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Aphasiology
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Preliminary analysis from a novel
treatment targeting the exchange of
new information within storytelling
for people with nonfluent aphasia and
their partners
Marcella Carraghera, Karen Sageb & Paul Conroyc
a Department of Human Communication Sciences, La Trobe
University, Melbourne, Australia
b Bristol Speech & Language Therapy Research Unit, University of
the West of England, Bristol, UK
c Neuroscience & Aphasia Research Unit, University of Manchester,
Manchester, UK
Published online: 15 Dec 2014.
To cite this article: Marcella Carragher, Karen Sage & Paul Conroy (2014): Preliminary analysis from
a novel treatment targeting the exchange of new information within storytelling for people with
nonfluent aphasia and their partners, Aphasiology, DOI: 10.1080/02687038.2014.988110
To link to this article: http://dx.doi.org/10.1080/02687038.2014.988110
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Preliminary analysis from a novel treatment targeting the exchange of
new information within storytelling for people with nonfluent aphasia
and their partners
Marcella Carragher
a
*, Karen Sage
b
and Paul Conroy
c
a
Department of Human Communication Sciences, La Trobe University, Melbourne, Australia;
b
Bristol Speech & Language Therapy Research Unit, University of the West of England, Bristol,
UK;
c
Neuroscience & Aphasia Research Unit, University of Manchester, Manchester, UK
(Received 30 March 2014; accepted 12 November 2014)
Background: Therapy for people with aphasia (PWA) can encompass a wide range ofaims
and methodologies from targeting the linguistic impairment to strategic compensation to
optimise communication, interaction, and vocational rehabilitation. Aphasia rehabilitation
ultimately has a social goal of optimising the communication of PWAwithin their typical
environment. Therefore, across treatment type, one unifying area of interest relates to the
generalisation of behaviours targeted in therapy to untrained tasks and contexts, particu-
larly those related to everyday communication. Two important aspects of everyday
communication relate to conveying new information and telling anecdotes/stories.
Measures of transactional success in storytelling have previously demonstrated reliability
and validity as an analytical method.
Aims: The study aimed to extend previous work on transactional success in storytelling to
a programme of therapy targeting both the PWA andthe communication partner (CP). The
effects of therapy were measured in untrained novel storytelling tasks.
Methods & Procedures: Four participants with chronic nonfluent aphasia and their CPs
were recruited and a novel dual-focus treatment was administered. For the PWA, therapy
targeted storytelling using the principles of “thinking for speaking”and story grammar. For
the CP, therapy drew on the principles of conversation coaching to increase facilitative
behaviours within storytelling to aid coconstruction of the story.
Outcomes & Results: Outcomes were influenced by the complexity of the target
stimuli: following therapy, three PWA demonstrated increased transfer of new informa-
tion within untrained simple storytelling. For the untrained complex storytelling
stimuli, improvements were limited to two PWA. There were also changes in how
PWA produced stories (i.e., the order of events within the story), with simple stories
becoming more inline with the sequence used by control participants. Regarding the
CPs, again there was an effect of complexity: for the untrained simple story, three CPs
improved the accuracy of their understanding while for the untrained complex story,
two CPs improved. Interestingly, one CP consistently demonstrated a decrease in the
amount of information successfully understood following therapy, despite improved
information exchange by her partner with aphasia.
Conclusions: The preliminary findings of this dual-focused therapy offer promise in
terms of targeting a range of skills relating to both the PWA and CP, whilst the context
of information exchange and storytelling promotes likelihood of generalisation of
targeted behaviours to untrained tasks.
Keywords: nonfluent aphasia; generalisation; interactive storytelling; information exchange
*Corresponding author. Email: m.carragher@latrobe.edu.au
Aphasiology, 2014
http://dx.doi.org/10.1080/02687038.2014.988110
© 2014 Taylor & Francis
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1. Introduction
Therapy for people with aphasia (PWA) encompasses a wide range of aims and methodolo-
gies from targeting the linguistic impairment (e.g., Carragher, Sage, & Conroy, 2013),
communication compensation (e.g., Hopper, Holland, & Rewega, 2002), interaction (e.g.,
Beeke, Maxim, Best, & Cooper, 2011), and vocational rehabilitation (e.g., Morris, Franklin,
Menger, & GD, 2011). Across all treatment approaches, one unifying area of interest relates to
the generalisation of behaviours targeted in therapy to untrained tasks and contexts, particu-
larly those related to everyday communication. However, capturing evidence of change
within everyday communication has proved difficult. Researchers within the field continue
to explore various methodologies in an attempt to reach consensus on the type of data we
should collect as well as optimal outcome measures and elicitation contexts in which to
measure the effects of therapy.
With regard to the question of which elicitation type and which data should we use to
measure the effects of treatment on everyday communication, one option relates to the
collection and analysis of naturally occurring conversation data. Certainly, conversation has
been observed to be the most common type of daily communication for PWA and matched
healthy control participants (Davidson, Worrall, & Hickson, 2003). Yet capturing evidence
of quantitative change in conversation has proved difficult, not least because no standar-
dised, quantitative measure of conversation exists (Beeke et al., 2011). Moreover, the high
demands of time and skill needed to carry out qualitative analysis of conversation present
challenges for service delivery in busy clinical settings (Bradley & Douglas, 2008).
Everyday communication is multifaceted, encompassing not only interaction but also
transaction (Davidson et al., 2003). One solution might be to use the naturally occurring
transactional opportunities in everyday communication to target treatment and to capture
evidence of change. Transactional communication encompasses various types of discourse
genre—conversation, expository, procedural (Armstrong, 2000). Central to transactional
communication is the conveying of new information, an aspect that is often responsible
for conversational failure for PWA (Ramsberger & Rende, 2002). Conversation data do
not lend itself to the measurement of transactional success for a number of reasons: lack of
external criteria on which to judge transactional success (Ramsberger & Rende, 2002);
potential lack of clarity regarding a speaker’s target word or meaning (Armstrong, 2000);
potential for a dissociation between the information expressed by the speaker and how this
is understood by the communication partner (CP) (Ramsberger & Rende, 2002); as well as
the opportunity for speakers to draw on shared knowledge, which may not be expressed
explicitly. Thus, in order to measure transactional success, it is necessary to use a context
that shares similarities to conversation but, crucially, offers potential for externally set
criteria and standardisation. One such context is storytelling, which offers a broad plat-
form on which to base outcome measurement and treatment. There are several advantages
to using storytelling data within therapeutic studies:
●Social perspective: storytelling is a means of self-expression (McAdams, 2001),
displaying and experiencing an evolving identity (Bierren, Kenyon, Ruth, Shroots, &
Svendson, 1996), engaging with others and passing on life experience (Randall, 2001).
Storytelling is a way in which we make sense of the world particularly during
challenging life transitions and traumatic events (Riessman, 1993), both of which are
relevant for individuals and their families living with the chronic effects of stroke.
●Validity: like everyday conversation, interactive storytelling captures evidence of
speakers’turn-taking and negotiating the “point”of the story (Norrick, 2000).
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Furthermore, narrative stimuli are rich with options as to what will be commu-
nicated and the perspective adopted by the speaker. This presents choices to the
PWA regarding expression of story events through verbal and/or nonverbal means,
compared to more traditional language assessment that places constraints on pos-
sible linguistic responses and syntactic constructions (Hernandez-Sacristan &
Rosell-Clari, 2009).
●Clinical validity: PWA engage in significantly less storytelling in daily life com-
pared to healthy controls (Davidson et al., 2003). Thus, the powerful benefits of
storytelling (as a way of engaging with others and as a means of coping) are
beyond the reach of a population who could benefit from this social activity. This
suggests that storytelling is a clinically valid context for treatment and outcome
measurement.
●Linguistic perspective: production of narrative/storytelling encompasses a wealth of
linguistic skills. This includes macrolinguistic skills (e.g., the planning and sequen-
cing of information within a structured framework and tailored towards the listen-
er’s perspective) and mircolinguistic skills (i.e., semantic and syntactic aspects of
production), which resonate throughout many language production activities in
daily life (Whitworth, 2010).
●Methodological rigour: as an outcome measure, storytelling offers several advantages
including replicability, the potential for standardisation across participants, and an
opportunity for comparison of performances across individuals and to nonlanguage-
impaired control participants (Ramsberger & Menn, 2003; Ramsberger & Rende,
2002).
