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Veverka has been accepted towards fulfillment of the requirements for M.A. degree in ipeech-Language Pathology :4me Major professor Date April 5. 1995 0-7639 MS U i: an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State University ‘ PLACE ll RETURN BOX to remove this checkout from your rocord. TO AVOID FINES rotum on or before date duo. DATE DUE ‘ DATE DUE DATE DUE SPOUSE OPINIONS TOWARD THE EFFICACY OF APHASIA TREATMENT BY Laura A. Veverka A THESIS Submitted to Michigan State University in partial fulfillment to the requirements for the degree of MASTER OF ART Department of Audiology and Speech Science 1995 ABSTRACT SPOUSE OPINIONS TOWARD THE EFFICACY 0F APHASIA TREATMENT BY Laura A. Veverka Family members often exhibit unhealthy attitudes toward adults with aphasia, possibly created by negative opinions about aphasia. This project examined wives’ opinions about speech-language treatment programs for their husbands. Subjects were twenty women, aged 60-75, who were married to men with mild or moderate aphasia. They were requested to respond to two questionnaires rating their husbands’ treatment program and their particiaption in that program. Responses on the Q2mmuni2ati9n_Ahilitie§_guestignnaire (CAQ) were subjected to chi square analysis; significant chi square values were analyzed for distribution of responses and means comparisons. Responses on the CAQ were correlated with responses on the reatment Pa ici at'o uest' (TPQ) using Spearman r; no correlation was significant. Results indicated that the majority of the subjects held positive opinions about their husband's treatment program, regardless of his aphasia severity level. Subjects' self- ratings of participation in treatment programs was not related to their opinions about treatment programs. ACKNOWLEDGEMENTS I wish to thank the faculty members at Michigan State University. The professional assistance of Janet Patternson, Ph.D., Leo Deal, Ph.D. and Ida Stockman, Ph.D. was truly appreciated for without these faculty members this project would not have been possible. I would also like to thank Genesys Regional Medical Center-Flint Osteopathic Campus for allowing me access to subjects. I sincerely thank all of the subjects for their participation in this project. I would also like to thank Valerie Fisher-Thompson CCC-SLP for her patience and support throughout this project. Finally, I would like to express a special thanks to my family and friends for their continued support throughout this project. iii TABLE OF CONTENTS List of Tables List of Symbols Introduction Review of Literature Psychosocial Effects of Aphasia on Family Members and Nonaphasic Spouses Attitudes of Family Members and Spouses Toward Adults with Aphasia Spousal Attitudes Toward Adults with Aphasia Treatment Influences that may Effect Spousal Attitudes Toward Partners with Aphasia Statement of the Problem Methodology Subjects Materials Procedure Results Responses to Questionnaire Regarding Clinical Skills and Changes in Spouses' Communication Abilities Responses to Questionnaire by Category of Questionnaire Responses to Questionnaire by Sub ects Grouped According to Aphasia Severity Rat ng of Spouse iv vi vii 11 14 17 21 21 22 26 27 27 28 33 Responses to Questions by Subjects Grouped According to Severity Rating of Aphasic Spouse and Category of Questions Correlation of Responses on Two Questionnaires Discussion Patterns of Response Across Questionnaire Category Patterns of Response Across Level of Severity Patterns of Response Across Questionnaire Category and Level of Severity Correlation of Spousal Self Ratings of Participation in the Treatment Program and Opinions of Treatment Summary and Conclusions Appendix A Communication Abilities Questionnaire Appendix A Participation In Treatment Program Appendix A Participation in Therapy Outside of Treatment Session Appendix B Ease of Questionnaire Understanding Appendix C Subject Response Type Across Questionnaire Category Appendix C Individual Mean Scores within Categories Appendix C Subject Participation Within and Outside of the Treatment Program List of References 37 41 46 47 50 54 55 57 63 64 65 66 67 68 69 LIST OF TABLES Expected and Observed Frequencies Across Questionnaire Categories Pattern of Differences Between Expected and Observed Values Mean Comparisons for Response Types on Questionnaire Categories Expected and Observed Frequencies Across Levels of Aphasia Severity Pattern Of Differences Between Expected and Observed Values Expected and Observed Frequencies within Questionnaire Categories and Level of Aphasia Severity Pattern of Differences Between Expected and Observed Values Comparison of Mean Response Values Across Question Types Within Two Aphasia Severity Groups Correlation Across Questionnaire Category and Participation in Scheduled Sessions and Self Regulated Home Practice Sessions correlation Among Spouse Participation and Aphasic Partners Level of Severity vi 29 31 33 34 36 38 4O 42 43 44 PRI: FCP: BDAE: SMOG: df: LIST OF SYMBOLS Personal Relations Index Functional Communication Profile Boston Diagnostic Aphasia Examination Simple Measure of Gobbledygook Degree of Freedom Expected Frequency Observed Frequency Clinical Skills Auditory Comprehension Skills Verbal Production Skills Number of Signs Number of Fewer Signs Probability Level Statistically Significant Mild Aphasia Moderate Aphasia Standard Score Mild Aphasia Moderate Aphasia vii INTRODUCTION A primary purpose for treating adults with aphasia is to facilitate Optimal use of communication at home (Lyon, 1992). Lyon (1992) suggested that restored use of communication abilities in the home environment may enhance the stability, comfort and quality of life within a family unit that includes an adult with aphasia: however, this goal is often not easily achieved. Despite documented gains in linguistic and communicative performance, there is little evidence to suggest that communication or quality of life is notably improved once adults with aphasia return home (Lyon, 1992, p. 7). This research project investigated one aspect of the bridge between communication skills in a treatment program and in the home environment. Treatment of aphasia typically results in improved communication abilities in a patient (Hagen, 1973: Basso, Capitani & Vignolo, 1979; Shewan & Kertesz, 1984). However apparent communicative success in treatment programs may not generalize to other environments. Spouses and clinicians have reported that communication effectiveness diminishes in adults with aphasia as they move from structured, supportive clinical sessions to less structured, unpredictable environments at home or in the community (Lyon, 1992). 2 Thompson (1989) reviewed 35 treatment studies of aphasia published in American clinical journals and forums between 1970 and 1987 and concluded that language proficiency among adults with aphasia is better in controlled, clinical settings than in unstructured environments. To understand the full spectrum of improvement, it is necessary to consider the patient's social environment, including persons within the environment. Interactions may be influenced by both an aphasic patient's communication skills and the expectations of communication partners. Most stroke patients have ostensible symptoms but their difficulties may be compounded by the behavior of relatives who themselves are often under considerable duress (Mulhall, 1978, p. 127). Mulhall (1978) stated that individual environmental factors, such as spousal misunderstandings, may significantly undermine gains made in therapy. Following the onset of aphasia, nonaphasic spouses may develop socially, psychologically or emotionally unhealthy attitudes toward their aphasic marital partner (Malone, Ptacek, & Malone, 1970). Unhealthy attitudes may develop as a result of resentment toward the adult with aphasia, role change, or the inability to communicate with the aphasic adult. Family members, particularly spouses, spend a great amount of time with an adult with aphasia and may assume an active role in the treatment program. Involvement in a patient's treatment program allows a spouse the opportunity to develop opinions about the treatment program and manner of service delivery. Opinions may then transfer into 3 positive or negative attitudes regarding the treatment program itself, the success of the treatment, or the communication skills of the person with aphasia. Positive attitudes toward treatment programs may facilitate rehabilitation benefits however, negative attitudes may undermine a patient’s progress in rehabilitation (Mulhall, 1978). As we study the rehabilitation process to determine effective practices in speech-language pathology, considering the role of family members in the treatment program can be as