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Approaches to aphasia treatment can be classified into “impairment-based approaches” or “consequences-focused approaches” (Thompson & Worrall, 2008). When described using the concepts of the International Classification of Functionality, Disability and Health (ICF: 2001) by the World Health Organization (WHO), “impairment-based approaches” focus on body functions and structures because the goal is to improve the language abilities. The “consequences-focused approaches” focus on activities, participation and/or environmental factors and the goal is to reduce the impact of aphasia on a person´s life (Thompson & Worrall, 2008). The aim of the social model of rehabilitation is to remove the barriers for participation and prevent the social isolation people with aphasia often experience (Dalemans, de Witte, Beurskens, van den Heuvel, & Wade, 2010; Davidson, Howe, Worrall, Hickson, & Togher, 2008; Northcott & Hilari, 2011; Parr, 2007). The “consequences-focused” approaches have their origin in the pragmatic perspective. They developed from functional approaches emphasizing the use of different communication methods (Davis, 2005; Davis & Wilcox, 1985; Hopper, Holland, & Rewega, 2002) to approaches considering the role of the communication partner (Simmons-Mackie, Raymer, Amstrong, Holland, & Cherney, 2010) and other actions designed to create an aphasia-friendly environment (Howe, Worrall, & Hickson, 2004, 2008; Worrall et al., 2005). Communication is an activity according to the ICF classification and this activity can be increased by using all available means of communication from speech to augmentative methods. This is called total communication (Lawson & Fawcus, 2001; Pound, Parr, Lindsay, & Woolf, 2002). It includes the use of speech and different nonverbal techniques. People with aphasia are encouraged to communicate in any way available.
The Finnish Brain Association (FBA) has arranged since 1997 Communication coursers for people people with stroke and who need augmentative and alternative communication methods because of severe aphasia or dysarthria, and their significant others. The goals of these courses are to encourage people with aphasia to use total communication, to offer people with aphasia an opportunity to interact and participate in conversations, and to guide the significant others to support the communication of their aphasic partners. The courses are carried out in two parts (8 + 4 days) at a three-month interval. The content of these courses is described in the article by Rautakoski, Korpijaakko-Huuhka, and Klippi(2008).
Group therapy and group discussions are the main tools during these courses. During group discussions, the participants are trained in the use of different communication methods. The participants with aphasia work in groups of four, and a speech-language therapist works as a facilitator and supports the conversation by drawing, writing, and offering picture cues. During 1999-2001, the effect of these courses was studied. People with severe and moderate aphasia and their partners perceived that although total communication including limited speech, spontaneous nonverbal means of communication, and low-tech devices was already used more or less before the course, their use further increased during the course (Rautakoski, 2011a). The partners indicated that the functional communication abilities of people with aphasia improved during the intervention, but people with aphasia thought that these abilities became weaker after the first part of the course but returned after the second part of the course (Rautakoski, 2012). It is possible that people with aphasia became more aware of their difficulties in communicating during the first part of the course and maybe could better monitor their own communication abilities (also Sorin-Peters & Behrmann, 1995).
The partners estimated that they already used different strategies to support the communication quite often before the course (Rautakoski, 2011b). However, they perceived that they increased the use of different strategies significantly after the first part of the course, especially to support the verbal comprehension and production. Six months after the intervention, they perceived a reduction in the use of these strategies. The conclusions were that the partners would need more practice, more individual guidance, or active up-keep after the intervention.
Inspired by these results, speech- language therapist Arja Nykänen at Kruunupuisto Punkaharju Rehabilitation Centre began to develop a new method for training couples where one partner had severe aphasia (Nykänen, Nyrkkö, Nykänen, Brunou, & Rautakoski, 2013).
The method is called ‘Communication Therapy for People with Aphasia and their Partners’ (APPUTE) (the name is an abbreviation of the Finnish name of the method, Afasian paripuheterapia). The APPUTE course comprises two 14-day-long courses offered at a sixmonth interval. Participating couples are offered daily speech therapy during the course.
3 During the APPUTE intervention, the couple practices functional communication strategies under the close guidance of the speech-language therapist, and using a structured program containing different tasks. The APPUTE program consists of three different kinds of communication tasks arranged according to the level of difficulty. According to the results of the 34 couples who have participated in the project, the
APPUTE method appears to improve the communication skills of people with severe aphasia and their partners, as well as the language skills of people with aphasia. However, it has to be taken into consideration that the participants with aphasia in this project were carefully selected. Most of them had Broca’s aphasia and they were all motivated to practice nonverbal communication methods (Nykänen et al., 2013).
Supporting activity and participation on the local level The rehabilitation models described above belong to the health care system and the communication therapy is conducted by a speech-language therapists. However, it is important to ensure that people with aphasia can regain their social life despite communication difficulties. The social approaches should promote participation in a social world (Simmons-Mackie, 2000). Therefore, the Finnish Brain Association has carried out a project called “Communication Cottage”. The goal of this project is to reduce the social isolation people with aphasia often experience and increase their participation. The plan of the FBA has been to start as many “Communication Cottages” as possible all around Finland and they have had collaboration with adult education centers. Many municipalities have an adult education center offering courses ranging from different languages to woodwork. There are currently 21 “Communication Cottages” in these adult education centers in different
municipalities aro und Finland and more municipalities are interested in starting such an activity. People with aphasia consider this activity very important. It is like a bridge back to the society. The surroundings at the adult education institutes are viewed as stimulating. People with aphasia see that they are back among “healthy” people. There is also one governmental action in Finland that supports the participation of
people with communication disorders like aphasia. According to the Finnish law on services for disabled people, people with a communication handicap can use the services of a speechinterpreter (The Interpreter Services Act, 2010). Speech-interpreters help people with communication disorders to communicate, as well as with reading and writing.