The current study stems from observations across the literature of mixed or underwhelm-
ing findings of generalisation following impairment-focused therapy. There is growing
evidence from therapy literature of the need to explicitly support PWA to generalise the
skills developed within therapy sessions to everyday communication (e.g., Carragher
et al., 2013; Whitworth, 2010). We hypothesised that targeting the combination of several
key ingredients might facilitate generalisation of behaviours targeted in therapy to an
untrained everyday communication task. These ingredients included the following:
(1) targeting microlinguistic and macrolinguistic skills and shaping nonverbal output
and compensatory strategies (e.g., reduced syntax and direct reported speech) to
optimise the communication of new information;
(2) using principles of thinking for speaking to improve narrative planning and
production for PWA;
(3) including the CP within the therapeutic focus to prime them to be receptive to the
PWA’s compensated storytelling and to shape their own behaviours to optimise
“uptake”of the PWA’s improved skills; and
(4) targeting information exchange within the everyday activity of storytelling. We
hypothesised that positioning therapy within the everyday activity of information
exchange and storytelling would close the gap and present less of a challenge for
PWA to generalise their improved skills to everyday use.
The current study builds on work by Ramsberger and colleagues (Ramsberger & Menn,
2003; Ramsberger & Rende, 2002) by extending interactive storytelling to a therapy task.
The paper outlines the novel approach of “Interactive Storytelling Therapy”,a
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standardised approach to shaping and enhancing the exchange of new information
between PWA and their CPs within a storytelling context.
2. Aims of the study
The current study will present a preliminary analysis from a pilot study of the effects of
Interactive Storytelling Therapy on untrained tasks. Specifically, the study aimed to
answer the following questions:
●Following therapy, do participants with a range of severities of nonfluent aphasia
successfully convey more information in response to untrained narrative stimuli?
●Following therapy, are CPs more successful in interpreting new information within
untrained narrative tasks?
●Following therapy, are there changes in the narrative structure used by the
PWA?
3. Method
3.1. Participants
Following ethical approval via standard UK protocols (NHS IRAS system), four PWA
were recruited. This study formed the third in a series of therapy studies targeting
incremental levels of language output in individuals with nonfluent aphasia. As part of
a larger group of participants (N= 9), these four participants had taken part in previous
therapy studies targeting verb retrieval (Carragher et al., 2013) and syntactic construction
(Carragher, Sage, & Conroy, in press). All participants presented with stroke-induced
chronic nonfluent aphasia. Presentation of nonfluent aphasia was confirmed on the basis
of converging evidence from clinical consensus, the results of standardised lexical
retrieval assessment (as indicated by a clinical score on the Boston Naming Test) and
impaired use of grammatical markers and syntactic structures in picture description
(Goodglass, Kaplan, & Barresi, 2001). Participants were at least 6 months postonset,
reducing the likelihood of further spontaneous recovery. As apraxia of speech often
co-occurs with nonfluent aphasia (McNeil, Robin, & Schmidt, 2008), presence of apraxic
errors did not form part of the exclusion criteria. Interparticipant variation existed for time
postonset, ranging from 26 to 80 months (mean: 51.5, SD: 27.5). The participants ranged
in age from 38 to 70 years (mean: 59.5, SD: 14.5); Table 1 provides background
information on the four participants with aphasia. In the current study, CPs participated
Table 1. Background information on the participants with aphasia.
Participants Gender
Age of leaving
education (years) Handedness Occupation
Age at time of
stroke (years)
TPO
(months)
BL Male 16 Right Pub manager 60 80
JH Female 23 Right Teacher 36 26
AT Female 16 Right Secretary 62 30
PM Male 16 Right Businessman 64 70
Note: TPO: time postonset.
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within the treatment. In each case, the CP was the PWA’s husband or wife, had known the
PWA prior to the stroke, and had no history of neurological impairment. Written informed
consent was obtained for each PWA and his/her CP prior to commencement of the study.
3.2. Background assessment
Interparticipant variation existed for severity: noun naming (Boston Naming Test, Goodglass
et al., 2001) ranged from 16 to 36 from a maximum score of 60 (mean: 26.3, SD:10.0);verb
naming (The Object Action Naming Battery, Druks & Masterson, 2000) ranged from 30.5 to
59 from a maximum score of 100 (mean: 44.3, SD: 11.7). Further details of the PWA and their
performance on a battery of linguistic and cognitive assessments are provided in Carragher
et al. (2013).
3.3. Assessment stimuli
Pretherapy and posttherapy assessment consisted of interactive storytelling in response to
video stimuli. At each time point, the PWA watched a video clip in the absence of the CP;
the CP then returned to the room and the PWA recounted the story. No instructions or
limitations were placed on the participants during their discussion of the video clip, i.e.,
they were not directed to, nor restricted from, using gesture, pointing, drawing, or writing.
The only instruction issued to the CP was that the PWA had viewed a video clip, they
were asked to find out what happened in the clip, and that they would later report their
interpretation of it to the researcher. Assessment stimuli included a simple video narrative
and a complex video narrative. Drawing on Weinrich, McCall, Boser, and Virata’s criteria
(2002), simple narratives were defined as video clips that involved only one to two actors,
one to two complicating actions and a resolution; complex narratives were defined as
video clips that involved more than two actors, four complicating actions, and a resolu-
tion. Data collected from control participants (N= 8) were used to distinguish simple
narrative video material from complex narrative material (see Outcome measures section
for more details on the collection and analysis of control data).
Assessment stimuli at both time points consisted of “Mr. Bean”
1
DVD footage. These
video clips were chosen for their minimal spoken language content, thereby minimising
the linguistic scaffolding available to the PWA in constructing the story. Cultural famil-
iarity was a further factor in the selection of assessment stimuli—“Mr. Bean”clips contain
highly familiar/imageable concepts and humorous content which is watched by adults as
well as children. Similar to real-life communication, once the referent of Mr. Bean had
been established, the CP would have access to some shared knowledge about the
protagonist (e.g., Whitworth, 2010). In order to minimise the effects of memory or
practice, novel stimuli were used across pretherapy and posttherapy assessment although
they were based on the same comic character. CPs were not told in advance the subject or
nature of the narrative topics in the assessment video stimuli.
3.4. Therapy stimuli
For the therapy sessions, video clips were sourced from YouTube and viewed by PWA
using an iPad. The Mr. Bean video footage was not used within therapy sessions; they
were reserved for pretherapy and posttherapy assessment only. Therefore, outcome mea-
surement reflects participants’ability to generalise behaviours targeted within therapy to
untrained, novel narrative stimuli. Video clips were selected for their interesting and
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newsworthy nature; they were often funny and therefore motivating for the couple to
discuss. The therapy video clips involved minimal or no use of language. As the PWA
presented across a range of aphasic severity, it was important that the video clips used
within the therapy sessions were capable of challenging the higher-level participants
whilst not alienating those PWA with fewer linguistic and communicative abilities.
Therefore, selection of the therapy stimuli erred on the side of complex narratives.
Within the therapy sessions, the higher-level participants were encouraged to include
details within their story construction whilst the participants with a more severe aphasic
impairment were encouraged to construct a more stripped-back story structure. See
Appendix 1 for an example of the video stimuli used during therapy. Outlined in the
following are the YouTube clips selected for the therapy sessions, the length of each clip,
and their current web address:
Seaplane fishing (00:54), http://www.youtube.com/watch?v=iY6AWs2QMbM
Pixar: Geri’s game (03:50), http://www.youtube.com/watch?v=9IYRC7g2ICg
Pixar: Pigeons (02:40), http://www.youtube.com/watch?v=oIlIVFBBbNw
Pixar: For the birds (03:00), http://www.youtube.com/watch?v=VkuBIrdi6eE
French clip (01:52), http://www.youtube.com/watch?v=3xAE6gjvQ7Q
3.5. Overview of Interactive Storytelling Therapy sessions
Therapy was delivered by the first author who is an experienced speech and language
therapist. In line with routine clinical intervention within the UK, participants received six
therapy sessions administered once a week. Each session lasted for approximately 1.5 hr.
Within each session, up to 45 min was dedicated to working with the PWA, up to 30 min
to working with the CP, and the remainder of the session used for video feedback and
discussion with the couple. The first therapy session focused on reflecting on current
storytelling behaviours before targeting these behaviours in subsequent practical sessions
(sessions 2–6). Figure 1 outlines the focus of therapy across sessions.