important as examining direct treatment effects. Spouses of aphasic patients are in a unique position to observe the rehabilitation process and the effects of treatment sessions. As a result, they can also facilitate treatment; yet few studies have investigated the attitudes of spouses toward their aphasic partners, and none has specifically investigated attitudes toward the treatment program itself. It is the intent of this project to examine the opinions of women toward the treatment programs designed for their husbands who have aphasia, thereby studying efficacy of treatment in an indirect manner. REVIEW OF THE LITERATURE Psychosocial Effects of Aphasia On Family Members and Nonaphasic Spouses Regardless of etiology, aphasia comes upon a person with little or no warning. Neither patients nor family members are allowed an opportunity to prepare for the problems associated with aphasia. The traumatic occurrence of aphasia affects not only the individual patient but also family members (Helmick, Watamori, 8 Palmer, 1976). Lack of education and understanding about aphasia may contribute to family difficulties when coping with the disability (Derman & Manaster, 1976). Derman and Manaster (1976) examined a program of family counseling for relatives of adults with aphasia that focused on three areas: family problems, the adult with aphasia, and factual information pertaining to aphasia. In initial counseling sessions nonaphasic relatives indicated difficulty expressing their feelings toward their family member with aphasia. During the counseling program family members had the opportunity to discuss similarities in experiences with the families of other adults with aphasia. As the program continued, families reported feelings of security and comfort with their aphasic family member. Derman and Manaster (1976) S noted that the counseling program seemed helpful in facilitating clinician and family member interaction, which in turn seemed to aid in the development of closer patient and clinician relationships, and increased the patient's desire and energy toward the rehabilitation program. In addition, the counseling program provided nonaphasic family members with an outlet for expressing guilt, anxiety, frustration and anger. Through peer interaction, family members resolved questions and learned to cope with problems concerning their aphasic family member. An apparent relationship exists between family member attitudes and recovery made by patients with aphasia (Turnblom & Myers, 1952; Biorn-Hansen, 1957). Turnblom and Myers (1952) emphasized the importance of family members in setting the atmosphere and determining patient motivation for rehabilitation success. In examining 30 aphasic patients' case records, Biorn-Hansen (1957) concluded that the relationship between the aphasic person and family members exerts influence on patient progress. Family members often experience changes within the family unit following the onset of aphasia. There may be a shift in responsibilities and functions as well as relationship changes between the adult with aphasia and his/her children. Changes may include irritability, altered social life, health problems, guilt, over- solicitousness and rejection (Malone, 1969). Malone (1969) interviewed 25 nonaphasic family members and noted that they reported 6 behavior changes such as role changes, increased irritability and guilt, unsatisfactory social life, financial problems, health problems, rejection. These changes often had adverse effects on children. The socioeconomic status of the subjects ranged from low middle class to high middle class according to the 1949 Index of Status Characteristics, and the aphasia of the family member ranged from minor to severe. Malone (1969) reported that family members experienced irritability to a greater degree after their relative became aphasic than before and that this irritability often led to feelings of guilt. In addition, the majority of subjects reported their guilt was manifested in one of two different manners: 1) family members felt they were responsible for the aphasic person's problems: 2) they felt the aphasia was punishment for things they had done wrong, or they felt that they were not doing all they should for their aphasic relative. Malone (1969) concluded that the findings of attitude change toward persons with aphasia suggest the need for professionals to recognize the importance of providing a counseling program for family members. He further concluded that family members cannot function as positive members of the rehabilitation process until they have been educated to the problems associated with aphasia. The psychosocial effects of aphasia upon nonaphasic spouses are similar to those experienced by nonaphasic family members. Changes in the marital relationship between 7 aphasic and nonaphasic spouses include role changes, irritability, altered social life, health problems, over-solicitouness and rejection (Malone, 1969). Malone (1969) indicated the most frequently reported problem is role change and the new way in which a spouse views his/her marriage partner. He further reported that nonaphasic females may assume either a dominating or maternal role in caring for the aphasic patient. Biorn-Hansen (1957) reported findings similar to Malone (1969) regarding role changes between spouses. Biorn-Hansen (1957) analyzed the case records of aphasic persons who had received counseling at a university speech and hearing clinic. The aphasic persons had been seen by a social worker over a period of three years, and case records were examined to obtain information pertaining to each aphasic person's background prior to the onset of the disorder, the nature of the problems discussed with the social worker, and services offered in meeting specific individual problems. The subjects ranged in age from 14 to 40 years old, with educational levels from the eighth grade to advanced professional training. Half of the subjects were married. One finding among married subjects was that wives forced to work outside of the home assumed a more socially important or dominant role within the marriage, reported a positive attitude toward that new role, and found it satisfying and difficult to relinquish once their aphasic 8 spouse recovered. Mulhall (1978) conducted structured interviews of 16 couples using the Personal Relations Index (PRI) to examine behavioral awareness of each nonaphasic spouse to his/her aphasic spouse. He reported that the exchange of marital roles between aphasic patients and spouses often frustrated the patient. The single most common finding was that the nonaphasic spouse's attempts to help and encourage the patient often heightened the aphasic patient's frustrations and reminded the patient of his/her disability. Mulhall (1978) concluded the most common self references on the part of nonaphasic female spouses were anxiety, depression, frustration and over-protectiveness. He reported that aphasic patients frequently indicated that they offered comfort and support to their nonaphasic relatives exhibiting coping difficulties. This finding is contrary to expectations of behavior between spouses. Attitudes of Family Members and Spouses Toward Adults with Aphasia Following the onset of aphasia, family members and nonaphasic spouses are typically confronted with unfamiliar communicative behaviors (Zraick & Boone, 1991). Lacking experience and knowledge about aphasia, family members and nonaphasic spouses may be unable to cope with the stress of their new situation (Zraick & Boone, 1991; Derman & Manaster, 1976). Without successful coping strategies family members and nonaphasic spouses may develop negative attitudes toward adults with aphasia (Malone et al., 1970: 9 Mulhall, 1978: Derman & Manaster, 1976; Zraick & Boone, 1991). An attitude has been defined as: A relatively enduring disposition or tendency to evaluate a person, object, or event in a particular way (Scarr 8 Vander Zanden, 1984, p. 314). Zraick & Boone (1991) evaluated the attitudes of spouses and family members toward aphasic communication partners. The subjects were equally divided into two groups. The experimental group contained nonaphasic spouses and their aphasic partners and was divided according to aphasic partner's type of aphasia (fluent or nonfluent aphasia). The control group contained 30 couples, neither of whom had aphasia. Experimental and control groups were matched for age and educational level. Zraick and Boone (1991) adapted a modified version of Stephenson's Q-sort Methodology (1953) to compare the attitudes of spouses of adults with aphasia to spouses of non-neurologically impaired adults. Utilizing the modified Q-sort technique to group like adjectives, subjects distributed cards containing statements from most to least representative