be reinforced by the manner of the therapist. (Parr et al., 1997, p. 78) A prime example of the need to assure the selection and use of socially valid procedures is clearly demonstrated by consumers of augmentative alternative communication (AAC). Lasker and Beukelman (1999) measured peers’ perceptions of storytelling by an adult with aphasia to investigate if peers accepted an augmentative alternative communication device. In this study peers ranked the AAC digitized speech to be preferred over natural speech. However, this finding is not always the case. Shadden (2005) underscores this point when describing a stroke survivor with limited verbal output (only able to say “yes” and “no”) who was opposed to augmentative forms of communication. Through a support group he was encouraged to use a total communication approach (gestures, drawings, writing). Eventually he began using a DynaVox® and was successfully communicating with everyone except his wife. Despite the potential this man had for communicating with the device, no gains were made in communicating with his spouse. This highlights the importance of therapeutic relevance to all the principals in the

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constellation of treatment. If one of the principals is not buying into the procedures, the potential for improvement may be compromised.

Socially valid outcome measures When measuring treatment effect, one of the pioneers of socially relevant intervention, Kazdin (1977), advocated two criteria by which to determine if treatment gains are socially valid: social comparison and consumer evaluation. Social comparison occurs when treatment is considered to be improved only when the target behavior is considered to be within “normal” functioning. This is considered one form of social validation since the rest of society performs in the same manner as the person with the now “normally” functioning behavior, therefore it is presumed that society would find this behavior acceptable. The drawbacks to using social comparison as a criterion of social validity are fairly apparent. It is, expensive, time consuming, and intuitively ludicrous to be required to gather social norms for every specific treatment target. However, once norms have been established, clear criteria can be set without the obstacles posed by subjective measures. Goldstein (1990) makes a germane point by arguing that social comparison neglects to account for profound differences among clients prior to treatment, and that many clients and significant others may be satisfied with smaller gains that still fall short of “normal.” Wells (1999, p. 912) asks, “What is the value of such an objective assessment when it is so unconfirmed by the perceptions of patients and carers?” Another problem is that social comparison only measures the change in level of impairment without considering changes in the ability to cope or compensate for problems. These issues may be why social comparison is not used as often as consumer evaluations. Kennedy (1992) reported that 91 percent of the JABA articles in 1983 that reported on social validity used subjective measures (i.e., consumer evaluation) and only 9 percent used normative comparison. Consumer evaluations These are the most common form of social validity used in determining treatment outcomes (Kennedy, 1992). Consumer evaluations typically take the form of rating scales of the person in treatment and/or caregiver. These may include quality of life (QOL) ratings, informal interviewing (which may include any of the principals involved), or specific judgments when comparing pre- to post-treatment abilities (i.e., comparing videotaped behaviors or writing samples). Sometimes, however, “anecdotal reports of client or family opinions are often not valued as ‘measures’ because they are considered subjective, unreliable, or unprofessional” (Simmons-Mackie & Damico, 2001, p. 22). In determining the social validation of treatment outcomes, many clinicians, however, value the opinions of the principals involved as much as


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they value behavioral measures. Many researchers and clinicians use objective behavioral measures as primary dependent measures, and social validation as secondary measures of treatment outcomes (Schwartz & Baer, 1991). A clinical fact of life is that some significant changes in behavioral measures may not signal a corresponding change as to the value of that change. When does a difference make a difference? That nagging outcome question needs to be addressed; and that is at the heart of social validation. Schlosser (1999) separates consumer reported outcomes into four groups: proximal, instrumental, intermediate, and distal. Proximal outcomes are directly related to the intervention, instrumental outcomes measure generalization, intermediate outcomes rate change in QOL, and distal outcomes rate changes on a larger level (i.e., national outcomes). Thus, when working on the ability to communicate information in conversation and measuring proximal outcomes, one could ask consumers, “How successful was Mr. R. at getting his message across?” If you choose to measure intermediate outcomes you could give a general QOL or well-being questionnaire to determine if the treatment improved psychosocial wellness. Outcomes also can be separated by activity limitation (previously referred to as disability in earlier WHO models) and participation restriction (previously termed handicap). For instance, if you plan to improve a person’s communicative interactions with a wide range of people, you would be attempting to reduce the participation restriction; and one option for a satisfaction measure would be to use the Communication Readiness and Use Index (CRUI) (Lyon et al., 1997) with any of the relevant principals involved. Multiple approaches may be used to measure consumer opinions. One option is forced choice (improved/not improved); another would be to provide a Likert scale (5 or 7 point), or use of a visual analogue scale (i.e., Communicative Effectiveness Index, CETI) (Lomas, Pickard, Bester, Elbard, Finlayson, & Zoghaib, 1989). Additionally, consumer opinions could be measured by having raters view video clips of the targeted behavior before and after treatment, and rate the behavior that is more effective. In humor, fruit-picking, and romance, timing is everything. Add successful therapy to the list. Perceptive clinicians begin with the end in mind. We need to plan ahead by determining the type of social validation measure that may be appropriate for the person enrolled in treatment. If a clinician plans to obtain ratings of pre/post ability one may want to videotape baseline ability before initiating treatment. Post-therapy ratings may be of limited value if pre-therapy behaviors are lost in the fog of history. Even if one does not intend to use video comparisons, it may be useful to have the person with aphasia and important others complete ratings of QOL or communication abilities (i.e., CETI) when treatment begins. Simmons-Mackie (2001) provides a comprehensive list of socially valid assessment tools to obtain stakeholder perspectives.

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The good, the bad, and the ugly Although consumer evaluations are extremely useful to gain insight into consumers’ perspectives, this is not a perfect science and not without its problems. Many of the subjective rating scales are inconsistent across studies. Validity and reliability of the scales are often unreported, and without the basics of adherence to psychometric principles, one runs the risk of producing measurements that have no real meaning. Schwartz and Baer (1991) provide advice on how to administer questionnaires to maximize validity and reliability. One common concern with subjective ratings is the risk of false positives. This occurs when people expect treatment to work, so they rate post measures more favorably. The placebo effect can intrude when expectations of improvement are presumed. This may not always be a bad thing, but it makes it difficult to attribute change to treatment procedures. One way to attempt to minimize this false positive bias is to counterbalance or “blind” the presentation of pre- and post-treatment samples when possible. Also, beware of potential social invalidity. Social invalidity occurs when consumers disapprove of some component of the program and are not direct or honest with their evaluations. Truthful opinions and responses that are unbiased by the desire to please or meet perceived expectations of an authority figure must be the goal as we gather data via our consumer opinion measures. We are not the first to draw attention to these dilemmas; others have voiced similar apprehensions (Goldstein, 1990; Tompkins, 1994). Another issue that is specific to communication impairments in aphasia is the concern that persons with aphasia may experience difficulty comprehending questions or communicating their perceptions. It is acceptable, and even recommended, to provide any needed assistance to help people with aphasia complete perception ratings. This is a far superior tactic compared to pushing their opinions aside, and so overlooking the values of the person at the center of the illness. Worrall and Holland (2003) suggest several accommodations such as changing the format (interview instead of self-completed questionnaire); simplifying questions and responses (use simple language and allow the person with aphasia to answer in yes/no format); adding visual cues (pictographs); and prompting and personalizing questions. We can benefit from the work of our colleagues in Canada, Australia, and the United Kingdom in generating and promoting “aphasia friendly” materials, and these can be used in harvesting valid opinions of treatment outcomes as well. An example of a pictorial QOL rating scale for people with aphasia is described by Engell, Hütter, Willmes, and Huber (2003). Maintenance of social validation Documenting maintenance has been an ongoing struggle in rehabilitation efforts and it should not be overlooked in social validation measures. If consumers report treatment has improved aspects of QOL at termination of the


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study, yet two months later QOL has trickled back to the original level, was treatment effective? This is a concern voiced by Kennedy (2002) as he argues to incorporate maintenance as part of social validation before considering a treatment to be effective.

Stakeholders Indeed, it appears that social validity may be measured only if direct consumers (persons receiving services), indirect consumers (such as the general public who may benefit indirectly from the service), and service providers share in the evaluation of services. (Kozleski & Sands, 1992, p. 120) The stakeholders are the principals involved in aphasia treatment, and the principals can be defined narrowly or as broadly as the community or society. These include the person with aphasia; spouses and caregivers; immediate and extended family members; acquaintances; friends and enemies; referring and co-working healthcare professionals; and third party payers. Maybe even pets. If a tail wags when a dog’s name is successfully emitted, that may be a form of cross-species social validation. Nearly everyone is affected somehow, either directly or indirectly, by the services we provide. It is difficult to determine the consequences of aphasia if we do not have a full appreciation of how the stakeholders perceive the consequences (Simmons-Mackie, 2001). Schwartz and Baer (1991) divide these consumers into four categories: direct, indirect, members of the immediate community, and members of the extended community. •

•

• •

Direct consumers are the primary stakeholders, the recipients of the intervention (i.e., the person with aphasia; or, when conducting caregiver training, the caregiver). This is a crucial target for social validity since understanding our clients’ perspectives of their own improvement on tasks or improved quality of life is crucial to determining the effectiveness and efficacy of our interventions. Direct consumers are the true focus of social validation of our services. They provide insight and direct information into their values; impressions of their well-being; and the impact of aphasia on their lives, expectations, hopes, and dreams (Worrall & Holland, 2003). Indirect consumers are strongly affected by the intervention but are not the direct consumers. Indirect consumers include spouse or spouses (if polygamous), life partners, children, or close friends or relatives of the direct consumer. Members of the immediate community interact with the direct and indirect consumers on a regular basis (teacher, boss, co-worker, neighbor, grocery store clerk, massage therapist, bartender). Members of the extended community who do not interact with direct or

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Different consumers have different viewpoints, expectations, and internal criteria for acceptability of outcomes. The measurement of quality of life is one area where this has been apparent. QOL is defined by the World Health Organization (WHO) as “an individual’s perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (World Health Organization, 1996, p. 5). QOL is an elusive measure of life satisfaction, and it may not be totally accurate or valid for a healthcare professional (nurse, doctor, or clinician) to judge another person’s quality of life. To do so may be fraught with measurement pitfalls (LaPointe, 1999). This was reinforced in a recent study comparing quality of life ratings between self-ratings of people with aphasia and ratings from family members or healthcare providers who served as proxies for the people with aphasia (Cruice et al., 2005). These Antipodean researchers found that proxy respondents showed a significant negative bias when rating QOL for the person with aphasia. According to these findings, we must be cautious in interpreting the evaluations of family members and healthcare providers’ ratings of treatment outcomes, especially when comparing these ratings with those of the direct consumer. Although QOL measures are best garnered directly from the patient, it is important to seek additional input from other stakeholders. Communication is not an isolated act except when sleep talking or mumbling in the bathroom. Procreation and communication are usually dependent on at least a social dyad. If we as clinicians ignore other consumers, the person with aphasia may experience continued isolation from the community and lose the chance for possible reintegration into the workforce.

Changing priorities in rehabilitation medicine While traditional health indicators are based on mortality (i.e. death) rates of populations, the ICF [International Classification of Functioning, Disability, and Health] shifts focus to “life”, i.e., how people live with their health conditions and how these can be improved to achieve a productive, fulfilling life. (WHO press release, November, 2001) As is evident from earlier sections of this chapter, the traditional medical model of aphasia intervention and healthcare in general has been evolving toward a social model over the past few years. Traditional rehabilitation mainly focused on impairment measures (i.e., range of motion exercise, muscle strength, words per minute, etc.), with less consideration of the direct


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consumer, family, and community perceptions. The neurolinguistic model of aphasia treatment included traditional stimulation and relearning techniques used in an attempt to improve language behaviors while perhaps recruiting or reorganizing new neuronal networks. More contemporary treatment principles attempt to generate increased attention on psychological and physical wellness (Lyon & Shadden, 2001). An example of this intervention emphasis is provided in the Life Participation Approach to Aphasia (LPAA; Chapey et al., 2001). In 2001 the WHO published the International Classification of Functioning, Disability, and Health (ICF). This is a coding scheme model to identify interactions between health conditions, body functions and structures, activities and participation, environmental, and personal factors. The WHO instituted a shift from focusing on impairment to social perspectives and this was a natural opening for an increasing emphasis on social validation of treatment outcomes. The ICF has gained attention in our discipline because it connects communication and life skills. The American Speech-Language Hearing Association (ASHA) has incorporated the WHO model into its code of ethics (ASHA, 2001). Individual speech-language pathologists are also incorporating health classification schemes (i.e., ICF) since they relate to the acquisition of funding, how we communicate to stakeholders, and how we converse within the profession (Threats & Worrall, 2004). The ICF framework is also appropriate to the application of clinical research, and can facilitate a bridge between clinical practice and current research (Threats, 2002). Patient-based measures in medicine With the tide of change in medicine and healthcare in general, and the evolution to patient-based outcomes, numerous health-related quality of life (HRQOL) rating scales are emerging. HRQOL measures typically include perceptions of social health, role functions, and general well-being. Interestingly, the new net of life features that are embraced by HRQOL measures may also incorporate spirituality, sexual function, life satisfaction, and aspects of the environment. These outcome measures may be generic for use across a broad range of medical conditions or specific to a select population. A few of the more common generic scales include the Sickness Impact Profile, Quality of Well-Being scale, and the WHOQOL-100. Some examples of specific scales include the ALS (Amyoptrophic Lateral Sclerosis) Functional Rating Scale and the Parkinson’s Disease Questionnaire (Andresen & Meyers, 2000). Each type of scale (generic or specific) may have different strengths and weaknesses (Guyatt, Feeny, & Patrick, 1993). Several of the popular scales used in the stroke population have been reviewed fairly extensively in the literature, with comparisons of the appropriateness, reliability, validity, responsiveness to change, and use in proxy assessments (Salter, Jutai, Teasell,

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Foley, Bitensky, & Bayley, 2005). However, there is no consensus on which scales are the gold standard for measuring societal perspectives of participation. Research and clinical validation of QOL scales continues at a feverish pace and no doubt the next five years will see some improvements and perhaps consensus on QOL scales that meet consumer, societal, and psychometric criteria.

Social validation in aphasia So far in this chapter we have reviewed the history, implementation, stakeholders, and health policy related to social validation. We now explore the underlying basis of social validation in aphasia therapy. If ever there was a middle earth in clinical aphasiology, this is it. Although some might conclude that the incorporation of social validation models to treatment outcomes in aphasia have been largely characterized by ignorance and apathy, over the past decade there have been stirrings that allow some optimism. The rising tide is apparently affecting our small area of healthcare as well. Aphasiologists have introduced social validation measures in treatments for syntax, discourse, group therapy, caregiver training, and augmentative and alternative communication. In pioneering work, Doyle, Goldstein, and Bourgeois (1987) were among the first to utilize social validation measures in aphasia. These investigators conducted a single subject design study to examine generalization and social validation of syntax training using the Helm Elicited Language Program for Syntax Stimulation (HELPSS). Five professional-level Veterans Administration employees who were naïve to the purposes of the study and the subjects served as judges. Pre- and post-treatment recordings were presented in a counterbalanced fashion, and raters judged if each response was adequate or inadequate. These rater judgments revealed that the syntax training improved trained grammatical constructs; however, there was no significant generalization to new sentence structures. More recently, other studies also have utilized pre- and post-treatment comparisons with “naïve” raters to determine the social validity of a written communication strategy (Lustig & Tompkins, 2002), Linguistic Specific Treatment (LST) (Jacobs, 2001), conversational coaching (Hopper, Holland, & Rewega, 2002), volunteer training (Hickey, Bourgeois, & Olswang, 2004), and writing ability (LaPointe, Katz, & Braden, 1999). LaPointe et al. (1999) recruited a varied assembly of people from the community to rate perceived changes in writing. Unlike most other studies, these naïve raters were not restricted to healthcare workers or students but a diverse cross-section of community members in respect to occupation, age, and education. Among the large sample (n = 141) of raters were teachers, blue-collar workers, professionals, students, a preacher, IT experts, and a model. Raters were shown counterbalanced pairs of writing samples (one from baseline and one approximately six months later) and asked to judge


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whether the first item or the second item was “better,” or whether there was no difference between the two items. These judges were able to discern change in writing ability after six months that correlated with the improvement following therapy in multidimensional scoring of writing samples. A crosssection of people in the community from a sample that was diverse in education, occupation, age, and gender were able to discern and judge as “better” samples of writing taken from six months post-therapy. People could see a difference. Of course it remains for us to determine whether or not this perceived change makes a difference. And that is what the social validation process is all about. Who should be the direct or indirect consumers who validate treatment outcomes? Careful selection should be employed when determining which consumers to target. The work has only started. We need to know the opinions of physicians, nurses, rehabilitation specialists, insurance providers, as well as the direct and indirect segments of society. Hickey and Rondeau (2005) compared ratings from groups with different knowledge of aphasia; one group was relatively unfamiliar with aphasia, and the other group consisted of second year speech-language pathology graduate students. Judges who were naïve to aphasia were more sensitive to change in pre- and posttreatment ratings, suggesting that members of the general public may provide more robust ratings. The most appropriate consumer groups to target should be carefully selected based on the treatment objectives. Raters who are naïve to the individual with aphasia cannot rate quality of life or broader change in daily communication abilities. Hinckley (2002) sought to describe the employment status and perceived life satisfaction of adults with chronic aphasia so she directly targeted persons with aphasia. In a unique alliance that included as a co-author the person with aphasia who was the focus of the study, Lasker, LaPointe, and Kodras (2005) described the progress of a professor with aphasia whose goal in therapy was to improve her teaching ability. She was an accomplished researcher and teacher in geography who specialized in geographic aspects of world hunger. Her over-riding objective was to return to the classroom to teach, and to continue her contributions to the university and her academic profession. The profundity of aphasia, particularly in verbal sentence formulation and production, in this professor was significant. Treatment modalities and communication options included computer-based AAC to supplement her laborious attempts at verbal production. These strategies and other communication options that featured key word prompts were arrived at by consensus with powerful input from the person with aphasia. After some gratifying improvement and adaptation to using the AAC device to augment and supplement her lectures, we attempted some social validation of her communication changes. We selected a unique segment of indirect consumers by targeting this professor’s students as persons who would provide ratings of social validity. By selecting students who were expected to understand and learn from her lectures, we were able to target stakeholders who were

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significantly impacted by the aphasia treatment outcome. The expectations of the students who needed to learn the class material would no doubt differ from expectations of an outsider viewing brief video clips with no investment in the class. Changes in teaching and communication effectiveness were reported by class members throughout the duration of a semester. This professor with aphasia continues to be reintegrated into the academic community and, despite persisting significant verbal production difficulty, has been able to achieve her primary objective of returning to the classroom. We think she has improved, adapted, accommodated, and persisted in a way that is measurable and has clinical significance to her and to us. A significant segment of stakeholders, her students, agree. Researchers also have compared social validity ratings to changes on objective behavioral measures and standardized test scores. Doyle, Tsironas, Goda, and Kalinyak (1996) investigated the relationship between unfamiliar listeners’ judgments of connected discourse in people with aphasia and the correct information units (CIU) of the samples. In this study the two measures were strongly and positively correlated. Lyon and colleagues (1997) compared consumer ratings to standardized aphasia tests and found that, despite the lack of significant improvement on the Boston Diagnostic Aphasia Examination (BDAE) and Communication Abilities in Daily Living (CADL) following communication training, caregivers and communication partners reported significant gains in communication on the Communication Readiness and Use Index (CRUI) and Psychosocial Well-Being Index (PWI). Ross and Wertz (1999) studied the relationship between change in listener perceptions and standardized impairment and disability measures. They did not find a significant relationship when comparing scores on aphasia batteries and disability measures to listeners’ perceptions of change in overall communication ability. These findings reinforce the notion that both social validity measures and standardized test measures can be valuable indicators of clinical significance and meaningful treatment outcomes. Psychosocial impact of aphasia: More than just language Aphasia does not affect a person in isolation. This is a condition that affects the entire constellation of those who orbit around the person with aphasia. With aphasia the affected person and family members experience devastating and life-altering changes that alter their expectations and needs in therapy. Many of these changes have been described by those who have experienced the process first hand (Hale, 2003; Montgomery-West, 1995). Concepts that are inherent in adapting to chronicity and the stages and phases of psychosocial effects of the illness experience have been elucidated in some of the literature on aphasia. Adaptation, adjustment, accommodation, and the concept of Aristos (making the best of a given situation) are treated in depth in a recent book on aphasia (LaPointe, 2005). All these factors impact the person with aphasia and complicate the establishment and verification of treatment


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outcomes. Personal roles for an individual with aphasia may be drastically altered by the aphasia. The traditional breadwinner role may be transformed into a position of starkly increased dependence. Other long-held roles can be metamorphosed into those that are unfamiliar and frightening. Aphasia can shiver the soul. Specifically, it can dramatically alter the sense of self and torque identity. Shadden (2005) poignantly highlights some issues of re-establishing identity in aphasia. She writes from the expertise of both professional and caregiver, and provides insights that are illuminating to even the most experienced clinician. Lubinski (2001) provides a detailed inventory of potential effects on the family, as well as family needs at different patient stages (severe illness or crisis, recuperation, rehabilitation, post-rehabilitation, and institutionalization). Familiarity with this process is essential to a holistic appreciation of the psychosocial needs of the family with aphasia. Emotional and psychosocial changes can engulf aphasia recovery. No one has studied this and contributed more to it than Chris Code. His career is marked by significant contributions to the science of aphasiology; and one of his most precious gifts may be that he has given us a richer understanding and appreciation of the psychosocial realm that accompanies the shock of aphasia. Code’s professional persona is a strange and wonderful amalgamation of Freud, Head, Schuell, Pogo, Ringo Starr, and Blind Lemon Jefferson. His continuing contribution is evident in recent collaborations on the influence of psychosocial elements on aphasia recovery (Code & Herrmann, 2003). In addition to renegotiating identity roles, people with aphasia often are isolated from society. This leads to limited opportunities to participate in verbal communication. Socially valid treatment demands consideration of psychosocial elements. Unfortunately “emotional experience and personal perspectives, social roles and psychosocial perceptions are neither objective nor easy to measure and are not traditionally seen as well suited to experimental investigation. Consequently, issues of personal experience are often neglected in rehabilitation” (Code & Herrmann, 2003, p. 122). That should not deter us from studying this complex area of inter-related variables. We have a responsibility to all who have or will have aphasia to attempt to understand these influences and how they may affect our interventions. Reimbursement This is a good time to reframe our thinking and restructure our treatments to create cost-effective and beneficial programs that are meaningful to patients, their families, and those paying the bills. (Carol M. Frattali, 1998, p. 242) Our late colleague and friend, Carol Frattali, captured our charge succinctly. Healthcare reimbursers have taken note of the need to provide therapy that influences life participation abilities. The new ICF health classification scheme may be used to establish reimbursement decisions. Reporting progress

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using social validation outcomes demonstrates the utility of our service to third party payers (Threats & Worrall, 2004). In addition, direct consumers are becoming more involved in selecting healthcare plans and providers to seek an option that suits their needs (Frattali, 1998). Healthcare services for people with chronic conditions, especially in the United States, are still woefully inadequate. The reduction in services and reimbursement for rehabilitation that we have witnessed in the past two decades is shortsighted and some would say corrosive. Priorities seem to have elevated insurance, pharmaceutical, and other profit-driven corporate interests above that of assuring a broad range of human services that are allowed and paid for as long as they are needed. We need social validation of rehabilitation efforts for chronic conditions such as aphasia. We also need societal accountability that addresses the question of why these services are not readily available to those who need them. A civilized society may be judged by the way that it cares for its needy. When geopolitical agendas are financed at the expense of human services in healthcare and education, the role of governments in serving public interests may indeed be questioned. History may not be kind. We can only hope that societal values become rebalanced, so that optimal regard can be paid to people in need of long-term healthcare; particularly those who struggle daily with the dreadfulness of aphasia.

Conclusion Social validation of treatment outcomes in aphasia has been relatively neglected, and we advocate that it should be an essential component of aphasia therapy. The principles of social validation can be incorporated during goal selection, establishment of priorities of treatment targets, selection of materials and procedures, determination of the context of treatment, and the measurement of socially relevant outcomes. Consumers represent a number of stakeholders, all of whom may hold different perceptions of the success or failure of therapy. In this chapter we have advocated continued research and implementation of social validation strategies as a means for determining the clinical significance of our services. Our ultimate objective is to enhance the quality of life and daily interactions of the people we serve. As has been noted before, this will advance the relevance of our interventions. Also it will facilitate socially relevant management by the clinicians who treat people with aphasia, as well as the future clinicians who are destined to treat us.

References Andresen, E. M., & Meyers, A. R. (2000). Health-related quality of life outcomes measurements. Archives of Physical Medicine and Rehabilitation, 81 (12, Suppl. 2), S30–S45. ASHA (2001). Scope of practice for speech-language pathology. Rockville, MD: ASHA.


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Chapey, R., Duchan, J. F., Elman, R. J., Garcia, L. J., Kagan, A., Lyon, J. G., et al. (2001). Life participation approach to aphasia: A statement of values for the future. In R. Chapey (Ed.), Language intervention strategies in adult aphasia (4th ed., pp. 235–245). Baltimore, MD: Williams & Wilkins. Code, C., & Herrmann, M. (2003). The relevance of emotional and psychosocial factors in aphasia to rehabilitation. Neuropsychological Rehabilitation, 13, 109–132. Cruice, M., Worrall, L., Hickson, L., & Murison, R. (2005). Measuring quality of life: Comparing family members’ and friends’ ratings with those of their aphasic partners. Aphasiology, 19 (2), 111–129. Doyle, P., Goldstein, H., & Bourgeois, M. S. (1987). Experimental analysis of syntax training in Broca’s aphasia: A generalization and social validation study. Journal of Speech and Hearing Disorders, 52, 143–155. Doyle, P. J., Tsironas, D., Goda, A. J., & Kalinyak, M. (1996). The relationship between objective measures and listeners’ judgments of the communication informativeness of the connected discourse of adults with aphasia. American Journal of Speech-Language Pathology, 5 (3), 53–60. Engell, B., Hütter, B., Willmes, K., & Huber, W. (2003). Quality of life in aphasia: Validation of a pictorial self-rating procedure. Aphasiology, 17, 383–396. Elman, R. (2005). Social and life participation approaches to aphasia intervention. In L. L. LaPointe (Ed.), Aphasia and related neurogenic language disorders (3rd ed., pp. 39–50). New York: Thieme Medical Publishers. Frattali, C. (1998). Clinical care in a changing health system. In N. Helm-Estabrooks & A. Holland (Eds.), Approaches to the treatment of aphasia. San Diego, CA: Singular. Goldstein, H. (1990). Assessing clinical significance. In L. B. Oswang, C. K. Thompson, S. F. Warren, & N. J. Minghetti (Eds.), Treatment efficacy research in communication disorders (pp. 91–98). Rockville, MD: American Speech-Language Hearing Foundation. Guyatt, G. H., Feeny, D. H., & Patrick, D. L. (1993). Measuring health-related quality of life. Annals of Internal Medicine, 118 (8), 622–629. Hale, S. (2003). The man who lost his language. London: Penguin Books. Hickey, E. M., Bourgeois, M. S., & Olswang, L. B. (2004). Effects of training volunteers to converse with nursing home residents with aphasia. Aphasiology, 18, 625–637. Hickey, E. M., & Rondeau, G. (2005). Social validation in aphasiology: Does judges’ knowledge of aphasia matter? Aphasiology, 19, 389–398. Hinckley, J. J. (2002). Vocational and social outcomes of adults with chronic aphasia. Journal of Communication Disorders, 35, 543–560. Holland, A. (1982a). Observing functional communication of aphasic adults. Journal of Speech and Hearing Disorders, 47, 50–56. Holland, A. (1982b). Remarks on observing aphasic people. In Clinical Aphasiology: Proceedings of the Conference 1982 (pp. 1–3). Minneapolis, MN: BRK Publishers. Also available online at http://aphasiology.pitt.edu/archive/00000749/ Hopper, T., Holland, A., & Rewega, M. (2002). Conversational coaching: Treatment outcomes and future directions. Aphasiology, 16, 745–761. Jacobs, B. J. (2001). Social validity of changes in informativeness and efficiency of aphasic discourse following linguistic specific treatment (LST). Brain and Language, 78, 115–127. Jones, R. J., & Azrin, N. A. (1969). Behavioral engineering: Stuttering as a function of stimulus duration during synchronization. Journal of Applied Behavior Analysis, 2, 223–230.

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evaluation of the variables associated with treatment acceptability and their relation to compliance. Behavioral Disorders, 18 (1), 67–76. Rogers, M. A., Alarcon, N. B., & Olswang, L. B. (1999). Aphasia management considered in the context of the World Health Organization model of disablements. Physical Medicine and Rehabilitation Clinics of North America, 10 (4), 907–923. Ross, K. B., & Wertz, R. T. (1999). Comparison of impairment and disability measures for assessing severity of, and improvement in, aphasia. Aphasiology, 13, 113–124. Ross, K. B., & Wertz, R. T. (2003). Quality of life with and without aphasia. Aphasiology, 17, 355–364. Salter, K., Jutai, J. W., Teasell, R., Foley, N. C., Bitensky, J., & Bayley, M. (2005). Issues for selection of outcome measures in stroke rehabilitation: ICF participation. Disability and Rehabilitation, 27 (9), 507–528. Schlosser, R. W. (1999). Social validation of interventions in augmentative and alternative communication. AAC Augmentative and Alternative Communication, 15, 234–247. Schwartz, I. S., & Baer, D. M. (1991). Social validity assessments: Is current practice state of the art? Journal of Applied Behavior Analysis, 24, 189–204. Shadden, B. (2005). Aphasia as identity theft: Theory and practice. Aphasiology, 19, 211–223. Simmons-Mackie, N. (2001). Social approaches to aphasia intervention. In R. Chapey (Ed.), Language intervention strategies in adult aphasia (4th ed., pp. 246–268). Baltimore, MD: Williams & Wilkins. Simmons-Mackie, N., & Damico, J. S. (2001). Intervention outcomes: A clinical application of qualitative methods. Topics in Language Disorders, 21 (4), 21–36. Threats, T. T. (2002). Evidence-based practice research using a WHO framework. Journal of Medical Speech-Language Pathology, 10 (3), xvii–xxiv. Threats, T. T., & Worrall, L. (2004). Classifying communication disability using the ICF. Advances in Speech-Language Pathology, 6 (1), 53–62. Tompkins, C. A. (1994). Applying research principles to language intervention. In R. Chapey (Ed.), Language intervention strategies in adult aphasia (3rd ed., pp. 571–583). Baltimore, MD: Williams & Wilkins. Wells, A. (1999). Family support systems: Their role in aphasia. Aphasiology, 13, 911–914. Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11, 203–214. World Health Organization (1996). WHOQOL-BREF introduction, administration, scoring, and generic version of the assessment. Geneva: Author. World Health Organization (2001). Press release, November. Retrieved February 2, 2006 from www.who.int/inf-pr-2001/en/pr2001–48.html Worrall, L. E., & Holland, A. L. (2003). Editorial: Quality of life in aphasia. Aphasiology, 17, 329–332.

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Interactional aphasia Principles and practices oriented to social intervention Jack S. Damico, Martin J. Ball, Nina N. Simmons-Mackie and Nicole Müller

One of the real accomplishments during Chris Code’s tenure as Editor in Chief of Aphasiology: An International and Interdisciplinary Journal has been his consistent advocacy of psychosocial issues and social models of aphasia treatment. This chapter is intended to advance his efforts and those of numerous other social scientists in clinical aphasiology by advocating a more direct focus on interactional aphasiology as a sub-discipline of clinical aphasiology. In the nineteenth century there was a flourishing of research and clinical experience that gave way to the first major focus on the human brain and its disabilities (Eling, 1994). Led by physicians and researchers who are now the recognized founders of medical and clinical aphasiology (e.g., Gall, Broca, Wernicke, Freud, Jackson), there occurred a great accumulation of knowledge regarding the brain and the consequences of brain damage. It took some time, however, before these data were placed within acceptable frameworks for various medical and clinical applications. John Hughlings Jackson, one of the founders of modern neurology, once discussed this problem of data overload. He suggested that although we have multitudes of facts, we require, as they accumulate, organizations of them into higher knowledge. He felt that we needed some better generalizations and working hypotheses (1882). Over the 125 years since this assertion, we can recognize both the problem that Jackson stated and several solutions that were eventually employed. With the formulation of neuropsychological approaches of brain functioning and damage pioneered by Lashley (1929) and Luria (1947), the focus on medical aphasiology led by Geschwind (1965), and the development of clinical aphasiology according to Schuell (1953), Darley (1975), and Porch (1967), the accumulated data over the last hundred years have been (somewhat) successfully applied to clinical populations. Despite these successes, however, there are problems with the ways in which the accumulating data are organized and employed within clinical populations. To an even greater extent than occurred in the nineteenth century, we are accumulating data and research findings that require additional generalizations and working hypotheses that are somewhat different from those that have preceded us. As suggested by Jackson, we have to organize our data into

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higher levels of knowledge to create effective working hypotheses of how these data fit within the framework of individuals who are trying to negotiate the impact of aphasia. This chapter proposes one way to better organize some of the data that currently confront us, an orientation that will assist our understanding and focus on language, interaction, and aphasia. In this chapter, we propose that we move toward a more formal, explicit, and high profile focus within our discipline of clinical aphasiology. A focus on authentic interactions in aphasia utilizing the research methodologies appropriate to these phenomena and the applications and practices drawn directly from theories and investigations directed to face-to-face interactions. We propose the creation of a sub-discipline of Interactional Aphasiology. Given the recent advances in clinical aphasiology toward a greater acceptance of qualitative research methods (e.g., Damico, Simmons-Mackie, Oelschlaeger, Elman, & Armstrong, 1999; Goodwin, 1995; Klippi, 1991; Wilkinson, 1999), and a growing focus on the functional and social considerations of aphasia (e.g., Ferguson, 1996; Holland, 1991; LeDorze & Brassard, 1995; Penn, 1987; Worrall, 1992), this proposal may not seem unusual or bold. Indeed, there have been a number of efforts over the past few years toward a focus on aphasia as a clinical and practical impairment that results in extensive interactional consequences. Despite these recent advances within the history of aphasiology, attention to authentic interactional data and how they impact on social consequences has only minimally been advanced. It certainly has not been a major focus within the organized efforts oriented toward clinical aphasiology. For example, in the loosely structured organization that holds the Clinical Aphasiology Conference every year, the vast majority of research papers presented have not focused on authentic interactional data or social consequences. Further, a reading of the current trends within the United States and within Europe shows they are far more oriented toward linguistic and processing approaches to intervention and to modular cognitive models, both to explain aphasia and to provide interventions. Those researchers who focus on authentic interaction in aphasia are certainly in the minority in the professions oriented to clinical aphasiology. This lack of orientation to interactional issues is surprising when the pervasiveness of the social and interactional consequences of aphasia is considered. One reason for this neglect appears to be that the issues of interaction in aphasia and of the social impact of aphasia are complex and involve numerous variables and considerations. When viewing this complexity, it is not surprising that the discipline of aphasiology with its medical and experimental orientations has not focused extensively on these issues. There are many areas of significance still to be investigated within the realm of aphasia. Aphasia, however, is a large field, capable of entertaining diverse orientations. The time is right for an explicit orientation embracing the complexity of authentic interaction and social action rather than ignoring it.