3.5.1. Session 1: reflection and goal-setting
The first treatment session focused on encouraging the PWA and their CP to reflect on the
baseline video-recording of their storytelling and to begin to increase their awareness of
various strategies and choices evident within their interactions. Video feedback was used to
facilitate discussion of the consequences of specific behaviours seen in the data. These
included strategies used by the PWA to convey events; strategies used by the CP to clarify
information or elicit further explanation; displays of negative emotion such as frustration;
alternatives to strategies seen in the video data; and, more broadly, sharing of the commu-
nicative burden and the overall effectiveness/success of the interaction. Couples were encour-
aged to extend their reflections beyond the recorded interactive storytelling to consider their
everyday conversations. During this initial session, therapy goals specific to each couple were
suggested, based on analysis of baseline interactive storytelling (see Appendix 2). The goals
were given brief descriptive, mnemonic labels (e.g., Drip drip and Pinpoint—see Appendix 2
for definitions) to facilitate participants to remember their individual goals and also to aid
discussion of specific strategies within the therapy sessions. For the PWA, therapy goals
related to components of story grammar (Ramsberger & Menn, 2003; Ramsberger & Rende,
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2002), such as introducing key referents, while for the CP, therapy goals related to repairing
breakdowns in understanding.
3.5.2. Practical sessions 2–6: PWA
This part of the treatment drew upon the principles of thinking for speaking (Marshall,
2009) and story grammar (Rumelhart, 1975). The practical sessions began with the PWA
viewing a video clip in the absence of their partner (see Figure 1). The video clip was
repeated as often as requested (participants usually requested a maximum of three
repeated viewings). The therapist facilitated the PWA to segment the narrative into
main events, broadly conceptualised as the beginning, middle, and end sections of the
story. Where relevant, the PWA was prompted to begin by introducing the story (Set the
scene goal) by stating the main referent as well as other contextual information such as
location or tone of the story (e.g., funny or sad). Throughout this process, the PWA was
supported in his/her conceptualisation of the story through a visual record; the researcher
used this to record the ongoing construction of the story by writing down words/phrases
Figure 1. Overview of therapy sessions.
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produced by the PWA and using drawing to depict gesture. The visual record served as a
useful anchor by which the PWA could monitor their progression as they constructed the
story.
Having established the main referent of the story, the PWA was prompted to think about
what happened next in segments (corresponding to the Chunk it up and Drip drip goals). This
involved describing key information and actions relating to the main referent. The PWA was
encouraged to produce an agent–verb construction, with the verb produced verbally or
through gesture, writing or drawing. The aim was to optimise (rather than correct) partici-
pants’output; therefore, any prompts or modelling provided by the therapist were carefully
built on the participant’s original output. For example, if the PWA gestured “running”,the
researcher prompted “Who”? followed by the gesture, with the aim of prompting the PWA to
produce a more contentful construction incorporating both verbal and nonverbal output
(related to the Show and Tell goal). If the PWA produced a content word in isolation (e.g.,
hungry), the researcher used wh-questions (e.g., who is hungry?) and modelling (e.g., bird
hungry) to facilitate the PWA’s production of argument structure. In line with a previous
therapy study (Carragher et al., in press), all modelling of syntactic constructions involved
morphologically reduced structures to maintain focus on communicative value rather than
grammatical correctness. The PWA was also facilitated to use direct reported speech (Hengst,
Frame, Neuman-Stritzel, & Gannaway, 2005) to depict characters’reactions within the story
and to produce evaluative comments in grammatically simplified ways. When the opportunity
arose whilst constructing the story, the therapist modelled how the participant could make use
of direct reported speech to convey tone and emotion and to carry some of the lexical and
grammatical load of narrative production. Furthermore, written feedback was used to demon-
strate how direct reported speech eliminates the need for numerous function words and
morphology (e.g., girl—cup of tea please rather than the girl said that she wanted a cup
of tea).
As the PWA progressed through the telling of each episode within the story, the
segmentation of the story was reinforced visually through the use of the visual record, i.e.,
clearly marking the first, second, third, fourth, etc. episodes of the story. This process was
repeated until the complete story had been discussed and sketched out in the visual record.
Throughout the story construction, the PWA was prompted to think selectively in terms of
what details to include or omit from the story to ultimately facilitate their partner’s
comprehension of the story. In particular, the PWA was encouraged to consider whether
a particular event or detail was key to understanding the story or more peripheral (issue of
selectivity raised by Marshall & Cairns, 2005).
By the end of this part of the session, the participant had produced the story three
times in total, with incremental withdrawal of support from the researcher:
(1) During the first telling, the PWA was maximally supported by the therapist to
segment the story into events, to prioritise establishing key referents, and to
combine verbal output with gesture, drawing, and writing. The therapist kept a
visual record of the story, which included key words, phrases, and drawings.
(2) In the second telling, the PWA was prompted to use the visual record to construct
the story. Moderate support was given to remind the PWA about the strategies
discussed and developed during the first story telling. Also at this stage, partici-
pants were facilitated to link together the various events within the story either
verbally (e.g., using connective devices such as and then) or nonverbally (e.g.,
using gestures or fingers to indicate first, second, third, etc.).
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(3) During the third telling of the story, the visual record was removed and PWA were
encouraged to construct the story independently, with the therapist providing
feedback or requesting clarification where necessary.
The aim here was not to foster rote-learning of a particular story. Rather, the approach was
to gradually withdraw support and to encourage independent use of key strategies to
support the PWA in constructing the story in an optimal, coherent manner with regard to
the sequencing of ideas and relevant information.
3.5.3. Practical sessions 2–6: CPs
The CP then rejoined the therapy session in order to discuss the video clip with their
partner with aphasia. At this point, the CP became the focus of therapy intervention (see
Figure 1). Therapy sessions were video recorded with the participants’consent in order to
facilitate later reflection. The therapist prompted the CP to recall the therapy goals agreed
at the start of the intervention; as therapy progressed over a number of weeks, this
discussion expanded to include topics that had arisen in earlier sessions. As the couple
began to discuss the story, the therapist intervened on a needs-basis when a trouble source
arose that the CP struggled to resolve. For example, the therapist offered a diagnosis of the
problem (i.e., relating to a lexical search, confusion regarding a referent, or a broader issue
regarding which part of the story was currently being discussed) and facilitated the CP to
select one of the targeted goal behaviours to employ, e.g., Move along or Stop and check
(see Appendix 2). If the CP struggled to select a strategy, the therapist suggested an
appropriate strategy and modelled this behaviour as needed. The therapist did not inter-
vene if the PWA omitted important details of the story or confirmed details about the story
that were incorrect; the goal of therapy related to the exchange and negotiation of
information between the couples rather than conveying specific details.
3.5.4. Practical sessions 2–6: the couple
Once the couple had finished discussing the story, the CP watched the target YouTube
video clip and then together the couple viewed the video recording of them discussing the
story (Figure 1). This enabled both the PWA and CP to engage in offline evaluation of the
strategies employed within the task. Discussion focused on the agreed goals for each
individual; where relevant, discussion included any novel issues that had arisen during the
session and goals were agreed for each couple to focus on in the homework task and in
the subsequent therapy session. The homework task consisted of each couple setting aside
time to each practice using goal behaviour in an everyday conversation and reflecting on
whether the strategy had been useful. The types of conversations in which participants
were encouraged to use the goals behaviours included catching up on what the PWA did
at the stroke group, relaying a conversation with a neighbour, etc. Stimuli were not
provided for the homework task; rather, the focus was placed on each couple developing
an awareness of opportunities for changed interactive behaviours and selecting strategies
as needed.
3.6. Outcome measures
Outcome measurement focused on transactional success (i.e., exchange of new informa-
tion) in comparison to control data. Control participants (N= 8) viewed the Mr. Bean
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video clips (used in pretherapy and posttherapy assessment) and were asked to describe
what happened. The control participants were nonlanguage-impaired, native English
speakers. They were not matched to the PWA in the current study but represented a
varied sample with respect to age (mean: 42 years; range: 17–64), years of full-time
education (mean: 16 years; range: 11–21) and gender (four males and four females). The
control participants’descriptions of the Mr. Bean video clips varied regarding quantity of
description as well as the details provided (e.g., one control participant described Mr.