of the aphasic patient. Zraick and Boone (1991) reported that the most frequently expressed attitudes by the experimental group were negative. Commonly expressed attitudes by those nonaphasic adults indicated that their aphasic spouses were demanding, temperamental, immature, worrying, and nervous. These attitudes were not noted among control group individuals. Zraick and Boone (1991) reported that nonfluent aphasic 10 adults were viewed by their nonaphasic spouses as less independent, less compliant, and less sociable than their fluent counterparts. Zraick and Boone (1991) further suggested that the negative attitudes expressed by the spouses of nonfluent aphasic adults may be due to the absence of words and struggle behaviors of the nonfluent aphasic adult. Malone, Ptacek, and Malone (1970) reported similar results regarding the negative attitudes of family members and nonaphasic spouses toward aphasic marital partners. Malone, Ptacek, & Malone (1970) revised a questionnaire developed by Boyles in 1959 designed to elicit the frequency and intensity of attitudes in the following areas: retributive guilt, unrealism, rejection, over protection, social withdrawal, and social desirability. The questionnaire was administered to 30 nonaphasic Spouses. Mean age of the subjects was 48 years old, and socioeconmic status ranged from lower- middle to upper-middle class. Language disability of aphasic partners ranged from moderate to extremely severe. Malone, Ptacek, and Malone's results indicated that nonaphasic spouses expressed disturbed attitudes 100% of the time in the areas of retributive guilt, unrealistic attitudes, rejection, and over protection. Malone, Ptacek, and Malone (1970) further suggested that the development of negative attitudes among nonaphasic spouses may stem from a lack of accurate information as well as an unrealistic 1] understanding of aphasia. Accurate information and counseling about aphasia may enhance coping strategies and decrease negative attitudes of family members and nonaphasic spouses and facilitate appropriate reactions to relatives with aphasia (Malone et al., 1970). Malone (1969) conducted interviews with 25 family members of adults with aphasia and concluded that the primary attitudes expressed by family members were over-solicitousness, rejection, and guilt. Biorn-Hansen (1957) found similar results regarding family member’s attitudes toward relatives with aphasia. After analysis of patient records from a counseling center, Biorn-Hansen concluded that family members frequently expressed rejection toward their relative with aphasia. In summary, family members of aphasic patients often view the patients as demanding, temperamental and nervous. Spousal Attitudes Toward Adults with Aphasia Research examining spousal and family member attitudes toward adults with aphasia has produced consistent conclusions (Biorn-Hansen, 1957: Malone, 1969: Malone et al., 1970 : Derman a Manaster, 1976: Helmick et al., 1976: Mulhall, 1978: Kinsella & Duffy, 1979: Kinsella & Duffy, 1980: Lyon, 1991; Zraick and Boone, 1991). Family members and nonaphasic spouses often convey negative attitudes toward adults with aphasia (Zraick and Boone, 1991). Attitudes of retributive guilt, rejection, and social withdrawal have been noted between nonaphasic spouses and 12 their marital partners with aphasia (Malone et al., 1970; Helmick et al., 1976: Kinsella a Duffy, 1980). Unrealistic attitudes and over-protection have been observed among nonaphasic spouses (Malone, Ptacek, & Malone, 1970: Helmick, Watamori, & Palmer, 1976: Kinsella and Duffy,1980). Malone, Ptacek, and Malone (1970) assessed the attitudes of 30 nonaphasic spouses toward their aphasic marriage partners using a questionnaire adapted from_figy1gs Attitude $9119 (1959). They concluded that the majority of the nonaphasic spouses conveyed attitudes of retributive guilt, unrealism, rejection, over-protectiveness and social withdrawal. Kinsella and Duffy (1980) assessed the attitudes of 79 spouses toward aphasic marital partners. The adults with aphasia were solicited from a rehabilitation center. The spouses were divided into three groups according to the disability status of their partner: groups were comparable in terms of physical handicap, functional dependency, and severity of handicap. The majority of the spouses were female with a mean age of 60.11 years and were predominantly from middle class and upper working class social status. Boyles Attitude_§ga1§ (1959) was adapted to assess the attitudes of spouses toward adults with aphasia. An equal appearing interval scale was used to measure the frequency and intensity of expressed attitudes in the areas of guilt, lack of realism, rejection, over-protection, and social withdrawal. Kinsella and Duffy (1980) reported conclusions 13 similar to Malone, Ptacek, and Malone (1970), but attitudes of retributive guilt and rejection were not significant among nonaphasic spouses. Kinsella and Duffy (1980) concluded that unrealism and over-protection were commonly observed. Unrealistic attitudes of nonaphasic spouses toward adults with aphasia (Malone et al., 1970; Kinsella & Duffy, 1980) may lead to over-protectiveness of aphasic marital partners (Helmick et al., 1976: Kinsella & Duffy, 1980). The presence of negative attitudes in nonaphasic spouses may create additional difficulties in the spousal relationship. Worry and anxiety about the aphasic adult's condition frequently led to a decrease in the participation of daily activities by nonaphasic spouses (Kinsella & Duffy, 1980). Over-protection among nonaphasic spouses may stem from support and care as well as from guilt (Kinsella & Duffy,1980; Ptacek, & Malone, 1970). Unrealistic language expectations may be a product of unrealistic attitudes eXpressed by nonaphasic spouses (Helmick et al., 1976). Helmick, Watamori, and Palmer (1976) investigated 11 nonaphasic spouses' understanding of their aphasic partners' language deficits. The Egzgh_1ndgx gt communigatign Ability (PICA) was used to assess the language skills of 11 aphasic adults. Ihg_£nngtigna1 cannnnigatign Exotilg (PCP) (Taylor, 1965) was completed by each nonaphasic spouse to assess his/her aphasic partner's communication. A Speech—Language Pathologist independently 14 completed the 292 as a comparative measure. Helmick, Watamori, and Palmer (1976) noted that nonaphasic spouses tended to view their aphasic partners' language performance as less impaired than Speech-Language Pathologists. Helmick, Watamori, and Palmer (1976) suggested that when nonaphasic persons misunderstand the nature of aphasic persons' communication disabilities, they may develop unrealistic language performance expectations which in turn may lead to frustration and depression among aphasic adults. The general lack of understanding of the aphasic's linguistic impairments, then, can be expected to create some difficulty in the spouse's ability to establish appropriate verbal interactions with the aphasic and can become an interfering factor in the language rehabilitation process (Helmick et al., 1976, p. 241). Treatment Influences that may Affect Spousal Attitudes Toward Partners with Aphasia Studies on the effect of aphasia treatment reveal inconsistent results (Darley, 1972). Some authorities contend that any degree of communication recovery is related to spontaneous reorganization of residual cerebral structures, while others maintain that retraining procedures initiate structure and increase the rate and degree of communication recovery following cerebral insult (Hagen, 1973, p. 454). There are continuing research efforts to demonstrate that aphasia treatment is efficacious (Wertz, Weiss, Aten, Brookshire, Garcia-Bunuel, Holland, Kurtzke, LaPointe, Milianti, Brannegan, Greenbaum, Marshall, Vogel, Carter, Barnes, Goodman, 1986). Most adults with aphasia improve during the course of formal language rehabilitation (Basso, Capitani, 8 Vignolo, 1979). Many adults with aphasia reach 15 a level of language recovery satisfying their requirements of daily verbal communication (Hagen, 1973; Basso et al., 1979: Shewan & Kertesz, 1984: Hertz et al., 1986): however, there are adults with aphasia who do not experience verbal communication improvement despite rehabilitation efforts (Sarno et al., 1979: Basso et al., 1979). Other aphasic adults regain the use of verbal communication without formal rehabilitation programs (Basso et al., 1979). Lack of verbal communication improvement among adults with aphasia may prevent Speech-Language Pathologists from attributing language recovery to formal rehabilitation programs (Basso et al., 1979). Efficacy studies to date typically evaluate patient's behavior changes as a result of treatment and have been critiqued on methodological grounds. These studies have not included nonaphasic