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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Speaking with those who cannot speak - communication with aphasics
The world of the aphasic
Possibilities and limitations of speech therapy
Speech training
Mistakes in dealing with aphasic patients
Man is the being that speaks. He alone has
the ability to speak;
this encapsulates what he is able to do.
To be dumb is to have an infirmity. A person
is one who can speak and use language. To
speak is to be a person. The personality of the
person is revealed by his speech, simply by
language alone.
Dolf Sternberger
Speaking with those who cannot speak - communication with aphasics
Loss of speech (aphasia) it the most severe form of disturbance in communication that anyone can suffer. Loss of speech as aphasia is considered worse than dumbness. The term aphasia includes many abilities which are involved in speech. In the case of aphasia, one or more of the following abilities can be disturbed: speech, understanding speech, reading, writing, spelling, counting and/or calculation. It is precisely because the aphasic is unable to articulate his aphasia, and extraordinary care has to be invested in order to understand him, that he is constantly in danger, not only of being unable to escape his "cage of speechlessness", but also of being abandoned in it. An example of this is seen daily in clinical practice in the handling of stroke patients with aphasia. Classification of aphasic disturbances is shown in the table.

As the number of trained speech-therapists is still insufficient to cope with all of the aphasic patients, every doctor who has anything to do with them must master the basic mechanisms for communication with these patients. In the long term, involvement of the relatives and others who are close is very important. To them, Martha L. Taylor's book "Understanding Aphasia" can be helpful (see References) link.
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The world of the aphasic
Usually speech is lost suddenly. Feelings of helplessness, despair and dependence arise in the aphasic, along with anxiety. Initially the patient can hardly comprehend why he can no longer speak, understand or write, and why he is not understood. These patients can easily get the impression that they have suddenly become mad. Aphasia is never an isolated or simple disorder, but is a complex handicap which leads to personality and behavioral changes. The patients usually tire rapidly, suffer from concentration and perception disturbances, are labile in mood, easily irritated and occasionally aggressive. Often this aggression is a reaction to the behaviour of those in the environment who do not understand. The ability to cope intellectually and physically varies a great deal from day to day.

The most important initial step is to explain to the aphasic in simple language that he is suffering from a speech disorder, what is its cause and that this will most probably improve with time or completely disappear. It is often necessary to explain this problem many times. It is also just as important to make it clear to the patient that he is not mad or mentally disturbed. It should be explained next that certain speech exercises have been planned for him and they will begin soon, and will make it easier for him to make himself understood again as soon as possible. These steps reduce anxiety and aggression and give hope.

Automatic terms of frequently-used speech (such as "hello", "how are you?") can be achieved by many aphasics. Many are also able to count, recite the alphabet or sing songs. However this spontaneous ability is not necessarily of prognostic importance. Speech cannot be improved by means of singing. Of course an aphasic who previously enjoyed singing, and is attempting to sing, should be encouraged.
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Possibilities and limitations of speech therapy
Spontaneous improvement can be obtained within 6 to 12 months after the acute phase of the illness. The reason for speech therapy is partly to accelerate this spontaneous improvement, and to achieve restoration of as much as possible of the body of speech. Speech therapy does not only have the objective of improving speech, but also provides a personal approach to the patient restoring him with support and motivation.

Speech therapy should not exhaust the patient. Short, frequent exercises are better than those which are longer, and tire him. It is useful if the patient is motivated and enthusiastic about speech therapy, but if this is given under pressure, it can endanger rehabilitation.

The use of substitute languages has not been shown to be effective in adults. It seems to be even more difficult for the aphasic patient to learn a new form of communication than to build up a limited number of common words. The mother tongue is relearn most rapidly by those who have mastered several languages.

Success of speech therapy depends on the severity of the speech disorder, the underlying disease, the remaining intellectual ability, age and the motivation which can be aroused for speech training. There are patients who remain completely aphasic in spite of excellent speech therapy, and others who learn to speak almost normally once again (President Eisenhower, Sir Winston Churchill).
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Speech training
The objective of practicing speech is to help the aphasic patient learn a limited number of words, which are targeted to his particular situation. For the patient confined to a hospital bed, words such as "plate", "bed", "bed-pan" are more important than "wood", "train" or "dog". It is also important to practice terms with immediate and actual significance rather than abstract terminology. The aphasic learns the name of things he can see, hear or feel more easily than general or compound terms. It is easier for him to relearn words such as "bread", "leg" or "shirt" in the earlier phases, than "food", "travel" or "clothing". Where words have similar meanings, the more usual term should be employed ("phone" rather than "telephone", "paper" rather than "illustrated magazine").