Bean driving a yellow car, another described Mr. Bean driving a yellow Mini, while
another simply reported Mr. Bean drove into a car park and omitted any details relating to
the car). In order to condense the control participants’descriptions to the core story
components, written transcripts of the control participants’descriptions were analysed for
the most commonly reported content words. Those content words that were reported by at
least 50% of control participants were interpreted as forming essential components or
ideas of the target story. Thus, content words that were produced by at least 50% of the
control participants were labelled “salient content words”. In this way, the control data
provided a maximum score for each Mr. Bean video clip. These “salient”content words
were used to develop model narratives for each clip consisting of the crucial parts of story
structure, i.e., setting, complicating actions, and resolution (Labov, 1972). The target
components for each assessment video clip are shown in the shaded columns in
Appendix 3. A similar measure of transactional success in storytelling had demonstrated
high validity and reliability as a method of analysis (Ramsberger & Menn, 2003;
Ramsberger & Rende, 2002).
3.7. Data analysis
Using data from control participants, it was possible to segment each assessment narrative
into distinct story segments, with a core group of target content words within each
segment. In the baseline storytelling data, differences in main ideas reported reflect
difference in the complexity of the narrative stimuli and are in line with data from the
control participants, i.e., control participants, PWA, and CPs produced more narrative
output for complex stimuli.
For each assessment point, storytelling data for each couple (i.e., Mr. Bean stimuli)
were transcribed by individuals who were blind to the aim of the treatment and the
sampling point; the first author verified accuracy of all transcripts. For the PWA, the
written transcripts were analysed to identify instances when they produced (either verbally
or nonverbally) a main idea that corresponded to those content words most frequently
produced across control participants (see Appendix 3 for the maximum score achievable
for each stimulus). For the CPs, written transcripts of their reporting of the story were
subjected to the same analysis (see Appendix 3). In this way, PWA and the CPs were
credited only for the information that was deemed essential across control participants.
4. Results
4.1. Number of salient ideas communicated by the PWA
It was not possible to carry out statistical analysis given (1) the inherent variability in
sampling phenomena such as information exchange within narrative production, (2) lack
of data on stability of information exchange over sampling periods, and (3) the lack of
rigidly defined accurate/inaccurate responses, i.e., CPs’retelling of the narratives were
10 M. Carragher et al.
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compared to the salient content words produced by the control participants; close syno-
nyms were accepted as correct. Raw and percentage data are presented for each PWA
and CP.
For the PWA, Table 2 outlines the raw and percentage data for the changes in number
of main ideas reported. Data are presented separately for the simple and complex narrative
stimuli. Following therapy, the simple narrative condition demonstrated numeric improve-
ments across the board: three participants improved their communication of salient ideas
(AT, BL, and JH) whilst the remaining participant (PM) demonstrated a slight drop of
0.5%. The complex narrative condition proved more challenging with only two partici-
pants (AT and PM) demonstrating increases in the number of salient ideas they expressed,
whilst two participants demonstrated numeric decreases (BL and JH).
4.2. Number of salient ideas communicated by the CPs
Following therapy, for the simple narrative stimuli, three CPs demonstrated numeric
increases in the number of main ideas they had successfully understood (partners of AT,
BL, and JH) whilst the remaining CP (partner of PM) demonstrated a drop of 12.8% (see
Table 3). For the complex narrative stimuli, two CPs (partners of AT and BL) demon-
strated numeric increases in the number of main ideas they understood, whilst two CPs
demonstrated numeric decreases (partners of PM and JH).
The pre/posttherapy data for simple and complex narrative stimuli were collapsed
together for each time point in order to compare mean change for each PWA and his/her
Table 2. Comparison of salient content words reported by the participants with aphasia in
pretherapy and posttherapy storytelling (% data shown in brackets).
Stimuli PWA Pretherapy Posttherapy Difference (%)
Simple AT 9 (60.0%) 11 (84.6%) +24.6
PM 7 (46.7%) 6 (46.2%) −0.5
BL 6 (40.0%) 6 (46.2%) +6.2
JH 6 (40.0%) 8 (61.6%) +21.6
Complex AT 12 (44.4%) 21 (67.7%) +23.3
PM 13 (48.2%) 18 (58.1%) +9.9
BL 8 (29.6%) 8 (25.8%) −3.8
JH 13 (48.2%) 14 (45.2%) −3.0
Table 3. Comparison of salient content words reported by the CPs in pretherapy and posttherapy
storytelling (% data shown in brackets).
Stimuli CPs Pretherapy Posttherapy Difference (%)
Simple AT 9 (60.0%) 9 (69.2%) +9.2
PM 10 (66.7%) 7 (53.9%) −12.8
BL 4 (26.7%) 7 (53.9%) +27.2
JH 10 (66.7%) 12 (92.3%) +25.6
Complex AT 4 (14.8%) 16 (51.6%) +36.8
PM 13 (48.2%) 13 (41.9%) −6.2
BL 3 (11.1%) 8 (25.8%) +14.7
JH 16 (59.3%) 18 (58.1%) −1.2
Aphasiology 11
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CP. Interestingly, the changes in the number of salient ideas observed in the performance
of the PWA do not appear to reliably predict changes in how many ideas will be under-
stood by their CPs (see Table 4 and Figure 2):
●Following therapy, for the simple narrative AT improved her communication of
salient ideas by 24.6% whilst her CP improved by a smaller margin (9.2%). For
complex narrative, the reverse is true: AT produced 23.3% more salient ideas but
her CP was correct in interpreting her expression by 36.8%.
●For PM, he communicated slightly less salient ideas for simple narrative after
therapy (−0.5%); his partner also demonstrated a decrease in the number of ideas
she successfully understood (−12.8%). For complex narrative, PM produced more
salient ideas following therapy (9.9%), but this did not result in his partner
successfully interpreting these (−6.2%).
●Following therapy, BL increased his communication of salient ideas for simple
narrative (6.2%), which his partner responded to by successfully understanding
27.2% more of these salient ideas. For complex narrative, BL produced less salient
ideas (−3.8%), but his partner was able to compensate for this and understood
14.7% more salient ideas compared to pretherapy levels.
●JH communicated 21.6% more salient ideas for simple narrative following therapy
and this was also reflected in her partner’s understanding (which increased by
25.6%). However, for complex stimuli, her communication of salient ideas reduced
by 3% and her partner’s understanding of these salient ideas also reduced by 1.2%.
4.3. Narrative sequence
For each PWA, therapy had emphasised and provided opportunities to practice narrative
planning skills (e.g., beginning by introducing the main referent, building up the story
event-by-event) and expanding content of output using verbal and nonverbal means (e.g.,
pairing a spoken agent with a gestured action to fill the verb slot within the construction).
Given the emphasis on narrative planning and structure, we analysed the output of the
PWA to investigate whether the order in which they delivered each narrative changed
following therapy. The control data provided a guide for the order in which the control
participants described each event within the story. Storytelling data from the PWA were
coded to identify each content word produced and to which scene it corresponded within
the target template (which represented an amalgamation of the control participants’
production).
For the simple narrative, pretherapy data suggest that some participants (most notably
AT and JH) reported narrative events out of sequence (see Table 5). This may have
Table 4. Comparison of mean change in number of salient content words
reported by the participants with aphasia and their CPs in pretherapy and
posttherapy storytelling.
Participant Mean difference: PWA (%) Mean difference: CP (%)
AT +24.0 +23.0
PM +4.7 −9.5
BL +1.2 +20.9
JH +9.3 +12.2
12 M. Carragher et al.
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Figure 2. Percentage of mean change following therapy for each PWA and CP within untrained
simple and complex narratives.
Aphasiology 13
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contributed to breakdowns in understanding between the PWA and his/her CP. Following
therapy, all participants improved in their narrative sequencing, i.e., sequencing more
closely followed the structure used by control participants and less needed to revise their
narrative production.
The complex narrative stimuli proved to be more challenging in terms of participants’
planning and sequencing (see Table 6). Participants AT and JH produced narrative that
was more closely aligned to the sequence produced by the control participants, i.e.,
reporting the first scene of the target narrative, followed by the second scene, third,
Table 5. Simple narrative: how the participants with aphasia organised and relayed the narrative
events in pretherapy and posttherapy storytelling compared to the structure used by control
participants.