family members as change agents in therapy or as sources of influence in the treatment process. In order for future efficacy studies to withstand scientific scrutiny, investigations should specify the nature of language disorders, the limits of spontaneous recovery, subject selection, etiology, site and extent of lesion, time postonset, and nonlanguage behavior characteristics (Darley, 1972). Severity of aphasia is a factor which should be considered when initiating a remediation program. Initial severity significantly influences a patient's extent of recovery (Shewan & Kertesz, 1984). Recovery has been reported to be more favorable among patients exhibiting a 16 less severe prognosis (Butfield & Zangwill, 1946; Darley, 1970; Shewan & Kertesz, 1984). The extent of language recovery among patients diagnosed with severe aphasia has been less significant than patients with milder aphasia (Shewan & Kertesz, 1984). Patterns of aphasic impairment have been associated with predictable recovery patterns (Butfield & Zangwill, 1946). Butfield and Zangwill (1946) reported improvement in the speech of patients diagnosed with mild and moderate aphasia. They further reported that patients diagnosed with severe aphasia exhibited only 40% improvement in speech (Butfield & Zangwill, 1946). Severity of language impairment during the initial evaluation is a moderately good predictor of the extent of recovery that may be expected in adults with aphasia (Sands, Sarno & Shankweiler, 1969, p. 204-205). Since family members and spouses spend a large amount of time caring for an adult with aphasia, they are often in a position to influence the rehabilitation process. The expression of positive or negative attitudes may affect the language rehabilitation process, a situation which may result in a greater or lesser amount of communication improvement. To date, efficacy studies have directly examined the effect of speech-language treatment on improved linguistic and communication skills. Given the nature of spousal attitude information, it would be prudent to examine efficacy in an indirect manner exploring the thoughts of nonaphasic spouses in an effort to fully understand the scope of the rehabilitation process. STATEMENT OF THE PROBLEM Following the onset of a cerebral vascular accident, an individual may be left without a means of verbal communication. Family members and spouses are often subjected to communication behaviors with which they are unfamiliar. Lack of relevant information about aphasia and the effects of the disorder may lead to the development of unhealthy attitudes among family members and Spouses. Family members and spouses often experience changes within the family unit following the onset of aphasia. Changes in family responsibilities, functions and relationships can exert a great influence, either positive or negative within the family unit. Irritability, altered social lives, accompanying health problems, guilt, over-protection and rejection are common responses among nonaphasic family members and spouses. The expression of unhealthy attitudes among family members and spouses often causes frustration within the family unit, reminding the adult with aphasia of his/her disability. Both family members and spouses show similar and often unhealthy attitudes toward adults with aphasia. Commonly expressed attitudes are retributive guilt, rejection, unrealism, and over-protection. Misunderstanding and lack 17 18 of pertinent information about aphasia may cause family members and spouses to generate unrealistic expectations of their aphasic relative. Inability to meet these unrealistic linguistic expectations may lead to frustration and depression in adults with aphasia. Since family members and spouses spend a large amount of time caring for an adult with aphasia, they are in a position to exert great influence on the rehabilitation process. The expression of negative attitudes can create difficulty in the aphasic adult’s ability to establish appropriate verbal interactions. The expression of unhealthy attitudes can interfere in the language rehabilitation process. Assessing spousal opinions toward partners with aphasia will allow professionals to describe the relationship between Spouse opinions and change in communication skills made by an aphasic as a result of treatment. Understanding the rehabilitation process requires examining efficacy directly, that is, the improvement in communication skills as a result of a treatment strategy, and also that we examine efficacy indirectly by questioning family members regarding their opinions and attitudes about the treatment process. Few studies have examined the relationship between the opinions of family members and the course of speech-language treatment. Studies in this area have in general concluded that nonaphasic spouses and family members convey negative l9 attitudes toward adults with aphasia. To date, no study has investigated opinions of spouses of aphasic patients about the therapy program designed for these patients. This study proposes to indirectly examine spousal attitudes toward therapy by collecting Opinions regarding efficacy of treatment in order to answer the following research questions: 1. Do differences exist in spouses' opinion scores across three categories of speech-language treatment information: clinical skills, auditory comprehension and verbal production? 2. Do differences exist between the opinion spouses of persons with mild aphasia and persons with moderate aphasia across the categories of speech~language treatment information? 3. Do differences exist between the opinion spouses of persons with mild aphasia and scores of spouses of three scores of spouses of persons with moderate aphasia within each of the three categories of speech-language treatment information: clinical skills, auditory comprehension and verbal production? 4. Do differences exist in the response patterns of spouses of mild or moderate aphasic communication partners on a self-rating scale of participation in 20 the treatment session and outside of the treatment session? Is there a relationship between subjects' self-perception of participation in the speech-language treatment program, and their opinion about their aphasic spouses’ speech-language treatment program? METHODOLOGY Subjects Subjects were 20 females living with a spouse who had been diagnosed as demonstrating aphasia. Subjects were between the ages of 60 and 75 years old, had been married five or more years, were native speakers of English, and had a negative history of neurological impairment. In addition, participants had completed a high school education and had auditory and visual acuity that was functional for daily activities. Ten subjects in this study were married to a person demonstrating a level 2-3 aphasia severity rating according to the Beaten Magnetic Aphasia Examinatiszn (BDAE) (Goodglass & Kaplan,l983). Ten subjects in this study were married to a person demonstrating a level 4-5 aphasia severity rating according the Bgstgn Diagngstig Aphasia Examination (BDAE) (Goodglass & Kaplan, 1983). Level 2 is defined as "Conversation about familiar subjects is possible with help from the listener. There are frequent failures to convey the idea, but the patient shares the burden of communication with the examiner." Level 3 is defined as "The patient can discuss almost all everyday problems with little or no assistance. Reduction of speech and/or comprehension, however, makes conversation about certain material difficult 21 22 or impossible." Level 4 is defined as "Some obvious loss of fluency in speech or facility of comprehension without significant limitation on ideas expressed or form of expression." Level 5 is defined as "Minimal discernible speech handicaps: patient may have subjective difficulties that are not apparent to listener." The spouses who were aphasic suffered a left cerebral vascular accident and received at least 8 weeks of treatment, having been discharged no more than 3 months prior to spouse’s participation in the study. Subjects were solicited from current and previous case loads of Speech-Language Pathologists in the Flint, Michigan, area. Materials Two questionnaires were created for this study. One, the mummies Abilities Questignnaire. was used to assess spousal opinions about the efficacy of aphasia treatment. It included questions in three categories of information typically used to examine treatment success: clinical skills, auditory comprehension abilities, and verbal abilities. A second questionnaire, the, Treatment Bettieinetien Queetienneizei was used to assess subjects' self-ratings of their participation in the treatment program and in follow-up at home. Several steps were taken to create the gemmnnieetien Abilitiee Queetienneitet Initially the investigators