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To continue developing this line of research and its clinical implications, and more importantly, to get clinicians and researchers, professors and students to employ the work based on strong research and the principles and practices that result from this research, it is necessary to extend the awareness that the long-term consequences of aphasia are generally linked to the interactional realm. For, as Garfinkel (1967) and Goffman (1974) have stated, the genesis of society and social action is in the face-to-face interactions between individuals.

An operational framework To create the needed orientation, an operational framework is required. There are several reasons for such a framework. First, it will enable the development of an effective set of principles or guidelines to direct future work and application within this proposed sub-discipline. To establish a disciplinary study, one must have a set of principles or constraints within which to operate. Second, once the framework is proposed and the principles developed, researchers oriented to this area can become more improvisational in their approaches to research and clinical application, and still be directed by the framework. This should enhance the creativity and originality of the research and clinical initiatives. Finally, an operational framework that represents an enhanced orientation will serve as an impetus to professionals interested in this area, so that they can adjust to the needs and opportunities of interactional aphasiology. Frankly, to incorporate people into a movement, you need a direction, people to advance and implement the movement, and, in effect, a flag or banner that others outside the vanguard will follow. The sub-disciplinary structure and its operational framework will supply such a “banner.” A sub-discipline of interactional aphasiology should consist of a set of principles and practices not just oriented to the social components or consequences of aphasia per se, but primarily to the interactional aspects that involve a focus on authentic face-to-face activities and the abilities and variables of interest within such authentic activities. The need to focus on face-to-face interaction can be accomplished in many ways; directly via methodologies like conversation analysis and other products of ethnomethodology, and indirectly as when we investigate the motivations, impact, and affective issues involved with authentic interaction and when we set about creating applications generated by the data collected. Further, this framework – even as a working endeavor – should be advanced in ways that will enhance the objectives, data, implications, and applications of research regarding authentic interaction to other aphasiologists and to those interested in clinical aphasia. To formulate this framework, we can draw from a large knowledge base. Other realms of social science have targeted interaction as social action in all its authenticity and complexity, and have focused on how social action is effectively established, negotiated, and


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sustained. Consequently, we can adopt some of this cross-disciplinary work into a study of social action that can enrich our appreciation of interaction in aphasia. This chapter discusses some of the social science research that may be outside the clinician’s typical experience, but is relevant to the establishment of interactional aphasiology. As a starting point, the following ten principles are suggested as the guiding values for the sub-discipline of interactional aphasiology.

Principles for interactional aphasiology Given the complexity of authentic interaction in all its various manifestations, it is important to have a set of principles available when engaging in data collection, analysis, and interpretation. These principles can guide how data are treated and what importance the data or patterns of data might hold. Further, a set of principles can inform the framework from which we operate to construct values, strategies, and techniques that can assist in increasing our knowledge and the applications of this knowledge in interactional aphasiology. Based on our research and a survey of the literature, there appear to be a number of interactional principles of social action that should be considered. Here is a list of those considered most important at present: Principle one: Authentic face-to-face interaction For the initial purposes of a framework in interactional aphasiology, there must be a clearly distinguished focus for our research and clinical endeavors. This focus should consist of a continual orientation of activity toward authentic face-to-face interaction in its various forms. That is, within this sub-discipline, the topic and context of interest should revolve around face-to-face interaction in terms of how it is systematically accomplished, what variables impact on face-to-face interaction, and the implications of neurological damage to this social dyad. In their classic sociology text, The Social Construction of Reality, Berger and Luckmann wrote, “The most important experience of others takes place in the face-to-face situation, which is the prototypical case of social interaction. All other cases are derivatives of it” (1967, p. 28). This principle suggests that people construct the meanings of objects and situations through their interactions with one another. That is, through their face-to-face interactions, individuals socially construct their behaviors, expectations, and beliefs (Gergen & Davis, 1985; Goffman, 1974; Rogers, 1980; Scheff, 1990). This belief and its applications provide an effective guide to determining what should be investigated, and what should become the object of descriptive assessment and compensatory intervention. The focus on face-to-face interaction is the basis for interactional sociology and it can serve us as a first principle as well in interactional aphasiology.

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Principle two: The constructive nature of interaction Within the social sciences there is a pervasive idea that both orients our attention to the social world and, consequently, must serve as the actual rationale for our endeavors within the sub-discipline of interactional aphasiology. This is the principle of social constructivism. It suggests that the major work and accomplishment of face-to-face interaction is the construction of the meanings of objects and situations based on our interactions with one another. That is, through face-to-face interactions, individuals socially construct their behaviors, expectations, and beliefs. Based on this principle, many of the human behavioral traits and psychological processes like self-identity, competence, and the capacity and reactions to intimacy are viewed less as stable internal constructs and more as the products of external interactions with others (Berger & Luckmann, 1967; Kemper, 1991; Shotter, 1984). The significance of this principle for interactional aphasiology lies in the fact that it provides one with a theoretical framework relating to the creation and preservation of both social and psychological behaviors. Rather than assuming that a particular trait or a specific behavior is due solely to a psychological construct or neurological module outside the social realm, this principle places the genesis of any trait, belief, or behavior squarely within the social sphere. Who we are and how we react is partially and importantly based on our previous and concurrent social interactions. In effect, this principle provides us with the rationale for why we should study face-to-face interaction. There is a social component to all human behaviors and traits, and to understand this phenomenon in aphasic patients, to understand how this phenomenon is modified and re-constructed, we must study where the social construction occurs – within face-to-face interaction.

Principle three: Local negotiation of social action Consistent with the first two principles, a third interactional principle also places the emphasis on the actual activities that occur during face-to-face interaction. This principle is based on the widely documented finding within ethnomethodology that successful social action is accomplished at the local level (Duranti & Goodwin, 1992; Garfinkel, 1967; Heritage, 1984). This means that any social phenomenon as it unfolds is locally and immediately constituted through the observable activities of the participants. This principle is consistent with the expectation that an individual’s “common-sense” knowledge during interaction is employed on an instance-by-instance basis to construct social action. In this sense, what participants in a social interaction will do in their next interactive turn is related to what their partners have done in the immediate prior turn. This reliance on the immediate and local actions and context such that one action helps determine the next creates a conditional relevance, so that a first action helps determine what may occur as a second action, and the second


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actually depends on what occurred as the first action (Goodwin & Heritage, 1990; Wilkinson, 1999). In any social action the importance of this local negotiation can be generally stated as a condition where actions project next actions. Said another way, the presence and impact of participants in an interaction impinge on each other as the face-to-face situation continues. In effect, authentic interaction is constructed through a continuous reciprocity of expressive acts. Consequently, when researchers and clinicians orient to face-to-face interaction, they can focus on the actual behaviors and possible interpretations as revealed in the actual data before them. This provides a mechanism for understanding social action without having to delve too far outside the actual interactional dyad. For our part in interactional aphasiology, we should orient the aspects of the local management of interaction to discover how and when this occurs. Principle four: The complexity of face-to-face interaction The fourth guiding principle provides us with a realistic set of assumptions regarding our task of trying to study, account for, and understand the impact of aphasia on face-to-face interaction. We should expect, recognize, and embrace the complexity of the authentic interaction as a human phenomenon. In authentic contexts, the reactions and interactions, the personalities and beliefs, the objective behaviors and subjective interpretations are emphatically close and local. During face-to-face activities, the skills, traits, and behaviors of each participant are continually interacting, and we must attempt to describe and account for them as best we can. Indeed, that is the objective of a research agenda focusing on interaction in aphasia. Without attention to the complexity, our efforts, our implications and our applications will fall short of the needs of our patients and clients. Damico et al. (1999) have discussed this issue, and the fact that one of the problems with much of the current experimental research in clinical aphasiology is that it doesn’t account for the complexity of the neurological and social phenomenon known as aphasia. The experimental research in the field is effective – as far as it goes – but it is simply not sufficient to account for authentic social interaction. In the sub-discipline of clinical aphasiology, the complexity must be recognized and various ways to account for the impact of aphasia in all its complexity must be a priority when designing and carrying out any research agenda. Principle five: The multiplicity of manifestations Keeping with the complexity theme, the fifth principle strives to emphasize and then guide the investigation of all the potential manifestations of semiotic, cognitive, social, and psychological activity that make up the tapestry of face-to-face communication. Within authentic interaction, we should expect that there are a number of potential manifestations needed to create the

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social action. That is, there might be linguistic resources, various types of cognitive skills and traits, social strategies and knowledge resources, verbal and non-verbal behaviors, neurological traits, and other potential semiotic systems that might be employed to create the emergent phenomena that we know as social action within face-to-face interaction. As an individual attempts to negotiate within face-to-face interaction, he or she employs a number of these manifestations to accomplish the desired objectives and the resultant interactional behavior – one that creates comprehensibility, predictability, and successful expectations – is most likely to be the emergent property of interactions between some of this multiplicity of manifestations (Perkins, 1998, 2001, 2002). To use a metaphor employed by Janet Emig (1983), the individual uses these manifestations to “weave a web of meaning.” For our purposes, then, we must be prepared to engage in an objective and detailed analysis of our data to determine what variables or manifestations produce the observed social actions (e.g., Simmons-Mackie & Damico, 1997). Principle six: Orient to the functional goal In order to best address the complexity and to keep a handle on the plentitude of symptoms and manifestations in face-to-face interaction, it is best to maintain that the catalyst for interaction is to accomplish social action. We should orient our first question to “how was an interaction (or an aspect of it) accomplished?” If we adopt this functional and strategic approach, then we can better handle the complexity of the phenomenon and its potential emergence via the resources available to the interactants in the dyad or social group. This focus on the functional aspects of face-to-face interaction is consistent with a emerging emphasis in clinical aphasiology over the past 15 years. Work by clinical researchers like Holland (1991, 1998; Holland & Thompson, 1998), Lyon (1996) and Elman (Elman & Bernstein-Ellis, 1995) have advocated a more functional approach to the description, assessment, and intervention in aphasia and these initiatives have greatly influenced the field. Within the sub-discipline of interactional aphasiology, a practical and functional orientation to face-to-face interaction and how it impacts on effectiveness should serve as the medium within which the data are interpreted. Principle seven: Social action as collaborative Another interactional principle necessary in interactional aphasiology is a reasonable consequence of most of the principles discussed thus far – social action is always a collaborative enterprise. In effect, face-to-face social action is always collaborative and so we should always remember to incorporate this characteristic. Indeed, it should be our watchword. If social construction is accomplished at the local level, then all social actions are active and dynamic


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enterprises wherein (at least) two participants are involved in a process of coconstruction. Social actions of all sorts (e.g., conversation, arguments, fights, nonverbal posturing) are not a series of discrete behaviors or messages that pass from an active individual to a passive one. Rather, all face-to-face interaction is a process of participants actively constructing and negotiating meaning in a coordinated and joint manner as the social action proceeds. In practice, we can focus on the aphasic or the non-aphasic interactant, the dyad or the group, but eventually any analysis or its interpretation should orient to the collaborative impact needed to construct an interaction (Goodwin & Heritage, 1990; Oelschlaeger & Damico, 1998; Perkins, 1995). Principle eight: The dynamic character of interaction Building on the previous point, the construction of our relations with others – especially due to the local management of the interaction – is highly flexible. Whatever patterns and strategies are introduced during an interaction, they will always be dependent on the interactions and reactions of the other participant. Consequently, the behaviors and goals, interactions and reactions will be continually modified through the exceedingly variegated and subtle interchange that goes on when accomplishing social action. We must always be aware of this fact. It is possible that this characteristic will eventually limit the wholesale applications of some of our research. But it is equally possible that we may find that, although individual manifestations change across contexts, individuals, and over time, general and underlying principles will be discerned. For the moment, however, the dynamic character of face-to-face interaction should serve as the caveat of the sub-discipline. Principle nine: Contextual impact Although some social researchers have tried to focus exclusively on conversation as the prime face-to-face interaction, there are other equally valid and authentic social dyads and groupings that may also require investigation depending on various contextual issues. Harvey Sacks (1992) and others (e.g., Goodwin & Heritage, 1990; Scheff, 1990; Schegloff, 1968), focusing on conversation, acknowledged this in their writings and their research foci. To determine which social dyads should be the focus of attention, one must recognize the contextual relevance of social action. Not only do the various manifestations of social action change depending on the local context, but, as with all aspects of human semiotic systems, context determines the prime social dyads and groups from one interactional opportunity to another. Therefore, we should employ an awareness of contextual relevance when determining what kind of face-to-face interaction should be the focus of our attention in various settings.

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Principle ten: Adopting methods suitable to the phenomena we study The last principle I want to discuss as necessary for the sub-discipline of interactional aphasiology involves the tools and methods that we should use to investigate authentic face-to-face interaction. That is, what kinds of research methodologies are adequate for conducting research on complex and authentic social action like this? For a host of reasons, the answer is that we should adopt qualitative research methodologies. Over the last few decades, there has been a trend in the philosophy of science to recognize that research and systematic investigation becomes scientific by adopting the methods of study appropriate to its subject matter. This stance is called “scientific realism” and is currently a dominant philosophical position rather than the formerly dominant neo-positivistic approach (Okasha, 2002; Papineau, 1996). Among other things, scientific realism suggests that science is defined by the results and findings not the methodology. Within this focus, qualitative research – by definition – appears to be the most appropriate research paradigm for interactional aphasiology. Basically, qualitative research refers to a variety of analytic procedures designed to systematically collect and describe authentic, contextualized social phenomena with the goal of interpretive adequacy (Damico et al., 1999). The idea of interpretive adequacy – what Graham Button has described as explication of social action – should be the goal of interactional aphasia, and so qualitative research methodologies are best employed within this subdiscipline. Of course, this qualitative research paradigm involves a number of traditions of inquiry. While we may be most familiar and even prefer – within this context – to employ the most analytic of the qualitative methodologies – conversation analysis, it is not the only tradition of inquiry we should employ. In fact, to completely investigate and understand authentic interactional data, its variables, complexity, and implications, conversation analysis is not sufficient by itself. Other qualitative traditions of inquiry are more appropriate in some instances. Other traditions of inquiry include biographical study, case study research, ethnography and ethnographic methodologies, grounded theory, historical methodology, and other types of naturalistic data collection strategies like participant observation, ethnographic interviewing, discourse analysis, artifactual analysis, focus groups, and lamination research and phenomenology (Damico & Simmons-Mackie, 2003; Damico el al., 1999). Within a sub-discipline of interactional aphasiology, this paradigm and these traditions of inquiry and the various naturalistic data collection strategies can assist us in achieving the other nine principles within the previously described operational framework.

Conclusion These ten principles should help orient us to an understanding of how social action is achieved in face-to-face interaction, and how it impacts on the social


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accomplishments and consequences of individuals with aphasia. Of course, we still have to develop the implications and applications that might arise from the sub-discipline of interactional aphasiology. For example, we must ask: “How do we get others to understand and focus on the interactional complexity of face-to-face interaction?” and “How can the practices resulting from this research be applied in clinical settings?” It is certainly possible that the principles proposed in this chapter are preliminary and naïve. In the final analysis, however, whether we adopt an approach consisting of these or other principles, whether we strive to create a sub-discipline or not, there is a need to embrace the complexity of aphasia and its implications within a social action framework. For, when addressing the issues and concepts in clinical aphasia, regardless of what we theorize and discuss about language and processing, grammar and modular cognitive systems, the real significance of all of these areas means nothing unless we see these abstract conceptions played out in the arena of authentic face-to-face interaction. After all, that is where the human creature exists.

References Berger, P. L., & Luckmann, T. (1967). The social construction of reality. A treatise in the sociology of knowledge. New York: Anchor Books. Damico, J. S., & Simmons-Mackie, N. N. (2003). Qualitative research and speechlanguage pathology: Impact and promise in the clinical realm. American Journal of Speech Language Pathology, 12, 131–143. Damico, J. S., Simmons-Mackie, N., Oelschlaeger, M., Elman, R., & Armstrong, E. (1999). Qualitative methods in aphasia research Aphasiology, 13, 651–665. Darley, F. L. (1975). Aphasia. Philadelphia: Saunders. Duranti, A., & Goodwin C. (1992). Rethinking context: Language as an interactive phenomenon. Cambridge, UK: Cambridge University Press. Eling, P. (Ed.) (1994). Reader in the history of aphasia. From Franz Gall to Norman Geschwind. Amsterdam: John Benjamins. Elman, R., & Bernstein-Ellis, E. (1995). What is functional? American Journal of Speech-Language Pathology, 4, 115–117. Emig, J. (1983). The web of meaning: Essays on writing, teaching, learning, and thinking. Portsmouth, NH: Heinemann. Ferguson, A. (1996). Describing competence in aphasic/normal conversation. Clinical Linguistics and Phonetics, 10, 55–63. Garfinkel, H. (1967). Studies in ethnomethodology. Englewood Cliffs, NJ: Prentice Hall. Gergen, K. J., & Davis, K. E. (Eds.) (1985). The social construction of the person. New York: Springer Geschwind, N. (1965). Disconnection syndromes in animals and man. Brain, 88, 585–644. Goffman, E. (1974). Interaction ritual: Essays in face to face behavior. Garden City, NY: Doubleday. Goodwin, C. (1995). Co-constructing meaning in conversations with an aphasic man.

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In S. Jacoby & E. Ochs (Eds.), Research in language and social interaction (Special issue of Construction), 28, 233–260. Goodwin, C., & Heritage, J. (1990). Conversational analysis. Annual Review of Anthropology, 19, 283–307. Heritage, J. (1984). Garfinkel and ethnomethodology. Cambridge, UK: Polity Press. Holland, A. L. (1991). Pragmatic aspects of intervention in aphasia. Journal of Neurolinguistics, 6, 197–211. Holland, A. L. (1998). Why can’t clinicians talk to aphasic adults? Comments on supported conversation for adults with aphasia: Methods and resources for training partners. Aphasiology, 12, 844–847. Holland, A., & Thompson, C. (1998). Outcomes measurement in aphasia. In C. Frattali (Ed.), Measuring outcomes in speech-language pathology (pp. 245–266). New York: Thieme. Jackson, J. H. (1882). On some implications of dissolution of the nervous system. In Selected Writings (Vol. 2, pp. 29–44). New York: Basic Books (reprinted 1958). Kemper, T. D. (Ed.) (1991). Research agendas in the sociology of emotions. New York: State of New York University Press. Klippi, A. (1991). Conversational dynamics between aphasics. Aphasiology, 5, 373–378. Lashley, K. S. (1929). Brain mechanisms and intelligence. Chicago: University of Chicago Press. LeDorze, G., & Brassard, C. (1995). A description of the consequences of aphasia on aphasic persons and their relatives and friends, based on the WHO model of chronic diseases. Aphasiology, 9, 239–255. Luria, A. R. (1947). Traumatic aphasia. The Hague: Mouton. Lyon, J. G. (1996). Optimizing communication and participation in life for aphasic adults and their prime caregivers in natural settings: A use model for treatment. In G. Wallace (Ed.), Adult aphasia rehabilitation (pp. 137–160). Boston, MA: Butterworth-Heinemann. Oelschlaeger, M. L., & Damico, J. S. (1998). Joint productions as a conversational strategy in aphasia. Clinical Linguistics and Phonetics, 12, 460–480. Okasha, S. (2002). Philosophy of science. A very short introduction. Oxford, UK: Oxford University Press. Papineau, D. (Ed.) (1996). The philosophy of science. Oxford, UK: Oxford University Press. Penn, C. (1987). Compensation and language recovery in the chronic aphasic patient. Aphasiology, 1, 235–245. Perkins, L. (1995). Applying conversational analysis to aphasia: Clinical implications and analytic issues. European Journal of Disorders of Communication, 30, 372–383. Perkins, M. R. (1998). Is pragmatics epiphenomenal? Evidence from communication disorders. Journal of Pragmatics, 29, 291–311. Perkins, M. R. (2001). Compensatory strategies in SLI. Clinical Linguistics and Phonetics, 15, 67–71. Perkins, M. R. (2002). An emergentist approach to pragmatic impairment. In F. Windsor, M. L. Kelly, & N. Hewlett (Eds.), Investigations in clinical linguistics and phonetics (pp. 1–14). Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Porch, B. E. (1967). The Porch index of communicative ability. Palo Alto, CA: Consulting Psychologists Press. Rogers, M. F. (1980). Goffman on power, hierarchy and status. In J. Ditton (Ed.), The view from Goffman (pp. 100–133). New York: St. Martin’s Press.


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Sacks, H. (1992). Lectures on conversation. Volume I. Oxford, UK: Blackwell. Scheff, T. J. (1990). Microsociology: Discourse, emotion and social structure. Chicago: University of Chicago Press. Schegloff, E. (1968). Sequencings in conversational openings. American Anthropologist, 70, 1075–1095. Schuell, H. M. (1953). Aphasic difficulties understanding spoken language. Neurology, 3, 176–184. Shotter, J. (1984). Conversational realities: Constructing life through language. Newbury Park, CA: Sage. Simmons-Mackie, N. N., & Damico, J. S. (1997). Reformulating the definition of compensatory strategies in aphasia. Aphasiology, 11, 761–781. Wilkinson, R. (1999). Introduction. Aphasiology, 4–5, 251–258. Worrall, L. (1992). Functional communication assessment: An Australian perspective. Aphasiology, 6, 105–111.

Part II

Research considerations

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From the study of language dysfunction and handicap to a better understanding of linguistic processing in normality Jean-Luc Nespoulous and Jacques Virbel

Introduction There are certainly several ways of paying tribute to a scholar and a friend such as Chris Code. Rather than referring explicitly to specific contributions he has made to aphasiology, we have chosen to offer him a chapter dealing with a somewhat new definition of the notion of “handicap” which, we thought, he might like, knowing how attached he has been throughout his career to a clinical approach such as the one we adopt here. Doing so, we hope Chris will react to our proposals, thus pursuing an interaction which began during a sabbatical year he partly spent in our laboratory, in Toulouse, a decade ago.

Deficits, normality, cognitive flexibility and adaptive and/or palliative strategies Probably for etymological reasons, the first definition given by dictionaries of the word handicap is related to horse-races and the equalization of the chances of success between riders by the imposition on the best horses of heavier weights to carry or of longer distances to run. According to this earliest definition, the word handicap has a proper “positive” sense since it refers to a horse, and more generally, to a sportsman or a player whose superiority is recognized and whose advantage is being attenuated in order to produce a more equitable competition with those less powerful than him. According to these same dictionaries, it is only in second place that, in a figurative sense, the word handicap has come to indicate all “deficiency, physical or mental”, likely to affect somebody in any activity whatsoever. With regard to the word handicapped – adjective, past participle, turned substantive – these same dictionaries frequently reverse the order of the meanings, so giving priority to the latter, with its “negative” semantic attributes. In the field of language, as in a good many other fields which will not be the subject of this article, the handicap – in the last acceptation of the

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term – usually evokes a certain type of deficit or dysfunction, lasting or momentary, compared to a state known as stable, or “normal”. The origin of such a dysfunction, as indicated above, is classically regarded as resulting from intrinsic physical and/or mental deficiencies (see above) but no one has yet extended the scope to the social sphere, thus agreeing to take into account various extrinsic or environmental parameters in the characterization of the handicap and those who suffer from it (Bernstein, 1975; Besse, de Gaulmyn, Ginet, & Lahire, 1992; Nespoulous, 1978). It is within this latter framework, non-restrictive and open, that we shall be positioning this article, convinced that at one time or another, to a greater or lesser extent, temporarily or permanently, all human beings – speaker and/or interlocutor – might find themselves in a situation of linguistic (or other) handicap. In this context, the observation and the fine characterization of such a dysfunction is not only able to provide invaluable information about the nature of the disturbances highlighted, but also to make it possible to better apprehend, through after-effect, (a) the full details of the functioning of language in a subject considered “normal” as well as (b) the strategies – “spontaneous” or induced, “natural” or technologically relayed – brought about to (try to) “adapt” to the dysfunction and to compensate as well as possible for the deficiencies affecting a speaking subject (Nespoulous, 1996). Our argumentation will be based primarily on data obtained from aphasic patients with whom one of us has been working for about 30 years, but we will frequently widen the range of our remarks to other populations (of handicapped persons) and to other (“handicapping”) situations so as to characterize the handicap in as general and as large a way as possible and to extract a maximum of information, particularly as regards cognitive flexibility, of the observation of degradations of communication, whatever the origins might be: pathological or not, occasional or durable, and so on. Some “central” dysfunctions of language in aphasia and their palliative strategies The cerebral lesion that causes aphasia creates at the same time a deficit and a communication handicap, making any verbal interaction difficult. Generally, the components of the language as a whole are not affected by the lesion and there are even cases where only one component proves to be dysfunctional. Comparisons of different patients presenting different selective deficits and showing evidence of “double dissociations” allow for the identification of various specific, and relatively autonomous, functional components, in the functional architecture of language in the human brain-mind, even with so-called “normal” subjects. It is on such bases, particularly over the past 40 years, that the traditional neuropsychological approach to language, also called cognitive neuropsycholinguistics, has developed (Nespoulous, 2004). Parallel to the generation of a deficit and a communication handicap,

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the cerebral lesion in handicapped subjects develops, often unconsciously, various palliative strategies that, in the best cases, allow subjects to circumvent the deficit and to overcome their handicap, at least partially. It is this tendency that makes Audrey Holland (1977, p. 173) state: “aphasics communicate better than they speak”. However, from the start, aphasiology has been much more concerned with the characterization of the underlying deficit (see above) than with the strategic and adaptive potential of the patient confronted with this deficit. It is certainly not a question of radically opposing the two approaches, insofar as they seem to be complementary: the first makes it possible to identify (a) the direct “negative” manifestations of the deficit (“linguistic symptoms”), as well as (b) the “positive” manifestations relating to the aspects of the linguistic function that have remained intact; and the second makes it possible to apprehend (c) the palliative strategies built up by the patient in spite of this deficit and thus his or her cognitive flexibility in the processing of linguistic information (Nespoulous, 1994). If one agrees to adopt such a double, or even triple, approach, with regard to aphasiology, one is ineluctably led to reject all characterization of verbal behaviour in (binary) terms of respect or violation by an individual of the canonical properties of his or her language, in favour of an adaptive vision of this behaviour. Speaking and understanding – just like acting and perceiving – become adapting to (or attempting to adapt to) the constraints of the situation in which one finds oneself, albeit more or less successfully, depending on whether one is aphasic or a so-called normal speaker (see the diagram below).

We will now give some examples to help illustrate our argument. Temporal adverbs to the rescue of deficient verbal inflections There are certain people with aphasia – called agrammatic – who are characterized by major difficulties in the management of grammatical morphemes

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and/or syntactic structuring of verbal messages. Among other symptoms, these patients present a reduction of inflexional morphology that leads them, in languages like French or English, to produce infinitives, in the first case, and gerunds (sleeping, walking . . .) in the second, instead of conjugated forms of the verbs. Such a reduction, likely to particularly disturb the temporal marking of utterances is, however, frequently compensated for by resorting to adverbs of time (yesterday, tomorrow . . .) or by employing phrases carrying temporal information (next week, last summer . . .). This type of strategy makes it possible for the patient to circumvent the deficit mentioned above and the communication can then continue effectively, at least on this point, all the more since there is more semantic precision in these lexical markers of time than in temporal inflections of the present, past or future (Nespoulous, 1973). Circumlocutions and gestures to the rescue of the missing word Inability to recall a word, or problems of access to the mental lexicon (or anomia) is a particularly frequent symptom of aphasia, whatever the clinical category may be. Although it is possible to observe a patient absolutely unable to find and/or to produce an adequate word – in a naming task (from pictures) or in spontaneous language – it is extremely rare that this lexical deficiency results in total mutism and an absolute absence of speech production. Usually, indeed, the patient will resort – just like a normal subject who has a transitory lexical difficulty – either to periphrastic strategies (i.e., he or she tries to formulate a definition of the word he or she is not able to recall), or to mimo-gestural strategies (i.e., the patient tries to mime the use of the object referred to by the word he or she is not able to find in his or her mental lexicon: Nespoulous, 1979). In so doing, these patients provide, moreover, the proof of the integrity of underlying semantic representations: they know what they want to say but cannot say it (see below). Phonemic paraphasias and “repair strategies” In nearly all the work relating to phonetic and/or phonemic disturbances in aphasia, as in preceding domains, clinicians and researchers have generally characterized the patients’ deficiencies negatively in terms of “performance errors”. More recently, however, and on the basis of new theoretical frameworks in phonology, the approach to such pathological phenomena has been greatly renewed (Béland, 1985; Moreau, 1993; Nespoulous, 1998; Nespoulous & Moreau, 1997; Paradis, 1988). Therefore, instead of resorting to a strictly descriptive taxonomy of the phonetic and/or phonemic “errors” (i.e., in terms of omissions, additions, substitutions and displacements of segments), it became possible (a) to predict the nature of the disturbances according to the canonical structure of the words the patient had to produce in a particular


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task, and (b) to apprehend them as the consequence of the use of “repair strategies” applied to a word of which the phonological structure was inaccessible to the patient, certainly because it was too complex. Thus, in the presence of a word like “brouette” (/bwεt/, which is “wheelbarrow”, in English), – certainly difficult to produce for an aphasic person just as for a child in the learning period because of the presence of the consonantal cluster /b/ – clinicians and researchers often simply spoke about (a) errors of omission, when the subject said /bwεt/, or (b) errors of addition, when he said /bewεt/. Considering such phenomena, the “theory of constraints and repair strategies” (Paradis, 1988) aims at considering that, faced with a consonant cluster like /b/, the patient who has difficulty in producing such a group makes use of at least two universal strategies of “repair”, which he can apply to simplify the syllabic structure of a word like “brouette”: the syncope, which leads the patient to delete the liquid consonant //, and the epenthesis, which leads him to insert a vowel between the two consonants. Certain patients thus showed that they resorted preferentially to one or the other of these two strategies, while others sometimes used one and sometimes the other of these two strategies, even on the same words (Nespoulous, 1998). Towards a new distribution of roles in dialogue . . . Since Bally (1942), it has been agreed to regard any speech act as the combination of “referential” elements (Bally’s dictum) and of “modalizing” elements (the same linguist’s modus). Thanks to the former, speakers set up the elements of the information they wish to communicate; they encode a “proposition”, according to the logicians’ definition of this term (i.e., the explicit relation of a predicate and its arguments); and they refer to people, objects, ideas, and so on that are part of the socio-cultural context of the community to which they belong. Thanks to the latter, the same speakers this time formulate the position they wish to adopt in relation to the above referential content; giving their speech their own particular “signature”. They thus express a doubt or a certainty; make comments; accept or refuse the propositional content that they themselves have set up or that has been set up by their interlocutors. However, several studies in aphasiology have clearly shown that cerebral lesions affect these two types of elements in unequal ways (Nespoulous, 1980, 1981; Nespoulous, Code, Virbel, & Lecours, 1998). So, while the wording of the referential elements of speech poses a major problem to aphasic patients, the great majority of them remain able to manage the modalizing elements. Thus an aphasic patient can say: “I cannot say it” (see above), but at the same time cannot say: “she cannot sing it”, to take two sentences that have, apart from anything else, the same lexical and syntactic characteristics (Nespoulous & Lecours, 1989). In “strategic” terms, it appears possible to exploit this kind of dissociation in order to consider recourse to a particular type of verbal interaction likely

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to improve the transmission of information between the patient and those close to him or her, in particular in a dialogue situation. Thus if the therapist or a member of the patient’s family addresses – in the context of a question requesting an opinion – the essential part, or even the totality, of the necessary referential elements, the patient should, in most cases, be able to produce the adequate modalizing elements in his or her answer, thus guaranteeing the success of the verbal exchange. This procedure is certainly not ideal. It has its limitations; but it must allow, at least initially, the freeing up of many communication situations that would be doomed to failure without the use of such strategies. Adapting like this to the constraints of the situation – here pathological – is by no means original: what do we do when we address somebody who does not have a good understanding of our language? What do we do when we speak to a child who is not yet proficient in the use of his or her mother tongue? What do we do if not to give a maximum of informative elements in our question so that our “non-expert” interlocutor can answer us, parsimoniously, but no less effectively? In the four illustrations above, the range of the concept of strategy differs, certainly. Thus, for example, the first three types appear to emerge spontaneously from the patient, because they would seem to be part of the general semiotic potential anchored (without their knowledge) in any human being; the fourth requires, at least partially, an inter-individual adjustment, which certainly will not escape the protagonist’s awareness. In all these cases, however, the verbal behaviour does not appear (or no longer appears) as a stereotyped human response but rather as a highly adaptive and flexible cognitive activity. We shall return to this later. Some “peripheral” dysfunctions of language and their palliative strategies In what precedes, we endeavoured to illustrate our introductory remarks by drawing our examples from a “central” pathology such as aphasia; a pathology that affects some of the components at the heart of human linguistic activity (phonological, lexical, morpho-syntactic processing, and so on). There are, however, other linguistic dysfunctions that, although only affecting the more “peripheral” components of the functional architecture of language, are still of interest for our purposes. These dysfunctions, sensory and/or motor, can be highlighted in certain aphasic patients, different from those considered up to now, as a result of cerebral lesions, which, too, are different. They can however also be observed among patients whose central nervous system is intact but who suffer from certain attacks that block the functioning of afferent (e.g., vision, hearing) or efferent (phonation, manual dexterity) systems. Contrary to the palliative strategies previously evoked in the context of “central” pathologies – strategies whose range, although real, remains limited


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– the “peripheral” dysfunctions sometimes lead the patients to develop whole systems of substitution: for example, the replacement of the audio-phonatory loop by a visuo-gestural system, sign language for the profoundly deaf; the replacement of visual information intake by tactile means, via Braille, for the blind (e.g., O’Regan & Noe, 2001). In such a context, resorting to external palliatives, produced by recent technological advances, proves to be crucial and not only because such palliatives are likely to facilitate the adaptation of certain patients to their deficit but because they raise, in return, important questions (a) as to the “deterministic” hardwiring of the human nervous system, and/or (b) as to its adaptive flexibility (Lenay & Pfaender, 2004).