Time point Scene Controls AT PM BL JH
Pretherapy Scene 1 ✓✓✓✓✓
Scene 2 ✓3✓✓3
Scene 3 ✓2✓✓1
Scene 4 ✓4✓✓✓
122
23
Posttherapy Scene 1 ✓✓✓✓✓
Scene 2 ✓✓✓✓✓
Scene 3 ✓✓✓✓✓
Scene 4 ✓✓31✓
Table 6. Complex narrative: how the participants with aphasia organised and relayed the narrative
events in pretherapy and posttherapy storytelling compared to the structure used by control
participants.
Time point Scene Controls AT PM BL JH
Pretherapy Scene 1 ✓✓✓✓✓
Scene 2 ✓✓✓✓✓
Scene 3 ✓✓5✓✓
Scene 4 ✓5356
Scene 5 ✓6465
Scene 6 ✓2✓✓6
4
Posttherapy Scene 1 ✓✓✓✓✓
Scene 2 ✓✓3✓✓
Scene 3 ✓✓11✓
Scene 4 ✓522✓
Scene 5 ✓4366
Scene 6 ✓✓54✓
53
4
3
4
6
14 M. Carragher et al.
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fourth, etc. However, participants PM and BL produced complex narratives that were less
aligned to control narrative sequence compared to their pretherapy level.
5. Discussion
The current study aimed to extend previous work on transactional communication in story-
telling (Ramsberger & Menn, 2003; Ramsberger & Rende, 2002) by conducting preliminary
analyses of the effect of a novel intervention targeting transactional success within storytelling
for people with nonfluent aphasia and their CPs. Interactive Storytelling Therapy targets and
optimises the coconstruction of stories by two people (Bronken, Kirkevold, Martinsen, &
Kvigne, 2012), a feature that may be especially important when one speaker has aphasia.
Therapy consists of a dual-focus targeting both the PWA and the CP in order to optimise the
exchange of new information. By using video clips to stimulate storytelling, the therapy
approach offers a method of standardising treatment sessions whilst maintaining features of
everyday interaction, e.g., the CP is blind to the video content thus simulating a real-life
communicative situation in which the PWA is imparting new information. Interactive
Storytelling Therapy establishes storytelling as a shared communicative activity between
speakers. In this way, it differs from narrative therapy (e.g., Whitworth, 2010), which focuses
solely on the production of the PWA, thereby omitting features of storytelling such as to
whom the story is addressed and how the teller and the recipient interact to achieve mutual
understanding (Goodwin, 1995).
Drawing on the principles of thinking for speaking, PWA were facilitated to segment
video narrative into distinct events, to selectively highlight specific details of the story and to
use a combination of verbal (e.g., syntactically reduced utterances and direct reported speech)
and nonverbal resources (e.g., gesture, writing, and drawing) in order to convey new
information to their partner. Components of story grammar (e.g., setting the scene by
introducing main characters) were used to facilitate narrative planning and production. For
the CPs, therapy drew on the principles of conversation coaching to educate partners on their
role within the interaction and ultimately increase facilitative behaviours within storytelling. It
was hypothesised that the sum of these strands of therapy would be improved negotiation and
construction of shared understanding within storytelling. Therapy was administered once a
week (each session lasting approximately 1.5 hr) for 6 weeks. This decision was based on
typical clinical intervention within the UK. However, optimal intensity/dosages for this
specific treatment are as yet unknown.
Effects of therapy were analysed within untrained narrative tasks by measuring changes in
the number of main ideas, which were (1) successfully communicated by the PWA and (2)
successfully understood by the CP. Video stimuli used within baseline and posttherapy
assessment were novel stimuli not previously seen by the participants. Therefore, any changes
would represent generalisation of behaviours targeted in therapy to untrained tasks. For the
PWA, three participants demonstrated increased communication of salient ideas within
posttherapy simple narrative, and two participants demonstrated increases in complex narra-
tive. For the CPs, numeric increases in simple narrative were seen for three participants, and
for the complex narrative, two participants demonstrated numeric gains. PM’s partner was
unique in that she demonstrated a decrease in the amount of information she successfully
interpreted across both simple and complex posttherapy storytelling. This is intriguing given
that her partner with aphasia PM improved in his conveying of main ideas. However, as
Fergadiotis and Harris Wright (2011, p. 1414) argue “discourse is successfully produced when
the listener is able to reconstruct the message sent and interpret its intended meaning”(p.
1414). Therefore, PM’s increased ability to communicate salient ideas from the target story
Aphasiology 15
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was not sufficient in its own right to increase his partner’s understanding of the story. This
highlights the need for further work to uncover the reasons behind the discrepancy between
PM and his partner’s response to therapy. Furthermore, this finding underlines the importance
of explicitly supporting PWA to generalise the behaviours targeted within therapy for use in
everyday communication. PM’s partner highlights the need to work with CPs to create space
within the interaction for the PWA to make use of their improved linguistic and commu-
nicative resources and to shape CPs’behaviours to accommodate a speaker with an impaired
language system.
Whilst the participant numbers within the current study are small and the therapy dose
relatively low, preliminary results appear to be promising, suggesting that the combination
of targeting both the PWA and CP within an everyday communicative activity assists in
the negotiation and transfer of new information relative to comparable narratives obtained
at baseline. The approach of evaluating CPs’retelling of a narrative to which they were
blind appeared to be a promising outcome measure that was both engaging and of interest
to all of these participants and represented a middle ground between experimentally
controlled tasks for eliciting monologic aphasic data and the more ecological but uncon-
strained sampling of conversation data. Further related research would be aided by
establishing more precise measures relating to narrative complexity through closer match-
ing of related narratives (e.g., ensuring that simple narratives are matched for identical
numbers of complications and key words) This could allow for use of nonparametric
analyses of apparent differences between pretherapy and posttherapy narrative samples in
order to more formally evaluate whether differences are statistically significant.
The current study represents an attempt to develop some degree of standardisation within
an interactive therapy protocol to promote generalisation to untrained tasks. Given the
tradition of interactive and conversation analysis therapy methods of having been highly
data driven and individualised in terms of therapy focus, the method described here represents
an attempt to develop a standardised template for intervention delivery and measurement.
Storytelling plays a vital role in making sense of the world, particularly in the wake of a
traumatic life experience (Kellas & Trees, 2006). Evidence suggests PWA engage signifi-
cantly less in storytelling than their healthy counterparts (Davidson et al., 2003); thus, story-
telling presents a psychosocially and clinically valid context for therapeutic focus. The
method evaluated within the current study has been characterised as a template consisting
of (1) working with the PWA to deliver new information in the context of storytelling and (2)
working with the CP to collaborate in the construction of the story. While the precise advice
and recommended strategies for a particular couple are tailored and individualised, this will be
within the limits of the central task of information exchange. This move towards some flexible
standardisation may support clinical application of this method, given that it is a defined
protocol that can be applied in a time-efficient manner without preplanning. Similarly, use of
first session information exchange measures can serve as baseline measures for posttherapy
evaluation that has ease of use and real-world clinical plausibility. Further research is
warranted in order to identify the exact mechanisms of change (or lack of change in the
case of PM’s partner). This could include analysis of the specific goal behaviours that
participants made use of following therapy.
“The ultimate goal of aphasia rehabilitation is a social one: to optimize the commu-
nication between the person with aphasia and his or her environment”(Van De Sandt-
Koenderman, Van Der Meulen, & Ribbers, 2012, p. S1). The range of aphasia therapies
has been conceptualised as deficit-focused, functional/disability-focused or participant-
focused (World Health Organisation [WHO], 2001). This study represents an attempt to
combine elements from impairment-focused therapy (i.e., thinking for speaking and story
16 M. Carragher et al.
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grammar) and a disability-focused therapy (i.e., conversation coaching targeting the CP)
in order to target the exchange of new information within storytelling. The inclusion of the
CP within therapy acknowledges the important roles played by both the PWA and the CP
in constructing shared understanding. Employing therapy techniques from various
approaches reflects clinical practice where therapists combine all approaches at their
disposal in supporting a PWA and their family through aphasia rehabilitation. Therapy
stimuli were sourced from YouTube and viewed using an iPad, thus utilising widely
available technology to create interesting, age-appropriate materials. Whilst further
research is required to expand this model of treatment delivery and outcome measurement
to a larger group of participants, the current study offers a novel approach whereby an
important aspect of everyday communication—conveying new information—is targeted
through the production patterns of the PWA and shaping facilitative behaviours of the CP.