considered categories of questions to be included in the questionnaire and reviewed relevant literature in aphasia 23 (Rosenbek et al., 1989: LaPointe, 1990), efficacy of aphasia treatment (Sarno et al., 1970: Barley, 1972: Basso et al., 1979: Shewan et al., 1984), and the attitudes of family members and spouses toward aphasic adults (Derman et al., 1967: Helmick et al., 1976: Mulhall 1978: Kinsella & Duffy, 1980: Zraick et al., 1991: LyOn, 1992). A pool of potential stimulus questions was created based on information gathered in this review. Questions were constructed considering questionnaire category, length of question, grammatical simplicity of question, semantic content of question, and response content (Fraenkel & Wallen, 1990). IntheWmWWme clinical skills category was included because interpersonal skills of a Speech—Language Pathologist are an important factor in determining clinical success (Sorensen, 1992). Combs, Avilia and Purkey (1971) suggested that the interpersonal skills of practicing Speech-Language Pathologists were as important to treatment success as therapeutic methods used in a person's treatment program. The comprehension skills category was included within the questionnaire because the basis of communication is highly related to understanding conversational and written discourse (Graham, 1990). The verbal production skills category was included because patients and family members tend to judge rehabilitation improvement on how well one is able to talk (Rosenbek, LaPointe & Hertz, 1989: Kearns, 1990). 24 Each category was accompanied by a set of instructions which directed the subject how to respond to each question type. Each category contained ten statements and each statement was followed by a four point response opportunity scale which assessed the subject's opinion. A response of 1 represented a question which was not applicable to the subject. A response of 2 represented a negative opinion. A response of 3 represented a opinion of uncertainty. A response of 4 represented a positive opinion. The Cemmunieatien Abilities Questionnaire appears in Appendix A. The final form of the Qemmnnieatien Abilities Questienneire was examined for readability and ease of understanding. Readability was calculated at the twelfth grade reading level using the SMOG Procedure (Melaughlin, 1969). A five point equal appearing interval scale was used to rate ease of understanding. Ten nonneurologically impaired adults within the same age cohort participated as subjects in the pilot study to assess ease of understanding. They were asked to read each question and indicate how easy it was for them to understand. Mean level of understanding was rated at 4.4, suggesting the majority of questions were easily understood. Results of this study appear in Appendix B. Following completion of the gennnnieetign Abilities Queetienneizei subjects were requested to rate themselves by the amount of participation in both scheduled treatment sessions and at home in practice treatment sessions. 25 Subjects received the Treatment Bartieipatien.Questienneire and selected the response which represented their level of participation in the treatment program. Ratings assessing participation in scheduled treatment sessions, part one of the Treatment Bertieipetien Queetienneitei appeared on a seven point equal appearing interval scale. A response of 1 represented no participation in treatment sessions. A response of 2 represented participation in less than 10% of the treatment sessions. A response of 3 represented participation in less than 25% of the treatment sessions. A response of 4 represented participation in approximately 50% of the treatment sessions. A response of 5 represented participation in approximately 75% of the treatment sessions. A response of 6 represented participation in approximately 90% of the treatment sessions. A response of 7 represented participation in all treatment sessions. On the second portion of the Treatment Bettieipetien Queetienneizei the subjects were requested to select the response which represented their participation in self~regulated practice treatment sessions outside of the formal treatment program. Ratings appeared on a five point equal appearing interval scale. A response of 1 represented no participation in tasks outside the formal treatment sessions. A response of 2 represented participation in treatment tasks outside of the formal treatment session less than once a week. A response of 3 represented 26 participation in treatment tasks outside formal treatment sessions approximately one to two times a week. A response of 4 represented participation in treatment tasks approximately three to four times a week. A response of 5 represented daily participation in treatment tasks outside formal treatment sessions. The Iteetment Bettiginatign Questiennaire appears in Appendix A. Procedure Subjects were solicited from the case loads of Speech-Language Pathologists in the Flint, Michigan, area. Following referral, subjects were contacted by telephone to request their participation in this project. A cover letter describing the project, an informed consent form and the questionnaire were sent in the mail. Each respondent was requested to complete and return the questionnaires as soon as possible. Those subjects who did not return their questionnaires within two weeks were contacted by telephone and urged to complete and return their questionnaires. If a subject did not return the questionnaires within one week of the second telephone conversation, a letter was sent requesting completion and return of the questionnaires. RESULTS Responses to Questionnaire Regarding Clinical Skills and Changes in Spouses' Communication Abilities Subjects’ responses on the gemnnnieetien Abilities Queetienneize were counted and organized into contingency tables to compare expected and observed frequencies of occurrence. Individual response data appear in Appendix C. Three analyses were completed. The first analysis examined responses in questionnaire categories, condensing across the severity level of the aphasic spouse. The second analysis combined subjects' responses according to severity of spouse's aphasia condensing across questionnaire category. The third analysis examined subjects’ reSponses grouped according to aphasic severity level and questionnaire categories. Chi square was computed for each contingency table. All values were significant at the p=.05 level, therefore, further analysis was completed in two parts, patterns of analysis and mean comparison. First, to examine pattern of distribution, expected and observed frequencies were compared across factors within each contingency table, and within individual cells. Patterns of distribution were recorded during observation across all factors in a table. To examine 27 28 the relationship of expected and observed frequencies in each cell, and to explore the sources of the significant chi square, the rule of +/-lo% difference between expected and observed values was created. For each cell, a value representing 10% of the expected frequency was computed. This value was rounded up to the nearest whole number, and then added to and subtracted from the expected frequency to create a range with the expected frequency as the center point. The observed frequency was compared to this range, and if it fell outside the range, the expected and observed frequencies were considered to differ by more than 10%. Cells in a contingency table that showed this difference were judged to be contributing to the significant chi square. Second, mean response values were calculated for levels of factors in each of the tables and nonparametric t-tests were conducted to determine significant differences between them. The following sections report results for each contingency table. Respenseeteeuestiennaire MWefQuestiennaire The hypothesis being tested is: There will be no significant differences in spouses' opinion scores across three categories of treatment information: clinical skills auditory comprehension and verbal production. Chi square (80.48, df= 6) was significant for frequency of response (four response types) in three question categories (clinical skills, auditory comprehension skills, verbal production skills). Table 1 shows expected and observed frequencies for 29 each cell of the contingency table. Table 1 Expected and Observed Frequencies Across Questionnaire Categories Questionnaire Rating Total Category 2 3 4 CS 0 3 O 13 O 12 O 172 200 1 E 16 E 37 E 14 E 133 AC 0 17 O 36 0 23 O 124 200 E 16 E 37 E 14 E 133 VP 0 28 O 62 O 7 O 103 200 E 16 E 37 E 14 E 133 48 111 42 399 600 Legend Rating 8 Question is not applicable to subject = Negative opinion = Uncertain o inion = Positive op nion swan-o Questionnaire Category C8 = Clinical Skills AC = Auditory