Technological palliatives Data processing and linguistic handicaps The relationship between data processing and linguistic handicaps is circumscribed by that which relates, on the one hand, to the treatment of statements (in “natural” language), and on the other hand, by the consideration of users of computerized devices. To simplify, it is possible to determine two situations, or classes of cases, that in fact are very closely related, are even interlinked, in reality. The first situation is that of the design and development of specific devices providing computerized assistance. The principle mainly at work here is that, as previously indicated, of semiological substitution: substitution of the modality of existence of information simultaneous with the sensory substitution of access to this new form of information. Thus text to speech synthesis systems and computerized Braille come to the assistance of the partially sighted or blind; conversely, vocal dictation that transforms (oral) speech into text compensates for the handicap of the hard of hearing or deaf; vocal commands or special keyboards compensate for difficulty in or impossibility of writing or typing resulting from certain motor handicaps of the upper limbs. The principal problems encountered in this class of application are partly ‘classic’, related to language: the objective of automation imposes a level of extent and detail of the linguistic data and of formalization of the models often over and above what the descriptions and the linguistic or psycholinguistics models propose, at all levels of language. For example (Maurel, Lemarié, Vigouroux, Virbel, Mojahid, & Nespoulous, 2004) on the one hand, the apparently very modest question of oral interpretation (or “translation”) of certain visual structures of the texts is much more complex than one might think (especially if one views writing as a non-pertinent “code” from a significant point of view), and, on the other hand, not many data have been gathered yet on this phenomenon (Virbel, 1989). But in addition, such data, as extended as necessary, must also be pertinent on the cognitive level. The procedure then aims at developing interdisciplinary

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research where the researchers of the disciplines concerned inter-react, and among them, as a recent new element, are researchers who are themselves handicapped. But it is the very notion of substitution that covers the greatest complexity, because in the end, it mobilizes that of identity or equivalence of contents. It can be noted that intra-modal substitution is already attested on different levels in the case of translations, summaries, transliterations and lists of contents. In addition, objects like logigrammes, used for example in the field of technical instructions, combine discursive and figurative aspects (in particular diagrammatic), and thus undoubtedly generate representations of different natures: propositional and analogical. Thus the question of knowing whether two messages of identical or different modality really are equivalent (questions which are the basis of the transpositions evoked here) constitutes a formidable problem of nature, both logical and cognitive, if one aims at least at introducing a form of guarantee of this equivalence reminiscent of a theorematic demonstration. This type of question is central in semantics, logic and philosophy of language, where major theoretical divergence exists, bringing into play the very design of language and of its relationships with the world and the mind. This is a crucial but rather speculative question, but which here leads to experimental possibilities relating to multimodal communication, not much studied until recently, but central in the context of the communication of handicapped people. “Information for all” and handicaps Another situation is that where, like anyone else, handicapped people need access to, and use of computerized devices: word processing, the Internet, databases, on-line services, computerized physical environments (domestic apparatus, cars, houses, etc.), be it for professional or private reasons (training, purchases, amusement, administrative procedures, reservations, etc.). Research in this area encounters questions of appreciably the same order, with an emphasis on the fundamental problem posed here, that of accessibility to information and to physical objects related to various cognitive or physiological deficits. Some of the problems experienced by handicapped people in the access to these devices are caused by the modes of interface used (screens, keyboards, the mouse) and of interactivity (for example: doubleclick on highlighted zones), which are not convenient, or even simply not practicable for the blind or partially sighted, or for those who have insufficient mobility in their hands. And, for example, on the first point, many new techniques are being developed as access interfaces (special keyboards, scanning, voice recognition, piloting by ocular movements, monitoring of facial expressions, interpretation of biological electric signals, laser stimulation of the retina, voice synthesis, multidimensional sound, tactile stimulation, return of effort, etc.). It may seem at first that this is a specific case of what has already been


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discussed, in the following sense: data processing, contributing to aid the exercise of the faculty of variously handicapped language, also does so when this faculty is exercised in relation to and through computerized devices. But in fact it goes far beyond a simple specific case. Indeed, what deeply characterizes the situation evoked is that it aims at constituting a particular case called “information for all”, by which is meant all users, all uses and all types of information. This point is very important because it appears as of now that it is the source of deep conceptual and methodological reformulations. For computing, this is indeed a challenge without precedent, which is at the origin of the recent foundation of the (in French) STIC: Sciences et Technologies de l’Information et de la Communication (Science and Technology of Information and Communication) for the structuring of research. In this movement, the consideration of the characteristics of users no longer comes at the end, but at the beginning and is situated at the centre of the design of cooperative, interactive systems, provided with certain dialogical aptitudes. Concepts such as those just mentioned, and others like utilizability, accessibility, adaptivity and adaptability are given new simultaneously operational definitions, for the conceptions of applications, and based on knowledge formed with the disciplines of human and social sciences or of the life concerned (and concernable). The work of J. Carrol (Carrol, 2002) is very representative of such developing knowledge in connection with “utilizability”. Another example is the case of the notion of assistance, which is not unrelated to our subject. The conceptual, logical and philosophical growth of knowledge brought to the concept of handicap, by J. Perry (and colleagues), one of the founders of the “semantic of situations” can also be appreciated (Perry, Macken, & Israel, 2004). According to him, handicap should not be considered in a static way, solely in opposition to performances considered normal, but in relation to a complex function of capacities and aptitudes, targeted tasks, and circumstances, by which is meant environment (infrastructural, artefactual): disability, inability and handicap thus receive relative definitions that bring into play a “circumstantial” conception, making it possible to conceptualize the background of the normal–pathological opposition, and to relativize this kind of opposition. With regard to linguistic handicaps in particular, a very great number of situations necessitate the reconsideration of the notions of deficit or variation compared to a supposed “normality” or an equally problematic “average”: the diminutions of performances due to ageing, fatigability, cognitive overload, professional crisis situations, incidents or accidents, ineptitudes relating to the learning capacities of the users, cannot merely be viewed as simple limits or suspensions of the success of conduct and performance, but must be studied in the light of more subtle theories of error and failure. Models of direct or mediated inter-human communication, like models of action and decision, must incorporate this kind of design of potential failure or error; all the more since, as we have already seen, the users in situations of

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failure develop palliative activities that may succeed only partially, or even not at all, but that must in no way be confused with other forms of failure. Here the central factor, in a normal, pathological or handicapped situation, is adaptation (of which learning is a part).

Communication, information and handicap Faced with this new situation, the STIC has resorted to two types of procedure, which are ideally inter-articulated, the limits of one calling on the other. One, which could also be called, as it is in psychology, “domain specific”, generalizes the classic conception of user “profiles”, and includes both the domains in the strict sense, as well as the processes concerned and the mechanisms of adaptation (of the users and the systems). The other, and this is what we shall concentrate on, aims to exploit and/or develop cognitive theories of information and communication, making it possible to highlight all the necessary conceptualizations in all cases. These theories, we emphasize, do not pretend to offer ready-made solutions to the problems that concern us here, but they can make it possible to situate the handicapped use of data processing and/or communication, both in an enlightening manner on the theoretical level and in an exploitable way on a more practical level. One of these, the speech acts theory (SAT), in addition to this first prerequisite, satisfies two others that are very important. For one thing, the SAT can stand up to formalization efforts of a logical nature essential to any automated treatment (Grice: Logic and Conversation, 1975 in Grice, 1989; Searle & Vanderveken, 1985). This remark leads us to the second prerequisite: research relating to SAT is being developed in an extremely wide interdisciplinary context (Champagne, Herzig, Longin, Nespoulous, & Virbel, 2002; Tsohatzidis, 1994; Vanderveken & Kubo, 2002): not only logic, as indicated (of mental states and action), but also linguistics, psycholinguistics and neurosciences of language, the philosophy of the mind and language, and several sub-specialities of computer science (design of cooperative systems, interactive systems, etc.), a set of domains tending to constitute contemporary pragmatism. The handicap “situated” in speech acts theory We had concluded (see above) with the need for an adaptive (in particular with reference to the constraints of the situation and the nature of the linguistic tasks) and non-stereotyped vision of communication, with the relativity of success and failure and with the existence of palliative activities in the handicapped subject. We would like to show how the reference to SAT can inform the preceding analyses of linguistic handicaps. First of all the SAT, as its name indicates, considers communication as an activity. This apparent truism in fact covers deep elements of renewal of the communication approach. In this:

From language dysfunction and handicap to normal linguistic processing •

•

•

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Like any action, communication does not abide by the true/false opposition, as propositions do, but that of success and failure. And as for most other types of action, this realm is not governed by an all-or-nothing principle (discrete), but on the contrary by gradualism, and it is also multi-source. The conditions for success and failure of speech acts are naturally particular in comparison to physical actions, for example (see below), nevertheless it may be noted that a general theory of error like that of J. Reason (Reason, 1993) proposes concepts that are relevant here: the concept of latent error (introduced surreptitiously right from conception and not dependent on the quality of subjects’ performances) and that of error caused by an attempt to recover an earlier error. Contrary to an “algorithmic” (and angelic) vision of action, we thus notice that communication is inherently and not anecdotally subject to risks, and risks it is only partially possible to anticipate. Like many other acts, communication is also an intentional activity (Cohen, Morgan, & Pollock, 1990) and the intentionality is, in this case, reflexive. Since the founding article of P. Grice (Meaning, 1956 in Grice, 1989), which associated the problem of intentionality with that of significance, and the later work of Strawson (Strawson, 1964) and Searle (Searle, 1969; 1981) on this question, it is considered that by an utterance u, a speaker does not simply aim to have his interlocutor recognize his intention to communicate the contents of u to her, but he also intends, through the use of adequate linguistic resources, to have her recognize this intention. It is by this feature of the demonstration of intentionality (which can also be expressed as intention to draw attention to such an intention) that communication marks its particular form of cooperation. Finally, like a number of intentional actions, the communicational action depends on necessary (but not sufficient) preconditions; and it is decomposable into sub-actions whose sequence comes back to the action concerned. In the technical sense, it is therefore liable to planning, and one can, for example, represent this planning both in terms of a “cognitive task analysis” (Salembier & Pavard, 2004) and in terms of a computer planning system (Pollock, 1990).

We thus note that the few aspects evoked – intention to attract attention, request for cooperation, satisfaction of preconditions, planning of the action – to characterize in-depth communicational activity can be also the cause of the characterization of multiple possibilities of failures of relative importance. Moreover, SAT can be considered a pioneer in this field: the initial work of J. Austin (Austin, 1962) was founded (inter alia) on a typology of the various ways of not succeeding in a speech act, and Searle’s later developments led him to develop the concept of conditions of success of speech acts, as distinct from that of conditions of satisfaction of their propositional content. There, too, proof was found that there are only a limited number of ways of not succeeding in a speech act and in a characteristic manner

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(because a speech act constitutes a structure). This was not without consequence for the conceptions of adaptation in communication situations, or, moreover, for the conceptions of language acquisition. Communication is thus successful only in so far as it avoids risks of failure that it is at least partly possible to anticipate, and one can seek to define an overall illocutionary structure on the classes of performance of speech acts (direct, indirect and implicit), linked to a structure of the classes of risks of failure of the same acts. One of the possibilities of communication failure lies in the plurality of linguistic resources for the same communicational goal. This phenomenon is well known for lexemes (synonymy) or more extended expressions (periphrases, definitions), or between certain syntactical structures (active vs. passive, full verb vs. verb support + nominalization, for example). SAT shines an interesting light on this question for our purposes, showing that this source of potential failure is also what gives language its flexibility. One can take the example of the reference (but the demonstration can extend to predicative and illocutory acts). As Frege established, the possibility of referring to an entity by several different expressions is not a deficiency of the language, but on the contrary a necessary property (Frege, 1952): one cannot not refer to this entity according to a particular experience we have had. But all the same, the classes of linguistic expressions of these (classes of) possible experiences are not unlimited, but in fact quite restricted: there are generally less than a dozen types, going from proper name to pronoun, with various kinds of determination in between (Charolles, 2002). Lastly, the cooperative nature of the reference (see Clark & Wilkes-Gibbs, 1990) forces us to take into account what we may know of our interlocutor’s experience of the whole. This aspect is fundamental, and, it would seem, the source of the most serious errors of appreciation; but in addition, it has been shown that if the manifestation of the intention to refer to a certain entity were sufficiently successful, it could overcome possible determinative referential improprieties: “the young woman at the end of the room who is holding a glass of Martini in her hand is the mayor’s daughter” can carry out a successful act of reference even if she is holding a glass of Coke. The theory of speech acts provides all the knowledge required, but in fact only within the framework of the untroubled use of language. It thus predicts the existence of several forms of relationship between the meaning of an utterance and the meaning aimed at by the speaker of this statement (in addition to the ordinary case where both coincide) such as irony, metaphor, implicature (a particular form of inference), indirect speech acts, and so on. (It acts as a prediction in that the theory provides an organized and exhaustive enumeration of all the possible cases with regard to a model.) However, research pertaining to the comprehension of this type of speech act in subjects affected with lesions of the right hemisphere showed that these distinctions are less clear-cut than envisaged and do not observe as clearly as was thought the hierarchy of complexity supposed between these types of speech


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act (Champagne et al., 2002; Champagne, Virbel, Nespoulous, & Joanette, 2003). Moreover, the situation is appreciably the same in normal subjects. One is then led to reconsider the right versus left hemisphere opposition in the treatment of language by the mind-brain; and at same time, these data suggest reasons for the choice of a formal model of representation among other logically equivalent models. Linguistic information The exact nature of linguistic information is without doubt important. It is easy to perceive that such information is structured in a complex fashion, and one might hope to find that linguistic theories offer profound and enlightening insights permitting the enrichment of reflection about hypotheses on the treatment of information by the mind-brain. One such theory was formulated by Z. Harris, whose most recent work, entitled A theory of language and information, speaks for itself (Harris, 1991). Harris, among many other contributions, defines four types of syntactic constraint that contribute to giving its “sentencehood” to a sequence of words, over which 11 types of informational constraint operate, which indicate “how sentences carry information”. These two classes of constraints are interdependent, the strongest among them being the relative order of introduction (what dependence operates on the products of the effect of which other?). Two points seem pertinent here: •

•

each application of a constraint contributes simultaneously to the structure of the sequence, and to a type of information carried by the sentence. Through its structured character, the notion of information defined within this framework is very distant from that defined in 1949 by C. Shannon and W. Weaver in The mathematical theory of communication (1949); the intermediate outputs of the different levels of application of the constraints are not dissimilar, at first sight, from childish or pidgin statements. So the constraint referred to as dependence on dependencies comprises only the predicative structure of a sentence. The constraint of linearization fixes the mutual order of the words according to their (types of) dependencies. Finally “actualizers” (noun determinants, person/tense of the verb, etc.) apply to this resulting structure, as products of the constraint of form reductions. Harris regarded these actualizers as traces of the reduction of metaphrases; that is, of sentences having elements of the basic sentence as arguments. Thus an intermediate state of a sentence (i.e., a sentence in a state where all the constraints have not yet been applied) such as “Max met Lea” would be, for example: “Max meet Lea before me say Max meet Lea”, which can be represented as: before(meet(Max, Lea), say(me, meet(Max, Lea))).

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We see that verbal morphology is not the only way of conveying information relating to time (see above). Another attraction of Z. Harris’ informational theory of language is that it provides a concept of the basic sentence (founded on the dependence on dependencies introduced above) operational in various contexts. The following summary of an experiment serves as illustration. The evaluation of performances of comprehension/memorization of texts of the narrative type relies on tests known as “cued recall”, where the subjects are invited to answer questions relative to a text read or heard beforehand. With the aim of formalizing this test (which questions to ask subjects, how, which responses to expect, which of those obtained are significant) a new semantic concept has been introduced, that of the question/answer (Q/A) structure associated with a text, a structure suggested by, but independent of, its exploitation in this test (Virbel, 1997). Such a concept is in fact already the product of two independent approaches (which have been shown to be compatible with other pre-existing semantic models, like the Rhetorical Structure Theory; RST; Mann & Thompson, 1988): Z. Harris’ linguistic theory, and more precisely its concept of basic sentences entering into the composition of textual sentences; and the logical theory known as “set of answers”, where the meaning of a clause is represented by the set of the clauses making up the responses to a question supported by the clause considered. Moreover, and perhaps especially, one can predict certain semantic properties of a text according to formal properties of the Q/A graph (e.g., the aspects of coherence), and it seems that far from being an experimental artefact, this Q/A structure possesses cognitive reality: textual units more densely attached to others by virtue of this Q/A relation would be more easily memorized. Thanks to a recent collaboration with researchers of the Institute of Psychology of the University of Rio Grande do Sol (De Mattos Pimenta Parente, Holderbaum, Virbel, & Nespoulous, 2003), the questionability of narratives; that is, the fact that the question–answer relationship between sentences is a good predictor of the memorization of an account, has been highlighted: the contents of the sentences most densely connected to the Q/A graph tend to be retained best. This result can be exploited not only in the development of experimental protocols, but also in that of various types of documents where the communicational efficiency is of prime importance (instructions in the event of incidents or accidents, for example). This research appears to be a good illustration of the mutual contributions of work done in “normal” and handicapped situations, and of the various subjects concerned.

Conclusion: Flexibility and adaptability of human verbal behaviour We have already emphasized the non-stereotypical nature of human verbal behaviour. Speaking and understanding, in this context, clearly require the best possible use of one’s semiotic potential to communicate with others,


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often in new situations. So communication constitutes a real challenge in that success is never guaranteed. The extent of the challenge varies in direct proportion to the “novelty”, and thus to the inherent difficulty of the new situation with which the protagonists are confronted. It also varies according to the momentary or durable nature of the situation. Thus, a pathological subject, affected with an often durable deficit, must face this challenge permanently, and with varying degrees of success according to whether the deficit is central or peripheral (see above). In the case of so-called ‘normal’ subjects, they will be confronted with many communicational challenges, more so if their pragmatic interactions are multiple and varied. They can also have difficulty with “degraded” situations, for example, an impoverishment of perceived signals or ignorance of modern technological media: knowing how to read is not a sufficient condition for being able to consult Web pages or surf the Internet; and knowing how to write is not the only skill needed to handle a word processor effectively! Even subjects said to be experts in certain complex linguistic tasks, like simultaneous interpretation, are nevertheless constrained – within the framework of their profession – to deploy various strategies of adaptation to deal with the cognitive difficulty relating to the task they have to achieve; and being bilingual is not the sole requirement for a good interpreter. We see from the above that the novelty and/or the difficulty of a situation of the types we have enumerated make the use of adaptive or palliative strategies essential in the pathological subjects who have served as initial illustrations, as well as in anyone engaged in unusual or complex situations. Consequently, the linguistic competence of a speaker/listener – pathological as well as normal – can no longer merely be reduced to the control of a certain number of rules – as has long been advocated by many linguistic models; it must integrate a certain number of pragmatic parameters relating to the contexts of use with linguistic tasks, all within the framework of what some call “situated cognition”. As a result, the diagram presented at the beginning of the chapter can be reformulated, in more general and inclusive terms, in the following way:

Therefore, the linguistic handicap, whatever its origin, has a somewhat amended status compared to the one it usually has in contemporary society.

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Instead of the variation from an increasingly illusive, not to say illusory, norm, it becomes at once (a) the situation experienced, to differing degrees certainly, by someone in certain circumstances, and (b) a crucial element in the characterization of the outcome of verbal behaviour as well as the functional architecture of language in human beings. In other words, it teaches us much more about the functional dynamics of this linguistic capacity that is said to be “Man’s domain” than the too mechanical computational metaphor prevalent at the time of the creation of cognitive science. Echoing the preceding diagram, the following could illustrate the road travelled:

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langage. In C. Fuchs (Ed.), La linguistique cognitive (pp. 171–194). Paris: Ophrys & Editions de la MSH. Nespoulous, J.-L., & Lecours, A. R. (1989). Pourquoi l’aphasique peut-il dire: “Je ne peux pas le dire” et pas “Elle ne peut pas la chanter”? (De l’intérêt des dissociations verbales dans l’étude du comportement verbal des aphasiques). Cahiers du Centre Interdisciplinaire des Sciences du Langage (pp. 135–182). Mélanges offerts à J. Verguin. Toulouse: Université de Toulouse-Le Mirail. Nespoulous, J.-L., & Moreau, N. (1997). Repair strategies and consonantal cluster production in Broca’s production. In Y. Lebrun (Ed.), From the brain to the mouth: Acquired dysarthria and dysfluency in Adults (pp. 71–80). Dordrecht: Kluwer Academic Publishers. Nespoulous, J.-L., Code, Ch., Virbel, J., & Lecours, A. R. (1998). Hypotheses on the dissociation between “referential” and “modalizing” verbal behaviour in aphasia. Applied Psycholinguistics, 19, 311–331. O’Regan, J. K., & Noe, A. (2001). A sensorimotor account of vision and visual consciousness, Behavioral and Brain Sciences, 24, 5. Paradis, C. 1988). On constraints and repair strategies. The Linguistic Review, 6, 71–97. Perry, J., Macken, E., & Israel, D. (2004). Prolegomena to a theory of disability, inability and handicap. Revue Parole, 29/30, 43–62. Pollock, M. (1990). Plans as complex mental attitudes. In P. Cohen, J. Morgan, & M. Pollock, Intentions in communication (pp. 77–104). Cambridge, MA: MIT Press. Reason, J. (1993). Human error. Cambridge, UK: Cambridge University Press. Salembier, P., & Pavard, B. (2004). Analyse et modélisation des activités coopératives situées. Activités, 1 (1), 87–99 (Revue électronique: http://www.activites.org/) Searle, J. (1969). Speech acts. Cambridge, UK: Cambridge University Press. Searle, J. (1981). Expression and meaning: Studies in the theory of speech acts. Cambridge, UK: Cambridge University Press. Searle, J., & Vanderveken, D. (1985). Foundations of illocutary logic. Cambridge, UK: Cambridge University Press. Shannon, C. E., & Weaver, W. (1949). The mathematical theory of communication, Urabana, IL: The University of Illinois Press (reprinted 1964). Strawson, P. (1964). Intention and convention in speech acts. Philosophical Review, 73, 439–460. Tsohatzidis, S. L. (1994). Foundations of speech act theory: Philosophical and linguisitc perspectives. London & New York: Routledge. Vanderveken, D., & Kubo, S. (2002). Essays in speech acts theory. Amsterdam: John Benjamins. Virbel, J. (1989). The contribution of linguistic knowledge to the interpretation of text. In J. Andre, V. Quint, & R. Furuta (Eds.), Structured documents (pp. 181–190). Cambridge, UK: Cambridge University Press. Virbel, J. (1997). Aspects du contrôle des structures textuelles. In J. Lambert & J.-L. Nespoulous (Eds.), Perception auditive et compréhension du langage (pp. 251–272), Marseille: Solal.

8

Production and perception of word tones in patients with brain damage Inger Moen

Chris Code, in his introduction to Classic cases in neuropsychology emphasizes the importance of the single case study: “Developments in neuropsychology owe much to the discovery and careful examination of sometimes rare and remarkable individuals” (Code, Wallesch, Joanette, & Lecours, 1996, p. 1). One of the many contributions of Chris Code to the development of neuropsychology, aphasiology and clinical linguistics is his remarkable ability to bring to light, and as editor of books and journals make available to the research community, single case studies that have provided new insight into the relationship between language, mind and brain (e.g., Code 1991; Code et al., 1996; Code, Wallesch, Joanette, & Lecours, 2002). The interest of clinical linguists in the prosodic features of speech goes back to a case study by Monrad-Krohn (1947) of a patient whose “melody of language”, rhythm and pitch variation, was disturbed as a result of left hemisphere damage, while her ability to sing was not affected. “The variations of pitch had by no means disappeared. On the contrary they were rather greater than usual in Norwegian, but they were neither adequate nor quite constant in their inadequacy” (Monrad-Krohn, 1947, p. 411). Monrad-Krohn’s patient had suffered left hemisphere damage, but the clinical-perceptual impression is that damage to either hemisphere may lead to deviations of sentence prosody. Acoustic investigations have revealed both normal and abnormal characteristics in the intonation of patients with Broca’s and Wernicke’s aphasia and right-hemisphere-damaged patients (Cooper & Klouda, 1987; Cooper, Soares, Nicol, Michelow, & Goloskie, 1984; Danly & Shapiro, 1982; Ryalls, 1982; Shapiro & Danly, 1985). It is, however, unclear to what extent these abnormalities are linguistic in nature and to what extent they are caused by poor control of the physiological mechanisms associated with phonation and fundamental frequency variation, or whether they are the result of a deficiency in the long-range planning of linguistic units (for a review and discussion, see Ryalls & Behrens, 1988). Speech prosody includes the linguistic categories of stress, rhythm, tone, duration, and intonation. In addition to having strictly linguistic functions, prosody can also be used to signal the speaker’s attitudes and emotions. The auditory correlates of prosody are variations in pitch, loudness, tempo,

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and rhythm. These features have a primary relationship with the physical dimensions of fundamental frequency, intensity, and time. A key issue in the investigation of prosody in the brain-damaged population is the search for the neuroanatomical underpinnings of the various prosodic functions. If the physical correlates of prosody – fundamental frequency, intensity, and time – are of primary importance when it comes to determining hemispheric specialization, we would expect unilateral brain lesions to result in the same type of behaviour, regardless of the linguistic functions of the disturbed physical features. We would, for instance, expect disturbed ability to modulate fundamental frequency to be evident as deviant pitch throughout a patient’s speech, regardless of the linguistic functions of fundamental frequency in the particular language. If, on the other hand, the linguistic functions are crucial when determining hemispheric specialization, we would expect the behavioural effect of unilateral lesions to vary depending on the linguistic functions of the physical correlates in the patient’s language. We might expect, for instance, that it would be possible for a patient with unilateral lesions to produce differences in pitch to signal intonational variation, but not to signal variation in lexical tone. A third possibility would be that both hemispheres are engaged in the processing of prosody, but that they process different acoustic features, for instance that one hemisphere processes fundamental frequency and the other hemisphere processes time (Gandour, 1998). During the last decades data have accumulated on prosodic disorders as a result of brain damage, data that have produced several major hypotheses concerning the neuroanatomical regions active in prosodic processing (for a review, see Baum & Pell, 1999). The most straightforward of these hypotheses assumes that all aspects of prosody are processed in the right hemisphere and integrated with linguistic information from the left hemisphere via the corpus callosum (Klouda, Robin, Graff-Radford, & Cooper, 1988). Van Lancker (1980) proposes a hypothesis which posits that affective or emotional prosody is controlled by the right hemisphere, whereas the left hemisphere is specialized for linguistic prosody. This is referred to as the functional lateralization hypothesis. This hypothesis assumes that there is a scale of prosodic features from the most linguistically structured (e.g., Chinese and Norwegian tones) associated with left-hemisphere specialization to the least linguistically structured (e.g., emotional tone, voice quality) associated with right-hemisphere specialization. A third major hypothesis assumes that the perception and production of prosody are mainly subserved by subcortical regions and are not lateralized to either of the hemispheres (e.g., Cancelliere & Kertesz, 1990). Several recent studies have supported the hypothesis that individual acoustic cues to prosody may be independently lateralized (e.g., Van Lancker & Sidtis, 1992).

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Tone languages Pitch variation is a property of all natural languages. No language is spoken on a monotone. But pitch differences function differently in different languages. In tone languages differences in pitch at syllable or word level are used to distinguish the lexical meaning of words. In these languages pitch variations are contrastive in the lexicon. In nontone languages pitch may be used to signal intonation at the level of the phrase and the sentence. Tone languages also exhibit sentence intonation, but generally with fewer possibilities of variation than nontone languages because of the use of pitch at the syllable and word level. There is general agreement that the primary acoustic correlates of tone are states and movements of the fundamental frequency of the voice (F0), although there may be concomitant changes in time, intensity and phonation. Tone languages are quite numerous. According to Fromkin and Rodman (1993) there are more than 1000 tone languages in Africa alone. However, when it comes to the investigation of language as a result of brain damage, the data from tone languages come from only a limited number of languages, to be presise, from different dialects of Chinese, from Thai and from Norwegian (for a review see Gandour, 1998). Tone languages differ with regard to number and shape of lexical tones. Mandarin Chinese, for instance, has four lexical tones: high level, rising, low level, and falling (Liang & van Heuven, 2004). Cantonese has six tones: high level, high rising, high-mid level, low level, low rising, low-mid level. In many tone languages there are sets of words that differ only in tone. In Thai, for instance, a language with five tones: mid, low, falling, high, and rising, a set of five words can be distinguished by variation in tone only: /khaa/, to be stuck; /khàa/, a kind of spice; /khâa/, to kill; /kháa/, to engage in trade; /khàá/, leg (Gandour, 1998). In Norwegian, a so-called pitch accent language, where the tonal contrast is restricted to one syllable in a word, pitch and stress are closely linked. The accented syllable is also stressed. The accented syllable carries one of two phonemically contrastive tones, referred to as Accent1 and Accent2. There are a number of minimal pairs differing only in tone: for example, vannet /1vane/ (the water); vanne /2vane/ (to water); skuffen /1skufen/ (the drawer); skuffen /2skufen/ (the showel) (Moen & Sundet, 1996).

The perception of tone after unilateral brain damage Studies of the perception of tonal contrasts in brain-damaged speakers of tone languages point to a left-hemisphere dominance in tonal perception. Hughes, Chan and Su (1983) in a study of 12 Mandarin Chinese patients with right-hemisphere lesions found that only five of the patients showed a mild defect in a tonal identification task. The majority of the patients achieved a perfect score.

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In another study of Mandarin Chinese Naeser and Chan (1980) found that the perception of Mandarin Chinese tones was impaired for their nonfluent mixed aphasic patient, a bilingual speaker of Mandarin Chinese and Cantonese. She scored only 55% correct on a listening identification test of the four Mandarin Chinese tones, whereas a normal control scored 100%. Her performance was poor across all four tones. A CT scan showed extensive cortical and subcortical damage to the left hemisphere. The right hemisphere was not affected. Yiu and Fok (1995) reported on the results of a tonal perception test in 21 right-handed Cantonese aphasic speakers: 11 anomic, 2 conduction and 2 Wernicke’s, 2 Broca’s and 4 transcortical motor aphasic patients. There were two control groups, a normal group of eight persons and a non-cortical brain-damaged non-aphasic group consisting of three dysarthric patients. Except for four of the anomic patients, where no CT scan was available, the other aphasic patients had left-hemisphere damage demonstrated on CT scans. The aphasic group performed significantly worse than the normal control group and the dysarthric patients. The performance of the normal controls and the dysarthric group was very similar. The aphasic subjects demonstrated errors with all tones, but they had more difficulty with the level than with the falling tones. The scores were not significantly different among the aphasic groups, and the scores did not correlate significantly with severity of aphasia or post-onset time. The normal performance of the dysarthric subjects suggests that the aphasic group’s perception problem can be attributed to left-hemisphere lesions and not to a general brain-damage effect. Gandour and Dardarananda (1983) studied the perception of tonal contrasts in a group of four Thai aphasic speakers, two Broca aphasic patients, one transcortical motor aphasic patient, and one conduction aphasic patient. In addition there were two controls, one right-brain-damaged nonaphasic patient and a normal speaker. The results of the perception test indicated that all four aphasic patients performed significantly worse than either of the controls. The right-hemisphere-damaged control achieved near perfect scores. This result is further support for the assumption that the tonal perception deficit in aphasic speakers of tone languages is not due to a general brain-damage effect. No difference in performance among the aphasic patients could be attributed to a specific aphasia syndrome. The aphasic patients’ tonal confusions were similar to those of normals, and their perception errors indicated that the perception deficit was general to all five tones rather than selective to individual tones. Moen and Sundet (1996) investigated the perception of the two tonal contrasts in East Norwegian in eight brain-damaged speakers, four lefthemisphere-damaged aphasic speakers and four right-hemisphere-damaged nonaphasic speakers. The aphasic speakers included two Broca’s and two anomic aphasic patients. There was a control group of ten normal speakers. The control group identified all the words correctly. The right-hemispheredamaged group’s performance was comparable to that of the normal controls:


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only one incorrect identification. In the left-hemisphere-damaged group, on the other hand, only one of the four patients identified all the target words correctly. The other three patients identified from 50% to 92% of the words correctly. The confusion between the two accents was bidirectional: 17% of Accent1 stimuli and 20% of Accent2 stimuli were reported as the other accent. The general unimpaired performance of right-hemisphere-damaged patients is not unexpected in view of the fact that dichotic listening experiments have demonstrated a right ear superiority in the perception of tonal contrasts (Moen, 1993; Van Lancker & Fromkin, 1973, 1978). Whether the reduced, but not completely disrupted, performance of the left-hemispheredamaged patients is due to residual mechanisms still operating within the damaged left hemisphere, to mechanisms in the right hemisphere, or to subcortical mechanisms is a moot point. There is little evidence in the studies reported here for a selective deficit in the perception of particular lexical tones. All tones seem to be equally difficult. The exception is Yiu and Fok’s study (1995). They found that falling tones were easier to identify than level ones. Gandour (1998) points out that the tones that seem to be most susceptible to confusion, for aphasic patients as well as for normal subjects, are those that are phonetically similar in height and shape to other tones in the same tonal system. The current evidence indicates that, on the whole, the aphasic patients make more of the same kinds of perceptual errors that the normal subjects make. There is a quantitative rather than a qualitative difference between the errors made by the two groups.

The perception of tone after general brain damage Moen, Simonsen, Oksengaard and Engedal (2004) investigated the ability of ten elderly patients with dementia of the Alzheimer’s type (AD) and ten age-matched normal control subjects to distinguish perceptually between the two Norwegian word tones. AD patients suffer from a progressive neurodegenerative disorder affecting both cerebral hemispheres. It is therefore possible that their perception of tonal distinctions might differ from that of patients with unilateral cerebral damage and from normal controls. The test stimuli were a set of drawings illustrating minimal pairs of words differing only in word tones. The test words were read by the examiner, and the subjects were asked to point to the pictures corresponding to the stimulus word. The test scores of half the AD patients matched those of the normal controls. The other five patients’ performance was impaired. The AD patients had all been tested with the Mini Mental State Examination, a test of cognitive ability. Low cognitive test scores corresponded on the whole to impaired performance on the word tone test, with one notable exception. The patient with the highest cognitive test scores made most mistakes on the word tone test. A possible contributing factor to his impaired performance might be

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linked to the distribution of his cerebral lesions. It is possible that the damage included areas implicated in semantic processing. He may have had problems distinguishing the meanings of the word pairs presented to him, in addition to a possible accent discrimination problem. In order to understand a spoken word, the listener has to convert acoustic input into meaning. This involves at least two distinct processes: phonetic and phonemic decoding, and lexical activation. If the ability to distinguish between two different phonological strings is impaired, this may lead to the activation of a wrong word in the mental lexicon. This is presumably the reason why some patients with aphasia fail to distinguish between minimal pairs of words differing only in word tones. If the distinction between different lexical items is reduced due to a breakdown in semantic memory, the ability to differentiate between pairs of words will also be reduced, and a wrong lexical item may be activated. Lexical semantic impairment is a well-documented characteristic of many AD patients (Bayles & Kaszniak, 1987), and the behaviour of the AD patients during the word tone test also indicated a semantic problem. Whereas patients with aphasia, who had been tested with the same test previously, pointed relatively unhesitatingly to one of the two pictures when the stimulus word had been presented, the AD patients talked about the pictures, and commented on similarities and differences in the drawings before they made their choice. In some cases they repeated the stimulus word, looked at the pictures and said, “There is no difference.” It is, however, not possible on the basis of this test alone to decide whether the AD patients’ problem was purely semantic or a combination of blurred semantic distinctions and reduced phonological perception.