At first, a small number of words should be learnt; those which are important for daily living, such as "bed", "chair", "toilet", "money", "watch", "bread", "butter", "tea", "phone", "doctor", "shoe", "mouth", "key", "soap", "hand", "leg", "table", "house". Words can be introduced later which have a particular relevance for the aphasic patient, for example "flowers", "seed", "betroth" for a gardener.

Furthermore it is important that the aphasic is taught words in a useful order, which is substantives, verbs and adjectives. Next would come adverbs, articles, prepositions and conjunctions. Many aphasic patients have greater difficulties learning the "small words" (prepositions, conjunctions and articles) than mastering substantives. This applies especially to patients with motor aphasia, but the reverse is true for those with amnesic aphasia.

Aphasic patients must be continually encouraged to speak. This is best achieved when speaking becomes a pleasant experience for the patient for which he is rewarded by praise or attention. In general, the aphasic patient should be offered plenty of opportunities to hear speech, although he should not be overwhelmed (listening to conversations, radio, television). As has been said, more frequent, short exercises are both more effective and more interesting than extensive speech practice for longer time spans. The aim of therapy should be realistic and dependent on possibilities which can be achieved in the short term. The aphasic should be treated empathetically, so that he recognizes that those around him understand how badly he is affected by his handicap.

Additional writing exercises can encourage both reading and speech. As the right side is usually affected in aphasic hemiplegic patients, the patient often has to use his left hand for writing. Writing exercises should be in script rather than capitals, as most people can manage script rather than printing letters. This would also result in the patient having to learn how to go on from printing to script later.

Reading practice is best carried out using printed or typed material as this is what most people read anyway. Aphasic patients are better at reading larger type than a normal size, possibly because the excessively large letters are more stimulating. Initially patients are not able to read for any length of time due to limited concentration. Many aphasic patients still spend time looking at their daily paper, even though they cannot read or comprehend it. Maintaining this habit can encourage the patient.
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Mistakes in dealing with aphasic patients
Forced speech or speech therapy is usually not effective. The effect of speech therapy depends to a large extent on how much the patient allows himself to be treated. It is also not helpful to invite visitors in the hope that this will encourage him to speak more (unless the patient himself would like it, and will not be exhausted by a prolonged visit).

It is also not useful to speak on behalf on the aphasic patient as this tends to extinguish self-trust, and increases his feeling of dependence.

It is always inappropriate to interrupt a person. This applies particularly to aphasic patients. He must be given enough time to seek his own words, without an impatient reaction of those around.

Initially it is of no great importance that the aphasic patient can pronounce each word perfectly, but he should be able to make himself understood. Every form of isolation leads to a reduction in the amount of speech he can manage, and every over-exertion to a disturbance of his confidence. It is most important that every attempt to converse with the aphasic motivates him to activity, and never blocks his self-initiative.

Ideally "speaking with those who cannot speak" would not only result in comprehension and partial relearning of speech, but would also lead to working through and conquering the disease which led to the aphasia.

Guide-lines for dealing with aphasic patients
 1. Explain the aphasia and show understanding.
 2. Emphasize improvement, instilling it into the patient's mind
 3. Explain that aphasia does not mean that the patient is mad or losing his mind.
 4. Use short, simple sentences and speak slowly.
 5. Do not insist on speech exercises.
 6. Frequent short exercises.
 7. Envisage realistic objectives for the therapy.
 8. Choose words appropriate for the personal situation of the patient.
 9. Order the importance of types of words (initially substantives, verbs and adjectives, then adverbs, articles, prepositions and conjunctions).
10. Writing exercises in script (left hand?), reading exercises with large type.
11. Praise, motivate, and encourage speech (radio, television).
12. Much patience, gentle criticism.
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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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