Such intervention may have implications for establishing and maintaining relationships, a
sense of achievement for the PWA and CP, and, more broadly, quality of life.
Acknowledgements
We are grateful to the participants with aphasia and their families for their time, effort, and
enthusiasm in taking part in the study. This work would not have been possible without the support
of speech and language therapists who cascaded information about the study to potential
participants.
Funding
This work is supported by a Research Bursary from the Stroke Association (TSA JRTF 2009/01).
Note
1. Mr. Bean is a socially inept character who gets himself into embarrassing, comic scenarios, such
as becoming frightened in front of others on a high diving board in a swimming pool.
References
Armstrong, E. (2000). Aphasic discourse analysis: The story so far. Aphasiology,14, 875–892.
doi:10.1080/02687030050127685
Beeke, S., Maxim, J., Best, W., & Cooper, F. (2011). Redesigning therapy for agrammatism: Initial
findings from the ongoing evaluation of a conversation-based intervention study. Journal of
Neurolinguistics,24, 222–236. doi:10.1016/j.jneuroling.2010.03.002
Bierren, J., Kenyon, G., Ruth, J., Shroots, J., & Svendson, J. (1996). Aging and biography:
Explorations in adult development. New York, NY: Springer.
Bradley, M., & Douglas, J. (2008). Conversation partner training –Its role in aphasia. Acquiring
Knowledge in Speech, Language and Hearing,10,18–21.
Bronken, B., Kirkevold, M., Martinsen, R., & Kvigne, K. (2012). The aphasic storyteller: Co-
constructing stories to promote psychosocial well-being after stroke. Qualitative Health
Research,22, 1303–1316. doi:10.1177/1049732312450366
Carragher, M., Sage, K., & Conroy, P. (2013). The effects of verb retrieval therapy for people with
non-fluent aphasia: Evidence from assessment tasks and conversation. Neuropsychological
Rehabilitation,23, 846–887. doi:10.1080/09602011.2013.832335
Carragher, M., Sage, K., & Conroy, P. (in press). Outcomes of treatment targeting syntax production
in people with Broca’s-type aphasia: Evidence from psycholinguistic assessment tasks and
everyday conversation. International Journal of Language & Communication Disorders.
Davidson, B., Worrall, L., & Hickson, L. (2003). Identifying the communication activities of older
people with aphasia: Evidence from naturalistic observation. Aphasiology,17, 243–264.
doi:10.1080/729255457
Druks, J., & Masterson, J. (2000). The Object Action Naming Battery. Hove: Psychology Press.
Aphasiology 17
Downloaded by [La Trobe University] at 17:22 04 May 2015
Fergadiotis, G., & Harris Wright, H. (2011). Lexical diversity for adults with and without aphasia
across discourse elicitation tasks. Aphasiology,25(11), 1414–1430. doi:10.1080/
02687038.2011.603898
Goodglass, H., Kaplan, E., & Barresi, B. (2001). The Boston Diagnostic Aphasia Examination
(BDAE). Baltimore, MD: Lippincott.
Goodwin, C. (1995). Co-constructing meaning in conversations with an aphasic man. Research on
Language and Social Interactions,28, 233–260. doi:10.1207/s15327973rlsi2803_4
Hengst, J., Frame, S., Neuman-Stritzel, T., & Gannaway, R. (2005). Using others’words:
Conversational use of reported speech by individuals with aphasia and their communication
partners. Journal of Speech, Language and Hearing Research,48, 137–156. doi:10.1044/1092-
4388(2005/011)
Hernandez-Sacristan, C., & Rosell-Clari, V. (2009). Syntax and conversation in aphasia. A strategic
restrictive use of Spanish and Catalan connector QUE by aphasic speakers. Clinical Linguistics
& Phonetics,23, 717–741. doi:10.3109/02699200903063053
Hopper, T., Holland, A., & Rewega, M. (2002). Conversational coaching: Treatment outcomes and
future directions. Aphasiology,16, 745–761. doi:10.1080/02687030244000059
Kellas, J., & Trees, A. (2006). Finding meaning in difficult family experiences: Sense-making and
interaction processes during joint family storytelling. Journal of Family Communication,6,
49–76. doi:10.1207/s15327698jfc0601_4
Labov, W. (1972). The transformation of experience in narrative syntax. In W. Labov (Ed.),
Language and the inner city. Philadelphia: University of Pennsylvania.
Marshall, J. (2009). Framing ideas in aphasia: The need for thinking therapy. International Journal
of Language & Communication Disorders,44,1–14. doi:10.1080/13682820802683507
Marshall, J., & Cairns, D. (2005). Therapy for sentence processing problems in aphasia: Working on
thinking for speaking. Aphasiology,19, 1009–1020. doi:10.1080/02687030544000218
McAdams, D. (2001). The psychology of life stories. Review of General Psychology,5, 100–122.
doi:10.1037/1089-2680.5.2.100
McNeil, M., Robin, D., & Schmidt, R. (2008). Apraxia of speech: Definition and differential
diagnosis. In M. McNeil (Ed.), Clinical management of sensorimotor speech disorders (2nd
ed.). New York, NY: Thieme Medical.
Morris, J., Franklin, S., Menger, F., & GD. (2011). Returning to work with aphasia: A case study.
Aphasiology,25,890–907. doi:10.1080/02687038.2010.549568
Norrick, N. R. (2000). Conversational narrative: Storytelling in everyday talk. Amsterdam: John
Benjamins.
Ramsberger, G., & Menn, M. (2003). Co-constructing Lucy: Adding a social perspective to the
assessment of communicative success in aphasia. In G. Goodwin (Ed.), Conversation and brain
damage. New York, NY: Oxford University Press.
Ramsberger, G., & Rende, B. (2002). Measuring transactional success in the conversation of people
with aphasia. Aphasiology,16, 337–353. doi:10.1080/02687040143000636
Randall, W. (2001). Acquiring a narrative perspective on aging, identity and everyday life. In G.
Kenyon, P. Clark, & B. De Vries (Eds.), Narrative gerontology: Theory, research and practice.
New York, NY: Springer.
Riessman, C. (1993). Narrative analysis. Thousand Oaks, CA: Sage.
Rumelhart, D. (1975). Notes on a schema for stories. In D. Bobrow & A. Collins (Eds.),
Representation and Understanding: Studies in Cognitive Science. New York, NY: Academic
Press.
Van De Sandt-Koenderman, M., Van Der Meulen, I., & Ribbers, G. (2012). Aphasia rehabilitation:
More than treating the language disorder. Archives of Physical Medicine and Rehabilitation,93,
S1–S3. doi:10.1016/j.apmr.2011.08.037
Weinrich, M., McCall, D., Boser, K. I., & Virata, T. (2002). Narrative and procedural discourse
production by severely aphasic patients. Neurorehabilitation and Neural Repair,16, 249–274.
doi:10.1177/154596802401105199
Whitworth, A. (2010). Using narrative as a bridge: Linking language processing models with real-
life communication. Seminars in Speech and Language,31,64–75. doi:10.1055/s-0029-
1244954
World Health Organisation (WHO). (2001). International classification of functioning, disability
and health (ICF). Geneva: Author.
18 M. Carragher et al.
Downloaded by [La Trobe University] at 17:22 04 May 2015
Appendix 1. Example of video stimuli used during therapy
Geri’s game (Pixar short film) is a 3:50 minute video clip, http://www.youtube.com/watch?v
=9IYRC7g2ICg
Summary: It’s autumn and an elderly man is in the park alone setting up a game of chess. He
proceeds to play with his own alias as an opponent. As he moves to each side of the chessboard, he
plays as a different “character”—on one side of the board he wears his glasses and is a timid
character; on the other side of the board he takes off his glasses and is a competitive and somewhat
aggressive character. As the game progresses, the competitive character (without the glasses) is
winning. The timid character (with glasses) pretends to have a heart attack and, while his “oppo-
nent”is distracted, switches the chessboard so that he is winning. Once the game resumes, the
competitive character realises he is no longer winning the game and he resigns. As the prize, he
hands over a set of false teeth. As the camera pans over from the park, the man is seen sitting alone
at the chessboard.