The production of tone after unilateral brain damage Studies of tone production in the speech of aphasic speakers of Mandarin, Cantonese, Thai, and Norwegian indicate that left-hemisphere damage may lead to deviant tone production, whereas the tone production of righthemisphere-damaged patients is relatively spared. Deficient tone production also seems to depend on type and severity of aphasia and time since onset of brain damage. A production deficit is most evident in the severly aphasic patients and more evident shortly after onset of brain damage than later. Non-fluent Broca’s aphasic patients have more problems producing correct tonal contrasts than fluent Wernicke’s or conduction aphasic patients (Gandour, 1987; Gandour, Petty, & Dardarananda, 1988; Gandour et al., 1992; Moen & Sundet, 1996; Naeser & Chan, 1980; Packard, 1986; Ryalls & Reinvang, 1986). There is, however, no indication of a particular pattern of tonal disruption in any specific type of aphasia. The evidence for a selective deficit in the production of particular tones is inconclusive at present. Investigations of Cantonese and Mandarin seem to indicate that static (level) tones may be more resistant to disruption than dynamic (contour) tones. Yiu and Fok (1995) found that their aphasic


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subjects made mistakes in the production of all six Cantonese tones, though Tone 6 (low level) was the easiest to produce. Liang and van Heuven (2004) studied a Mandarin aphasic subject. In their study, out of the four lexical tones, the least compromised tone was Tone 1 (high level, 88% correct). The second best production was Tone 3 (low dipping, 20% correct). According to Liang and van Heuven, Tone 1 and Tone 3 can both be analysed as static tones: the high level tone and the low level tone, respectively. The dynamic tones, Tone 4 (the falling tone, 16% correct) and Tone 2 (the rising tone, 9% correct) were the most difficult to produce. On the other hand, evidence from Thai seems to indicate that falling tones are easier to produce than level tones. Gandour et al. (1988, 1992), in a series of acoustic phonetic studies on tonal disruption in brain-damaged subjects in Thai, found that almost all tonal substitutions resulted in mid, low, or falling tones. The mid, low, and falling tones are all characterized by a falling fundamental frequency contour throughout their duration, whereas the high and rising tones are not (Gandour, 1998). As a result of the reduction of transglottal air pressure, the pitch has a tendency to drop over the course of an utterance. It may be the same mechanism that makes a rising pitch contour more difficult to produce than a falling one. This mechanism cannot, however, account for the superior production of the level tones in the Chinese aphasic speakers. East Norwegian differs from the Asian tone languages under review in having only two tones, Accent1 and Accent2. Both accents are associated with a low pitch level. The difference between them is located in the beginning of the syllable, before the pitch reaches its lowest level. Accent2 has an extensive fall in pitch from the beginning of the syllable to its lowest pitch level. Accent1 may either have an initial narrow fall or a constant low level. The pitch pattern may be described as high-low in Accent2 syllables and as low in Accent1 syllables. Accent1 is the unmarked accent, the pitch pattern used when the opposition between the two accents is neutralized, and it is the accent given to new loanwords. An investigation of tonal production in East Norwegian aphasic patients (one Broca and two anomic) tested the ability to differentiate between minimal pairs of words differing only in tone. The test material was a set of drawings illustrating minimal pairs of this type. The target words were written below each drawing. The three aphasic patients all failed to produce correct distinctions between the two accents in some of the minimal pairs (Moen & Sundet, 1996). It is noteworthy that most of the mistakes involved the substitution of Accent1 for Accent2. There may be two possible explanations for these unidirectional mistakes, an articulatory explanation and a phonological one. From an articulatory point of view, Accent2, with a high fall, may be more difficult to produce than Accent1, with a limited fall or a low level. From a phonological point of view most of the accent mistakes involve the replacement of a marked feature by an unmarked one. According to the theory of phonological underspecification (e.g., Kenstowicz, 1994) only the marked accent will be specified in the lexical phonological representation. The patients’ accent substitutions could then be

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accounted for by assuming that Accent2 words occasionally are retrieved from the mental lexicon without accent specification. These words will then, by default, be assigned Accent1. If the substitution of Accent1 for Accent2 reflects an articulatory problem and not a phonological one, it would be expected that Accent1 would not only replace Accent2 in words that are members of minimal pairs. One of the patients from the study, the Broca aphasic person, was also tested in a reading test that did not consist of minimal pairs. In this test he produced a clear distinction between the two accents. It is therefore unlikely, in the case of this patient, that the problem was an articulatory one (Moen & Sundet, 1999). The theory of underspecification cannot alone account for this patient’s accent production. If phonological underspecification was the only mechanism at work, one would expect some Accent1 contours on Accent2 words regardless of whether they were members of minimal pairs or not. In addition to a theory of phonological underspecification, a connectionist model of lexical access might account for the patient’s tonal productions. This type of model assumes that when a target word is accessed, the target word together with phonologically similar words will be activated (e.g., Dell, 1988). If the target word is the member of a minimal accent pair, two identical segmental phonological structures with different prosodic patterns will be activated. The patient then has to choose between these two. When the target word is not a member of a minimal pair, the patient does not have to make a choice between two identical segmental structures with different pitch patterns. As a result, the correct accent is also produced on Accent2 words. Studies of intonation in nontone languages have shown a narrowing of the fundamental frequency range in the speech of aphasic patients (Cooper et al., 1984; Ryalls, 1982). Gandour et al. (1992), however, in their investigation of tonal production in brain-damaged Thai speakers, found that the patients’ deviant tone production could not be attributed to a compressed tone space. Not only was there no compression of the fundamental frequency range, but the patients’ tone space was actually wider than the normal range. Liang and van Heuven (2004), on the other hand, in their study of a Mandarin speaker, found the patient’s F0 range to be less than half that of a normal control. And Moen (2004), in a study of three Norwegian patients with Broca’s aphasia, arrived at a similar result. There was a phonological distinction between the two word tones in the speech of all the patients, but phonetically the F0 variation in the aphasic patients covered a narrower frequency span than in the speech of the normal controls. Why these studies have arrived at such different results is unclear.

Conclusions Investigations of the tonal perception and production in brain-damaged speakers of tone languages have demonstrated reduced ability in both tasks in left-hemisphere-damaged patients, whereas tonal production and


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perception is spared in right-hemisphere-damaged nonaphasic patients, indicating that the processing of lexical tones is the property of the left hemisphere. Whether the reduced, but not disrupted, performance of the left-hemisphere-damaged patients is due to residual mechanisms in the left hemisphere, to mechanisms in the right hemisphere, or to subcortical mechanisms, is unclear. There is little evidence of a selective deficit, a rank order of difficulty, in the perception of particular types of tones. The exception is Yiu and Fok’s study of Cantonese tones, which found that falling tones were easier to identify than level ones. There is no indication of different perceptual deviations depending on type and severity of aphasia. In general, aphasic patients make the same kind of perceptual errors as normal subjects do, but they make more errors. When it comes to the tonal production of brain-damaged patients, the results of the investigations are in some respects less clear. The ability to produce, like the ability to perceive, tonal contrasts is normal in the righthemisphere-damaged subjects and reduced in the aphasic left-hemispheredamaged subjects. The severity of the tonal production disability seems to depend on type of aphasia and on time post-onset of brain damage. Anterior Broca’s aphasic patients have more problems than posterior fluent aphasic patients. And the problems are most severe in the period shortly after brain damage. There is no indication of a particular type of tonal disruption associated with a specific type of aphasia. There is no clear evidence of selective production deficits of particular tones. But there are indications that a falling tone may be easier to produce than a rising or level tone, possibly due to the general tendency to reduce the transglottal air pressure during an utterance.

Directions for future research Although the nature of the mechanisms underlying reduced tonal perception and production are at present unclear, the current evidence indicates that tonal processing is impaired following left hemisphere damage in tone languages. There are, however, few investigations of tonal processing in patients with subcortical damage, such as patients with Parkinson’s disease. Further investigations of this patient group might expand our knowledge of the neuroanatomical bases for the processing of tonal contrasts. Most studies of tones in the brain-damaged population have focused on single words or short utterances in relatively few languages. Future research will, it is hoped, include longer stretches of speech and data from a wider range of the numerous tone languages of the world.

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References Baum, S. R., & Pell, M. D. (1999). The neural bases of prosody: Insights from lesion studies and neuroimaging, Aphasiology, 13 (8), 581–608. Bayles, K. A., & Kaszniak, A. W. (1987). Communication and cognition in normal aging and dementia. London: Taylor & Francis. Cancelliere, A., & Kertesz, A. (1990). Lesion localisation in acquired deficits of emotional expression and comprehension, Brain and Cognition, 13, 133–147. Code, C. (1991). The characteristics of aphasia. Hove, UK: Lawrence Erlbaum Associates Ltd. Code, C., Wallesch, C.-W., Joanette, Y., & Lecours, A. R. (1996). Classic cases in neuropsychology. Hove, UK: Psychology Press. Code, C., Wallesch, C.-W., Joanette, Y., & Lecours, A. R. (2002). Classic cases in neuropsychology: Vol 2. Hove, UK: Psychology Press. Cooper, W. E., & Klouda, G. V. (1987). Intonation in aphasic and right-hemispheredamaged patients. In J. H. Ryalls (Ed.), Phonetic approaches to speech production in aphasia and related disorders (pp. 59–77). Boston/Toronto/San Diego: Little, Brown & Co. Cooper, W. E., Soares, C., Nicol, J., Michelow, D., & Goloskie, S. (1984). Clausal intonation after unilateral brain damage, Language and Speech, 27, 17–24. Danly, M., & Shapiro, B. E. (1982). Speech prosody in Broca’s aphasia. Brain and Language, 16, 171–190. Dell, G. S. (1988). The retrieval of phonological forms in production: Tests of predictions from a connectionist model. Journal of Memory and Language, 27, 124–142. Fromkin, V., & Rodman, R. (1993). An introduction to language (5th ed.). New York: Harcourt Brace Jovanovich. Gandour, J. (1987). Tone production in aphasia. In J. H. Ryalls (Ed.), Phonetic approaches to speech production in aphasia and related disorders (pp. 45–57). Boston/Toronto/San Diego: Little, Brown & Co. Gandour, J. (1998). Aphasia in tone languages. In P. Coppens, Y. Lebrun, & A. Basso (Eds.), Aphasia in atypical populations (pp. 117–142). Hove, UK: Lawrence Erlbaum Associates Ltd. Gandour, J., & Dardarananda, R. (1983). Identification of tonal contrasts in Thai aphasic patients. Brain and Language, 18 (1), 98–114. Gandour, J., Petty, S. H., & Dardarananda, R. (1988). Perception and production of tone in aphasia. Brain and Language, 35, 201–240. Gandour, J., Ponglorpisit, S., Khunadorn, F., Dechongkit, S., Boongird, P., Boonklam, R., et al. (1992). Lexical tones in Thai after unilateral brain damage. Brain and Language, 43, 275–307. Hughes, C. P., Chan, J. L., & Su, M. S. (1983). Aprosodia in Chinese patients with right cerebral hemisphere lesions. Archives of Neurology, 40, 732–736. Kenstowicz, M. (1994). Phonology in generative grammar. Oxford, UK: Blackwell Publishers. Klouda, G. V., Robin, D. A., Graff-Radford, N. R., & Cooper, W. E. (1988). The role of callosal connections in speech prosody. Brain and Language, 35, 154–171. Liang, J., & van Heuven, V. J. (2004). Evidence for separate tonal and segmental tiers in the lexical specification of words: A case study of a brain-damaged Chinese speaker. Brain and Language, 91, 282–293.


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9

Subcortical aphasia Historical perspective and contemporary thinking Bruce E. Murdoch

Introduction The concept that structures lying below the level of the cerebral cortex in the subcortical regions of the brain may be involved in language processing has been the subject of controversy for more than a century. In recent years evidence provided primarily through cliniconeuroradiological investigations has greatly increased awareness and acceptance that subcortical structures such as the basal ganglia and thalamus have a role to play in language. This evidence to a large extent has come from a relatively small group of researchers who have provided theories and mechanisms by which subcortical structures may influence language processing, backed up by empirical evidence. The work of these researchers would not have come into the public domain without the support of journal editors with sufficiently open minds to accept and publish work that ran counter to contemporary thinking. One such journal editor has been Chris Code. Chris has always kept an open mind on all aspects of brain function relating to the occurrence of aphasic disorders and through his editorship of the journal Aphasiology has always provided a forum where new theories relating to language processes and language disorders can be espoused and debated. Without Chris Code and his willingness to support and publish work relating to new aspects of brainrelated function, much of the progress towards furthering our understanding of subcortical language mechanisms would have been greatly retarded. The present chapter discusses subcortical language mechanisms and subcortical aphasia from a historical perspective, and presents the latest thinking in relation to how subcortical structures may influence language and language disorders. The progress made towards greater enlightenment of subcortical language processes can in many ways be linked to encouragement provided by Chris Code and other editors of journals prepared to extend the boundaries of contemporary theory and practice.

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Historical perspective Ever since the era of “phrenological science” the cerebral cortex has been considered the neural substrate of higher psychological function, including language. In keeping with this view, the standard “associationist” anatomofunctional model of language organization was deeply rooted in cortical areas and their fibre connections (Lichtheim, 1885; Wernicke, 1874). According to this still influential model, linguistic representations are stored in discrete cortical areas, and consequently subcortical brain lesions were thought to only produce language deficits if they disrupted the white matter fibres that connect the various cortical language centres (e.g., disruption of the arcuate fasciculus in instances of conduction aphasia). Despite the emphasis on the cerebral cortex, evidence to suggest the occurrence of aphasia associated with subcortical brain lesions has been available since the late nineteenth century. More than a century ago Broadbent (1872) proposed that words were “generated” as motor acts in the basal ganglia. Marie (1906) challenged the traditional view of aphasia and described a clinical syndrome that he called “anartria,” secondary to dysfunction of a specific subcortical region involving the caudate nucleus, putamen, internal capsule and thalamus (Marie’s quadrilateral space). Monakow (1914) also championed the participation of the lentiform nucleus in the pathogenesis of aphasia. Perusal of the monumental anatomoclinical summaries published in the early twentieth century, such as those by Moutier (1908), Henschen (1922) and Nielsen (1946) also reveals a number of cases of language disturbances associated with lesions apparently limited to subcortical structures. Unfortunately, these empirical data were subjected to radically different interpretations by the various authors. Moutier supported the “quadrilatèrè” proposed by his teacher Pierre Marie. In contrast Nielsen explicitly denied any role of subcortical structures in mental activities, interpreting his observations in strict adherence to the traditional Wernicke–Lichtheim model. Later, Fisher (1959) described aphasia as a clinical feature in a patient with left thalamic haemorrhage. Penfield and Roberts (1959) suggested that the thalamus had an integrative function in language processing. Since the late 1970s, the traditional view of language processing in the brain has been challenged by the findings of an increasing number of cliniconeuroradiological correlation studies that have documented the occurrence of adult language disorders in association with apparently subcortical vascular lesions. The introduction in recent decades of new neuroradiological methods for lesion localisation in vivo, including computed tomography in the 1970s and more recently magnetic resonance imaging, has led to an increasing number of reports in the literature of aphasia following subcortical lesions (for reviews of in vivo correlation studies see Alexander, 1989; Cappa & Vallar, 1992; Murdoch, 1996). In particular, these new neuroimaging techniques have allowed more precise identification and localization of subcortical lesion parameters (Alexander, Naesar, & Palumbo, 1987; Cappa & Wallesch, 1994),

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and hence the ability to evaluate the influence of specific lesions in producing motor and cognitive anomalies. Therefore, although the concept of subcortical aphasia remains controversial, recent years have seen a growing acceptance of a role for subcortical structures in language and the development of a range of models that attempt to explain the nature of that role. Prior to discussing models of subcortical participation in language, however, it is necessary to first review the relevant subcortical neuroanatomy and the reported clinical features of subcortical aphasia.

Neuroanatomy of the subcortical region The basal ganglia, thalamus and subcortical white matter pathways represent the subcortical structures that have been afforded the most consideration within contemporary models of subcortical participation in language. More recently, studies based on deep brain stimulation have also suggested a possible role for the subthalamic nucleus in language processes (Whelan, Murdoch, Theodoros, 2003; Whelan, Murdoch, Theodoros, Silburn, & Hall, 2004a). Further, a role for the cerebellum in language has also been suggested (Docking, Murdoch, & Ward, 2003; Leiner, Leiner, & Dow, 1993). Clinically, the basal ganglia represent a functional system of interconnected components that typically include the corpus striatum (i.e., caudate nucleus, putamen and internal [GPi] and external [GPe] segments of the globus pallidus), subthalamic nucleus and substantia nigra (pars compacta [SNPC] and pars reticulata [SNPR]). Anatomically, this system is largely positioned at the cortico-subcortical boundary, and functionally has been hypothesized to be composed of a number of neural circuits subserving motor, cognitive and limbic functions (Alexander & Crutcher, 1990; Alexander, Crutcher, & De Long, 1990). In general, the basal ganglia can be considered to comprise a group of “input structures” (the caudate nucleus, putamen and ventral striatum) that receive direct input essentially from all areas of the cerebral cortex and “output” structures (the GPi, the SNPR and the ventral pallidum) that project back to the cerebral cortex via the thalamus. Contemporary thinking is that the striatum acts as a “multi-laned” throughway that forms part of a series of multi-segmented circuits connecting the cerebral cortex, basal ganglia and thalamus (Alexander, De Long, & Strick, 1986; Graybiel & Kimura, 1995; Middleton & Strick, 2000). Thus basal ganglia anatomy is characterized by their participation in multiple “loops” with the cerebral cortex, each of which follows the basic route of: cortex → striatum → globus pallidus/substantia nigra → thalamus → cortex in a unidirectional fashion. Within contemporary theories of subcortical participation in language, it has been suggested that the basal ganglia mediate linguistic processes by way of these cortico-striato-pallido-thalamo-cortical pathways (Crosson, 1985; Wallesch & Papagno, 1988). Consequently, these loops constitute the neuroanatomical basis of subcortical participation in language.

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Syndromes of subcortical aphasia The majority of studies that have attempted to explore the notion of subcortical participation in language have investigated the impact of vascular thalamic and striatocapsular lesions on linguistic abilities (Murdoch, 1990), giving rise to syndromes of thalamic and striatocapsular aphasia. Despite the fact that the aphasic symptom complex associated with thalamic lesions appears to approximate a more uniform syndrome than its striatocapsular counterpart, heterogeneity within each aphasic category has been documented with respect to language profiles and recovery rates (Murdoch, 1996). This inconsistency has been partly attributed to methodological limitations including the wide-ranging scope of assessments utilized and experimental designs employed. Kennedy and Murdoch (1990) emphasized that general measures of language function typically utilized in the assessment of subcortical aphasia, may have lacked the requisite sensitivity to detect more subtle, high-level linguistic deficits within this population. Furthermore, it has been suggested that the complexity of circulatory dynamics and the protean nature of spontaneous vascular lesions may have also contributed to the inherent variability of symptoms observed (Graff-Radford, Eslinger, Damasio, & Yamada, 1984). Thalamic aphasia Numerous studies have documented aphasia after dominant thalamic lesions, the function of the thalamus in language being described in terms of an integrative role (Penfield & Roberts, 1959; Schuell, Jenkins, & Jiménez-Pabón, 1965), arousal mechanisms (Luria, 1977; McFarling, Rothi, & Heilman, 1982; Riklan & Cooper, 1975), modulation and integration of cortical areas to permit language processing (Ojemann, 1983), semantic verification of formulated cortical language segments in verbal production (Cappa & Vignolo, 1979; Wallesch & Papagno, 1988), managing of verbal memory (Reynolds, Turner, Harris, Ojemann, & Davis, 1979) or a selective engagement of cortical mechanisms leading to an impairment in the semantic–lexical interface (Nadeau & Crosson, 1997a, 1997b). Commonly, language disturbances resulting from lesions of the thalamus are of a mixed transcortical sensory aphasia (Crosson, 1992; Murdoch, 1996) and characterized by word finding difficulties, paraphasias, neologistic output, perseveration and reduced spontaneous speech output in the presence of relatively preserved repetition and variable, but often good, auditory comprehension abilities (Crosson, 1984; Jonas, 1982). This profile, however, has been documented to vary (Cappa & Vignolo, 1979; Crosson, 1984), including reports of normal language abilities in individuals following thalamic haemorrhage (Cappa, Papagno, Vallar, & Vignolo, 1986). Despite this variability, language disturbances following thalamic lesions do present a more uniform clinical picture than those associated with striatocapsular lesions, and it is

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generally accepted that a typical thalamic aphasia can be characterized by the clinical presentation. Striatocapsular aphasia Although in vivo correlation studies have documented beyond reasonable doubt that language impairments may occur in association with lesions confined to the striatocapsular region of the dominant hemisphere, manifestations of language pathology subsequent to lesions of the basal ganglia and internal capsule have failed to establish a homogeneous symptom complex with no unitary striatocapsular aphasia being identified (Crosson, 1985; Kennedy & Murdoch, 1993; Nadeau & Crosson, 1997a, 1997b). Furthermore, the effects of striatocapsular lesions on language abilities appear, in general, to be more enduring than the impact associated with thalamic lesions (Wallesch, Kornhuber, Brunner, Kunz, Hollerbach, & Suger, 1983). Indeed, reported language profiles extend from normal to severe impairments on the parameters of auditory and reading comprehension, spontaneous speech, repetition, naming and writing (Alexander & LoVerme, 1980; Damasio, Damasio, Rizzo, Varney, & Gersh, 1982; Vallar, Papagno, & Cappa, 1988). Although language disorders are common subsequent to dominant hemisphere striatocapsular lesions, it has been suggested that the more overt language symptoms in such cases may be related to concomitant cortical dysfunction (Nadeau & Crosson, 1997a). Mega and Alexander (1994) showed that the basal ganglia play a more subtle role in the generation of words. More recent evidence indicates that the basal ganglia have a broader role in complex aspects of language, that is, executive language functions (Copland, Chenery, & Murdoch, 2000b). Despite the documented variability of language disturbances associated with striatocapsular aphasia, some researchers have identified a distinct pattern of impairment that conforms to the anterior-nonfluent/posterior-fluent cortical dichotomy (Cappa, Cavallotti, Guidotti, Papagno, & Vignolo, 1983). Other authors have also identified three patterns of language disturbance associated with putaminal and internal capsule lesions, including: (1) Broca’s type or transcortical motor aphasia with dysarthria, following lesions of the striatocapsular region with anterior extension; (2) Wernicke’s type aphasia subsequent to striatocapsular lesion with posterior extension; and (3) global aphasia following combined anterior and posterior lesions of the basal ganglia and/or internal capsule, plus extension (Murdoch, Thompson, Fraser, & Harrison, 1986; Naeser, Alexander, Helm-Estabrooks, Levine, Laughlin, & Geschwind, 1982). Despite this apparent consensus, several other studies have questioned the accuracy and utility of the anterior–posterior dichotomy by describing a number of cases in which the patterns of language impairment could not be accounted for in terms of this anatomical distinction (Kennedy & Murdoch, 1993; Wallesch, 1985).

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Theoretical models of subcortical participation in language The possible existence of subcortical aphasia as a clinical entity has catalyzed the development of contemporary language theories that proffer functional roles for subcortical nuclei, including the striatum, globus pallidus and thalamus. These theoretical constructs specifically promote a network model of language organization (Cappa & Vallar, 1992), whereby cortico–subcortical– cortical pathways represent the neural basis of linguistic processing, in preference to exclusive cortical–cortical connections. The work of Alexander and colleagues (1986, 1990) provides the basis for our understanding of the anatomical and functional organization of cortico–subcortical–cortical circuits. Seminal schemas proposed parallel yet functionally segregated basal ganglia–thalamocortical pathways to underlie skeletomotor, occulomotor, cognitive and limbic functions. To date, the skeletomotor circuit has proffered the greatest contribution to the conceptualization of basal ganglia–thalamocortical organizational substrates. As such, contemporary models of subcortical participation in language have largely evolved from theories of motor control, the foundations of which were established within studies of basal ganglia dysfunction in primates with experimentally induced 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) toxicity (Starr, Vitek, & Bakay, 1998). Based on clinicoanatomical evidence thus far, three major basal ganglia– thalamocortical circuits have been speculated to participate in the mediation of linguistic processes (Cappa & Vallar, 1992): (1) the anterior “complex” loop (i.e., dorsolateral prefrontal and lateral orbitofrontal circuits (Alexander et al., 1986): frontal association cortex–caudate nucleus–globus pallidus– ventral anterior thalamus–frontal association cortex; (2) the anterior “motor” loop (i.e., skeletomotor circuit; Alexander et al., 1986): sensory motor cortex– putamen–globus pallidus–ventral lateral thalamus–sensory motor cortex; and (3) the posterior loop (Van Buren & Borke, 1969): temporoparietal cortex–pulvinar–temporoparietal cortex. The anterior “complex” and “motor” pathways were hypothesized to mediate lexical–semantic expression and articulation respectively, and the posterior loop to facilitate auditory comprehension (Cappa & Vallar, 1992). Additional subcortical–cortical pathways have also been postulated to participate in the regulation of language (Cappa & Vallar, 1992), including: temporal auditory cortex–caudate nucleus pathway facilitating auditory comprehension (Damasio et al., 1982; Van Hoesen, Yeterian, & Lavizzo-Mourey, 1981); amygdala–temporal neocortex–dorsomedial thalamus (Cappa & Sterzi, 1990) and caudate nucleus– supplementary motor area–anterior (Naeser, Palumbo, Helm-Estabrooks, Stiassny-Eder, & Albert, 1989) regulating speech production. The functional specificity of language-dedicated subcortical circuits to date has been largely restricted to the elementary linguistic faculties of auditory comprehension and verbal expression (Alexander et al., 1986). It is anticipated, however, that contemporary research may serve to expose functional subdivisions within

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nonmotor basal ganglia–thalamocortical circuits, which reflect a similar level of organizational complexity to that of the somatotopic channels identified within subcortical motor circuitry (Alexander et al., 1986). Indeed, this disclosure may potentially involve the elucidation of the neural substrates underpinning language at both single word and sentential levels of processing. Several theories have attempted to explicate the subcortical neural mechanisms underlying receptive and expressive linguistic abilities. These include: the subcortical white matter pathways (Alexander, Naeser, & Palumbo, 1987), response–release semantic feedback (Crosson, 1985), lexical decision making (Wallesch & Papagno, 1988), and selective engagement (Nadeau & Crosson, 1997a) models. Subcortical white matter pathways model The subcortical white matter pathways model (Alexander et al., 1987) dismisses a role for the subcortical nuclei in language and advocates cortico– cortico, corticostriatal, thalamocortical and corticobulbar white matter pathways as critical to the facilitation of auditory comprehension and verbal expression. The fulcrum of this theoretical schema developed from a series of robust clinical-neuroradiological studies that highlighted an array of receptive and expressive language deficits in individuals with large striatal lesions, extending into the surrounding white matter pathways (Alexander et al., 1987). This profile was in stark contrast to that observed in patients with relatively circumscribed lesions of the putamen and caudate nucleus, which resulted in covert or nominal disturbances to language such as mild word finding difficulties and hesitant verbal output. This finding consequently supported a minimal function hypothesis for basal ganglia participation in language and directed discussion towards the white matter pathways linking cortical–cortical and subcortical–cortical regions. Vascular lesions of the striatum that extended beyond the lateral boundary of the anterior limb of the internal capsule, incorporating the anterior, extra anterior, anterior superior, superior or posterior periventricular white matter (PVWM), temporal isthmus, insular cortex and/or external capsule, were documented to produce a range of expressive and receptive language deficits (Alexander et al., 1987). More specifically, nonthalamic lesions with extensions into the anterior superior PVWM were reported to result in transcortical motor aphasia, largely evidenced as sparse verbal output and difficulty initiating speech. This symptom complex was hypothesized to result from damage to the fibre pathways connecting the supplementary motor area and Broca’s area. Anterior superior PVWM pathway disconnection was postulated to restrict limbic inputs to cortical language centres, resulting in reduced speech drive. Repetition deficits were reported to arise from lateral and/or superior lesion extensions relative to the putamen, which implicate the external and extreme capsules and, potentially, the arcuate fasciculus. In relation to

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speech motor control, corticobulbar fibres within the superior PVWM and genu of the internal capsule, in addition to corticocerebellar and thalamocortical fibres within the anterior portion of the superior PVWM and anterior limb of the internal capsule, were inculpated. The temporal isthmus, linking the medial geniculate nucleus of the thalamus to the primary auditory association cortex, and the auditory association callosal pathway connecting Wernicke’s area and the right temporal association cortex were identified as the subcortical white matter pathways integral to auditory comprehension. Posterior striatal lesion extension incorporating these structures typically resulted in comprehension deficits and neologistic output. Furthermore, wide-ranging lesion extension relative to the putamen, including the anterior limb of the internal capsule, extra anterior PVWM, anterior PVWM, anterior superior PVWM and temporal isthmus was reported to result in global language impairment. Alexander et al. (1987) avoided attributing a role in language functioning to the thalamus on the basis that language deficits resulting from thalamic and putaminal lesions are subserved by disparate pathophysiological mechanisms. Given that white matter pathways provide the means by which components of the language system communicate with each other, the importance given to these pathways in the model proposed by Alexander et al. (1987) would, on the surface, appear reasonable. However, the findings of more recent studies refute the notion that white matter pathway disconnection provides a valid datum for clinical manifestation of subcortical damage (Cappa & Vallar, 1992). Response-release semantic feedback model A postulated thalamo-cortical alerting system (Ojemann, 1976) represents the plinth of the response-release semantic feedback (RRSF) (Crosson, 1985) model. The model proposes a role for subcortical structures in regulating the release of preformulated language segments from the cerebral cortex. According to this model, the conceptual, word-finding and syntactic processes that fall under the rubric of language formulation occur in the anterior cerebral cortex. The monitoring of anteriorly formulated language segments, as well as the semantic and phonological decoding of incoming language, occurs in the posterior temporoparietal cortex. Language segments are conveyed from the anterior language formulation centre to the posterior language centre via the thalamus prior to release for motor programming. This operation allows the posterior semantic decoding centres to monitor the language segment for semantic accuracy. If an inaccuracy is detected, then the information required for correction is conveyed via the thalamus back to the anterior cortex. If the language segment is found to be accurate during monitoring, then it is released from a buffer in the anterior cortex for subsequent motor programming. In addition to subcortical structures participating in the preverbal semantic monitoring process, the model also specifies that the

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striatocapsular structures are involved in the release of the formulated language segment for motor programming. Specifically, it is suggested that this release occurs through the cortico-striato-pallido-thalamo-cortical loop in the following way. Once the language segments have been verified for semantic accuracy, the temporoparietal cortex releases the caudate nucleus from inhibition. The caudate nucleus then serves to weaken inhibitory pallidal regulation of thalamic excitatory outputs in the anterior language centre, which in turn arouses the cortex to enable generation of the motor programmes for semantically verified language segments. According to this model, Crosson (1985) hypothesized that subcortical lesions within the cortico-striato-pallido-thalamo-cortical loop would produce language deficits confined to the lexical–semantic level. The original conception of the response-release mechanism in Crosson’s (1985) model has since been revised and elaborated in terms of the neural substrates involved (Crosson, 1992). Although the actual response-release mechanism in the modified version resembles that in the original conception, the route for this release is altered. The formulation of a language segment causes frontal excitation of the caudate, which increases inhibition of specific fields within the globus pallidus. However, this level of inhibition alone is not sufficient to alter pallidal output to the thalamus. An increase in posterior language-cortex excitation to the caudate, which occurs once a language segment has been semantically verified posteriorly, provides a boost to the inhibition of the pallidum. The pallidal summation of this anterior and posterior inhibitory input allows the release of the ventral anterior thalamus from inhibition by the globus pallidus, causing the thalamic excitation of the frontal language cortex required to trigger the release of the language segment for motor programming. Overall, the revised model provides an integrated account of how subcortical structures might influence language output through a neuroregulatory mechanism that is consistent with knowledge of cortical–subcortical neurotransmitter systems and structural features. Lexical decision making model In line with the RRSF model, the lexical decision making (LDM) model (Wallesch & Papagno, 1988) also proposes a cortico-striato-pallido-thalamocortical loop as the neural platform for linguistic operations, including a specific thalamocortical arousal mechanism, consistent with Ojemann’s (1976) theorem. Despite evident parallels, however, distinct incongruities prevail between these theoretical constructs with respect to functional cortical organization viewpoints, and the nature of proposed subcortical mechanisms. Wallesch and Papagno (1988) postulated that the subcortical components of the loop constitute a “frontal lobe system” comprising parallel modules with integrative and decision-making capabilities rather than the simple neuroregulatory function proposed in Crosson’s (1985) model. Specifically,

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the basal ganglia system and thalamus were hypothesized to process situational as well as goal-directed constraints and lexical information from the frontal cortex and posterior language area, and subsequently to participate in the process of determining the appropriate lexical item, from a range of cortically generated lexical alternatives, for verbal production. The most appropriate lexical alternative is then released by the thalamus for processing by the frontal cortex and programming for speech. Cortical processing of selected lexical alternatives is made possible by inhibitory influences of the globus pallidus on a thalamic gating mechanism. This most appropriate lexical alternative has an inhibitory effect on the thalamus, promoting closure of the thalamic gate, resulting in activation of the cerebral cortex and production of the desired response. Cortical processing of subordinate alternatives is suppressed as a consequence of pallidal disinhibition of the thalamus, and the inhibition of cortical activity. Selective engagement model Selective engagement (SE) theory represents the most contemporary schema of subcortical participation in language and principally proposes a frontal– inferior thalamic peduncle (ITP)–nucleus reticularis (NR)–centrum medianum (CM) system to subserve the “engagement” of cortical components that mediate attentional and behavioural processes, including language (Nadeau & Crosson, 1997a). This proposed linguistic frontal lobe system complied with the tenets of the LDM model, with the exception of two distinct anomalies. In particular, selective engagement theory disputes a role for the basal ganglia in language and redefines nonspecific thalamic nuclei (i.e., NR, CM and parafascicular nucleus) as critical to the mediation of linguistic processes. Nadeau and Crosson (1997b) considered ventral anterior (VA) and ventral lateral (VL) thalamic participation in language an insolvent hypothesis. This postulate was largely fuelled by two lines of evidence, including: (1) an observed decline in the incidence of aphasia following surgically induced lesions of the VA and VL thalamus, concomitant with enhanced stereotactic technique accuracy (Fox, Ahlskog, & Kelly, 1991), and (2) the fact that aphasia resulting from tuberothalamic territory infarcts involving the VA nucleus typically resembles that following paramedian territory lesions, which spare the VA thalamus. Postulated thalamic engagement of the cortex, however, was in line with Ojemann’s (1976) proposed ventral thalamic focal altering mechanism in addition to Crosson’s (1985) VA responserelease system, relative to the galvanization of verbal output channels. The expansion of these postulates to consider the activation of more extensive language-dedicated cortical mosaics (Ojemann, 1983), largely under NR control (Nadeau & Crosson, 1997a), accommodated manifestations of receptive as well as expressive language deficits observed subsequent to lesions of the thalamus. The RRSF and LDM models previously discussed focused primarily on output versus input mechanisms, providing no discernible explanation

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for comprehension deficits. In contrast, the structural complexity of the neural system subserving SE mechanisms accommodates the spectrum of aphasic characteristics observed following lesions of the dominant thalamus (Nadeau & Crosson, 1997b), perhaps approximating a more cogent axiom of subcortical participation in language than its antecedents. An important feature of the selective engagement theory is that it discounts a role for the basal ganglia in language. A variable symptom complex with respect to observed manifestations of language pathology in the presence of classically defined striatocapsular lesions formed the basis of this postulate. In more detail, Nadeau and Crosson (1997a) analysed the linguistic profiles of 50 cases subsequent to relatively uniform striatocapsular infarctions, including the caudate head, putamen, anterior limb of the internal capsule and portions of the globus pallidus. Vast heterogeneity relative to the severity and incidence of language deficits including fluency, articulation, comprehension, repetition and naming was reported. Nadeau and Crosson (1997a) hypothesized that an integral role for the basal ganglia in language would be fortified by a coherent aphasic syndrome, in the event of uniform damage. Based on the above evidence, therefore, a minimal function hypothesis with respect to the contribution of the basal ganglia to language functions was promoted. Nadeau and Crosson (1997a) largely attributed language disturbances subsequent to lesions of the basal ganglia to cortical hypoperfusion. Thrombotic or embolic occlusions primarily of the middle cerebral artery (MCA), or less commonly the internal carotid artery, were identified as precursors to striatocapsular infarction (Weiller, Ringelstein, Reiche, Thron, & Buell, 1990). More importantly, circulatory dynamics pertaining to the rate of arterial recanalization and the efficiency of anastomotic circulation following basal ganglia infarction, were considered integral factors in determining the presence or absence of aphasia. Perisylvian cortex ischaemia by way of MCA occlusioninduced cystic infarction, neuronal drop out or generalized tissue dysfunction (Nadeau & Crosson, 1997a), provided a tenable explanation for the variable array of expressive and receptive language deficits associated with striatocapsular infarcts. Furthermore, haemorrhagic basal ganglia lesions were also postulated to disturb cortical circulatory dynamics relevant to language functions. Pressure effects inducing cortical ischaemia were held responsible for consequent manifestations of aphasia. Evidence is available that disputes Nadeau and Crosson’s (1997a) claim that lesions of the striatocapsular region fail to establish a homogeneous aphasic syndrome. A coherent aphasic syndrome relative to generative aspects of language, including verbal fluency, sentence generation and extended discourse, has been reported (Mega & Alexander, 1994). This finding suggests a need to revisit the notion of basal ganglia aphasia, paying particular attention to the scope and sensitivity of linguistic assessments utilized in addition to circulatory dynamics (Crosson, Zawacki, Brinson, Lu, & Sadek, 1997). Indeed, this evidence supports a potential role for the basal

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ganglia in mediating linguistic processes. In all probability, this role may entail the regulation of thalamocortical engagement. Proposed mechanisms include the switching of engagement between neural nets (Malapani, Pillon, Dubois, & Agid, 1994). Limitations of theoretical models of subcortical participation in language Each of the models outlined above has a number of limitations and consequently no one model has achieved uniform acceptance. A major limitation of these models is that they fail to fully explain the considerable variability in clinical presentation of subcortical aphasia. According to Cappa (1997), a further problem is that the models suggest such extensive and widely distributed systems subserving lexical processing that specific predictions appear to be difficult to disprove on the basis of pathological evidence. In other words, these models do not lend themselves readily to empirical testing. Yet another limitation arises from the nature of the research on which these models are based. The available models of subcortical participation in language are largely based on the observation that certain contrasting deficits of language production arise in subjects with particular subcortical vascular lesions when tested on traditional tests of language function. These language measures were typically designed for taxonomic purposes regarding traditional cortical-based aphasia syndromes and may be inadequate for developing models of brain functioning. It has also been argued that language deficits associated with subcortical vascular lesions may actually be related to concomitant cortical dysfunction via various pathophysiological mechanisms. For instance, due to limitations inherent to currently available neuroimaging techniques, cortical infarction may not have been detected by neuroimaging. Consequently, inaccurate lesion parameters may have served to contaminate our conceptualization of subcortical aphasia thus far. In addition to the recognized shortcomings of current neuroimaging techniques, a number of physiological mechanisms have also been proposed that potentially attribute manifestations of subcortical aphasia to cortical dysfunction. Subcortical lesions have been reported to exert distance effects on the cerebral cortex, including cortical hypoperfusion and hypometabolism (Perani, Valler, Cappa, Messa, & Fazio, 1987). Reduced cerebral blood flow results in ischaemia-induced neuronal loss (Lassen, Olsen, Hojgaard, & Skriver, 1983) and ischaemic penumbra (i.e., maintenance of tissue viability in the presence of neuronal dysfunction), both mechanisms having the potential to disable cortical activity. Also, subcortical lesions may result in diaschisis or the functional deactivation of distance-related cortical structures (Metter et al., 1983). As yet, however, the relationship between the structural site and aetiology of subcortical lesions, the extent of diaschisis, cortical hypometabolism and hypoperfusion, and associated language function remains to be fully elucidated.