Comprehension Skills VP 2 Verbal Production Skills E = Expected frequency 0 = Observed frequency Expected and observed frequencies were examined for pattern of distribution across both response type and questionnaire category. Looking across the four response types, expected and observed values were unevenly distributed, with at least two-thirds of expected frequencies and one-half of observed frequencies in response type four, indicating positive opinions. That is, for all question 30 categories, most respondents indicated positive regard for aspects of treatment examined in this questionnaire. The distribution of expected frequencies across the remaining three response types was 19% in response type two, and approximately 7% each in response types one and three. Observed frequencies were unevenly distributed across all response types and question categories. The 10% difference rule was applied, and exceeded in nine of twelve cells in the first contingency table: cells representing response types one, two and four in the auditory comprehension category were the exception. For those cells with greater than 10% difference, expected values exceeded observed values for response types one, two and three in clinical skills question category and response types three and four in the verbal production category. Observed values exceeded expected values for response type four in the clinical skills question category, response types one and two in the verbal production question category, and response type three in the auditory comprehension question category. The relationship of expected and observed frequencies was examined more closely in response type four because of the high number of responses in all question categories. In the clinical skills question category, observed frequency exceeded expected frequency by almost 30% (10% difference rule in expected frequency= 13.3, actual 10% difference= 39). In the auditory comprehension question category expected frequency exceeded observed frequency by 31 only 7% and in the verbal production question category expected frequency exceeded observed frequency by 23%. The relationship of expected and observed frequencies across response types is shown in Table 2. Table 2 Pattern of Differences Between Expected and Observed Values Response E=O { E>O O>E 1 AC CS VP 72 1 AC cs VP 3 CS VP AC 4 AC VP CS Legend Rating a Question is not applicable to subject = Negative opinion = Uncertain opinion a Positive opinion hUNP Questionnaire Category CS a Clinical Skills AC = Auditory Comprehension Skills VP - Verbal Production E = Expected frequency 0 = Observed frequency Subjects, in general, expressed a positive opinion regarding aspects of treatment examined in this study. More subjects than anticipated regarded the clinical skills of the Speech-Language Pathologist, including the treatment format, as positive. In reporting changes in the communication skills of their aphasic spouses, the anticipated number of subjects did indeed report a positive opinion regarding the 32 auditory comprehension skills of their spouse: however, fewer subjects than anticipated reported a positive opinion regarding the verbal production skills of their spouses. In all three question categories the majority of observed responses were ratings of four, with inconsistent distribution of observed frequencies in other response types. To further examine differences in the distribution of observed frequencies, mean response values were calculated for each question category and subjected to the Two Sample Sign Test. The mean response value for auditory comprehension question category was greatest (3.74) followed by the clinical skills question category (3.0) and then verbal production category (2.92). Results of comparisons between means are presented in Table 3. The mean response value for the clinical skills question category was significantly greater than the mean response value for the auditory comprehension question category (N=20, x=2, p=.0004) and the verbal production question category (N=20, x=2, p=.0002): means for the auditory comprehension and verbal production question categories were not significantly different (N=20, x=s, p=.994). 33 Table 3 Mean Comparisons for Response Types on Questionnaire Categories Category Mean t p Comparison CS 3.74 vs .62 .0002* VP 3.30 CS 3.74 vs .44 .0004* AC 2.92 VP 3.30 vs .38 .994 AC 2.92 Legend Categories of Comparison CS vs VP = Clinical Skills vs Verbal Production CS vs AC = Clinical Skills vs Auditory Comprehension VP vs AC = Verbal Production vs Auditory Comprehension *= Statistically significant Respeneeteonestienneirebxaubjeetefimuped Aeeetdinetemnesiefiemitxsatineeffimee The second hypothesis being tested is: There will be no significant differences between the opinion scores of spouses of persons with mild aphasia and spouses of persons with moderate aphasia across three categories of treatment information. Chi square (36.72, df= 9) was statistically significant for the contingency table examining subjects' response patterns across four response types, when grouped according to the severity of their spouses' aphasia. Table 4 shows expected and observed frequencies. 34 Table 4 Expected and Observed Frequencies Across Levels of Aphasia Severity Severity Rating Total Level 1 2 3 4 Level 0 37 O 31 O 29 O 203 4 & 5 E 23.5 E 50.5 E 21 E 205 300 Level 0 10 O 70 O 13 O 207 2 & 3 E 23.5 E 50.5 E 21 E 205 300 47 101 42 410 600 Legend Rating Question is not applicable to subject Negative opinion Uncertain opinion Positive opinion 5 = Mild aphasia according to BDAE 3 = Moderate aphasia according to BDAE OH we pump mam Expected frequency Observed frequency For both severity groups the majority of expected and observed frequencies were response type four, reflecting subjects’ positive opinions about aspects of their spouse's treatment program. The expected frequency of response was 17% in response type two (negative opinion) and 7% in each of response types one and three. Frequencies of observed responses were unevenly distributed across types one, two and three. Applying the 10% difference rule between expected and observed frequencies in individual cells, values in six of the eight cells exceeded the calculated ranges. The two 35 exceptions were response type four in both aphasia severity groups (Expected Frequency for both groups was 205, Observed Frequency was 203 for the mild group, and Observed Frequency was 207 for the moderate group). Expected frequency exceeded observed frequency for response type two in the mild aphasia group and response types one and three in the moderate aphasia group. Observed frequency exceeded expected frequency in response types one and three in the mild aphasia group and response type two in the moderate aphasia group. The relationship of expected and observed frequencies across response types and subject groups is shown in Table 5. Subjects in both aphasia severity groups expressed positive opinions regarding aspects of treatment for their spouses. The anticipated number of subjects in both aphasia severity groups expressed a positive opinion, indicating no influence of severity at this level of response. In the mild subject group fewer subjects than expected indicated a negative opinion, where as in the moderate group a greater number of subjects than expected indicated a negative opinion. 36 Table 5 Pattern of Differences Between Expected and Observed Values Response E=O E>O O>E 1 2&3 4&5 2 4&5 2&3 3 2&3 4&5 4 2&3 4&5 Legend Rating = Question is not applicable to subject a Negative opinion = Uncertain o inion Positive op nion 5 = Mild aphasia according to BDAE 3 = Moderate aphasia according to BDAE 8'02" Expected frequency Observed frequency on we huNH The mean response value was calculated for each severity group: for the mild aphasic group the response value was 3.32 and for the moderate aphasic group 3.31. A nonparametric t- test revealed no significant difference between means (N= 20, X= 2, p= >.05). Subject groups showed no difference in mean response values or in number of responses indicating a positive opinion. 