Appendix 2.Individual goals for PWA and their conversation partners
Initials PWA CP Goals for therapy
AT ✓Chunk it up: think about the story in smaller, more
manageable chunks
Set the scene: detail the initial contextual information about
the story or give a general impression of the tone of the
story
Drip drip: tell the story bit by bit, leaving time for partner to
ask questions
AT-CP ✓Stop and check: check your understanding as you go along
by asking questions and summarising what you’ve
understood
Move along: during an unproductive lexical search for
PWA, keep the conversation moving by briefly
summarising the story so far and prompting PWA to tell
you the next part
Who does what: establish how many people are involved in
the story and their role within the story
Pinpoint: be specific about what you understand and what
you don’t understand
PM ✓Set the scene: detail the initial contextual information about
the story or give a general impression of the tone of the
story
Drip drip: tell the story bit by bit, leaving time for partner to
ask questions
Show and tell: use gesture or acting in combination with
speech to convey parts of the story
PM-CP ✓Move on: if you know the word the PWA is trying to say,
keep the conversation going. If you don’t know the word,
ask questions such as “Do you mean…?”
Who does what: establish how many people are involved in
the story and their role within the story
Pinpoint: be specific about what you understand and what
you don’t understand
(continued )
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Appendix 2. (Continued).
Initials PWA CP Goals for therapy
BL ✓Set the scene: detail the initial contextual information about
the story or give a general impression of the tone of the
story
Chunk it up: think about the story in smaller, more
manageable chunks
Drip drip: tell the story bit by bit, leaving time for partner to
ask questions
Show and tell: use gesture or acting in combination with
speech to convey parts of the story
BL-CP ✓Stop and check: check your understanding as you go along
by asking questions and summarising what you’ve
understood
Who does what: establish how many people are involved in
the story and their role within the story
Pinpoint: be specific about what you understand and what
you don’t understand
JH ✓Stop and listen: use conversation partner’s questions to
clarify details of the story with yes/no responses
Set the scene: detail the initial contextual information about
the story or give a general impression of the tone of the
story
Chunk it up: think about the story in smaller, more
manageable chunks
Drip drip: tell the story bit by bit, leaving time for partner to
ask questions
JH-CP ✓Go for the jugular: establish the basic details/events first
and then enquire specifically about background
information or more fine-grained detail
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Appendix 3.CPs’retelling of stories, scored in comparison to the most frequently occurring content words produced by control
participants
Pretherapy simple narrative
target AT’sCP PM’sCP BL’sCP JH’sCP
Mr. Bean drives into a car
park in a mini
Mr. Bean (1)
drives (1)
car park/parking lot (1)
mini (1)
Well Mr. Bean (1)…with
Rowan Atkinson in it was
a TV programme …and I
assuming that this …this
part of a TV programme
…which shows Atkinson
as Mr. Bean …driving (1)
into a car park (1) with his
usual incompetence …
He saw a car (1) going into a
car park (1) …the bloke
who turned out to be
Rowan Atkinson (1)
Rowan Atkinson (1) driving
(1) a car (1) …
Right I think Ron Atkinson
was driving (1) a mini (1)
into a car park (1) …
He parks too far from the
ticket machine and can’t
reach his ticket
parks/pulls up (1)
too far/not close enough (1)
ticket machine (1)
can’t reach (1)
ticket (1)
not being able to reach (1) the
ticket machine (1)
couldn’t reach (1) the ticket
(1) the ticket machine (1)
I don’t know …was he going
somewhere to pay for
something and using his
plastic card …
but it didn’t show him going
into the car park it showed
him reaching (1) for a
ticket (1) to press the
button and he couldn’t
press it
He uses a grabber to get the
ticket
grabber/stick/litter picker (1)
get/grab/pull out (1)
ticket (1)
so he has some sort of
extended arm (1) …and
then gets (1) the ticket (1)
…out of the machine …
so he got something I
presume out of the car …
like a grabber thing a pick-
me-up thing (1) to pull out
(1) the ticket (1)
and he used his stick (1) to
either push the plastic card
in or …type out
something or other I don’t
know I don’t really know
so then he went inside the car
and he found a litter-
picking stick (1), reached
out of the car to press the
ticket, got (1) his ticket (1)
He drives recklessly into the
car park
drives (1)
recklessly/quickly (1)
car park (1)
and drives off (1) I don’t
know whether he’s coming
in or going out …
and then he went to park (1)
the car somewhere …and
it’s was a black and …
yellow and black car
and then drove (1) …into the
car park (1) and then it
ended …and the car was
either yellow or cream
Total: 15 9 10 4 10
(continued )
Aphasiology 21
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Appendix 3. (Continued).
Posttherapy simple narrative
target AT’sCP PM’sCP BL’sCP JH’sCP
Mr. Bean is in the pool,
looking around
Mr. Bean/he (1)
arrives (1)
pool (1)
looking/had a look around
(1)
Mr. Bean (1) eh Mr. Bean …the
scene appears to be Mr. Bean
walks into a swimming pool (1)
Right so back to the swimming
pool (1) …Mr. Bean (1) again
…so I assume from that it was
going to be funny …he’s
standing on the side of the pool
wearing his trunks …
Right what I got …Rowan
Atkinson (1) …and he said slide
at first …well he said there were
two slides at first didn’the…but
I- I never carried on with two
slides …and then I found out it
were in swimming baths and the
slides were in the swimming
baths (1)
Right …Mr. Bean (1) again he’s
still in the swimming pool (1) but
he’s sort of on the side …
looking round (1) at the
excitement
He spots an elephant slide in
the children’s pool and
decides to go on it
spots/sees (1)
elephant (1)
slide (1)
go on it/have a go/drawn to
(1)
and sees (1) a couple of kids with
toy elephants (1) or real
elephants I suppose toy elephants
playing about …and he wants to
get involved (1) …
and there were two lads …coming
from down the slide (1) …I
presume young lads …and he
thought he’d go up (1) Mr. Bean
thought he’d go up,
(see reference to “slides”above) (1) and he spots (1) …that there’s two
elephant (1) slides (1) with trunk-
there’strunks with slides and he
sees …them and he thinks I’ll go
on there (1)
As he’s about to slide into the
water, the lifeguard blows
the whistle
sat on/got on/go on/have a
play/slide down (1)
lifeguard (1)
blows whistle/whistles/
stop/get off
(1)
so in his clumsy way he clambers
(1) onto the slide and then ….
where they’re all possibly
jumbled together he’s about to
join into this and the attendant (1)
comes along and says “oi we’re
not having this (1) …you’re …
it’s dangerous or whatever it is”
started going up (1) but he got
stopped (1) by the instructor (1)
who said he couldn’t…and for
children only …
Anyway …it sounded like he were
coming down (1) and he
shouldn’t have been …he were
doing something wrong …and
lifeguard (1) or something like
life guard whatever …at
swimming baths …were
complaining to him …telling
him he hadn’t to do it (1) no no
no …
so he goes over there and he’s like
going up (1) the steps and then
he gets to the top sort of thing …
and the life guard (1) whistles (1)
and says you’re not allowed on
there (1) it’s only for …young
children or whatever …
Mr. Bean climbs back up the
slide
climbs back/gets off/pulls
himself up (1)
slide (1)
and that’s it and he doesn’t (1) …
that’si
t
and that was the end of it and then he got sent off (1) did he and then he’s sort of a bit stunned
…and sort of starts to get back
down but he’s losing his footing
in sort of stumbling …and then
but then he just gets down (1) …
while the life guard watching and
doesn’t go on the slide
Total: 13 9 7 7 12
(continued )
22 M. Carragher et al.
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Appendix 3. (Continued).
Pretherapy complex narrative
target AT’sCP PM’sCP BL’sCP JH’sCP
Mr. Bean notices the diving
board and climbs to the
highest level
Mr. Bean (1)
notices/sees (1)
diving board (1)
climbs/heads (1)
top/highest level (1)
Another Mr. Bean (1) story …
he’s at the swimming pool …
decided to show off …finds
himself on the top deck (1) ….