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Overall, the validity of the aforementioned operative models of subcortical participation in language remains largely unattested due primarily to a previous incapacity to strictly define the extent of vascular neuropathology. A further encumbrance to empirical ratification rests with the inadequacy of animal models in providing an appropriate linguistic platform for investigation (Crosson, 1992). The value of model-driven and theoretically founded studies of cognition cannot be overestimated in quests to extricate the subcortical–cortical mechanisms underpinning language (Cappa & Sterzi, 1990). The utilization of existing frameworks, however, in the context of advancing scientific techniques is considered critical to their ultimate interpretation. In line with this proposal, a recent resurgence in functional neurosurgery to treat the motor symptoms of Parkinson’s disease, involving the generation of discrete surgically induced lesions of the subcortical nuclei, would appear to provide an unprecedented opportunity to empirically test contemporary theories of subcortical participation in language.

Pallidotomy, thalamotomy and deep brain stimulation Over the course of the past decade or so, primate research has served to catalyse the development of a sound theoretical framework that has enhanced our understanding of the pathophysiology underlying movement disorders, such as those seen in Parkinson’s disease. This, combined with advances in neuroimaging and neurosurgical techniques and a degree of disillusionment with drug treatments for movement disorders, has led to a revival of stereotactic neurosurgical procedures such as pallidotomy (involving lesioning of specific components of the globus pallidus) and thalamotomy (involving lesioning of specific nuclei in the thalamus) in the treatment of Parkinson’s disease. In addition to their patent therapeutic value, the discrete circumscribed lesion sites provided by these procedures afford an unprecedented opportunity to empirically test contemporary subcortical language theories. More recent, as an alternative to ablative procedures such as pallidotomy and thalamotomy that overtly destroy neural tissue, deep brain stimulation (DBS) involving implantation of electrodes within a range of subcortical targets such as the subthalamic nucleus (STN), has gained increasing support as the preferred method of treatment for Parkinson’s disease. In that DBS has been documented to simulate the effects of ablative lesions (i.e., block neuronal activity at the target site), this technique also provides an opportunity to test models that implicate structures such as the STN and thalamus in language. The majority of studies reported to date pertaining to the impact of pallidotomy (Lombardi, Gross, Trepanier, Lang, Lozano, & Saint-Cyr, 2000; Scott et al., 2002; Trepanier, Saint-Cyr, Lozano, & Lang, 1998), and thalamotomy (Fukuda, Kameyama, Yoshino, Tanaka, & Narabayashi, 2000) on cognitive function have been largely neuropsychologically based. Assessment batteries have typically included measures of attention, memory,

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concentration, visuospatial abilities and executive functioning. In regard to language, the domains of confrontation naming, verbal learning, semantic and phonemic fluency have been afforded considerable scrutiny, however, indepth linguistic analyses were not included. Recently, a series of studies by Whelan, Murdoch and colleagues have addressed this problem by utilizing a battery of high-level language tests to examine the effects of pallidotomy (Murdoch, Whelan, & Theodoros, 2003; Whelan, Murdoch, Theodoros, Silburn, & Hall, 2004b; Whelan, Murdoch, Theodoros, Silburn, & HardingClark, 2000), thalamotomy (Whelan, Murdoch, Theodoros, Silburn, & Hall, 2002) and DBS of the STN (Whelan et al., 2003, 2004a) on linguistic function. Overall these studies provided evidence to suggest that the concatenation of subcortical nuclei comprising basal ganglia–thalamocortical circuits plays a fundamental role in high-level linguistic processes potentially underpinning the recruitment and directed interplay of frontal and temporoparietal cortical regions. With regard to the STN, the findings of Whelan et al. (2003, 2004a) highlighted the need to modify contemporary theories of subcortical participation in language to incorporate the STN. More specifically, the outcomes of their research challenged unilateral models of functional basal ganglia organization with the proposal of a potential interhemispheric regulatory function for the STN in the mediation of high-level linguistic processes. Indeed, the STN may contribute to the mediation of linguistic processes by indirectly regulating thalamocortical outputs within the cortico–subcortical–cortical language circuits.

Functional neuroimaging Further clarification of the role of subcortical structures in language is likely to come through the use of functional neuroimaging techniques and neurophysiological methods such as electrical and magnetic evoked responses. Functional neuroimaging techniques such as functional magnetic resonance (fMRI) and positron emission tomography (PET) enable brain images to be collected while the subject is performing various language production tasks (e.g., picture naming, generating nouns) or during language comprehension (e.g., listening to stories). These techniques therefore enable visualization of the brain regions involved in a language task, with a spatial resolution as low as a few millimetres. Although functional neuroimaging does therefore offer a tool to unravel the role of subcortical structures in language, results from functional neuroimaging studies to date have proven less than definitive (Cabeza & Nyberg, 2000). These studies have, however, revealed a number of cortical and subcortical structures beyond the perisylvian cortex to be active during linguistic processing (Crosson et al., 1999; Peterson, Fox, Posner, Mintum, & Raichle, 1989; Warburton et al., 1996), providing support for a distributed network model of language organization (Mesulam, 2000). In particular, word generation studies have shown consistent activation of medial frontal cortex, usually near the boundary of pre-supplementary motor

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area (SMA) and the rostral cingulated zone. Although the pre-SMA is known to have extensive subcortical connections, including projections to the striatal grey matter spanning the internal capsule and to the caudate nucleus and putamen, as well as receiving connections from ventral anterior and dorsal medial thalamus in the majority of functional neuroimaging studies, these subcortical components have not shown consistent activity in functional neuroimaging studies of word generation. This reported inconsistency in activation of the basal ganglia and thalamus may be the product of limitations in numbers of subjects studied, number of trials during functional neuroimaging and experimental design. Recently Crosson et al. (2003), using fMRI, observed significant activity in the subcortical structures during lexical generation tasks but not during nonsense syllable generation. They inferred the existence of a left pre-SMA–dorsal caudate–ventral anterior thalamic loop involved in lexical retrieval. Further, Crosson et al. (2003) hypothesized “that activity in this loop was related to maintaining a bias toward the retrieval of one lexical item versus competing alternatives for each response during word generation blocks” (p. 1075). Several PET studies have also demonstrated activation of the thalamus and basal ganglia during completion of language tasks such as picture naming (Price, Moore, Humphreys, Frackowiak, & Friston, 1996a) and word repetition (Price et al., 1996b).

Conclusion Speculation has existed since the end of the nineteenth century that subcortical brain structures have a role in language. Although it is generally accepted that the thalamus has a role in language, little consensus has been reached regarding the involvement, not to mention the role, of the basal ganglia in language. In particular controversy still exists as to whether the structures of the striatocapsular region participate directly in language processing or play a role as supporting structures for language. Consequently, the important question that remains to be answered is: Do the subcortical structures have an inherent language function that contributes a specific cognitive function beyond that of the cortex, or do they simply participate in regulating and enhancing functioning of the cortical language centres? Contemporary theories suggest that the role of subcortical structures in language is essentially neuroregulatory, relying on quantitative neuronal activity. Recently reported findings suggest that subcortical structures may be involved in maintaining response biases across time that are set by the cortical components of cortical–subcortical–cortical loops (Copland, Chenery, & Murdoch, 2000a). Hypotheses generated by these theories of subcortical participation in language require testing in order to advance our understanding of the importance of subcortical brain mechanisms to language function.

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10 Mechanisms of lexical selection and the anomias Tobias Bormann, Gerhard Blanken and Claus-W. Wallesch

Introduction “Aphasia can be approached from several directions, reflecting the range of interdisciplinary interest, and each approach has its own story to tell” (Code, 1989, p. ix). Chris Code, to whom this chapter is dedicated, has used a variety of approaches to aphasia and the aphasic person, including the neurolinguistic, psychosocial, brain science, historical and therapeutic perspective. Chris’s personality and scope of interest are a major reason for the success of Aphasiology – the journal he edits. GB and CWW came into contact with Chris Code through our common interest in recurring utterances (Blanken, de Langen, Dittmann, & Wallesch, 1989; Blanken, Dittmann, Haas, & Wallesch, 1988; Blanken, Wallesch, & Papagno, 1990; Code, 1982a, 1982b). As we also did related research on the psychosocial impact of aphasia on the person and his or her family, Chris spent some (at least for us) scientifically fruitful and socially rewarding months with us in Freiburg in the early 1990s. With regard to recurring utterances, we took different perspectives: Whereas Chris was mainly interested in their pathophysiological basis, we focused on their meaning for neurolinguistic models of word production. Using the “classic approach” of model-based cognitive neurolinguistics, the group of GB, first in Freiburg, then in Magdeburg, and now in Erfurt, have broadened their scope to include other phenomena of deficient word production into their research and modelling. This chapter reflects their present state of insight. Chris Code summarized the strengths and weaknesses of the cognitive approach: Occasionally people find themselves at a loss with cognitive theories, especially when more than one theory or model can be applied to a single symptom complex (e.g., paraphasia, dyslexia) in a given patient, producing different interpretations and predictions. [. . .] Single case investigations were championed in early cognitive neuropsychology, but they have fallen out of favour with some in recent years, although theory development is constrained by data from single cases and their theory-driven investigation. (Code & Wallesch, 2006, p. 821)

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We would like to encourage further model-driven research into the phenomenology of aphasia, and present this chapter as an example of the use of the cognitive approach. For virtually every aphasic patient, speech production is a difficult task. Deficits of single word production affect, to varying degrees, patients with all aphasic syndromes, and have been studied extensively. Frequently, patients show phonological errors by substituting, adding, deleting or exchanging target sounds. It is assumed that, in these cases, the patient has usually been successful in accessing the intended word form, but is, however, unable to appropriately prepare this abstract phonological form for output (e.g., Butterworth, 1992). Other patients already have difficulties retrieving the correct phonological word form from the mental lexicon. The mental lexicon is a long-term store containing entries of a speaker’s words. For written language, an independent orthographic lexicon is assumed, which may be accessed independently of phonological lexical access (e.g., Rapp, Benzing, & Caramazza, 1997). In some models, the word’s syntactic features (so-called lemma information, e.g., syntactic category or gender) are part of the speaker’s lexical knowledge as well (see Levelt, Roelofs, & Meyer, 1999). It is widely agreed that lexical access in speech production is controlled by semantics, a memory system, which has either been fractionated into verbal and other modality-specific parts (e.g., Shallice, 1988) or which may be a single modality-neutral unitary system (e.g., Hillis, Rapp, Romani, & Caramazza, 1990). Evidence for the independent access to semantic and phonological information can be observed in aphasic patients. Often, they indicate that they know an object and can give details on how and in which contexts it is encountered. This suggests that the patient has successfully processed, for example, the picture and that the semantic system is working adequately to allow access to semantic knowledge about the object. Often, these patients can be cued to correctly name the object by giving them the word’s first phoneme or onset (e.g., “ti” for “tiger”). Patients with difficulties accessing the correct word form in their mental lexicon are usually called “anomic” (Goodglass & Baker, 1976). The respective anomia has also been termed “phonological anomia”, or “classical anomia” (Geschwind, 1967). In contrast, difficulties at the semantic level give rise to a condition termed “semantic anomia” (Howard & Orchard-Lisle, 1984; see Nickels, 1997, for a review). The underlying difficulty is assumed to affect the semantic system, either as a consequence of progressive degeneration of brain structures thought to support semantic memory, or as the consequence of a stroke (Hillis et al., 1990). These two conditions may be identified by confronting the patient with other tasks that are supposed to involve the semantic system (e.g., word–picture matching). This “cognitive” approach in neurolinguistics is guided by a set of assumptions, namely that a brain lesion can selectively affect some processing components of the cognitive apparatus while sparing others, and that a

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patient’s performance is based on the formerly intact and now (often selectively) lesioned cognitive structure (e.g., Caramazza, 1984, 1986). The “cognitive” approach has proven most fruitful in revealing the cognitive architecture of language processing. In a careful analysis, a patient’s performance is related to a model of normal word processing, and the functional lesion within this model is inferred from performance in different tasks as well as from variables affecting this performance (e.g., Rapp, 2001; Shallice, 1988). In addition, patients may display dissociations among tasks that are not observed in normal subjects. If such performance cannot be reconciled with existing models of word processing, these models need revision. A patient’s performance may thus, for example, contribute to models of lexical processing (Caramazza, 1997; Dell, Schwartz, Martin, Saffran, & Gagnon, 1997).

Models of word production Most psycholinguistic models of word production have been based on normal individuals’ slips of the tongue (Dell, 1986; Fromkin, 1971; Garrett, 1975) and on reaction time studies with healthy subjects (Levelt et al., 1999). All models distinguish between semantic, syntactic, and phonological information, and most authors conceive of the lexicon as some sort of network. Lexical entries are thought to be nodes in the network that receive activation from other nodes, usually those representing semantic information. In most models, selection occurs when a lexical node receives activation above a certain threshold. However, models differ considerably with regard to the way the respective information is represented and how information at the different levels may interact. Modular models assume discrete, non-overlapping processing and very limited interaction. A successful model of this type has been advocated by Levelt and co-workers (Levelt, 1989; Levelt et al., 1999; Roelofs, 1992, 1997). It conceives of lexical access as a two-stage process. In the first step, a cohort of meaning-related lemmas is activated based on the available semantic information. Lemmas are assumed to be modality-independent representations of a word’s syntactic features. They receive activation from their respective lexical concepts at the semantic level. The lemma that receives most activation is selected from this cohort, and activation spreads down to the next level, the level of word form. Usually, only one lemma is being selected and subsequently activates its corresponding word form. Thus, while lemmas may be activated in parallel, word forms are not. Only in the (rare) cases of near-synonyms, which are very similar in meaning (sofa, couch), does the model allow for parallel activation of more than one word form (Jescheniak & Schriefers, 1998; Levelt et al., 1999). Within this two-stage model, semantic errors are attributed to mis-selection at the lemma level or substitutions at the level of lexical concepts (Levelt et al., 1999). On the other hand, errors of omission are supposed to result


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from a block at the level of word form. As there is no feedback between the word form level and the lemma level, the phonological word form level is not assumed to influence lexical selection, and the two error types, semantic errors and errors of omission, are considered independent events. In contrast with this discrete serial model of lexical access, other models allow for parallel activation of word forms and for an influence of phonological information on lexical selection. Cascading models have rejected the idea of discrete serial processing and allow for parallel processing at different levels of the system, including the word form level (Caramazza, 1997; Humphreys, Riddoch, & Quinlan, 1988). Processing at a later stage may operate despite incomplete information from earlier levels and does not have to wait until processing at these earlier levels is completed. In the model of Caramazza and co-workers (Caramazza, 1997; Caramazza & Miozzo, 1997) the idea of a lemma level is explicitly rejected. Semantic information activates a cohort of meaning-related word forms. Syntactic information is assumed to be represented in an independent network. Another type of model is the interactive model of Dell and colleagues, which assumes a semantic feature level, a lemma level and a phoneme level (Dell, 1986; Dell et al., 1997). It differs from the previous models in that it assumes feedback connections between adjacent levels of representation. Selection occurs at the lemma level after activation has spread between the levels for some time, thus allowing both semantic and phonological information to influence lexical selection. Figure 10.1 provides a sketch of (a) the discrete serial model (of Levelt and co-workers), (b) the cascading model (of Caramazza and co-workers), and (c) the interactive model (of Dell and co-workers). The “nodes” at the semantic level represent holistic lexical concepts in the discrete serial model and semantic features in the cascading and interactive models.

Figure 10.1 Sketch of three different models of word production (see text).

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Variables influencing lexical access In accordance with the postulated levels of processing, a number of variables have been identified that influence processing at the different levels within the system. These variables are important in inferring the functional lesion of an individual. For example, Butterworth (1992) suggested that a frequency effect points to a lexical deficit, while an influence of word length on phonological paraphasias suggests a post-lexical origin. This has been termed the “critical variable approach” (Shallice, 1988, p. 72). It may, however, be of interest not only to investigate the influence of different variables on correct responses but also to investigate the influences of the different variables on the respective errors. In most patients, at least those with phonological anomia, lexical entries are not consistently unavailable. First, providing a cue often helps patients to overcome temporary difficulties. Second, when item-consistency across several administrations of a naming test is assessed, there is usually great variability. Thus anomia seems to affect access to a lexical entry, but not to indicate permanent loss of lexical entries (however, see the case of Howard, 1995). Naming performance has been shown to be affected by a target’s concreteness as well as its familiarity. These variables are thought to affect semantic processing. Concrete targets are supposed to have richer and more robust semantic representations than abstract ones (e.g., “honour”, “faith”). Consequently, patients with semantic impairments are often found to be sensitive to abstractness and familiarity. Furthermore, a word’s syntactic category may determine ease of lexical access. It has often been reported that patients have more difficulties producing verbs compared to nouns (e.g., Miceli, Silveri, Villa, & Caramazza, 1984). On the other hand, patients have been reported who demonstrate selective sparing of verbs or nouns, even in only one modality. For example, Caramazza and Hillis (1991) presented two aphasic patients who seemed to have selective difficulties producing verbs only in the oral or written modality, respectively. Most impressively, these patients also exhibited difficulties producing a homophone when it referred to actions (“to watch”), but not when it referred to an object (“the watch”). Other patients revealed intact access to function words but impaired access to content words in speaking, and the reverse dissociation in writing (Rapp & Caramazza, 1997). One of the most important factors influencing processing at the lexical level is word frequency. It has been reported to affect access to a word’s phonological form. Healthy subjects are faster at producing words of higher frequency (Jescheniak & Levelt, 1994), and aphasic patients are better at naming words of higher frequency than words of lower frequency. This “frequency effect” in aphasia has been taken as a strong clue to a lexical deficit (e.g., Butterworth, 1992). In cognitive models, the advantage for frequent words may be simulated by a lower threshold, which means, the more


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often a word is encountered during everyday life, the lower its threshold and the easier its selection. Some authors have suggested that age of acquisition (i.e., the age at which a word was first learned) is a stronger predictor of ease of lexical access. Age of acquisition is highly correlated with word frequency, but studies carefully controlling for this correlation reported an independent influence of age of acquisition for healthy subjects (e.g., Barry, Hirsh, Johnston, & Williams, 2001) as well as for aphasic speakers (Hirsh & Ellis, 1994). Aphasia may result in temporarily or permanently raised thresholds of the lexical entries. In many cases, then, no entry may receive activation above the threshold level and thus no entry will be selected. In this case, the patient would give no response (see Dell, Lawler, Harris, & Gordon, 2004). It has indeed been demonstrated that patients produce more errors of omission in response to pictures of low frequency words (Kremin et al., 2003). In contrast, semantic errors have been shown to be relatively independent of word frequency. For example, Nickels and Howard (1994) did not find an influence of frequency on semantic errors. They did, however, report an effect of imageability on naming for some of their patients. On the other hand, Caramazza and Hillis (1990) observed that in one patient, RGB, semantic errors were more numerous for low frequency target words.

Semantic neighbourhood Recently, Blanken, Dittmann, and Wallesch (2002) have identified another, relatively neglected, variable that influences lexical access. Semantic concepts differ with respect to the size of the semantic category they belong to. For example, a lemon is part of the relatively large semantic category of “fruits”. In contrast, other items may come from a small or no specific semantic category, such as “cage” or “anchor”. The size of the semantic neighbourhood should influence the chance of semantic errors as, for items from large semantic categories, semantic competition is higher and mis-selections are more likely. Blanken et al. (2002) presented the case of MW, a German globally aphasic subject with relatively preserved oral naming skills. MW’s responses revealed a clear dependency on semantic neighbourhood: With items from large semantic categories, he produced many semantic errors and fewer omissions. In contrast, when a target word was a “low competition” item, the patient showed few semantic errors and more omissions. Under both conditions, the sum of both error types was comparable, indicating that the items did not differ in their overall difficulty. The results were proposed to be incompatible with Levelt’s discrete two-stage model of lexicalization. In this model, both error types are assumed to be independent of each other. Particularly, the number of omissions should not be related to the previous occurrence of a semantic error.

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We tested six further patients with aphasia following a stroke to replicate MW’s pattern of performance. These six patients were part of a larger group (Bormann, Kulke, Wallesch, & Blanken, 2006). Three patients were diagnosed as suffering from Wernicke’s aphasia and three were diagnosed with amnesic aphasia, according to the Aachen Aphasia Test (AAT; Huber, Poeck, Weniger, & Willmes, 1983). They were shown 33 pictures of objects with many and clear semantic competitors and 33 object pictures having few or weak semantic rivals. Both target groups were matched for frequency, age of acquisition, length and normed picture name agreement. The 66 pictures were presented in a pseudorandomized order. Their first response within 5 seconds was scored as correct, omission, semantic error, or other. The average frequencies of semantic errors and errors of omission for both types of items were submitted to an analysis of variance with repeated measures. For the analysis by subjects, error type and item type were within-subject variables. For the analysis by items, item type was a between-item factor, while error type was a within-item factor. Both analyses resulted in a significant main effect for error type, with omissions being more frequent than semantic errors, F1(1, 5) = 10.74, p < .05; F2(1, 64) = 20.76, p < .01. The other main effect, item type, did not reach significance (both F < 0). The interaction of both variables was significant, F1(1, 5) = 9.68, p 72 >72 13 12

Nature of aphasia Non-fluent Non-fluent Non-fluent Non-fluent Fluent Non-fluent Fluent Fluent

BDAE 1 severity 1 2 2 3 3 3 5 5

CETI 2

VASES 3

12.90 23.59 63.25 61.18 73.0 59.50 85.68 94.87

33 22 22 31 37 30 36 40

1 Goodglass, H., & Kaplan, E. (1983). Assessment of aphasia and related disorders (Boston Diagnostic Examination for Aphasia). Philadelphia: Lea & Febiger. 2 Lomas, J., Pickard, L., Bester, S., Elbard, H., Finlayson, A., & Zoghaib, C. (1989). The Communicative Effectiveness Index: Development and psychometric evaluation of a functional communication measure for adult aphasia. Journal of Speech & Hearing Disorders, 54, 113–124. 3 Brumfitt, S., & Sheeran, P. (1999). VASES: Visual Analogue Self-Esteem Scale. Bicester, UK: Winslow.

13 Stroke stories Conveying emotive experiences in aphasia Elizabeth Armstrong and Hanna K. Ulatowska When patients suffer a loss of language, must they also lose their sense of self ? (Oliver Sacks, 2005)

Introduction For many years, Professor Chris Code has worked in both clinical and academic capacities highlighting the impact of aphasia on the individuals involved and their family/carers, and has investigated reactions and “adjustment” to aphasia. He has also mentored many research students and academics, and facilitated the description of aphasia from numerous angles, including linguistic approaches. The current chapter encapsulates both of these areas that he has influenced significantly, addressing the ways in which people with aphasia describe emotional experiences, using a variety of linguistic tools to achieve expression of attitudes, opinions, and feelings. Language as a system of meaning serves many functions, including the conveying of information and the obtaining of goods and services, as well as social bonding and the construction and expression of identity. As one of our most powerful social tools, language enables us to engage other people in our lives and to participate in theirs. In order to do this, we employ a variety of linguistic resources that not only relate our experiences in a factual manner, but also convey our particular stance on those experiences, so that our opinions, feelings, judgements and values are apparent and ultimately negotiable, that is, can lead to dialogue in which these aspects are discussed. We also aim to make our conversation interesting to others, but perhaps most importantly, we also use our language to organize and make sense of our reality (Hydén, 1997). Individuals with aphasia are potentially disadvantaged in all of these endeavours because of their language impairment. To date, studies of aphasic language have predominantly focused on the information-giving function of language, that is, the imparting of relatively concrete information in terms of naming objects or descriptions of pictures. It is the purpose of this chapter to raise issues related to evaluative language and associated linguistic resources,

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and to discuss ways in which they are relatively impaired or preserved in aphasia. We present discourse samples of aphasic speakers analysed from the perspectives of both the nature of evaluative language in aphasia, and its vital role in the expression and construction of identity. We also discuss implications of such discourse analysis that would include taking clinicians and their aphasic clients beyond the realm of factual language in the therapy situation.

Evaluative language The role of evaluative language in social interaction has been of interest to linguists concerned with the role of language in social life for a number of years. In a summary of this work, Hunston and Thompson (2003) suggest three functions of evaluative language: 1 2 3

to express the speaker’s or writer’s opinion, and in doing so to reflect the value system of that person and their community; to construct and maintain relations between the speaker or writer and hearer or reader; to organize the discourse.

In order to achieve these functions, a variety of linguistic and nonlinguistic devices are employed that enable individuals to express their attitudes, feelings and judgements. Labov (1972) cites various methods of evaluation used to “signal salience” of information that is separate from the specific ongoing action involved in the recount. Such information could involve the speaker’s reflection on the action in question, providing direct speech for illustrative purposes, or use of forceful language such as heavily emotive words, intensifiers, superlatives, and comparatives. Prosodic patterns related to evaluative language, including marked changes in volume, speech rate and pitch have also been investigated (Peterson & McCabe, 1983). The importance of evaluative language has been acknowledged in many applied linguistic fields already, including media studies, education, second language learning, and sociolinguistic studies of culturally diverse groups (Biber & Finegan, 1989; Carter & Nash, 1990; Labov, 1972; Martin, 1995; Stubbs, 1986). Its centrality to meaning is highlighted by Cortazzi and Jin (2003), who discuss its role in narratives, noting that “Evaluation is held to be the key to narrative: through evaluation, speakers show how they intend the narrative to be understood and what the point is” (p. 103) and that “the evaluation makes the narrated events reportable, repeatable, and relevant” (p. 105). Labov and Waletsky (1967) similarly point out that it is the evaluative function of a narrative that communicates the meaning of the narrative by establishing some point of personal involvement. Throughout many different genres, speakers articulate who they are through the use of evaluative language. In effect, they are expressing their identity

Stroke stories 197 through providing the listener with an insight into how they view their world.

The role of evaluation in narrative and identity One of the main contexts in which evaluative language has been explored is the narrative. For several years now, there has been significant interest in the field of social science in the function of narratives. This has occurred in relation to the individual’s construction of his or her reality and identity, as shared with others in life stories, as that individual attempts to reflect and “makes sense” of his or her life experiences. Hydén (1997, p. 49) writes: The narrative’s importance lies in its being one of the main forms through which we perceive, experience, and judge our actions and the course and value of our lives. Ochberg (1988, p. 174) also suggests that the stories can actively impact on individuals’ futures: They shape how we conduct our lives, how we come to terms with pain, what we are able to appropriate of our own experience, and what we disown – at the familiar price of neurosis. The role of narratives as a coping mechanism has also been acknowledged through the way we put our emotions into words (Smyth & Pennebaker, 1999). In recent years, medical sociologists and anthropologists have focused on illness narratives in the exploration of how individuals experience and “deal with” disruptive life changes as the result of a variety of chronic illnesses (e.g., Becker & Kaufman, 1995; Faircloth, Boylstein, Rittman, Young, & Gubrium, 2005; Jordens, Little, Paul, & Sayers, 2001; McKevitt, 2000). Re-construction of identity following the onset of chronic illness and in the ensuing years has been of particular interest, and is said to be revealed, among other ways, through the organization of, and the language used in illness narratives (Bury, 1982; Hydén, 1997). Much of the literature on illness narratives to date, however, has focused on illnesses where the person involved has resultant physical changes/impairments/disabilities. Because of the very nature of their impairment (i.e., impaired communication), the stories of people with aphasia or other cognitive impairments have rarely been explored.

Evaluative language and aphasia To date, as noted above, studies of language use in aphasic speakers have largely concerned themselves with factual language. Such language has involved the speaker naming concrete objects and actions, or producing

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discourse dealing with descriptions of pictures, retelling stories or specific practical activities, such as catching a bus, or paying bills. And yet, as mentioned, individuals with aphasia are especially vulnerable to issues of identity change and related psychosocial issues (Code, Hemsley, & Herrmann, 1999; Hemsley & Code, 1996; LaPointe, 2001; Shadden, 2005; Shadden & Agen, 2004) which are often worked through, in other conditions, via language. While clinicians attempt to address such issues with their clients through different forms of counselling, the role of language is often underplayed in this context. Little is known up to this point about how individuals with aphasia talk about their feelings, how their language impairment may compromise this expression, or what resources they employ to work through and assert their “new” identity post stroke. How does their language reflect their psychological state? And how can the clinician access such communication? While studies have reported on attitudes, feelings, and identity issues of people with aphasia (e.g., Kagan & Duchan, 2004; LaPointe, 2001; Moss, Parr, Byng, & Petheram, 2004; Parr, Byng, Gilpin, & Ireland, 1997), the focus of these studies was to elucidate the aphasic experience, rather than to explore the linguistic style or devices employed by the aphasic speakers to convey evaluation. Of the few studies that have specifically used emotive topics to explore the narratives of aphasic speakers, the primary purposes have involved investigation of such cognitive and linguistic abilities of aphasic speakers as their ability to organize and maintain coherence across their discourse (Ulatowska & Olness, 2001), or their ability to convey emotionality as determined by listeners (Borod et al., 1996; 2000). The focus of these studies again, however, has not been on examining the lexical or grammatical resources used to convey the specific emotive content of the narratives or on evaluative language specifically. Nonetheless, it is of interest that speakers with left hemisphere damage have been reported to produce “better” discourse (in terms of overall coherence) when discussing emotional rather than non-emotional topics (Borod et al., 2000), suggesting that the element of emotion may well be a facilitating and hence significant factor for speakers with aphasia. Individuals with aphasia have also been noted to use evaluative language as part of overall text organizing devices (Ulatowska & Olness, 2001). Results from one study to date (Armstrong, 2005) that has undertaken a specific lexicogrammatical analysis of evaluative language in personal accounts of aphasic speakers, suggests that the aphasic speakers involved used fewer evaluative resources than non-brain-damaged speakers. However, this study focused on verb usage in particular, which is only one of numerous resources involved in evaluation.

Aphasic narratives Due to the multi-faceted processes involved in conveying attitudes, feelings, and opinions, including non-verbal and prosodic means, the description

Stroke stories 199 involved in this chapter is obviously not comprehensive or all-encompassing. Rather, the purpose of the discussion is to begin to explore the evaluative language resources available to aphasic speakers, and to suggest potential taxonomies both for describing these resources and for using them in a clinical context. For clinical purposes, such descriptors can provide information on the speaker’s linguistic abilities, supplementing formal test results and other analyses of more structured discourse samples. They can also provide a window into the individual’s psychological state with regard to their perceptions of identity, and ways of viewing the world – vital insights when planning and monitoring therapy goals and treatments. The discourse samples on which the present discussion is based were obtained from corpora collected in Australia by Armstrong and in the US by Ulatowska, Olness, and colleagues, and consisted of people with aphasia discussing what happened when they had their strokes. They varied in time post onset (a factor that will be discussed), and their aphasias ranged from mild to moderate degrees of severity. Amount and intensity of evaluation What is immediately obvious when scanning different narratives is the varying amounts of evaluative language used in each – specific evaluative devices to be described below. People vary in their motivation to evaluate and provide personal and/or emotional aspects of accounts, as noted by previous researchers (e.g., McKevitt, 2000; Moss et al., 2004). Potential factors influencing evaluation include cultural background, personality, gender (although still a controversial issue), as well as, of course, motivation to participate in the study at hand (see McKevitt, 2000, for an overview of these issues). In the case of aphasic individuals, severity of aphasia as well as the amount of time that has elapsed since the onset of the language disorder (potentially affecting memory of the event, or perhaps their cognitive ability to reflect on past events) may influence the kinds of language the speakers are able to use, as well as want to use. It appears that such language occurs on a continuum within speakers’ discourse. At the more emotive end of the continuum is the discourse of a 55-year-old African American woman, SL, who had suffered a stroke 5 years previously. SL provided a narrative rich in evaluation, as she explored her feelings at the time of her stroke. She drew on numerous images throughout, using much metaphoric language to convey her feelings. In the setting stage of her narrative, she recounted the following: Example 1 At that time, in my mind, I could see the picture of the old lady. When I say old, I mean a hundred, a hundred and two or a hundred and five and she was sitting in a wheelchair and she was leaning forward like (speaker leans forward). She was leaning forward and she had nothing

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in her arms, nothing in her arms. And she was dressed and she had a robe on and she was turned to the side or something like this (speaker twists her body). And there was a nurse prancing prancing around in front of her and made a a attempt to feed this lady in her mouth and I pictured that as being me. And I said no no God this can’t be me . . . Such depiction of SL’s mental state at the time provides a detailed example of what Labov would note as external evaluation, where the narrator quotes her feelings at the time, and also her talking to God. There is a suspension of the actual chain of events in the physical realm, while the narrator elaborates on particular feelings occurring to her at the time. Accompanying each such “section” of the record of events, however, is emotive language conveyed with the immediacy of the present tense and said as if the narrator was still in the situation. A different type of evaluation is evident in the discourse of the following speaker, CP (aged 68, 3 months post onset of her aphasia), who provides more detail of actual action related to the onset of the stroke, but who also provides evaluation as the narrative progresses, yet less floridly than the previous example. Interestingly it is embedded in the action in the form of conversational dialogue: Example 2 Well I was scared when I had my surgery and when I had my stroke. I was scared because I didn’t know what had happened to me. And ah, I got up, I tried to get up. But I fell back down and then my daughter em said what’s wrong with you momma. I said, I don’t know what’s wrong. And they said sit down before you fall again. I said, shoot it’s something wrong with me. And they looked at me and said it sho’ is. In contrast to the above, an example of a text containing little evaluation at all is the following from a 70-year-old male, FP, in which he recounts getting to hospital and what happened on arrival. At this point, it was only 1 month since FP had suffered his stroke: Example 3 On the day it happened I got on the Friday morning and just collapsed on a belt at the uh hospital . . . swell . . . (–) – the one . . . Clinician: Westmead? Westmead . . . Westmead. And just waited there until oh well 4 o’clock in the afternoon. And said oh you’ll have just have to wait. And so they waited there and waited. They put it on the bed and keep me there for Saturday, the Friday, the Saturday, the Sunday, Monday and didn’t food me anything. They just more or less . . . give me . . . (–) food no food and that was it.