37 Besmnseetemiestiensbxsybjeetefimned memuwm andceteserxefnuestiens The third analysis was undertaken to determine whether specific combinations of question category and spouse’s aphasia severity level contributed more than others to the distribution patterns seen in the previous analyses. The third hypothesis being test is: There will be no significant differences between the opinion scores of spouses of persons with mild aphasia and spouses of persons with moderate aphasia in each of the three categories of information: clinical skills, auditory comprehension and verbal production. Chi square for this analysis was significant (150.4, dfe 15). Expected and observed frequencies are shown in Table 6. Expected frequencies were consistent with previous distributions (approximately two-thirds of responses in type four, 17% in type two and 7.5% each in types one and three) for all combinations of aphasia severity and questions category. Observed frequencies were between 52% and 86% in cells representing response type four, and inconsistently distributed across response types one, two and three for the remaining combinations of aphasia severity and question category. Applying the 10% difference rule, expected and observed frequencies differed by more than 10% in all cells except the two cells representing response type four within the auditory comprehension question category (E3 68.3, 0= 66 for mild 38 O8 69 for moderate). Expected frequencies exceeded observed frequencies in the following aphasia-severity question category groups: response type two in the mild aphasia auditory comprehension question category group, response types three and four in the mild aphasia verbal production question category, response types one and two in the mild aphasia clinical skills question category, response Table 6 Expected and Observed Frequency within Questionnaire Categories and Level of Aphasia Severity Group Rating Total Severity Within 1 2 3 4 Questionnaire Category [ 4 & 5 O 15 O 4 O 15 O 66 100 AC E 7.83 E 16.8 E 7 E 68.3 4 & 5 0 l9 0 26 0 4 O 51 100 VP E 7.83 E 16.8 E 7 E 68.3 4 & 5 0 3 O 1 O 10 0 86 100 CS E 7.83 E 16.8 E 7 E 68.3 2 & 3 O 1 O 22 O 8 O 69 100 AC E 7.83 E 16.8 E 7 E 68.3 2 & 3 O 9 O 36 O 3 0 52 100 VP E 7.83 E 16.8 E 7 E 68.3 2 & 3 O 0 O 12 O 2 O 86 100 CS E 7.83 E 16.8 E 7 E 68.3 47 101 42 410 600 39 Chart 6 (cont’d) Legend Rating = Question not applicable to subject a negative opinion = Uncertain opinion = Positive opinion «buNH Questionnaire Category CS a Clinical Skills AC = Auditory Comprehension Skills VP = Verbal Production Skills 4 a 5 = Mild aphasia according to BDAE 2 a 3 = Moderate aphasia according to BDAE E a Expected frequency 0 = Observed frequency type one in the moderate aphasia auditory comprehension category, response types three and four in the moderate verbal production question category, and response types one, two and three in the moderate clinical skill category. Observed frequencies exceeded expected frequencies in the following aphasia severity question category groups: response types one and three in the mild auditory comprehension question group, response types one and two in the mild verbal production question category, response types three and four in the mild clinical skills question category, response types two and three in the moderate auditory comprehension category, responses types three and four in the moderate verbal production category, and response types one, two and three in the moderate clinical skills question category. The relationship of expected and observed frequencies across response types and aphasia severity-question category groups is shown in Table 7. 40 Mean response values were calculated for each aphasia severity-question category group and subjected to nonparametric t—tests (Two Sample Sign Test). Previous means comparisons showed significant differences among question categories but not levels of aphasia severity, therefore t-tests were conducted among means within each severity group rather than across aphasia severity groups. Table 7 Pattern of Differences Between Expected and Observed Values Response E=O E>O O>E 1 4&5 CS 4&5 AC 2&3 AC 4&5 VP 2&3 CS 2&3 VP 2 4&5 AC 4&5 VP 4&5 CS 2&3 AC 2&3 CS 2&3 VP 3 4&5 VP 4&5 AC 2&3 VP 4&5 CS 2&3 CS 2&3 AC } 4 4&5 AC 4&5 VP 4&5 CS 2&3 AC 2&3 VP 2&3 CS 41 Table 7 (cont'd) Legend Rating = Question is not applicable to subject a Negative opinion a Uncertain opinion = Positive opinion honour-4 Questionnaire Category = Clinical Skills = Auditory Comprehension Skills = Verbal Production Skills 8863 5 a Mild aphasia according to BDAE 3 8 Moderate aphasia according to BDAE (DH an» H ma» Expected frequency Observed frequency Significant differences between means were found for comparisons involving auditory comprehension versus clinical skills questions categories, and clinical skills versus verbal production categories in both the mild and moderate aphasia severity groups. Comparisons between auditory comprehension and verbal production question categories were nonsignificant in both aphasia severity groups. Probability values are shown in Table 8. Correlation of Responses on Two Questionnaires The degree to which subjects perceived themselves as involved in their spouse's treatment program may have influenced their responses on the gennnnieetien,Aniiitiee Qneetienneizei To explore the nature of this relationship, correlations were computed between responses on the cemnnisatienapiiitiesnuestienneireandTmtment Bertieimtieneueetienneirei 42 Table 8 Comparison of Mean Response Values Across Question Types Within Two Aphasia Severity Groups Severity Comparison p Level CS (3.79) vs AC (3.32) .011 4 & 5 CS (3.79) vs VP (2.87) .011 AC (3.32) vs VP (2.87) >.05 CS (3.74) vs AC (3.00) .02 2 a 3 cs (3.74) vs VP (2.98) .011 AC (3.00) vs VP (2.98) >.05 Legend Questionnaire Category CS = Clinical Skills AC 2 Auditory Comprehension Skills VP e Verbal Production Skills 4 2 & 5 = Mild aphasia according to BDAE & 3 2 Moderate aphasia according to BDAE Nonparametric Spearman r was computed for responses within questionnaire categories, condensed across aphasia severity groups, and for responses within combined questionnaire category aphasia severity groups. The first analysis compared subjects' responses according to question category on the gennnnieetien Ahiiitiee Qneetienneite with responses on part one of the Treetnent Bettieinatien Queetienneite (participation in treatment sessions) and part two of the Tzeetnent Bettieipetien Qneetienneize (participation in home based practice sessions). The two final hypotheses being tested are: There will be no significant differences between spouses of mild or moderate aphasic communication partners on a scale of 43 participation in the treatment session and outside of the treatment session: There will be no significant relationship between subjects’ self-perception of participation in the speech-language treatment program, and their opinion about their aphasic spouses' speech-language treatment program. No correlation was significant. Results are shown in Tables 9 and 10. Table 9 Correlation Across Questionnaire Category and Participation in Scheduled Sessions and Self Regulated Home Practice Sessions Questionnaire Self-Regulated Scheduled Category Home Sessions Sessions r p r P CS .1304 .584 .0129 .957 AC 1 .1856 .433 .0500 .834 VP .1531 .519 .1555 .513 Legend Questionnaire Category CS = Clinical Skills AC = Auditory Comprehension Skills VP = Verbal Production Skills * = Statistically Significant The second analysis compared subjects' responses in combined aphasia severity—question category groups with responses on parts one and two of the Iteetnent Pettieinetien Queetienneizei Results are shown in Table 10. No correlation was significant. The third analysis examined the relationship of subjects' self ratings regarding their 44 participation in their spouse's treatment program within each subject group (based on aphasia severity level). Subject self—ratings on the two parts of the Treetment,£eztieipetien Questiennaize were compared using the Mann Whitney U: results showed subject self ratings on the participation in treatment session and participation in self-regulated home practice sessions was not significantly different. For the mild aphasia severity group z= .2097 and p= .8339, for the moderate aphasia group z= 1.172 and p= .2411. Table 10 Correlation Among Spouse Participation and Aphasic Partners Level of Severity Aphasia Participation Participation Severity Home-Regulated Scheduled Sessions Sessions r p r p 4 & 5 CS .4051 .246 .0349 .924 4 & 5 VP -.1118 .759 -.2568 .434 4 & 5 AC .4791 .161 .3421 .333 2 & 3 CS .0334 .927 .0053 .989 2 & 3 VP .3078 .387 .1055 .772 2 & 3 AC .1048 .773 .3024 .396 45 Table 10 (cont'd) Legend Questionnaire Category CS = Clinical Skills VP = Verbal Production Skills AC = Auditory Comprehension Skills 4&5 = Mild aphasia according to BDAE 2&3 = Moderate aphasia according to BDAE DISCUSSION This project examined female spouses' opinions about their aphasic husbands' treatment in a speech-language program- The Qommunioetion.Abilities Questionnaire and the Treetment Bertieipetien Queetienneire were distributed to 20 subjects to solicit opinions regarding their husbands' improvement in auditory comprehension skills and verbal production skills. Subjects were also requested to render opinions about the clinical skills of the Speech-Language Pathologist treating their husband's. The Treatment Pertieipetien Queetienneire asked subjects to rate themselves on the amount of time they participated in their husband's treatment sessions and in self-directed practice sessions at home. Responses on the Qonmanioation Abilities Questionnaire were organized into contingency tables, created according to question category and severity of spouse's aphasia. Re8ponsee on the Treatment Eartioioation Questionnaire were correlated with responses on the gemmnnieetien Abilities Queetienneiret Results are discussed according to comparison categories. 