Rowan Atkinson’s (1) gone to a
swimming pool …he’s runs up to
the either diving board (1) or the
view I didn’t get that out of it
properly …he went up some steps
…
I haven’t a clue something
about Rowan Atkinson (1)
on a diving board (1)
Right I think Ron Atkinson’s in the
swimming baths and he’s…he goes
up some steps to get up to the high
diving board (1) which is there’s two
diving boards and he goes on the
highest one (1) …
He peers over the edge and
becomes afraid as he
realises the height and
holds on to the rail
peers over/looks down (1)
edge (1)
afraid/panicked/frightened
(1)
holds on (1)
rail (1)
too high (1) for him …and he got to the I presume the edge
(1) of the diving board …didn’t
like it (1), flapped his arms …then
he turned round as if he was going
to perhaps dive backwards …
and then he’s there trying to he looks
over the edge (1) and he’s too scared
(1) so he yelps out and jumps back
…and sort of holds onto (1) the
handle rail (1) he’s quivering and
he’s all scared …
Two boys appear on the
diving board
two (1)
boys (1)
appear/come up (1)
and I imagine the lads (1) are
showing off and …. Winding
him up and diving off the
board I’m not quite sure if they
were spring board or at the top
and then two (1) lads (1) two children
appeared (1) …not quite sure
where they came from …
and he had mates …that’sitI
don’t know what he were
doing with his hand up there
like that ((mimics BL’s raised
hand))
and then there’s two (1) lads (1) who
come up (1) …oh and he’s wearing
trunks that have got blue and orange
and maybe some other colours on …
but then he …
The boys look impatient so
Mr. Bean pretends not to
be afraid and has to dive in
impatient/check watches (1)
pretends (1)
dive in/jump off (1)
he were he said he were
frightened (1) or nervous or
…
because he’s so scared they’re sort of …
sort of …taking the mick out of him
a bit and saying you know …tapping
their arms as if they’re waiting for
him(1) to get off and he’s sort of …
he’s really scared so
Mr. Bean eases down onto his
front and hangs off the
board by his hands
eases down/lowers/climbs
down (1)
hangs off/holds (1)
onto/dangles/clings (1)
diving board (1)
hand (1)
and he bent down (1) to put his hands
down
eventually he ends up …hanging (1)
off the edge of the diving board (1)
(continued )
Aphasiology 23
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Appendix 3. (Continued).
Pretherapy complex narrative
target AT’sCP PM’sCP BL’sCP JH’sCP
One of the boys stamps on
Mr. Bean’s hand and he
falls into the pool
one (1)
boys/lads (1)
stamps (1)
hand/finger (1)
falls (1)
pool (1)
and one (1) of the children (1) stamped
(1) on his hands (1) but he still went
in the water (1) in a fashion …
and he were on about his feet I
don’t know what he was
talking about with his feet …
can’t think of owt else …he
didn’t tell me much did he
and then they stand on (1) …one one of
his hands (1) on his fingers and then
he drops (1) into the water (1) and …
sort of dives
Total: 27 4 13 3 16
Posttherapy complex
narrative target AT’sCP PM’sCP BL’sCP JH’sCP
Mr. Bean is in the pool and
realises his trunks have
come off and are floating
in the water
Mr. Bean (1)
realises/notices (1)
trunks (1)
come off/lost (1)
floating (1)
Mr. Bean’s (1) in the pool …
swimming or trying to swim in
his usual probably incompetent
way …til he discovers a pair of
trunks (1) floating (1) about …
and he thought well I’m
struggling now cos I’minthe
altogether …(1)
Back at the pool again …Mr.
Bean’s (1) in the water …
without any trunks (1) on …
they’ve fallen off (1) …not quite
sure why they would have …but
he wouldn’t have probably know
that …
Well Rowan Atkinson (1) jumped in
pool, lost (1) his trunks (1) …
It was Mr. Bean (1) or Rowan
Atkinson …not Ron Atkinson
…and he was …it was like a
like a follow-on of the diving
into the pool one which we did
ages ago …so he’s in the pool
and his trunk- and he realises (1)
he’s swimming about and he
realises that he hasn’t got his
trunks (1) on and they’re on the
side …
He swims over to get his
trunks but a little girl picks
them out of the water
swims (1)
get (1)
trunks (1)
little/little/young (1)
girl/child (1)
picks out/grabs (1)
before he could do anything a little
(1) girl (1) who he was probably
swimming next to picks up (1)
the trunks (1) so he’s left then
without …the …
without his trunks (1), a little (1)
girl (1) who had got (1) them was
walking off with them …
a child (1) picked (1) them (1) up …
run off (1) with them
and then …there’s a couple with a
young (1) child (1) who pick (1)
up his trunks (1) and take them
away so he’s obviously
panicking a bit …
(continued )
24 M. Carragher et al.
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Appendix 3. (Continued).
Posttherapy complex
narrative target AT’sCP PM’sCP BL’sCP JH’sCP
The lifeguard blows the
whistle to tell everyone to
get out of the pool so Mr.
Bean hides underwater
lifeguard (1)
blows whistle (1)
everybody out/get out (1)
pool (1)
hides/ducks down (1)
underwater (1)
by this time …for some reason and
I should have asked because
that’s my fault the pool cleared
…and Mr. Bean was left in there
…whether it’s closing time or
whatever I’m not sure …and the
only people there are two pool
attendants (1) …so he’s…and
one of them is a female ….so
Mr. Bean is struggling to …keep
out of sight if you will …he’s
swimming about in the altogether
because he …keeping under the
water (1) presumably to keep out
of sight (1) but having to surface
keeps surfacing …
the instructor (1) and an assistant
were on the pool side …the
pool- they got more people in
and they called time (1) it must
have been time to go …or
whatever to get out …so they
get called out …Mr. Bean didn’t
want to get out he was
embarrassed cos he hadn’t got
his trunks on …he looked very
sheepish …
but he just stays in the water and
then but then it’s the end of the
…day so the whistle gets blown
(1) to …get out of the pool (1)
…so …he doesn’t, he tries to
hide (1) under the water (1) about
three times and they keep
blowing the whistle (1) and
nobody knows he’s hid
When everyone has left the
pool, Mr. Bean tries to
sneak out of the pool
tries (1)
sneak out (1)
pool (1)
and for some reason I should have
asked again the two pool
attendants left …but one of them
so he tries (1) to get
out (1)
eventually everybody had got out of
the pool …he got out (1) …
and then everyone seems to have
gone away so he sort of …
comes out (1) of the pool and
then tries (1) to make his way to
the changing rooms
(continued )
Aphasiology 25
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Appendix 3. (Continued).
Posttherapy complex
narrative target AT’sCP PM’sCP BL’sCP JH’sCP
He hides from the female
lifeguard who has come
back into the pool
hides (1)
female (1)
lifeguard (1)
comes back (1)
pool (1)
and one of them’s a woman (1) …
so …that’s my fault I should
have asked for more detail
shouldn’tI…the I can’t…I
cannot rem- Mr. Bean then …
gets out of the pool …thinking
he’s safe but by this time …well
he’ll have got out of the pool
won’t he but then the woman
that’s right the woman would see
him and he he starts running
around trying to escape her …
the instructor walked away but the
assistant (1) was still around …
but hadn’t noticed that he hadn’t
got any trunks on …
A group of girls come out of
the changing room, see Mr.
Bean and scream so he
runs off
group (1)
girls/schoolgirls (1)
come out/come in (1)
see (1)
scream (1)
runs off/runs away (1)
and by this time there are more kids
(1) have appeared (1) into the
pool area so he then he dives
back in again so he’s back in the
same position he was in before
…and that appears to be the
story [great, anything else?] …
well I can’t remember I think it’s
cos I didn’t ask properly what
actually happened between Mr.
Bean, the girl picking Mr. Bean’s
trunks up and …these two
attendants appearing and
disappearing …whether Mr.
Bean was out of the pool by that
stage …and when the kids arrive
it’s all a bit of a bit of a sort of
intermix if you will
Mr. Bean walked towards the
changing room as some girls-
young girls (1) came out (1) …
and he got all embarrassed and
they laughed a bit …and that
was the end of it
and then …then Atkinson got out
naked …and he were in front of
all people (1) that were watching
or on side of baths …and they
were in costumes they were all
people …waiting to go into
baths or been in baths …and
that’s it [asked to explain BL’s
drawing] well that was Rowan
Atkinson but he scrubbed him
out …and that was little boy on
side and they were trunks there
…little boy got his trunks out of
baths run off and then he went up
here …this is supposed to be
Rowan Atkinson and I presume
this is audience and they were all
in swimming gear …so I
presume they were waiting to go
in or they had just got out or
something [and what happened at
the end?] I don’t know
but then there’s a big group (1) of
school girls (1) outside who see
(1) him…naked and start
screaming (1) and he’s about a
bit ((gestures startled)) and then
that’sit
Total: 31 16 13 8 18
26 M. Carragher et al.
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