Stroke stories 201 In this account, there is minimal evaluation. While it must be noted that males in the samples examined tended to use less evaluative language overall than females, similar to other reports (e.g., Holmes, 1998; Page, 2003), further discussion below reveals how FP’s discourse changed over time, although was never as emotive as the females’ discourse. However, a more detailed examination over a larger number of samples would obviously have to be undertaken before any statements regarding the effect of gender could be made. Functions of evaluation Speaker’s attitudes and maintaining social relations between speaker and listener As Hunston and Thompson (2003) note, it is difficult to separate out the different functions of evaluative language, and for the purposes of this discussion and the data being presented, the first two functions as described by these two authors will be discussed concurrently. As noted particularly in the first two examples above, the speaker fulfils the two functions of conveying stance and engaging the listener simultaneously. Other examples expressing the commonly cited fear and the feeling of not knowing what was happening, experienced in the early stages post stroke, also convey the narrator’s feelings, while capturing the listener’s interest by highlighting that this incident was something out of the ordinary, emotional, and significant (“that was a scariery moment; I was terrified; that was the most frightening thing; I didn’t know what had happened to me; what’s the matter?”). In terms of the language conveying the speaker’s psychological state at the time, Frank’s (1995) major stages of illness provide a framework within which to view such examples. Frank suggests that there is a chaos stage in which the individual is in a state of confusion, with things happening around him or her over which he or she has no control; a restitution stage, where the person aspires to return to “wellness” and a previous state of normality; and a quest stage, in which individuals see purpose in their illness and their struggle through the barriers encountered along the way, and see a way forward based on their experience. The above examples of fear and confusion fit appropriately with the chaos stage, while an example of a restitution theme is the following, although it must be noted that the prior text for this speaker involved chaos narrative as well: Example 4 I said I’m handicapped but I will not be but at that moment I saw that picture “I said no.” If it was the devil showing me the way that I was going to be he is a LIAR. HE IS A LIAR. HE’S A LIAR. Because I’m not down yet. But girl that was a scariery moment. I had to make sure I could talk. I was lying in a position flat on the floor. Thankyou Jesus Thankyou Jesus.

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In this part of her narrative, SL resolves not to be handicapped, and shows a fighting spirit, using the religious imagery, as well as imagery of herself not being down yet as if in a fighting context. Another speaker, JB (68 years old, 15 years post onset) said, “Only thing I was thinking about was getting myself together so I could do for myself.” It is of interest, that JB later became a volunteer at the local hospital, working with people with aphasia. Her “narrative” at that time hence became that of quest, as she saw a role for herself in assisting others through the experience and seeing meaning/ purpose in her own experience. Another common theme to aphasic narratives also involved thinking of premorbid status as an independent capable person who is now unable to do the simplest things, and also of the fear of becoming dependent on others: Example 5 I’ve got a college degree . . . two years in the running I was on the dean’s honours list and now I’m back learning first grad math, second grade math. And it’s like my life is just like a wiped off blackboard. (PC, aged 57, 2 years 3 months post onset) Example 6 When I went to hospital I went by myself ah ah I was very independent cause after twenty years you have to be inde you know in ah a displaced housewife you have to be independent and strong and I went to hospital by myself . . . and now I was scare because I was the mother I’m the child and I have you know there’s no one else and my kids and I was their mother like my father was my father you know . . . you were the strong figure . . . and I and I was get caught I would be somebody daughter again I didn’t want to be somebody’s kid because I was so scared. (AS, aged 55, 4 years 7 months post onset) In these examples, again strong feelings are expressed in such a way as to engage the listener beyond the factual account. The juxtaposition of the college degree and learning first grade maths is potent in Example 5, as is the discussion of independence and strength related to being a child again in Example 6. Organization of the text The third function of evaluation, as noted above, is to organize the text in a coherent manner. While numerous other organizing forces exist within discourse, such as cohesive devices, logical connections, and chronological continuity, evaluation is important in maintaining the “point” of the story, and linking relevant points together. The positioning of the evaluation within the narratives is thus of significance in understanding both the nature and the degree of resources retained by the aphasic speaker. For the

Stroke stories 203 non-brain-damaged speaker, evaluation can occur at almost any point in the narrative. For example, Labov (1972) suggests that it can occur towards the end of the narrative, as the speaker provides a summary of the “point” of the story. However, it can also actually interrupt the “action” itself in order for the speaker to talk to the listener more directly, or even for the narrator to engage in reported self-talk (external evaluation). Longacre (1996) notes that evaluation is also effective when associated with the climax of the story. As noted above, the evaluation can also be embedded throughout the narrative via lexical choices that convey certain emotive/attitudinal meanings and/or by propositions that form part of the narrative itself. Organization of these types can depend on linguistic skills (although little has been written on cognitive/syntactic capacity required of each type). The aphasic data discussed here revealed evaluation at various points throughout the speakers’ narratives. Evaluation was noted in some as being part of all aspects of the narrative; that is, the setting, complicating action, resolution, coda, all in the external evaluation mode discussed by Labov, where the speaker temporarily postpones the sequence of events to reflect in some way. Consider the following example involved in the setting (evaluation in italics): Example 7 Um um when I went to the hospital I went by myself ah ah I was very independent cause after twenty years you have to be inde you know in ah a displaced housewife you have to be independent and strong and I went to the hospital by myself and I wanted to find out what I had first . . . (AS) For other speakers, the evaluation was embedded throughout the sequence of events: Example 8 I tried to get up. But I fell back down and then my daughter em said what’s wrong with you momma. I said “I don’t know what’s wrong.” And they said sit down before you fall again. I said shoot it’s something wrong with me. And they looked at me and said it sho’ is. And I tried to write and I couldn’t write and that scared me. (CP) Linguistic devices As can be seen in the examples above, a variety of linguistic devices are employed by speakers to realize evaluative meanings. As complexity can vary within the use of any of the realms of devices described below, it is difficult to defend a sequencing of them in this regard. For this reason, the reader should be aware that the following order of description has no particular significance, and that each of the devices is capable of being used in both simple and complex forms.

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Evaluative words/phrases Explicit evaluative meanings are conveyed in a number of ways in the lexicogrammar, examples of which are found in many of the above quotations. Mental clauses involving mental verbs such as “felt”, “worried”, were used in the aphasic texts, realizing the speaker’s perspective on a particular proposition, person or thing, while descriptive clauses (e.g., “I was scared, something was wrong”) (described further in Armstrong, 2005) also provided evaluation. Word level evaluative meanings were also conveyed through evaluative verbs (e.g., “saddled with”, “flopping”), evaluative nouns (e.g. “a burden”), adjectives (e.g., “funny”, “scared”, “numb”), and adverbs (e.g., “naturally”). In addition, intensifiers (e.g., “most frightening”, “really wanted”) and modal adjuncts (e.g., “unfortunately”) were further resources (for a full account of potential lexical resources, the reader is directed to Martin, 2003). Hence, it is clear that at least at the mild to moderate level of severity, aphasic speakers do retain the evaluative function at the lexicogrammatical level. Even in the presence of clauses that are not syntactically or semantically “correct”, evaluation is obviously present. Consider the following extract from the narrative of a man, MD, aged 60, with a moderate degree of aphasia: Example 9 I know I was gonna be sick some day. I know it. Maybe it was for dreams I did have . . . Anyway I did do cripple. Yeah I did sick it was my head. Ha. I guess I had it for sixty years but I had some fun . . . It is to laugh. I have I am still for fun . . . It is to laugh. I have I am still for fun because I am still alive . . . In this example, lexicogrammatical breakdown is obvious, however the evaluative meanings are clear through both the use of individual words such as sick, cripple, fun, as well as the whole process involved, for example it was for dreams, I did do cripple, I am still for fun. It is obvious, however, that range of wording, when compared with nonbrain-damaged speakers is potentially restricted in the narratives of aphasic speakers (as found by Armstrong, 2001, 2005), depending on both severity and type of aphasia. While aphasic speakers may retain emotive words, they may be of a general/high frequency nature rather than as broad an array as non-aphasic speakers might use. In addition, the more sophisticated devices such as modal adjuncts, adverbs, and intensifiers may indeed be less available to aphasic speakers, as evidenced in the data examined. Repetition Repetition is a frequent and important evaluative device in discourse, performing an emphasizing function. It can occur along a continuum from

Stroke stories 205 the simplest form, where a word or complete proposition is repeated, to the most sophisticated form, in which a proposition is re-phrased either in a literal or metaphorical form throughout the discourse. Repetition is well recognized as a feature of aphasic discourse (Armstrong, 1997; Ulatowska & Olness, 2001). While it can be pathological in the form of perseveration, it may also be a strategic evaluative resource used by an aphasic speaker for the purpose of emphasis. Consider the following example of repetition at the word level: Example 10 In my right hand it really tried to scare me because I couldn’t write. And that was one time I was really scared. And I was scared then to first when they told me I had to have my heart surgery and that really scared me. (CP) The following provides an example of repetition at the phrase and clause level, emphasizing the deep emotion felt by the speaker: Example 11 I thought about killing myself. That was the most frightening thing that ever happened to me. Because I told my supervisor about killing myself. I really wanted to kill myself. (PC) Direct speech As mentioned, one of the devices used by several of the speakers was direct quotes during the narrative, involving dialogue between the narrator and others in the story, and other participants’ dialogues, as well as the narrator’s self-talk. Labov (1972) considered direct speech as being one of the highest forms of evaluation in that it “translates our personal narrative into dramatic form” (p. 396). Ulatowska, Streit-Olness, Samson, Keebler, and Goins (2004) found large amounts of direct speech in personal narratives of good storytellers in African American adults. Interestingly, Ulatowska and Olness (2001) also reported on its use in African American aphasic narratives, where it was used effectively as a means of engaging the listener in a highly emotive and immediate way. While in the examples above, direct speech was used by relatively mildly aphasic speakers, the following example from a more severely affected speaker, GB (aged 47, and 4 years 2 months post stroke) indicates that it is still possible to use this sophisticated device even in the presence of relatively severe aphasia. GB’s language was affected in terms of lack of grammatical complexity and lexical variety (Broca’s type aphasia), with the use of direct speech achieved without completeness of clauses or projection:

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Example 12 “Help me, help me,” I don’t speak. I I am rushed to Memorial, only to Memorial. Um um six o’clock. Tests won’t though. Um thought I was getting better, but no speak. “Help me, help me” no, no I don’t have words. Noon. “Help me please,” I don’t see, I don’t mmmm no sounds. Five o’clock, um, my little brother and, um, Pat, my lifelong friends, okay. And “it’s okay, we’ll we’ll, we’ll get out of your way” and um, “take me home please.” This evocative section reveals restricted lexicogrammatical form, and yet much emotion. The primary way in which this speaker engages the listener here is through the juxtaposition of time elements and direct speech. The direct speech was not projected by a clause stating who said what and yet the meaning is clear. Metaphoric language Metaphoric language is used in a number of contexts (e.g., literature, casual conversation) to engage the listener/reader through imagery. Some but not all of the aphasic narratives included such language. One might hypothesize that individuals whose language was more severely impaired would have greater difficulty with metaphoric language, as it is considered “inherently complex” from both semantic and syntactic perspectives (Halliday, 1994). And indeed, the narratives produced by some of the milder aphasic speakers contained rich imagery. Consider the following examples: Example 13 It was this wrestler or it was like something was pushing down on me . . . and finally I got up enough strength and I gained on him. (SL) Example 14 It’s like my life is just like a wiped off blackboard. (PC) A more severely impaired speaker in our corpus also used a degree of imagery, although the following excerpt is obviously less explicit than the first examples due to word-finding difficulties: Example 15 And a little bandage of brain or something or other went sss and went up in the air. And went down there and went out . . . for keeps. That’s what’s been building back ever since. That’s building up this brain uh . . . up. (FP) Further studies would have to explore the degree to which metaphoric language is impaired in severely aphasic individuals, and whether or not it is

Stroke stories 207 possible to produce at a phrase or even single word level (e.g., using the above example, wrestler . . . pushing down). Change in evaluation over time While it is noted that identity reconstruction is an ongoing process and that narratives can change over time, in the case of the aphasic speaker, time also provides potential recovery of language function and cognitive function, as well as the time to reflect on what has happened. On the other hand, the farther we are from an event, our memory for factual details may deteriorate somewhat. From our corpora, the narrative of one aphasic individual, FP, was examined over a 12-month period at 3-month intervals, in order explore the potential effects of time on aphasic narratives. At the first interview, the speaker FP provided the factual account given above in Example 3. At 3 months post onset, a similar narrative was elicited. In the following months, however, more detail emerged, as well as reflections on his impairments, followed by his progress: Example 16 And uh I just lay there and said very little to anybody. Didn’t say a word and didn’t want to say anything cos I had . . . I couldn’t even speak to anybody. Example 17 I can almost write now . . . normally . . . and speak and I can speak properly. And uh while I’m writing I I get a bit tired in the arms . . . and the hand writing. But uh . . . allright otherwise OK. It must be noted that this speaker’s linguistic resources improved over time in all respects, as well as evaluation. Hence, in this regard, it would appear that FP’s aphasia certainly inhibited his expression of evaluation in the early stages post onset.

Implications From this preliminary exploration, it is clear that while individual variation exists, mildly to moderately aphasic speakers are able to make use of evaluative language to convey their attitudes and feelings, and to use evaluative language in a way that helps to organize their discourse coherently. In this way, they are capable of bonding with, and engaging the listener, as well as using language to express their identity, and to some extent, construct and confirm their own view of reality in their post-stroke context. Severity, as well as factors related to premorbid style, may affect type of evaluation used, although both external and embedded evaluation were evidenced, as well as evaluation as dialogue – all seen in non-brain-damaged discourse. The fact

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that evaluation could be ascertained from incomplete utterances through use of evaluative words and phrases supports the notion that aphasic speakers do not have to be syntactically correct or even semantically accurate in order to convey meaning. However, the samples used for discussion here were limited to mildly and moderately aphasic speakers. Aphasia obviously has the potential to impact on evaluative language use in terms of quality and also the kinds of devices used. The extent to which different severities of aphasia affect/ restrict expression of evaluation will form the basis of future investigations. In terms of the experience of suffering a stroke and being aphasic, it appears that the aphasic speakers in the samples examined conveyed the chaos and, to a lesser extent, the restitutive stages of their illness, as reported in narratives of other populations suffering from chronic illness. The fear, uncertainty and disruption caused by the stroke was obvious in all the accounts, related to both the initial life-threatening situation and potential changes to future independence, as well as ongoing chaos. The importance of verbalizing such emotions has been reiterated throughout the narrative literature, including the significance to the individual in terms of managing life experiences and relationships. Hence, given the strengths noted above, it may well be that the illness narrative, as well as other potentially emotive narratives, may be powerful contexts to be used in clinical and external situations for providing aphasic individuals with the opportunity to express important issues of identity changes experienced post stroke. The narrative may well provide an opportunity for clinicians to engage with the aphasic person in dealing with these ongoing emotions. Concurrently, the emotive narrative provides a meaningful communication experience for aphasic speakers to practise their verbal expression in the clinical situation. In so doing, they gain stimulation for language other than factual expressions involved in typical therapy activities such as naming, or discourse tasks focused on picture description. While the effects of severity and type of aphasia on amount and type of evaluative language used may constitute further studies, non-verbal means of conveying evaluation could also be explored. Longitudinal studies documenting recovery of language function could address some of the issues that complicate the picture in aphasia, such as the impact of the speaker’s psychological state in the early stages post stroke, as well as level of cognitive impairment, affecting such aspects as memory, and ability to reflect. In addition, co-construction of evaluation in dialogue would be an important area to explore in order to further address the social nature of stance and attitude. Such explorations should further elucidate the issues involved in evaluation and its significance for aphasic individuals.

Acknowledgments This project was supported by grants from the following: Department of Veterans Affairs Rehabilitation Research and Development Program,

Stroke stories 209 National Institute on Deafness and Other Communication Disorders, Callier Center for Communication Disorders at the University of Texas at Dallas, Community Partners Program (a collaborative program of the University of Texas at Dallas and Baylor Institute for Rehabilitation). Our thanks to both the institutions and participants involved

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Part III

Clinical considerations

14 Counseling families and adults with speech and language disorders The view from a wellness perspective Audrey L. Holland Introduction The scope of Chris Code’s contributions to neurolinguistics, and especially aphasiology, has been vast. Both as a scientist and as an enabler, through the journal Aphasiology, he has enhanced what we know about both right and left hemisphere language processing, and how to influence it through treatment. He has also been very open to the importance of the so called “softer sides,” that is our understanding of discourse and pragmatics and, finally, the psychosocial issues that surround negative changes in normal language functioning. This chapter has been written to honor that part of his enormous influence on the field. According to the American Speech-Language-Hearing Association (ASHA) Scope of practice (2001) counseling families of children with speech, language, and hearing disorders, as well as adults who have such disorders, is an integral part of clinical responsibility. Counseling is perhaps the most important way we have to help our clients, yet it is likely to be that aspect of practice that most Speech-Language Pathologists and Audiologists feel most uncomfortable about, and are most likely to avoid. There are probably many reasons for this. Our reluctance might be explained by a lack of explicit training. Although we are given a wealth of information concerning potential counseling problems faced by individuals and families with communication disorders, we are not instructed in how to manage them. Counseling is often just tagged on to the end of disorderspecific courses, rather than having a focus as a special art, and a skill that can be learned in a general way, and then burnished by the specific problems evidenced by say, an adult and his family who face the realities of living with aphasia following a stroke. But I suspect there is an additional, probably bigger, reason. Why are we experts in communication so nervous about assuming our counseling role? Most counseling approaches used with communication disorders have been borrowed from a clinical psychology that emphasizes psychopathology and its effects on behavior. This, despite the fact that the counseling problems faced

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by experts in communication disorders do not stem from psychopathology per se, but from some form of catastrophe imposed on individuals who for the most part (even those most likely to be victims of traumatic brain injury) were at least coping with life in a fairly normal way. To my knowledge, our discipline’s reliance on abnormal psychology has seldom been examined, although it might explain why many practitioners feel uneasy with their counseling roles. Most families and individuals who experience communication disorders don’t fit easily into a psychopathological model. Much of what follows stems from my conviction that a more appropriate model for our counseling lies elsewhere; not in what we know about illness and psychopathology, but rather in models that are grounded in wellness. The recent explosion of information and interest in Positive Psychology provides the best example, particularly as it is illuminated by the work of Seligman and his colleagues (e.g., Seligman, 1991, 2002; see also Reivich & Shatté, 2002). In fact, although I have used the word “counseling” in this chapter, I believe the notion of “coaching” as is reflected in the growth of contemporary interest in the phenomenon of Life Coaching, is probably a more appropriate description of our counseling activities. From the vantage point of Speech-Language Pathology (hereafter simply referred to as SLP), it seems to me one of the most appealing aspects of a focus on wellness and positive psychology as a model for counseling is that it fits squarely and comfortably with that aspect of counseling with which we are most comfortable, namely our educational role. In my understanding of Seligman and his colleagues’ work, positive psychology attempts to teach individuals a number of exercises and very specific approaches that they can learn to use daily (or thereabouts) to increase their resilience and optimism (among other things) and that can contribute meaningfully to their leading happier and more fulfilling lives. Our discipline produces good teachers – from helping children to move lateral lisping into more acceptable /s/ production, to re-establishing semantic skills in aphasic adults. To the extent that our counseling can capitalize on our teaching skills, we should be more comfortable with our counseling roles.

What is counseling in SLP? These remarks are limited to working with adults who have communication disorders resulting from catastrophic events and their families; nevertheless, almost all of the ideas I will be discussing also have a place in work with the children and families who seek our help. In what follows, I first define counseling, then I enumerate the disorders that I believe would fall under the rubric of “catastrophic” and provide a very cursory glance at the general problems each presents. I then outline a tentative model for counseling in adult catastrophic disorders. Next, I provide information concerning some basic characteristics of good clinicians, and then briefly digress into a discussion of group versus individual counseling. Then, I finally get back to the initial

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question I raised concerning our professional anxieties about the counseling role. What is counseling? Briefly, counseling is a listening process that is geared to understanding how the world looks to the person being counseled. Once careful listening has increased the clinician’s understanding, counseling moves on to guide the counseled person to express feelings, concerns, anxieties, and so forth. The third aspect of the counseling process involves advising, that is, providing the information people need to hear to help them understand what is happening to them, how to get on with their lives, and to live in a realistic, yet optimistic and resilient fashion. Then comes the most difficult step; helping individuals to translate the information into action that is helpful, satisfying and successful. That is, the goal of counseling is to help individuals and families to live as successfully as they possibly can, despite the intrusion of the unexpected stroke, the unanticipated dementia, the communicationcompromising disorder such as laryngeal cancer, or the sudden and dramatic traumatic brain injury. The major aspects of communication counseling have been well summarized by Webster (1977) as follows: 1 2 3 4

To receive information that the individual and his or her family wish to share with you. To give information. To help individuals clarify their ideas, attitudes, emotions and beliefs. To provide options for changing behaviors.

The intent of counseling in situations such as those encountered with communicatively impaired individuals and their families is to help them: 1 2 3 4 5 6 7

to grieve for what has been lost to understand it as fully as possible to develop coping strategies and increase resilience to make peace with the disorder to make sensible adaptations to it to capitalize on strengths to minimize weaknesses, and to live as fully as possible, despite impairment.

We need to be reminded that, for those of us in this profession, counseling is seldom the general focus. Rather, counseling occurs “around the edges” of more direct treatment. This in no way denigrates its importance. Far from it, it accentuates the responsibility of clinicians to be on their counseling toes at all times.

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Who has these catastrophic conditions? Although individuals who stutter (or their families), or families and individuals who as adults are continuing to cope with autism-spectrum disorders or other developmental disabilities, may have significant counseling needs, this is too big a topic for a brief chapter. It seems sensible, therefore, to focus here on those who have previously been coping somewhat successfully, and whose problems come without warning, creating a crisis. The point here is that before the onset of these conditions, most individuals have been living in relative wellness (even a majority of individuals with TBI). Their problems also have unique, significant, and reverberating effects on families, who are, in the main, largely as unprepared for their unwelcome intrusion as are those who incur the problems in the first place. The most important way to differentiate these disorders and their distinctive needs is based largely on their typical progression and time course. That is, there are different counseling agendas for those who will improve and those who will deteriorate. Make no mistake; all of these disorders are to some degree chronic. However, in large measure, (although not without exception) these two types of catastrophic problems have different implications for the nature of the counseling challenges they provide. The first type of disorder involves chronic conditions that tend to improve, to experience some recovery spontaneously over time, or that change in a positive direction substantially with clinical intervention. These include conditions such as aphasia and right hemisphere cognitive disorders following stroke, laryngeal cancer, operable and non-metastatic brain tumors, some forms of encephalitis, traumatic brain injury and the like. For such disorders, after the initial listening and the information-providing is done, the counseling focus should be on measured and graceful acceptance, on building realistic optimism and resilience, and on coping in a balanced positive way toward living successfully with the disorder. The second type of disorders includes conditions such as dementia, primary progressive aphasia, Parkinsonism, multiple sclerosis, and the particularly challenging disorders of amyotrophic lateral sclerosis and brain tumors such as glioblastoma multiformae, which have an unrelentingly grim prognosis. For these disorders, listening and providing information of course must happen, but the truly challenging counseling responsibility is mutually to work toward acceptance, learning to live the best of what is left of one’s life, and even possibly to deal with some end-of-life issues such as making peace. It is important to add a few words about depression and learned helplessness. Without exception, the problems mentioned above all have the potential for resulting in reactive depression. For disorders that involve brain damage, there is the additional possibility that a concomitant depression, brought about by faulty or disturbed patterns of normal neural transmission, may also occur. Finally, individuals may have come to their present disorder already carrying a suitcase full of depression. Counselors in communication


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disorders lack the technical skills to treat depression, both behaviorally and pharmacologically. But because depression is so likely to co-occur in some form with the catastrophic problems we deal with, it is extremely important for us to be highly sensitive to the problems that forecast it. According to DSM-IV, depression includes mood disorders, lack of zest, unexplained weight loss, sleeping problems, psychomotor problems, excessive fatigue, feelings of worthlessness, statements of futility, and such. When these problems persist, our ethical responsibility is to state our concerns directly and to make appropriate referrals. A useful model Although it has significant shortcomings, a crisis model, particularly as Webster and Newhoff adapted it (1981), can be useful for understanding the process whereby individuals can learn to deal with catastrophic events. First developed by Elisabeth Kubler-Ross for dealing with grief, death and dying (1969) it has been useful with many chronic health issues as well. Webster and Newhoff discuss the relevance of crisis to families and individuals following stroke. Specifically, four stages are postulated to occur as individuals progress toward healthy resolution. They are, in order, Shock, Realization, Retreat, and Acknowledgment. Not all individuals go through all stages, and not all individuals actually reach satisfactory acknowledgment (more on this below). Nevertheless these stages set the tone for what are the important counseling parameters for SLPs to keep in mind as they conduct counseling related to communication. Following are some examples. Soon after an aphasia-producing stroke, neither families nor aphasic individuals are in a particularly good position to take advantage of the information we might have to offer them concerning aphasia and its aftermath. I am aware that good clinicians almost without exception provide such information. Nevertheless, someone like me (who is unlikely to see aphasic individuals until they complete their course of formal rehabilitation) almost always hears that things weren’t explained, that individuals and their families had no idea what to expect, and so forth. This happens because early shock pretty much precludes the ability to absorb new information. This does NOT mean that we should stop providing it in the most acute stages, probably in writing and for placement on fridge magnets and the like, to be consulted later. But it DOES mean that the first of Webster’s (1977) counseling functions probably should be primary. Listening to what people wish to share, to their fears about the future and such, and simply holding hands and being there is what matters then. And only after some realization about what this problem might actually be, can information be productively used. (For a detailed look at an approach to aphasia management in the acute stage, readers are referred to Holland & Fridriksson, 2001.) Although retreat seems to me to be the least universal of these crisis stages, we must be aware of the delicate nature of denial, and the need to deal with it

218 Holland clinically should it occur in the individuals we work with. A common finding in our clinic for individuals with chronic aphasia is that when families of those who are newly discharged from rehabilitation complete the required Communication Effectiveness Index (CETI) (Lomas, Pickard, Bester, Elbard, Findlayson, & Zoghabib, 1989), their scores are substantially better than they will be the next time they do the CETI, after they have lived with the disorder for a longer period of time. This is an issue for gentle and careful family counseling. Acknowledgment is not a synonym for “giving up.” It is recognizing where one is, making room for one’s changed condition, and ideally moving on with life. Ram Dass, who finished his book Still here, after a stroke resulted in aphasia and hemiplegia, eloquently described his experiences, and the good that resulted from them. He notes (2000, p. 185): The stroke was like a samurai sword, cutting apart the two halves of my life. It was a demarcation between the two stages. In a way, it’s been like having two incarnations in one; this is me that was “him.” Seeing it that way saves me from the suffering of making comparisons, of thinking about the things I used to do but can’t do any more because of the paralysis in my hand. In the “past incarnation” I had an MG with a stick shift, I had golf clubs, I had a cello. Now I don’t have any use for those things! New incarnation! Mezirow (1991) has written extensively about the role of transformative learning in adults, producing evidence that many individuals go through what he terms “disorienting dilemmas” that cause them to re-evaluate, reflect critically, find out that they are not alone, and for many, restructure the meaning of our lives. This is the sense of acknowledgment that counseling should strive toward, if not always achieve. What are the characteristics of a good SLP counselor? Robert Crum, a child psychologist with extensive experience in working with children and families with communication disorders remarked to me recently (personal communication, October 2004) that in his view, SLPs were masters at presenting relevant information, but that their other counseling skills were not nearly as highly developed. I agree. In our training curricula, counseling and interviewing often are approached together. This makes it almost a given that we should see their respective roles as more overlapping than they actually are. In addition, we learn early on that we must communicate as much of our expertise as possible to our clients. Along the way, we forget that we are only one of the “experts.” Along with the individual whose expertise is living inside the problem, and those whose expertise is living beside the problem (i.e., the family), we bring the expertise of “the one who has seen many such.”


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But we have not lived it. Exquisite awareness of the three sources of expertise is one characteristic of the successful counselor. There are others, of course. I believe that the next most important clinical skill is the ability to be a good listener. (Luckily, listening well is a learnable skill.) Good listening comes in many forms, including affirmative and supportive listening, reflective listening, and critical listening. It involves sensitivity to both a message’s manifest (surface) content and its latent (deeper emotional) content, and whether or not these two message levels are in agreement. Often, insights result from our ability to listen, not only with our ears, but with our eyes as well to non-verbal features of communication including prosody, intonation and body language. Counseling skills also include our own words and body language. Some technical skills consist of a variety of learnable techniques, such as how to reflect what someone is saying, knowing how to ask appropriate questions, communicating support and affirmation verbally. Because I am an active and involved counselor, as opposed to a neutral and passive one, I also come down on the side of providing advice, but giving it tentatively and from my outsider position, as noted above. And we also must capitalize on our information giving skills. As Crum (personal communication, October 2004) suggests, we need to know what is relevant and what is acceptable to a given client about issues ranging from what can be expected over the next few years concerning a disorder, to how to get the most from services available in the community. As a counselor, I try very hard to communicate in every way that I am consistently “being there,” as a helper, an advocate, and as, simply, a listener. Next, I believe that competent SLP counselors know who they are.1 They know their strengths, and what things are not within their basic competencies. This puts them in a position to work with clients from their own strengths and capabilities. I firmly believe that a major reason for my being a good counselor is that I know pretty well who I am, and how to capitalize on it when I counsel. Finally, in an overarching way, good counselors must be optimists who like people, enjoy challenges, know and accept themselves, and communicate their positivity. Group vs. individual counseling A few words about the manner in which counseling is conducted seem to be in order. Whether to choose a group or an individual format seems to me to largely be a matter of mutual choice, agreed on by the counseling clinician and those being counseled. I personally gravitate toward group work for a number of reasons. First, given my earlier comments about who are experts, it seems likely that when there is more than one of those other experts around, there should be a lot to share, thereby greatly increasing the extent of expertise in the room. Second, as Mezirow (1991) points out, social interaction greatly enhances the likelihood of transformative learning. Third it is

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cheaper and more practical, often bringing the group within the reach of individuals who otherwise would not be able to afford counseling. But should individual counseling be the order of the day, then I think the clinician has increased responsibility for sharing what has been learned from working with others and being a surrogate expert. And, it must be added, frequently our counseling of individual clients occurs “around the edges” of more direct therapy. I also prefer family groups and groups for individuals who have the disorders to meet separately. I have learned the value of this over the years, mostly from the people I have worked with. The focus of combined groups almost invariably settles on the individual with the problem, with family needs going by the wayside. And this seems to occur despite the fact that family members dominate the talking time.

Concluding comments This has been a cursory review of counseling issues for clinicians dealing with adults and families who have neurogenic communication disorders. It is not a clinical roadmap; rather it attempts to point out the major counseling issues for these people, and to provide a rationale for treating them. The most important underlying message (the latent one) is that professionals in this field must take their counseling responsibilities seriously, and that counseling individuals with neurogenic communication disorders is among the most important things we do to influence individuals in their return to their everyday lives.

Acknowledgment A version of this chapter appeared in the newsletter of the California Speech and Hearing Association in Autumn, 2005. I am grateful for CSHA’s permission to expand on and modify it here in honor of Chris Code.

Note 1 A number of self-inventories are useful to clinicians. These include the MyersBriggs and the Values in Action (VIA). A form of the Myers Briggs can be taken on the Internet at www.Humanmetrics.com and the VIA can be taken at www.Authentichappiness.org

References American Speech-Language-Hearing Association (2001). Scope of practice in speechlanguage pathology. Available as pdf file at www.asha.org Holland, A., & Fridriksson, J. (2001). Management for aphasia in the acute phases post stroke. American Journal of Speech-Language Pathology, 10 (1), 19–28. Kubler-Ross, E. (1969). On death and dying. New York: Macmillan.


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Lomas, J., Pickard, L., Bester, S., Elbard, H. Findlayson, A., & Zoghabib, C. (1989). The Communicative Effectiveness Index: Development and psychometric evaluation of functional communication measure for adult aphasia. Journal of Speech and Hearing Disorders, 54, 113–124. Mezirow, J. (1991). Transformative dimensions of adult learning. New York: Wiley. Ram Dass (2000). Still here. New York: Riverhead. Reivich, K., & Shatté, A. (2002). The resilience factor. New York: Broadway Books. Seligman, M. (1991). Learned optimism. New York: Knopf. Seligman, M. (2002). Authentic happiness. New York: Free Press. Webster, E. (1977). Counseling with parents of handicapped children: Guidelines for improving communication. New York: Grune & Stratton. Webster, E., & Newhoff, M. (1981). Intervention with families of communicatively impaired adults. In D. S. Beasley & G. A. Davis (Eds.), Aging: Communication processes and disorders. Orlando, FL: Grune & Stratton.

15 Cultural dimensions of aphasia Adding diversity and flexibility to the equation Claire Penn

The cultural context in which assessment and therapy take place provides probably the most powerful explanation for many of the features of aphasia the clinician encounters and is the key to most aspects of therapy and longterm outcome. Certain sociocultural contexts provide a unique opportunity to examine recovery in aphasia. This chapter presents some evidence and some insights regarding the cultural dimension of aphasia, and proposes some implications for assessment and intervention. Though the evidence I draw on is based on my experience in South Africa, I believe that in the context of globalization and with increasing diversity in every clinician’s caseload, there are some clear universal principles that emerge. I argue that: 1 2

3

Multilingual persons with aphasia use the tools in their linguistic repertoire differently and respond to aphasia in different ways. There tends to be a very fine, often indiscernible, line to be drawn between pathological and normal language in the context of natural language use. Narrative discourse provides at the same time a culturally relevant assessment tool and an opportunity to explore the complexity of language and its use, a window onto cognitive and pragmatic processes and an genre for meaningful intervention.

The context of practice that I draw from is South Africa, in which 11 official languages are acknowledged but in which many more languages and regional variations exist, where practically every inhabitant is bi- or multilingual, where there is daily interface of languages, and where language use is coupled strongly with sociopolitical identity. This situation has necessitated the development of methods of assessment and intervention for individuals with speech language pathology that are not based on the western model. It is not appropriate for example to approach a rural illiterate Zulu-speaking aphasic patient with an item from one of the well-known aphasia tests: “Roses are red and violets are. . .”. Neither is it

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appropriate to assume that a traditional one-to-one model of aphasia therapy will work in a situation characterized for the most part by lack of resources, lack of access, and poverty. However I argue that being aphasic in a multilingual context such as South Africa may not be altogether bad. In fact the nature of language use in that society may well provide a scaffolding framework for compensatory strengths to emerge in the presence of language pathology. It would seem that certain tasks and certain analysis frameworks allow highly significant cultural features to emerge, which have strong implications for the clinician and shed light on language processing in general. This chapter proposes that a number of the stylistic and syntactic aspects to be seen in the discourse of such aphasic persons reflect the compensatory efforts of a group whose sociolinguistic status (marked by diverse daily interface/contact) provides well-rehearsed shift strategies. Those individuals with aphasia therefore have a particularly well-stocked armamentarium of strategies for deployment during conversational interchange. Underlying much of my work is the basic premise that aphasic language is about compensation. It has long been recognized that many of the behaviours we see in aphasia are not necessarily aphasic symptoms, but the adaptation of the organism to the primary deficit. Goldstein for example in 1948 said: “The aphasic patient has to achieve a condition which allows him to react as well as possible to the tasks arising from the environment” (p. 21). Such compensatory explanations of aphasia are frequent in explaining aphasic symptoms, and in bilingual patients and in specified sociocultural contexts these compensatory behaviours may play out in a very specific and interesting way. The prime evidence that I will draw from in this chapter is Afrikaans. This is one of the languages unique to South Africa that has a relatively short history, yet ironically is one of the most studied and documented. It existed much in today’s form from about 1850, and was given legal recognition in 1925 when it became the language of the church and government. It is a language that is diverse in terms of region, dialect and social class, originating not only from the Dutch used by the seventeenth-century settlers in South Africa, but also having features of Malay, Portuguese, Khoin, French and German as well as English (Combrink, 1978; Roberge, 1995). This is the home language of a large number of people in South Africa (7 million) and until recently was the medium of education for a number of non-first-language speakers (Kroes, 1978). Viewed as the language of the oppressor for many years, it has been the topic of extensive debate among politicians and educationalists and in the formulation of the language policy of the new South African government. There is distinct dialectal version of Afrikaans that has developed in a group of mixed racial heritage, largely resident in the Cape Province. This community developed through events of Dutch colonization in the seventeenth century and the interaction between the settlers and the indigenous people of the Cape. There are estimated to be more than 3 million users of

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Cape Afrikaans, which differs from the language of standard Afrikaans speakers in a number of different ways. These have been highlighted by van Rensburg (1997), McCormick (1989, 1995) and others, and include differences in phonology, lexicon, syntax and stylistic variables. The codeswitching and code-mixing1 that have been documented extensively in this dialect reflect important sociocultural factors. The strong oral tradition of this group, as well as its unique dynamic position in society, account for some of these aspects, including “intensive linguistic exchange” (McCormick, 1995, p. 204) and language contact factors with a very strong effect of English, often spoken to children in the home and at school by second language speakers. Little work has been done on aphasia in Afrikaans, but given what we know about the structure of Afrikaans and its origins, areas particularly susceptible to aphasic breakdown for agrammatic patients at least are the verb and operations surrounding the verb movement. Extrapolating from the extensive and explicit work of Kolk, Heling, and Keyser (1990) and Batsiaanse and colleagues on Dutch aphasia, verb movement and retrieval difficulties as well as problems with prepositions and articles and sentence embedding would be anticipated (e.g., Bastiaanse & Jonkers, 1998; Bastiaanse & van Zonneveld, 1998; Edwards & Bastiaanse, 1998; Vermeulen, Bastiaanse, & van Wageningen, 1989). Much of the cross-linguistic work that has been done has been based on tasks that are sentence or clause based, including picture and sentence matching, sentence completion and anagrams. However the impact of the task strongly influences the accuracy and nature of the language obtained, and there remains a scarcity of studies at a discourse level, especially for the person with mild aphasia. This genre is a particularly fruitful one in any group (such as those in South Africa) where literacy is limited, especially in older members of society for whom oral narrative is a strong tradition. This chapter thus focuses on some specific linguistic structures that are particularly prevalent in the discourse genre. Selecting these aspects serves to illustrate the close connection between linguistic and pragmatic factors in aphasic breakdown. Studying them in the two languages of bilingual subjects and in aphasic and control subjects provides the opportunity to separate out normal from compromised processes, and to examine compensatory strategies operating that are independent of or dependent on specific linguistic factors in discourse. Some pragmatic and syntactic findings provide interesting insights not just for the bilingual patient, but for, I hope, aphasia in general.

The evidence A series of studies have been undertaken on the narrative discourse of bilingual persons with aphasia in South Africa and matched controls (Archer, 2006; Kalmek, 2001; Nabeemeah, 2002; Venter, 2000; von Bentheim, 2001). The goal of the research has been to examine the connected language of


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bilingual persons living in a multilingual context in order to better understand the cultural influences on aphasia, and to determine ecologically valid assessment and therapy approaches. Participants We now have data from 62 bilingual participants, 31 people with aphasia and 31 matched controls. All aphasic participants were right handed and developed aphasia as a result of a single CVA. They had to be a least 3 months post onset of stroke and were rated as having a mild to moderate degree of aphasia on the Western Aphasia Battery (WAB) (Kertesz, 1982; adapted for language and culture). Participants with severe aphasia were excluded from the study, as the task involved connected language. Participants were also required to be under the age of 69 years with at least 7 years education. Control participants who had no history of neurological or psychiatric problems were matched for age, gender, language, cultural group, education and occupation. An adapted version of Paradis’ bilingualism questionnaire was administered to each participant (Paradis, 1987) to ensure the language status of this group and to document patterns of language exposure, current contexts of language use, patterns of acquisition, family and educational language patterns, and differential recovery patterns. The participants were tested in both their languages on the same tasks by linguistically and culturally matched individuals on separate days. Tasks and analysis framework A range of narrative tasks were employed, following the protocol of Ulatowska and her colleagues (1993, 1998; Olness, Ulatowska, Carpenter, Williams-Hubbard, & Dykes, 2005). We used picture description, picture sequence, the narrative of personal experience and a fable task. In line with the framework of Ulatowska et al., our analysis included a range of measurements. Productivity measures included calculation of narrative length, proposition analysis, T-units, words per T-unit, and error analyses. A number of lexical and syntactic aspects were also examined, including verb and word order aspects which will be considered here. Quality of narrative was measured using a 5-point rating scale. This was based on the work of Labov (1972, 1984) and included the dimensions of Relevance, Character, Supporting description and Ending. The ratings were conducted by culturally matched speech-language pathologists from the Cape community. Three raters reached acceptable agreement on these measures. The analysis also examined specifically the presence of “ethnic discourse markers” described as features particular to a certain cultural group, as well as a range of stylistic and pragmatic devices including code-switching, repetition and evaluation.

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Results The findings of some of this research have been published in detail elsewhere (Ogilvy, von Bentheim, Venter, Ulatowska, & Penn, 2000; Penn, Venter, & Ogilvy, 2001). In this chapter I focus primarily on the narratives of personal experience from the bilingual Cape Afrikaans group (with 14 participants), as the particular nature of their data seems to highlight particularly well the essential challenge of differentiating normal features of discourse, cultural markers and stylistic markers from frank aphasic errors. A summary of the main findings appears in Table 15.1. Productivity measures The productivity measures for the aphasic participants and the controls for their narratives of personal experience in Cape Afrikaans are summarized in Table 15.2. These results reflect group means but exclude, where relevant, A2 whose very lengthy sample (1288 words) rendered him an outlier. In general the control subjects produced longer narratives with a greater number of T-units. The mean length of the narrative for the aphasic sample was 167 words (range 83–285), indicating generally a shorter and more diverse sample size for the aphasic group than for the controls, whose range was 226 to 512 words. This difference was found to be statistically significant (Mann Whitney U test, U = 5.0, p = .22). The numbers of T-units and propositions were comparable when the sample of A2 was included in the tally of the means, but were significantly fewer for aphasic subjects when S2’s sample was excluded. This is similar to the findings of Olness, Ulatowska, Wertz, Thompson, and Auther (2002) who found a lower number of propositions in their aphasic African American group. Table 15.1 Summary of narrative findings in a group of bilingual Cape Afrikaans speakers with and without aphasia • Control samples longer than the aphasic samples in both languages tested • Fewer complex or non-canonical sentence forms in aphasic samples in both languages • Evidence of wider verb variety and complexity in control than aphasic samples • More evidence of verb errors (aux omission) in aphasic samples, and incomplete sentences • Some tense shift patterns distinctive in aphasia • Equivalent evidence of dialectic features and ethnic markers in aphasic and in normal samples (in both English and Afrikaans) • Some marked qualitative/coherence rating differences between aphasic and control samples in temporal sequencing • Qualitative differences in evaluative elements • More language alternation in aphasic than control narratives • Less language alternation in English than in Afrikaans narratives


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Table 15.2 Group data for productivity measures in Cape Afrikaans (means) Variable

Aphasic participants (n = 7)

Controls (n = 7)

Number of words*

167 SD = 122.31 28 SD = 14.81 9.16 25.3 SD = 11.7 2.0 SD = 0.37 0.52 SD = 0.27 0.44 SD = 0.17 0.3 SD = 0.11 27.5 SD = 10.58 16.7 SD = 5.82 0.53 SD = 0.22 0.86 SD = 0.23 0.12 SD = 0.076 24.71 SD = 37.69 38.33 SD = 17.9295

316.57 SD = 111.98 38.26 SD = 12.57 10.23 31.7 SD = 11.6 2.24 SD = 0.28 0.47 SD = 0.27 0.4 SD = 0.14 0.2 SD = 0.11 50.86 SD = 21.42 26.6 SD = 8.66 0.54 SD = 0.13 0.88 SD = 0.19 0.18 SD = 0.09 18.57 SD = 6.425 69.42 SD = 25.178

Number of propositions* Words per T-unit Number of T-units* Verbs per T-unit Auxiliaries per T-unit Tense shift per T-unit Copulas per T-unit Tokens* Types* TTR Tokens/T-unit Subordinates/T-unit* Verbs–verb tokens Number of verbs*

Note: * indicates significance without outlier.

Because of the wide variation in sample size, direct comparisons of other productivity measures were possible only through ratios expressed in relation to the T-unit. The mean length of the T-units was 9.16 words for the aphasic subjects (range 7.5–12) and 10.23 for the control subjects (range 8.3–14). This was not statistically significant. The mean number of verbs per T-unit was also found not to differentiate groups. However, the total number of verbs, the number of verb types and tokens, and the number of subordinations per T-unit were significantly higher in the control sample and this is discussed in more detail in the following section.

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Syntactic features In general there were more frank errors and a higher presence of incomplete and minor utterances in the aphasic samples. There were fewer complex or non-canonical sentence forms in aphasic samples in both languages, and there was evidence of wider verb variety and complexity in control than in aphasic samples. There was lower diversity of verbs and more evidence of verb errors (auxiliary, shown as “Aux” omission) in aphasic samples, as well as of incomplete sentences. Disrupted auxiliaries were found in aphasic samples only and took various patterns. Auxiliary doubling was found as in the following instance: Maar ek het nog altyd gebid het But I always prayed Other examples show Aux omission, for example: Ek veld loop I walk field Ek op die plaas gebly I lived on the farm Ek gele in die bed I lie on the bed The sample of one participant with a moderate (rather than mild aphasia) was interesting as she had more frank syntactic problems. Interestingly her difficulties with the auxiliary are manifested in each attempt at use. In her narrative of personal experience, for instance she produced 12 T-units, 9 of which were complete and 3 of which were inaccurate or abandoned attempts. All these false starts related to the management of the past tense auxiliary: Aux omission:

Ek ge- gedink hy gaat my klap (omission of het) I thought he would hit me

Incomplete Aux: Ek het ged gedink (incomplete) . . . Ek was baie bang I thought . . . I was very scared (arguably changed from Aux to copula form) Abandoned Aux: Ek het die man wat vir my geslaat het so — I (past tense Aux) the man who hit me so — (abandoned, presumably because of processing demands induced by syntactic complexity/embedding)


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The rest of her verb use consists of copulas and the use of historical present tense. Other errors noted in the aphasic sample included (1) omission of aux “het” and marker “ge” but maintenance of the past tense word order: A2

Ek veld loop (Target Ek het in die veld geloop) I walk in the veld Ek op die plaas gebly (Target Ek het op die plaas gebly) I lived on the farm Ek het hospital twee jaar agt maande (Target Ek het ?in die hospital twee jaar agt maande gewees) I was in hospital for 2 years and 8 months

(2) Using the past tense marker ge- (rather than the auxiliary plus -ge) to denote past: Ek gelê in die bed (Target Ek het in die bed gelê) I lay in the bed Other syntactic aspects were common to both aphasic and control samples in Afrikaans. Those common to both have been described as “syntactic convergence features” and are a documented feature of Cape Afrikaans (McCormick, 1995). Word order changes/verb movement Afrikaans samples were examined for the presence of English word order. This optional change to subject–verb–object (SVO) from subject–object–verb (SOV) in Afrikaans is often triggered by a specific main clause verb type (I know, I think, I see) and by the use of the copula in the subordinate clause. Also, following the verb complementizer wat (what/which) in Standard Afrikaans will require verb to be in clause final position. In Cape Afrikaans an optional rule allows the verb to precede the object; for example: A2

En ek sien hier staan ’n ry trokke And I see here stands a row of trucks Dink ek iets is darem nie reg hier nie is I think something is really not right here

Versus the following examples where verb final position is kept: Ek dink ek gaan darem nie so na aan hom draai nie I think I will really not turn so close to him

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Penn Ek het gedink ek gaan nou nooit weer uit die hospitaal uit kom nie I thought I would never again get out of hospital Ek dink toe en ek wil gaat na haar toe met ’n bos blomme I then thought and I wanted to go to her with a bunch of flowers A6

Miskien my spraak gaan weg Perhaps my speech would go away

Such examples were found in both aphasic and control subjects, and variation was found within subjects, so reinforcing the dialectal nature of this shift. The presence of English word order in the Afrikaans sample, while not exclusive to the aphasic samples, seemed more prominent among these, and has some important clinical implications. A large body of literature has demonstrated that aphasic patients have problems processing sentences in which the order deviates from the canonical one (Thompson, Lange, Schneider, & Shapiro, 1997). There are interesting therapeutic implications arising from this, suggesting that SVO therapy may be more effective than SOV therapy, or that when there are optional contexts (seen in normal production), these should be identified and reinforced in therapy (using for a starter, I know, I think, I see verbs). Post-verbal expansion frames should also be supported. There are some very promising results from therapy programmes that are verb focused and are sensitive to the processing demands imposed by certain syntactic operations (Mitchum & Berndt, 1994). An examination of tense-shifting in the samples proved this to be an interesting and related phenomenon. Tense-shift occurred regularly in the narrative samples in both aphasic and control samples. The aphasic samples showed errors in the verb specifically at these junctures, suggesting that this is a “danger point”, and possibly a focus of therapy. None of these errors were observed in the narratives of the control participants. Shifting to the present tense in Afrikaans reduces verb complexity, and avoids word order and morphological changes. It is associated in narrative with the use of the historical present as well as direct speech. The conversational historical present is a stylistic device that adds a theatrical component to a narrative (Wolfson, 1978). It also conveniently obviates the necessity for past tense which, as the above examples demonstrate, has processing costs particularly in Afrikaans. The fact that it was found more frequently in the aphasic than the control subjects suggests that verb variety and complexity was a choice for the controls but not always a possibility for the aphasic speakers. One of the participants showed a unique effect: use of present tense for the entire narrative in Afrikaans and the past tense for the same story in English. This is perhaps a reflection of complexity of past tense in Afrikaans. While this device occurred in the English samples it was less frequent. An example of both of these aspects is provided from an English narrative:

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And on my way back, well I was on foot, I have to walk home. And suddenly I hear something behind me and I know things is not good for me because we live in crime, we live in lots of things. And I said to myself “Wow terrible things is going to happen!” Then I start walking faster but my heart was start doing this and I was feeling real ice. I was real scared and I said to myself “If home can just be very near me now.”

Quality aspects of discourse Coherence A coherence rating was undertaken for all the transcripts using a 5-point rating scale for Temporal organization, Relevance, Character, Supporting description and Ending. As Figure 15.1 suggests, a marked difference was found between the coherence of the narratives of the aphasic subjects and that of the controls in clarity and temporal sequencing. The clear difference between the coherence of the aphasic and the control narratives is markedly in contrast to some of the productivity and complexity measures utilized in which often no marked differences could be found. This finding has important implications both for assessment and for therapy and seems to reflect the sensitivity of narrative discourse not solely to linguistic factors but to cognitive and social aspects as well. Ethnic markers In the transcripts there were some examples of lexical items typifying this dialect and the retention of some old forms of Afrikaans (probably reflecting the age group). These included words such as Kooi (bed), daai (the demonstrative “that”), gaat (for gaan (go)) and Slaat (for slaan (hit)).

Figure 15.1 Coherence ratings for narratives of aphasic and control participants.

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There are many examples of loan words in the samples, mostly from English, reflecting the high contact patterns between languages in the Western Cape region of South Africa. Examples of loan words were found in most word classes including nouns, conjunctions, adjectives, verbs and adverbials (see Appendix 15.1) (Branford & Claughton, 1995). Dialectal aspects were also features in both aphasic and control samples, which included, in Afrikaans, regularizing of irregular past tense, shift from SOV to SVO triggered by specific verbs, topicalization, and reduplication. In the English transcripts, ethnic markers included deletion of contractible forms of “be” and “have”, changes in number concord, deletion of past tense marker “-ed”, deletion of adverbial suffix and preposition substitution, confirming features of the dialect documented by McCormick (1995) and others. Stylistic and pragmatic factors Certain stylistic features have been identified as enhancing the properties of narrative, and the narrative genre has been found to yield a high number of such elements (known as evaluative elements) that help to dramatize a story and provide it with a speaker’s particular structure and “flair”. Also known as “intensifier elements” of the narrative, they convey the narrator’s feelings about characters and events and include ritual utterances, phonological intensifiers, lexical items, repetition and gesture, comparatives, syntactic devices such as ellipsis and topicalization, as well as direct quotations, asides and sound effects (Chafe, 1982; Dorian, 1997; McCormick, 1995; Wolfson, 1978). Labov (1984) suggests that evaluative devices are used to direct discourse to the intended audience. Those with well-developed discourse competence will be able to select a level of detail within which to cast ideas, highlight certain aspects to make the story understandable or exciting, and alter sequences and shift perspectives to portray feelings of other participants. They are closely linked to the ethnic markers identified and it is probably not appropriate or feasible to differentiate them, especially in Cape Afrikaans. Though evaluative features were present in both aphasic and control samples, there were differences between the control and aphasic groups in this regard, with more frequency and diversity of such narrative elements occurring in the control group. In the data we found rich examples of such devices including ellipsis and topicalization, the use of ritual utterances, comment clauses, expressive phonology, direct speech, repetition and enactment. Examples of these are provided in Appendix 15.1. Direct reported speech is a fascinating feature of narrative that occurred frequently in the samples. It has a strong pragmatic function serving as a stylistic device that enriches a narrative but can also be regarded as a well-documented simplification strategy mechanism to avoid tense shift and embedding, exploited fairly frequently by aphasic persons (Hengst, Frame, NeumanStritzel, & Gannaway, 2005; Penn, 1987). Further it has been considered as a


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powerful measure of the degree of bilingualism and is often foregrounded by a language switch (Dorian, 1997). Many examples of reported speech were found in both aphasic and control samples, and in both of the languages tested. One of the most delightful is the following, which also illustrates the relationship between direct speech and code-switching: En ek se vir hom “Ek wil Kaap toe gaan” Hy se. “Eish but you’ve just missed the train”. “Ah uh”. Hy se vir my “But you are not alone”. Maar ek is alone. Ek se vir hom “Of course I’m alone. Daar’s niemand by my nie. I’m not alone!” Wilkinson, Beeke, and Maxim (2003) and Goodwin (2003) comment on the pragmatic function of enactment, which is used to describe and report events: a demonstration of what participants did or said rather than a description of the event. This typically involves using direct reported speech as an index of change of voice/footing shift as in the example above. These authors demonstrate the evidence from aphasic conversational samples of how persons with aphasia use such enactment in a distinctive way to deal with the contextual demands of conversation – to describe events and actions and enabling the presentation of the past and future in the here and now. Direct speech used in combination with intensifiers (as discussed above) including expressive phonology, repetition, gestures, quantifiers and proforms (which only derive meaning in context), enables such enactment to occur. Given the strong cultural correlations of such enactment, this suggests a powerful medium of therapy especially for more moderate to severe cases of aphasia. Repetition Repetition has been identified as an ethnic stylistic feature (e.g., in the discourses of African American individuals) but also as an aphasic strategy (Ulatowska, Streit-Olness, Hill, Roberts, & Keebler, 2000). One might predict that repetition/reduplication might appear more frequently in Afrikaans aphasic samples, first because reduplication is a feature of the dialect, and second, because it is well documented as a compensatory and stylistic device Repetition was found in all samples (English and Afrikaans) and as the examples illustrate, has an obvious stylistic function. However repetition seemed to occur more frequently in the aphasic groups and is probably serving the role of emphasis in the face of restricted linguistic competence. Language alternation patterns were interesting and correlated closely within individual language history profiles. Not unexpectedly such language alternation/code-switching occurred more in aphasic than in control samples. An impoverished linguistic system may well account for the presence of

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such code-switching in aphasic samples, but the fact that language alternation occurred more in Afrikaans than in English samples and was used by the control group only in Afrikaans points to more subtle contextual influences reflecting changing patterns of language use in South Africa and political variables.

Discussion The findings presented above suggest that while some aspects of the analysis differentiated aphasic from non-aphasic bilingual persons, there are a number of apparently non-standard features of language common to the two groups. Some may be a function of the genre of elicitation and some a function of the specific language and the context in which the data were collected. The point made by Ulatowska and Olness (2001, p. 107) that “the key question in any attempt to look at the interaction between dialect and aphasia is discerning which differences are attributable to the dialect and which are attributable to the pathological processes” needs to addressed. In the sample of fluent bilingual aphasic participants studied, we found a range of linguistic and stylistic features in their narratives, reflecting aspects that can be hypothesized to be aphasic in origin, but also unique aspects of the languages in their regional form. It is argued that the “default mode” of natural language in this context, which includes patterns of code-switching, flexible word order and stylistic intensification, provides a robust compensatory and scaffolding structure for some of the primary aphasic deficits and that the genre of narrative provides a strong basis for such pragmatic strengths to emerge. Aspects such as enactment and language alternation may in fact reflect attempts to compensate for a reduction in processing capacity in the on-line task of narrative. There are some aspects of the data that seem to be features of the narrative genre (across cultures and languages); there are some aspects that have features that are specific to Afrikaans (and the non-standard variety in particular); finally there are features that have been identified as possible aphasic compensatory features which reflect preserved pragmatic competence in the face of linguistic erosion. This study suggests that, at least in this population, it may be impossible/ unrealistic to attempt to single out explanations for the appearance in the samples of each of the above three aspects. Indeed this would probably be an oversimplification of dynamic and complex data. What might be possible however is to suggest that some of the features are common to all three dimensions, whereas some are more likely to emerge in certain genres, in certain ethnic groups, or in the presence of aphasia. Figure 15.2 presents this interaction. Many of the dimensions examined (e.g., repetition, word order changes, historic present tense, repetition and code-switching) have been commented on in the literature relating to all three.


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For example, spontaneous verbal repetition in aphasia has been identified as a compensatory strategy (Leiwo & Klippi, 2000; Oelschager & Damico, 1998; Penn, 1987) but also as an ethnic marker (Labov, 1972; Ulatowska et al., 2000). Word order changes similarly may be viewed as a compensation device in aphasia (Menn, Reilly, Hayashi, Kamio, Fujita, & Sasanuma, 1998; Saffran, 1980; Schnitzer, 1974), a reflection of syntactic convergence (McCormick, 1995) or as having a stylistic purpose (Labov, 1972). Examples of all three appeared in the narratives of the aphasic and control subjects. Code-switching (or language alternation) is a particularly challenging and paradoxical behaviour. This is a highly complex phenomenon depending on factors such as age, internal state and experience in bilingual speakers. It may be used to emphasize a point, to replace an unknown word, for clarification, to express group identity, to cross social and ethnic boundaries, or for conversational purposes (Auer, 1999). Factors that influence type and amount of code-switching include the genre, the purpose, the topic, the interlocutors and their relationship, their relative level of bilingualism and the structure of the languages (including the phonetic structure). There are apparent examples in the data at all points along a continuum. Some language alternation is conversational, some is participant related, some seems linked to linguistic difficulty, and some is obviously dialectal and probably more linked to the notion of fused lect which McCormick (1995) suggests characterizes Western Cape dialect. In traditional formulations of code-switching in bilingual aphasia, it has been suggested that this feature may be a pathological phenomenon and a reflection of an unstable language system. Research suggests that bilingual individuals with neurogenic communication disorders may not exhibit normal linguistic flexibility (Fabbro, Skrap, & Agliotti, 2000), ranging from rare documented cases of pathological code-switching to more subtle difficulties. For example, in a comparative study on Spanish-English bilingual speakers with aphasia and neurologically normal speakers, Munoz, Marquardt, and Copeland (1999) found that aphasic speakers demonstrated greater frequency of

Figure 15.2 Discourse model indicating interaction between variables.

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code-switching patterns and concluded that their subjects demonstrated an increased dependence on both languages for communication. These authors viewed this greater frequency of code-switching patterns as an inability to separately access languages. Fabbro et al. (2000) suggest that any lesion in the brain may affect flexibility of language use in bilingual speakers, and that frontal lobe lesions in particular (where the primary deficit is a difficulty in shifting set) may lead to reduced flexibility. Other explanations of code-switching in normal and child language studies similarly point to the possible processing costs of code-switching. However, contextual aspects seem to play as important a role. In an electrophysiological study of code-switching by Moreno, Federmeier, and Kutas (2002) who used event-related potentials to compare switches between two languages in bilingual speakers, it was found that for some speakers in some contexts the processing of a code switch was less costly than the processing of an unexpected within-language item. This finding suggests that the ease of switch is determined by context and task, and that the process of codeswitching per se does not necessarily use up additional resources. In fact it suggests that language switching may provide the bilingual person with aphasia additional options to those of the monolingual aphasic speaker, and that at least under conditions of conscious control, code-switching may provide an extra mechanism for the bilingual person to cope with the challenges of aphasia. Thus, paradoxically, while language alternation may reflect disruption in access to either language in aphasia, it may also reflect an attuned and sophisticated appreciation of contextual factors and it is therefore likely that the natural context may “prime” such strategies in the bilingual speaker. Explanatory paradigms for code-switching in aphasia thus should go further than pathological explanations and should incorporate both sociocultural and pragmatic factors.

Conclusions The data described above suggest that any explanations of pathological language must be context-bound and that certain sociocultural contexts provide a unique opportunity to examine recovery in aphasia. It should be remembered that each participant in the study showed a unique profile, masked by group results, but providing a fascinating explanatory basis for the language profile and compensatory choices. Persons living in a society with diverse cultures and languages may well have linguistic and cognitive flexibility that will serve them well in the event of aphasia. Further the realities of the natural context may serve as a prime for the emergence of positive strategies in recovery. The challenge for the clinician is to have an understanding of these aspects and to harness them meaningfully in therapy.


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Working with the multilingual patient implies some modification of assessment procedures to include the examination of interaction with varying interlocutors, making a detailed sociocultural analysis of a speaker’s language history, language context, attitudes towards language use and in situ observation of the effectiveness of mechanisms such as code-switching and its processing demands on both the speaker and the listener. These are probably more useful than structured or adapted language tests. In short our evaluation should be geared at unearthing the well-practised adaptation patterns that the individual has already developed and that may be drawn on in the presence of aphasia. Perhaps, as the literature suggests, bilingual people are more adept at reading the interlocutor’s home language, communication style and modality preferences and applying metalinguistic strategies. How well that capacity is retained may depend both on the neurological limitations of the individual and on premorbid sociolinguistic strategies. Similarly, the results suggest that we may have to be less precise about which language to remediate. Indeed if the context is one in which languages are mixed and the strategies adopted result in ease of communication, perhaps this could work, particularly if a partner-based approach to therapy is adopted. Finally, some of the implicit features of multilingualism may be harnessed effectively in therapy. I would suggest too that the cognitive demands of translation and their potential as a therapy tool should be explored. In line with other therapy techniques that are thought rather than language centred, the operation of translation, accessing as it does possibly shared and discrete memories, may well facilitate language recovery. Given the increased diversity of clinical caseloads, monocultural models of service delivery are no longer appropriate. I predict that cultural speechlanguage pathology is an emerging necessity of the twenty-first century and clinicians should be expanding their understanding of the influence of cultural variables on language behaviours as well as the repertoire of assessment and therapy activities (Penn, 2002). Taking culture into account undoubtedly makes things more complex, but may lead to explanations for some unresolved phenomena. This dimension builds strongly on the work of aphasiologists like Chris Code, who even when it was unfashionable, has always placed emphasis on the critical psychosocial dimensions of aphasia. Indeed, diversity and flexibility are the essence of the human condition and are probably nowhere better expressed than in the phenomenon of aphasia.

Acknowledgments Earlier sections of this chapter were presented at the 10th Congress of the International Association of Clinical Linguistics and Phonetics held in Louisiana, USA, in 2004 and in a presentation entitled Cultural influences in

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bilingual ageing presented at the American Speech and Hearing Convention in Philadelphia in the same year. I am deeply indebted to Brent Archer for his help with analysis of this material; and to Dale Ogilvy, Analou Venter, Ingrid von Bentheim, Kauthar Nabeemeah and Lisa Kalmek who were involved in various phases of the larger project.

Note 1 The terminology surrounding language alternation is confusing. For the purposes of this chapter I will use code-switching to reflect alternating of units from two language across sentence boundaries; alternation of elements longer than one word within a sentence as code-mixing; and lexical borrowing to describe inclusion of single foreign words into a language.

References Archer, B. (2006). Afrikaans aphasia: Some generational differences. Undergraduate research project, University of the Witwatersrand. Auer, P. (1999). From codeswitching via language mixing to fused lects: Towards a dynamic typology of bilingual speech. International Journal of Bilingualism, 3 (4), 309–332. Bastiaanse, R., & Jonkers, R. (1998). Verb retrieval in action naming and spontaneous speech in agrammatic and anomic aphasia. Aphasiology, 12, 951–969. Bastiaanse, R., & van Zonneveld, R. (1998). On the relation between verb inflection and verb position in Dutch agrammatic aphasics. Brain and Language, 64, 165–181. Branford, W., & Claughton, J. S. (1995). Mutual lexical borrowings among some languages of Southern African: Xhosa, Afrikaans and English. In R. Mesthrie (Ed.), Language and social history. Cape Town: David Philip. Chafe, W. L. (1982). Integration and involvement in speaking, writing, and oral literature. In D. Tannen (Ed.), Spoken and written language: Exploring orality and literacy (pp. 35–54). Norwood, NJ: Able. Combrink, J. G. H. (1978). Afrikaans: Its origins and development. In L. W. Lanham & K. P. Prinsloo (Eds.), Language and communication studies in South Africa (pp. 69–95). Cape Town: Oxford University Press. Dorian, N. C. (1997). Telling the monolinguals from the bilinguals: Unrealistic code choices in direct quotations within Scottish Gaelic narratives. International Journal of Bilingualism, 1 (1), 41–54. Edwards, S., & Bastiaanse, R. (1998). Diversity in the lexical and syntactic abilities of fluent aphasic speakers. Aphasiology, 12, 99–117. Fabbro, F., Skrap, M., & Agliotti, S. (2000). Pathological switching between languages after frontal lesions in a bilingual patient. Journal of Neurology, Neurosurgery and Psychiatry, 68, 650–652. Goldstein, K. (1948). Language and language disturbances: Aphasic symptom complexes and their significance for medicine and theory of language. New York: Grune & Stratton. Goodwin, C. (2003). Conversation and brain damage. New York: Oxford University Press.


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Hengst, J. A., Frame, S. R., Neuman-Stritzel, T., & Gannaway, R. (2005). Using others’ words: Conversational use of reported speech by individuals with aphasia and their partners. Journal of Speech, Language and Hearing Research, 48, 137– 156. Kalmek, L. (2001). Narrative strategies in bilingual aphasia. Masters dissertation, University of the Witwatersrand. Kertesz, A. (1982). Western Aphasia Battery. San Diego, CA: The Psychological Corporation & Harcourt Brace Jovanovich. Kolk, H., Heling, G., & Keyser, A. (1990). Agrammatism in Dutch. In L. Menn & L. K. Obler (Eds.), Agrammatic aphasia: A cross-language narrative source book. Amsterdam: John Benjamins. Kroes, H. (1978). Afrikaans in education. In L. W. Lanham & K. P. Prinsloo (Eds.), Language and communication studies in South Africa. Cape Town: Oxford University Press. Labov, W. (1972). Language in the inner city: Studies in the black English vernacular. Philadelphia: University of Pennsylvania Press. Labov, W. (1984). Intensity. In D. Schiffrin (Ed.), Meaning, form and use in context: Linguistic applications. Washington, DC: Georgetown University Press. Leiwo, M., & Klippi, A. (2000). Lexical repetition as a communicative strategy in Broca’s aphasia. Aphasiology, 14, 203–224. McCormick, K. (1989). A sociolinguistic study of English and Afrikaans in District 6. Unpublished PhD thesis, University of Cape Town. McCormick, K. (1995). Code-switching, code-mixing and convergence in Cape Town. In R. Mesthrie (Ed.), Language and social history. Cape Town: David Philips. Menn, L., Reilly, K. F., Hayashi, M., Kamio, A, Fujita, I., & Sasanuma, S. (1998). The interaction of preserved pragmatics and impaired syntax in Japanese and English aphasic speech. Brain and Language, 61, 183–225. Mitchum, C. C., & Berndt, R. S. (1994). Verb retrieval and sentence construction: Effects of targeted intervention. In G. W. Humphrey & J. M. Riddoch (Eds.), Cognitive neuropsychology and cognitive rehabilitation (pp. 317–348). Hove, UK: Lawrence Erlbaum Associates Ltd. Moreno, E. M., Federmeier, K. D., & Kutas, M. (2002). Switching languages, switching palabras (words): An electrophysiological study of code-switching. Brain and Language, 80, 188–207. Munoz, M. L., Marquardt, T. P., & Copeland, G. (1999). A comparison of the codeswitching patterns of aphasic and neurologically normal bilingual speakers of English and Spanish. Brain and Language, 66, 249–274. Nabeemeah, K. (2002). Narrative discourse in Mauritian Creole. Masters research report, University of Cape Town. Oelschager, M. L., & Damico, J. S. (1998). Spontaneous verbal repetition: A social strategy in aphasic conversation. Aphasiology, 12 (11), 971–988. Ogilvy, D., von Bentheim, I., Venter, A., Ulatowska, H., & Penn, C. (2000). Discourse, dialect and aphasia in the Western Cape. South African Journal of Communication Disorders: Special Issue on Communication Disorders in Multilingual Populations, 47, 111–118. Olness, G. S., Ulatowska, H. K., Carpenter, C. M., Williams-Hubbard, L. J., & Dykes, J. C. (2005). Holistic assessment of narrative quality: A social validation study. Aphasiology, 19 (3/4/5), 251–262. Olness, G. S., Ulatowska, H. K., Wertz, R. T., Thompson, J. L., & Auther, L. L.

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(2002). Discourse elicitation with pictorial stimuli in African Americans and Caucasians with and without aphasia. Aphasiology, 16 (4–6), 623–633. Paradis, M. (1987). The assessment of bilingual aphasia. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc. Penn, C. (1987). Compensatory strategies in the chronic aphasic patient. Aphasiology, 1 (3), 235–245. Penn, C. (2002). Cultural narratives. Folia Phoniatrica et Logopedica, 54 (2), 95–99. Penn, C., Venter, A., & Ogilvy, D. (2001). Aphasia in Afrikaans: A preliminary analysis. In M. Paradis (Ed.), Manifestations of aphasic symptoms in different languages. Oxford, UK: Pergamon Press. Roberge, P. T. (1995). The formation of Afrikaans. In R. Mesthrie (Ed.), Language and social history. Cape Town: David Philip. Saffran, E. M. (1980). The word order problem in agrammatism. Brain and Language, 10, 163–280. Schnitzer, M. L. (1974). Aphasiological evidence for five linguistic hypotheses. Language, 50, 300–315. Thompson, C. K., Lange, K. L., Schneider, S. L., & Shapiro, L. P. (1997). Agrammatic and non-brain-injured subjects’ verb and verb argument structure production. Aphasiology, 11 (4), 473–490. Ulatowska, H. K. (1998). Narrative discourse battery. Callier Communication Centre: University of Texas. Ulatowska, H. K., Freedman-Stern, R., Weiss Doyle, A., & Macaluso-Hayes, S. (1983). Production of narrative discourse in aphasia. Brain and Language, 19, 317–334. Ulatowska, H. K., & Olness, G. S. (2001). Dialectal variants of verbs in narratives of African Americans with aphasia: Some methodological considerations. Journal of Neurolinguistics, 14, 93–110. Ulatowska, H., Streit-Olness, G., Hill, C. L., Roberts, J., & Keebler, M. W. (2000). Repetition in narratives of African Americans: The effects of aphasia. Discourse Processes, 30, 265–283. Van Rensburg, C. (1997). Afrikaans in Afrika. Pretoria: J. L. van Schaik. Venter, A. (2000). Narrative discourse of Afrikaans speaking coloured aphasics in the Western Cape. Masters research report, University of Cape Town. Vermeulen, J., Bastiaanse, R., & van Wageningen, B. (1989). Spontaneous speech in aphasia: Correlational study. Brain and Language, 36, 252–274. von Bentheim, I. (2001). Narrative discourse in English speaking aphasics in the Western Cape. Masters research report, University of Cape Town. Wilkinson, R., Beeke, S., & Maxim, J. (2003). Combining language and functional abilities: The use of enactment by speakers with aphasia in conversation. Paper presented at British Aphasiology Congress, Newcastle. Wolfson. N. (1978). A feature of performed narrative: The conversational historical present. Language in Society, 7, 215–237.


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Appendix 15.1: Sample examples of evaluative devices used in the narratives of bilingual aphasic and control participants (translations in italics) (Extracts from the samples are identified as A for aphasic samples, C for control samples, and Afr and Eng for Afrikaans and English.) Ellipsis and topicalization A3 Eng: All of a sudden from nowhere . . . There it was A4 Eng: Bearing in mind that I was eighteen . . . I decided to argue C1 Afr: Hoe hy die een aan die arm gryp . . . weet ek nie How he grabbed one by the arm, I don’t know C3 Eng: The size of the snake . . . I was mesmerized A9 Afr: Maar ongelukking is ek daai dag. But unlucky I was that day A9 Afr: Hoe het ek deur die drade gaan, weet ek nie How I got through the wires, I don’t know Ritual utterances A4 Afr: Het ek vir hom gesê “wo!” I said “hey” what is happening to me now C1 Afr: Dis net soos in die movies sien It’s just as (you) see in the movies C1 Eng: You can’t see your hand in front of you And I’m thinking “maybe there’s absolutely nothing” C4 Eng: I was really showing off C5 Afr: Maar ek gaan iets probeer hier But I will try something here Ongelukkig is ek daai dag Unlucky I was that day C5 Eng: I don’t even want to listen to this Do you know what that cost us eventually? So we couldn’t argue

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Comment clauses A1 U sal seker nie weet vam n tiekie nie You probably don’t know about a ticky Dis nou n ware storie, ne? It’s a true story now, okay? Expressive phonology A1 Afr: Oooo ek was bang A4 Eng: It happened maaany years ago C1 Afr: Ons is veeeer van alle plekke af C3 Afr: ’n Groooot boom Quantifiers A3 Eng: All of a sudden That was the worst experience of my life A4 Afr: Hy het alle reg die pad te gebruik He had every right to use the path C2 Afr: ’n Hele klomp mense Daar was baie van hulle C3 Eng: It was the biggest snake I have ever seen C4 Eng: I took all my clothes off C5 Eng: We were just married And I’m thinking “maybe there’s absolutely nothing” C4 Eng: I was really showing off Repetition A1:

Ek is bang. Ek is baie bang I am scared. I am very scared A2 Afr: Hy kom kom die slang gryp He comes comes to grip the snake A3: That was the worst experience of my life . . . It was the most terrible experience of my life A5: Ek het gelê en gelê I lay and lay A4: Maar ex sal nooit vergeet nie. Ek is nou . . . Ek sal dit nooit vergeet nie But I shall never forget it. I am now I shall never forget it.

Cultural dimensions of aphasia C3: C5: C7:

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I can actually, I can actually see it Most beautiful beautiful paw paws All we see is farms and farms and farms En ons wag en wag en wag And we wait and wait and wait

Direct reported speech A1: A3: S8:

“Die water is; Oe Vader jy moet my nou help” The water is . . . “Oh Father you must help me” Maar die doktor . . . sê die Doktor “Nee man” But the doctor . . . the doctor said “no man” “and she just walked past and said “Kom sluit die deur toe” (Come close the door)

Language alternation (code mixing and lexical borrowing) From English into Afrikaans: Aphasic We went to hand out those eh um dinges And sy s grapes is the treasure and sy moet verstaan Hy het ’n groot, ’n groot a big crop gekry He got a big crop I just gave him one tramp to the head (Eng: thump) Sitting with a whole klomp newspapers (Eng: clump) Why must I sukkel (Eng: struggle) Those big ouens came and arrested us (fellows)

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From Afrikaans into English: Aphasic Dit was die grootest in my lewe This was the biggest in my life Iemand het hom geld gegive Someone gave him money Ek het nie gepanic nie I did not panic (Note the adoption of English morphological endings in some cases, as well as retention of Afrikaans morphology on loanwords.) Dit was nie ’n nice ondervinding nie That was not a nice experience Ek was bang dat n stray bullet deur die venster sou kom I was scared a stray bullet would come through the window En die kerels, ons is groot pals And the fellows, we are big pals (Note the noun characteristically has retained the English number marking.) One two three is hy dood 1 2 3 he’s dead As jy werk sal jy geld vat, as jy sit by die huis op jou bum sal jy niks vat. If you work you will get money if you sit on your bum at home you’ll get nothing. (Note this example of the dropping of the second negative is a common feature reflecting instability of this structure in modern Afrikaans.)

16 Assessment of aphasia in a multi-lingual world Susan Edwards and Roelien Bastiaanse

Introduction Many disciplines engage in the assessment of aphasia, which is conducted in various languages, in various forms, across many countries and for different purposes. In this chapter we consider the use of assessments, briefly review the development of aphasia assessments and describe some types of assessments. The need for procedures and materials for testing bi-lingual speakers with aphasia has been recognized for some time (Paradis, 1987), and there are a growing number of tests that are used across different languages. Some of these are translations and some are specially adapted for each new language. In this chapter, we consider why it is necessary to make adaptations rather than translate tests to use in different languages. By way of illustration, a brief description is given of the development of two tests that are used across two languages: the PALPA (originally written in English and then adapted for Dutch) and the Verb and Sentence Test (VAST: originally written in Dutch and then adapted for English). However, it is sometimes necessary to assess people in a language other than their primary language, a contemporary problem we discuss.

Background The assessment of aphasia has developed over the past hundred years from meticulous, if idiosyncratic, clinical examinations, through the development of batteries based on psychometric testing, batteries influenced by cognitive neuropsychology, and those motivated by linguistic investigation of aphasia. No assessment is theory free, although the underlying theoretical motivation behind the development of an aphasia assessment may not be explicit or may have got lost over time. In the early stages of assessment, neurologists such as Hughlings Jackson (1932), Freud (1891) and Henry Head (1926) carefully recorded symptoms that they observed in their clinics and related these symptoms to presumed sites of cerebral lesions. Jackson (1932) developed clinical tests comprising tasks that are still used today by some neurologists in their clinical examinations, such as naming the doctor’s pen and watch, and

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counting. The neurologists searched for evidence of the major clinical signs of aphasia; problems with word retrieval, sentence construction and understanding commands. Highly learnt serial speech such as counting or reciting the days of the week was tested to establish if non-propositional speech had been retained (Jackson, 1932). Many similar tasks are found today both in clinical examinations and in some published aphasia tests, although the motivation for inclusion is far from clear. The early aphasiologists were spurred on with their work because of the number of young men they encountered who had language problems. These were young men returning from the “great” war who, through warinduced brain injury, faced years ahead with aphasia. The purpose of these early aphasiologists was to document symptoms and there was no attempt, at least no systematic attempt, to suggest treatment. Following the Second World War, a new impetus arose in the UK, the USA and the USSR to formulate a means of documenting aphasic symptoms, but now there were also some parallel efforts to think about treatment following assessment (Wepman, 1951). During the war, psychometric testing had been developed and the new tests of aphasia used these developments, mimicking the rubric of the psychiatric assessment by using an array of tasks for this purpose, probing skills in reading, writing, speaking and comprehension of spoken language. The familiar tasks (used by the early twentieth-century neurologists) of serial speech and repetition of language were included by clinicians and survive today. These tests were based on the classical view of aphasia, which was that the condition affects primarily expression or understanding of language, and is termed expressive or receptive aphasia (Eisenson, 1973). This view seriously under-rates the complexity of aphasia and was overtaken by a more detailed and sophisticated understanding of the nature of aphasia during the latter half of the twentieth century and beyond. A very different view of aphasia was held by Wepman (1951), developed by Schuell and published as The Minnesota Test of Aphasia (Schuell, 1965). Hildred Schuell’s view of aphasia was based on Pierre Marie’s (1926) idea that aphasia was a unitary syndrome. This diverged from what had been the mainstream view since the classic descriptions of Broca (1865), Wernicke (1874), and Lichtheim (1885). Marie abandoned the idea that there were different aphasia symptoms and conceived aphasia as a unitary phenomenon. This view held that aphasia is a condition in which language is affected, and which differed from person to person not by syndrome but by severity and by the presence or absence of deficits involving written language and articulation. Schuell was one of the last followers of this theory. It may surprise some readers to learn that her assessment (and presumably the theory behind it) was used extensively not only in regular clinical assessments but also in research in the latter half of the twentieth century (David, Enderby, & Bainton, 1982; Edwards, Ellams, & Thompson, 1976). The early death of Schuell curtailed the development of this idea and the publication of the

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Boston Diagnostic Aphasia Examination (BDAE) by Goodglass and Kaplan in 1972 re-established the neo-classic view of aphasia. Another important assessment tool, inspired by and similar to the BDAE was published in 1982: the Western Aphasia Battery (WAB; Kertesz, 1982). These two assessments of aphasia set out to categorize participants/patients by classical aphasic syndromes, and despite the low proportion of the clinical population that can be successfully categorized (Goodglass & Kaplan, 1972; Kertesz, 1982) the BDAE and the WAB are the most widely used assessment tools in North America and Western Europe. The BDAE has proved to be very robust, with the third edition published in 2000 (Goodglass, Kaplan, & Baresi, 2000), almost 30 years since the first edition, and versions of this test have appeared in a number of languages other than English. Slightly earlier than the publication of these two tests, Alexander Romanovich Luria (1966, 1970) was developing similar ideas on clinical assessment in the USSR, although his work took some time to reach Western Europe in translation. His concept of clinical aphasia types was slightly different from those in Western Europe and has been, and remains, very influential in Russia and the Nordic countries. Another test that aims for diagnosis of type of aphasia is the Aachen Aphasia Test (Huber, Poeck, Weniger, & Willmes, 1983). This has been widely used in Western Europe and has been adapted from the original German to Dutch, Italian and English and is considered the principal test in Germany, Switzerland, Austria, The Netherlands, Italy and Belgium. In summary, since 1970, four main aphasia assessment tools have been developed that are still widely used around the world. The main goals of these tools were: • •

to assess the severity of aphasia in the four language modalities (comprehension and production of spoken language, reading and writing) to classify the patients in one of the classical aphasia types.

Before moving on to discuss more recent assessments that focus on features of aphasia, it is interesting to note the relatively new publication of an assessment that has followed a classical design in terms of modalities, production and understanding of written and spoken language, and in test items. This test, the Comprehensive Aphasia Test (CAT; Swinburn, Porter, & Howard, 2004) includes many classic items such as naming, word fluency and repetition, but has additional tests for cognitive functions that may impact on aphasia, and a means of exploring the “disability and emotional sequelae of acquiring aphasia” (p. 5). The CAT is a collection of tests developed for diagnosis of impairment; to provide guidance for further assessment and motivation for treatment. It can be used for predicting and tracking changes in language behaviour over time. It is comprehensive in the areas covered but, as it is designed to be administered within two sessions, exploration is brief. Extensive guidance is given on administration, including assessing “grammatical well-formedness” (although some of the analysis is debatable), and on

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the development of the test. Test data collected from aphasic and nonaphasic subjects are given for each section, providing a really useful clinical reference. The structure of this test while closely resembling the classic tests discussed above, has additional features that reflect research in the field as well as the “broad church” approach current in clinical practice. Further, an explicit aim of the test is to provide guidance for intervention. It is currently only available in English.

Single words and grammar: Tests and connected speech data Although the classic assessments have been successfully used in clinical practice in many countries, their contribution to planning treatment and setting goals for aphasia therapy has been limited. There are two reasons for this. First, changes in aphasic language behaviour are often slow and/or limited and may be restricted to part of the language system. These tests are not sensitive enough to measure such changes. Second, they focus on the severity of aphasia across different modalities and not on the nature of the underlying language deficits. They are therefore limited in providing guidance for treatment. Areas of relative weakness can be identified from the results and general goals set, but the results do not readily lead to detailed planning for either deficit based or so-called “functional” aphasia therapy. While the relative impairments in different modalities can be identified, these tests do not set out to identify the assumed underlying nature of language deficits. Towards the end of the twentieth century, a different type of assessment was developed that sought to address this matter. In seeking to reveal something about the nature of the aphasic deficits, authors of these tests were obliged to make at least something about their theoretical assumptions explicit. As a result, we find a divergence in the type of tests that started to be published. We now briefly review some of these. Single word battery Towards the end of the twentieth century, a new and different way of assessing aphasia was developed, based on neuropsychological and neurolinguistic theories. In many laboratories people were working on experimental tasks within modular, word processing models (e.g., Ellis & Young, 1988). A major development was the publication of an extensive clinical test battery, the Psycholinguistic Assessment of Language Processing in Aphasia (PALPA), a battery of tests for the assessment of production and processing/comprehension of spoken and written words and sentences (Kay, Lesser, & Coltheart, 1992). This battery of tests was based on ideas from neuropsychology and especially from work with developmental and acquired dyslexia. Rather than testing for an array of aphasic symptoms, as tests up to that date had done, the new way of assessing aphasia was based on notions of modules and


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connections between modules. Tasks were developed to test the functioning of the assumed modules (and inter-modular connections) such as the auditory analyser, and phonological assembly. This concept eschewed the pursuit of a relationship between lesion site and symptoms that had been paramount in the neo-classical view. In this test, performance is interpreted within a defined modular, serial model of single word processing, which the authors have conceded was “under-developed”. Instead of sites of lesion, language deficits are located within modules or in the connections between modules. In addition to locating the source of the difficulties within this box and arrow plan, some control of certain psycholinguistic variables was built into most of the tests. The selection of these variables was based on experimental evidence that they influenced spoken or written word processing. References to this evidence are given throughout the battery. The variables included word frequency, imageability, length, and regularity of spelling. The PALPA, although largely concerned with investigating single word processing and production, also included two tests of sentence comprehension in the English version. Both tests investigate the same array of syntactic variables; one has spoken stimuli and the other written. A further test investigates “locative relations” using eight locatives within 24 NP + PP constructions. Versions of the PALPA are available in a number of languages (e.g., Spanish, Dutch, German and, recently, Russian). The PALPA is strong on investigating noun production and understanding, but verbs are largely ignored. However, from the late 1980s on, it became clear, that word class is an influential factor in word and sentence processing in aphasia. Several studies found that aphasic patients treat verbs and nouns differently (e.g., Jonkers & Bastiaanse, 1998; Kohn, Lorch, & Pearson, 1989; Miceli, Silveri, Villa, & Caramazza, 1984). Further, within the class of verbs, various factors seem to play a role: instrumentality (Jonkers, 1998; Jonkers & Bastiaanse, 2006), argument structure (Kiss, 2000; Thompson, Lange, Schneider, & Shapiro, 1997), morphology (Bastiaanse & van Zonneveld, 1998; Friedmann, 2000). It would seem that the variables that influence noun and verb processing are different. For example, the effect of frequency may play a role in noun retrieval, although there is much individual variation (Kay & Ellis, 1987; Zingeser & Berndt, 1988), but has not been found in verb production (e.g., Kemmerer & Tranel, 2000, McCann, 2005). Some experimental materials used to investigate aphasia have been adapted for clinical practice, for example An Object and Action Naming Battery (Druks & Masterson, 2000), the Thematic Roles in Production (TRIP; Whitworth, 1996) and parts of the Verb and Sentence Test (VAST; Bastiaanse, Edwards, & Rispens, 2002). Batteries focused on grammatical abilities There is an extensive amount of literature and a relatively large number of theories on sentence comprehension impairment. Many laboratories have

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developed their own tests, suitable for exploring their theories of language comprehension, but there has not been a systematic adaptation of these procedures for clinical practice, although many ideas are used in clinical practice, at least in the UK. An exception is a relatively new test, the Verb and Sentence Test (VAST; Bastiaanse et al., 2002), a test that has been motivated by neurolinguistic theories, but developed for clinical practice as well as for use in research laboratories. A unique feature of this assessment is that for all the aphasic features that are tested, there are published treatment protocols or ideas. We will come back to this test later. Spontaneous speech During the latter half of the twentieth century, the application of linguistic theory to aphasia started to seep into clinical practice and noticeably into clinical assessment of aphasia. Not only did some linguistically motivated assessments begin to appear but there was also a move to a completely different methodology. One major methodological development was the use of samples of connected or spontaneous speech data to investigate phonology, lexis and grammar. In these studies, aphasic speech samples were compared with non-aphasic samples collected in the same conditions. These studies provided insights into how aphasic language sounded when the speaker was permitted to produce chunks of speech, rather than answering questions or naming pictures. The picture that emerged was one that supported the subtraction notion: it was possible to see the extent to which the language system had been preserved, and the extent to which it deviated from non-aphasic, normal language. So, for example, for Dutch, Wagenaar, Snow, and Prins (1975) and Vermeulen, Bastiaanse, and van Wageningen (1989) found that there were certain linguistic dimensions distinguishable, on which aphasic speakers could be independently impaired. In English, comparisons of aphasic and non-aphasic speech were made using matched speech samples (Edwards, 1995; Edwards & Garman, 1992; Edwards & Knott, 1994, Garman & Edwards, 1995). The Dutch and English work was brought together applying the framework developed for the English studies to data from both languages. Edwards and Bastiaanse (1998) examined grammatical and lexical features in Dutch and English fluent aphasic speakers and found a reduction in the proportion of complex sentences and verb diversity in the English aphasic speakers compared with the control data. The use of connected speech data now plays an important part in evaluating effectiveness of treatment. Researchers are interested in whether improvements found in test performances extend to connected speech (Bastiaanse, Hurkmans, & Links, 2006; Edwards & Tucker, 2006; Webster, Morris, & Franklin, 2005). However, the assessment of connected speech data is not straightforward. There are issues concerning segmentation and reliability, and features to be noted and scored. See Edwards (2005) for a discussion on the use of connected speech data in assessment. These same issues also impact


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on what, on the face of it, looks like an easier task, the investigation of lexis within connected speech samples. Given that lexical retrieval is a pervasive problem in aphasia, it is not surprising that there are a myriad of studies investigating word retrieval. If one wishes to employ range of vocabulary as a measure of improvement over time, or as a measure to separate types of aphasia, then there are various methodologies. Wright, Silverman, and Newhoff (2003) have compared the use of three different measures of vocabulary; type–token ratio (TTR); number of different words (NDW) and a D(iversity) measure developed by Malvern, Richards and colleagues (Malvern, Richards, Chipere, & Durán, 2004; Richards & Malvern, 1997). The D measure, a measure of lexical diversity, is obtained via special software. It is calculated by first randomly sampling words from a transcript to produce a TTR against tokens for the empirical data. The software then finds the best fit between this empirical curve and the theoretical curves generated by the model by adjusting the value of D. Higher values of D represent greater lexical diversity. The authors claim that this procedure is suitable to use with small samples and ensures that all researchers carry out measurement in the same way (p. 60). In the aphasia study, Wright et al. (2003) found that TTR and NDW correlated when the sample size was held constant, although this entailed ignoring some of the data. The D measure correlated with the two other measures only when sample size was held constant, thus illustrating the complexity of computing lexical diversity in connected speech. Other spontaneous speech analysis systems have specifically been developed to analyse the grammatical aspects of Broca’s aphasia (Saffran, Berndt, & Schwartz, 1989; Thompson et al., 1997). The only system that has been published to date as a clinical tool and is therefore accessible to clinicians is the Quantitative Production Analysis (Berndt, Wayland, Rochon, Saffran, & Schwartz, 2000; Saffran et al., 1989). Of course, some highly motivated therapists do use procedures that are still experimental. An overview and critical analysis of spontaneous speech analysis methods can be found in Prins and Bastiaanse (2004). They claim that only a few methods are valid and reliable and not all are suitable to measure improvement. Nevertheless we remain committed to the importance of examining samples of spontaneous speech when trying to measure the effectiveness of treatment. After all, as the main goal of treatment of speech production is improving language use in daily life, we need to continue to try to monitor and measure relevant features of connected speech very carefully.

Translating tests: Clinical imperatives and empirical pitfalls There is a reasonably widespread understanding that a straightforward translation of the vocabulary of tests is not sufficient when trying to produce a version of a test in a language other than the original. Cultural issues need to be taken into account, such as choice of vocabulary items, illustrations and the topics utilized, but the issue of translation is broader. There is also a

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growing awareness that the psychometric variables that may be controlled for in the original test, such as frequency, age of acquisition and imageability, may only hold for the original language of the test. At a very simple level, clinicians working in the UK know that most of their clients/patients will not be able to name the bagel or wreath in the Boston Naming Test (Kaplan, Goodglass, & Weintraub 1983). However, the problems are wider than lack of knowledge of certain objects or foods. There is not always a one-to-one translation across verbs. For example, Dutch has one word badmintonnen for to play badminton and one word schaken for to play chess so a verb to verb translation is not always possible. Further, sentence constituents such as adverbs, that are free morphemes in English and Dutch, may be bound morphemes in some languages, Finnish and Hungarian, for example. We cannot be sure that the verbs take the same argument structure in the language into which the test is being translated. Some will but others will not. If the test includes production and comprehension of sentence structure, then the problems are even greater as we will see below. There is a large amount of linguistic data on English and a number of European languages on which to draw conclusions but this is not the case for many other languages. In addition, the linguistic tradition differs across the world and the information available about a language may be incompatible with the theoretical motivation of the original test.

Translating tests: Two examples In this section, two tests that have been translated and adapted to another language will be discussed. First the PALPA, which was developed in English and has been made available for Dutch. Second, the VAST, a test that was developed for Dutch and has been adapted to English. Some problems that were encountered in the adaptation of these tests are discussed here. Translation and adaptation of the PALPA to Dutch The English PALPA is a test battery that consists of more than 50 subtests, divided into four parts: auditory processing, reading and spelling, picture and word semantics and sentence comprehension. The items in most subtests are controlled for word frequency, length, regularity of spelling and other factors, which make a word-to-word translation into another language impossible. Thus only the principles of the PALPA could be preserved in adapting the test for Dutch, although new words that were included in the test were matched on the same variables and new pictures were necessary. Although many high-frequency English words have high frequency in Dutch, word length is not always the same. In addition, there are problems with trying to assemble irregularly spelled words as there are fewer irregularly spelled Dutch words compared to English. Although Dutch has a considerable number of loanwords that are irregularly spelled, it was not possible to


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obtain the same distribution of regularly and irregularly spelled words in the Dutch version of the PALPA Not only did new pictures need to be drawn for words that were not included in the English version, but some pictures had to be changed to account for cultural difference. For example, the picture of a stamp in the word comprehension subtest in the English version needed to be replaced as it has a picture of Queen Elizabeth II on it. Naturally, the subtests for low imageability words, synonym judgement and word semantic association, could not be translated literally. All these adaptations were quite easy to implement, but a real problem arose when the subtests at the sentence level were considered. The theoretical motivation of this part of the PALPA is quite weak compared to that underlying the tests focused on single word processing. It was decided to omit this part in the Dutch PALPA and to develop a new, well-motivated test for comprehension and production of verbs and sentences, which we called the Verb and Sentence Test (VAST). This was subsequently translated and adapted to English. Translation and adaptation of the VAST to English The Verb and Sentence Test was originally developed for use in Dutch. When the translation and adaptation of the PALPA was finished, the need was felt for a test that could assess comprehension and production of verbs. The subsection of PALPA that tests sentence comprehension was not adapted in the Dutch version and thus there was a need for a new test of sentence comprehension and production. The type of sentence structures to be included for assessment was carefully considered: sentences that had the basic word order for Dutch plus sentences with “moved” NPs and verbs were selected for testing. One of the principles guiding the development of the VAST was that only linguistic variables that have been shown to be affected in aphasia would be included. So verbs were controlled for frequency, name relation with a noun and transitivity. For sentences the main variable was word order, thus in testing Dutch sentences, it was necessary to include sentences that had the basic word order, so sentences with “moved” NPs (passives, wh-questions) and “moved” (embedded vs. matrix vs. question order) verbs were included. The second principle was that the VAST should be a tool that could be used with a broad range of aphasia types. Finally, the VAST should be “treatmentoriented”: for each tested variable a treatment programme or method should be available that shows that this variable can be successfully trained. This resulted in 10 subtasks. The VAST has been translated into and adapted for a number of languages: English (Bastiaanse et al., 2002), Norwegian (Bastiaanse, Lind, Moen, & Simonsen, 2006), French and German. The tests in the latter two languages are not yet standardized. When translated into English, a number of problems were encountered. First, a main variable in the Dutch version was “position of the verb”. In

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Dutch the verb can take different positions in the sentence, whereas in English it always precedes the object. So “verb movement” could not be included in the English version. It was decided to add two extra sentence types: subject clefts and object clefts. These structures are not in the Dutch version because they are ambiguous in Dutch. In the first version of the Dutch VAST, one test was included which entailed the selection of the correct wh-word (who, what, when and where). While Dutch non-brain-damaged speakers were able to perform this test, none of the first 10 aphasic patients who were tested with these materials could to do the task because they did not understand what they were supposed to do. It was then decided to remove the task. Because we suspected that the task could be valuable, an adapted version was made for the trial English version of the VAST. This proved to be as problematic in English as it had been in Dutch and so was not included in the final version. The English VAST is similar to the Dutch version in terms of structure, but many lexical items as well as the sentences needed to be changed. Some changes were made because the variables they were controlled for did not translate, for example there were different frequency ratings across the two languages. The verb “to skate” is much more frequent in Dutch than in British English (and has a zero frequency in Australian English). Other actions are expressed by a verb in Dutch, but by a verb phrase in English: for example, to play badminton is one word in Dutch, badmintonnen, as mentioned above. The same problems arose with the verbs that have a name relation to a noun in Dutch, but not in English, or the other way around. Thus the list of verbs was adapted. The phrasal verbs were removed and those that did not achieve a high name agreement score were omitted. A number of new verbs were added and all variables checked. All items in all subtests were trialled on non-aphasic English speakers.

Assessment when it is not possible to use standardized tests We have seen above that there are tests being developed for use in a range of languages, yet in many European countries there are now an increasing number of people whose first language is not that of the host country. The increase in demand on speech and language therapy services has arrived before we have the necessary range of standardized tests for clinical practice despite a longstanding awareness of the need for assessments designed for bilingual speakers (Paradis, 1987). Unfortunately, some clinicians do try to use direct translation but, as we have illustrated above, this is far from satisfactory. As the new migrants age within their new countries, there are an increasing number of people who have acquired aphasia but do not have native competence of the language of their adopted country, and clinicians are in the position of having to do the best they can. The development of language assessments needs to be within a context of knowledge of the language of the assessment, and we have endeavoured to demonstrate why straightforward translation of a


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test into another language will not provide an assessment tool that can be of any use. Unfortunately, a detailed knowledge of the languages we need is just not available. There is some work underway in the UK by Bryan and her colleagues investigating the comparative influences on test scores of age and having English as an additional language, but to date resources are pitifully small. This then creates a real practical dilemma for the clinician. In striving to provide equality of medical provision, the clinician needs some way of assessing the presenting disorder if only to advise the patient, his or her family and the other medical staff involved in the care of the patient/client. Practically, a clinician still needs to make some kind of assessment in order to offer advice, as a minimum of care. The clinician can choose to work through a translator, selecting parts of tests that can most easily be translated. As we have argued above, this is less than satisfactory because in changing tests, standardization is lost and so the results can only be used for guidance and must be interpreted with extreme caution. They can, however, be used to demonstrate to other professionals how aphasia has affected the patient’s/ client’s language. The alternative is to offer no help, clearly an unacceptable position. It may be that there will be sufficient academic interest or political pressure to create assessment batteries in a much wider range of languages. Despite more than a hundred years of aphasia investigations by talented researchers (such as Chris Code), public awareness of aphasia in monolingual contexts is minimal, as Chris and his colleagues have demonstrated (Simmons-Mackie, Code, Armstrong, Stiegler, & Elman, 2002), and our knowledge of how to assess aphasia in a multi-lingual world is equally limited. We are beginning to explore how to create assessments that are applicable in cross-language research and how best to assess people who are aphasic in a multi-lingual world. There is much work still to be done.

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17 Computerized aphasia treatment outcomes research The past and a proposal Richard C. Katz and Robert T. Wertz

Almost 20 years ago, we were in the final stages of our 5-year Phase III study testing the efficacy of our computerized aphasia treatment protocol. At that time, I was approached by one of the two editors of a new, soon-to-bereleased, journal, called Aphasiology. Dr. Code asked if I would write a “lead article for a forum” on the use of computers in aphasia therapy. The Aphasiology forum became not only a staple of that journal, but a model for others as well, and as the role of computers in rehabilitation grew, the 1986 forum articles, and the many subsequent articles on computerized treatment published in Aphasiology, helped to propel this aspect of treatment forward by offering an international platform to ask questions and discuss and debate findings. We will always be grateful to Chris for providing, at that critical time, the opportunity to discuss with our colleagues from all over the world our work and the works of others. Determining the value of aphasia treatment software is complicated by the changing perspectives of clinicians as to what the primary objective of therapy is – to improve language skills, functional communication, or quality of life. Similarly, continual advances in computer hardware and system software provide new opportunities and just as quickly condemn last year’s programs to obsolescence. The purpose of this chapter is to review selected computerized aphasia treatment studies; place them in the five-phase outcome research model (Robey & Schultz, 1998); and suggest additional research necessary to test the efficacy, effectiveness, and efficiency of computerized treatment for aphasia.

Phase I, Phase II, and Phase III studies Phase I and Phase II studies are brief, employ small samples, and do not require external controls. Phase I objectives are to develop the hypothesis about the treatment that will be tested in later phases in the five-phase model; establish the treatment’s safety; and detect whether the treatment is “active,” essentially, whether aphasic people who receive it improve. Phase II research builds on the results of Phase I studies. The hypothesis is refined, an explanation for the outcome is developed, the target population is specified, the

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treatment protocol is standardized, the validity and reliability of the outcome measures are demonstrated, and the treatment dosage is adjusted to maximize outcome. Phase III efficacy studies are long, complex, and expensive. Large sample size is required to obtain acceptable statistical power, and, usually, the means for obtaining the large sample size requires a multi-center effort in which several institutions contribute participants to obtain an adequate sample. The required study design is a randomized controlled clinical trial in which participants who meet selection criteria are assigned randomly to treatment and no-treatment groups. Randomization controls for treatment selection bias and other potential biases, and the treatment versus no-treatment comparison constitutes a true test of the treatment’s efficacy. Of course, explicit protocols and rigid controls across participating centers are essential to ensure program fidelity and that the trial is truly cooperative – everyone is doing the same thing. For almost 30 years, researchers have been creating and testing aphasia treatment software. Early single-subject and small group outcome studies, now designated as Phase I and Phase II computer studies (Wertz & Katz, 2004), demonstrated that independent use of the computer in treatment of aphasia was feasible and that treatment was “active,” but they did not establish whether improvements in outcome measures were of sufficient magnitude to justify use of the computer, or resulted from the specific intervention provided. Moreover, these Phase I and II studies did not demonstrate whether the treatments provided were efficacious, effective, or efficient. Computerized writing treatment Seron, Deloche, Moulard, and Rousselle (1980) reported perhaps the first Phase I study to use a computer (a Digital Equipment model PDP–10 minicomputer, time-shared) to provide a multi-step cognitive intervention for written spelling errors of adults with aphasia. Ninety words divided into three groups (depending on number of syllables and complexity) served as stimuli. An experimenter read aloud the stimulus word and the subject attempted to type the word on the computer terminal. Intervention consisted of three levels of feedback: the number of letters in the target word (indicated by square “boxes” displayed on the screen); whether the letter typed was in the word; and, when the correct letter was typed, whether that letter was in the correct position. Five subjects completed the program in 7 to 30 sessions. Pre- and post-treatment tests required the subjects to write by hand a generalization set of single words from dictation. Performance varied among subjects, but all decreased significantly (p

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