46 47 Patterns of Response Across Questionnaire Category Observed frequencies were unevenly distributed across questionnaire categories, with the majority of the subject's responses indicating positive opinions about their spouse's treatment program and treatment progress. These results are contrary to previous research in which family members and spouses demonstrated negative attitudes toward adults with aphasia (Malone, 1969: Derman & Manaster, 1967: Kinsella & Duffy, 1980: Malone et al., 1970). That is, most subjects believed the Speech-Language Pathologist managing the treatment program for their spouse demonstrated good clinical skills and that their spouse's improved in auditory comprehension and verbal production skills as a result of the treatment program. The difference in results regarding attitudes may suggest that Speech-Language Pathologists are recognizing the importance of providing counseling and explanations regarding behaviors following a cerebral vascular accident (Malone, 1969) and offering information about aphasia. Counseling and explanations may in turn help in understanding deficits following a cerebral vascular accident, allowing spouses to anticipate realistic improvements (Malone, 1969). Responses in category four (representing a positive opinion) suggest that subjects were generally of the opinion that their husbands exhibited improvement. Closer examination reveals that opinions regarding clinical skills of the Speech-Language Pathologist greatly exceeded 48 expectations and observed responses in the auditory comprehension category approximated expected responses. On the other hand, observed responses in the verbal production category were much lower than expected. This suggests that, despite positive opinions, subjects may have had unrealistic expectations for their spouse's improvement. So while it appears that wives have positive opinions about all aspects of treatment, the greatest number of responses indicate positive opinions regarding clinical skills. Positive opinions toward Speech-Language Pathologists' skills may be related to the unique therapeutic communicative style Speech-Language Pathologists use as they attempt to develop successful helping relationships with aphasic adults (Sorenson, 1992). Four possible explanations for the pattern of responses are offered. Speech-language rehabilitation programs are designed to improve auditory comprehension and verbal production skills. It is possible that improvement in these areas is influenced by the clinical skills of the Speech-Language Pathologist. That is, if the Speech-Language Pathologist demonstrated outstanding clinical skills or if a spouse or client believes the Speech—Language Pathologist demonstrates outstanding clinical skills, patient performance or the perception of patient performance is enhanced. Positive communication skills used by Speech-Language Pathologists may increase the ease with which spouses communicate with their aphasic partners (Sorenson, 1992). 49 Positive communication skills include personality variables (attentiveness, animation, friendliness, relaxed and noncontentious demeanor) that are incorporated into the treatment regimen. The primary focus of clinical skills used by Speech-Language Pathologists is to attempt to modify communication behavior in a functional direction utilizing both technical and interpersonal skills (Sorenson, 1992). Speech-Language Pathologists in the current study may have conveyed to the subjects both knowledge about aphasia and strategies to decrease communication deficits outside the structured treatment sessions: and in turn, subjects felt at ease with the Speech-Language Pathologists. As a result, regardless of treatment effectiveness or documented abilities of clinicians, subjects rated the Speech-Language Pathologists high on clinical skills, responding to the level of comfort they felt. Alternatively, it is possible that subjects expressed positive opinions on the Qemmnnieetien Abilities Queetienneire because they perceived their spouses to have improved by virtue of enrollment in a treatment program. Speech-Language therapy programs are designed to foster change in client behavior, although change in the anticipated manner may not always occur. Subjects may have assumed that because their spouses were receiving Speech-Language treatment, they must be improving in communication skills, regardless of the presence of confirmatory data. One final explanation is the presence of the Halo 50 Effect. Wives may have felt an emotional bond to their spouses' Speech-Language Pathologist and wanted to express only positive opinions about their husbands' clinician. Patterns of Response Across Level Of Severity Severity of aphasia did not influence subjects' mean response ratings across question categories or distribution of expected and observed frequencies in response to category four. Basso, Capitani, Luigi and Vignolo (1979) reported that severe and long-standing deficits following a cerebral vascular accident influence one’s prognosis. Following this, it was anticipated that fewer subjects whose spouses had moderate aphasia would express positive opinions regarding aspects of treatment than would subjects whose spouses had mild aphasia. While this was not the case, difference between subject group responses was noted for response category two representing a negative opinion. A negative opinion regarding treatment was expressed more frequently by spouses of moderate aphasics than spouses of mild aphasics. This is consistent with the conclusion of Basso at al., (1979). Table 3 showed that responses other than a positive opinion, that is, response types one, two and three were evenly distributed in the mild aphasia group and concentrated in response type two for the moderate aphasia group. The response pattern of interest was that while the majority of subjects' responses reflected positive opinions regarding aspects of treatment, of those subjects who expressed negative opinions, more than two-thirds had spouses 51 with moderate aphasia. This suggests that disruption in communication patterns can cause frustration in the nonaphasic spouse. Frustration on the part of spouses with moderate aphasia may account for the increase in negative opinions and may be secondary to role reversal. That is, men with moderate aphasia may not assume their former marriage roles, thus increasing their spouse's responsibility for performing unfamiliar activities. This creates a situation in which the female spouse performs a dual role within the marriage, leading to heightened frustration and potentially unsuccessful communication attempts. Patterns of Response Across Questionnaire Category and Level of Severity The two patterns observed in the data was a high frequency of observed responses in response type four and the next highest frequency in response type two were examined across subjects grouped according to both aphasia severity level and question category. Frequencies of response in response type four were similar in both aphasia severity levels across all question categories. The smallest observed frequency in the two cells representing verbal production. In reSponse type two, in both severity groups, the greatest frequency of response was in the verbal production question category: between a quarter and a third of subjects indicated a negative opinion regarding their spouses’ improvement in this area. 52 Looking across response types four and two in this analysis, and patterns of observed frequencies in the analysis of subjects grouped according to spouses severity of aphasia, three conclusions can be drawn. First, as previously noted, the majority of responses reflected positive opinions regarding aspects of treatment, with clinical skills having the greatest observed frequency. Second, when collapsed across question category, mean response type values did not differ according to severity of spouse's aphasia, giving the impression that severity of aphasia did not influence ratings. However, severity of aphasia may have influenced the pattern of response, but only when considered in conjunction with question category. Data in the current project shows that subjects whose spouses have mild aphasia provide negative opinions about the verbal production skills of their spouses far more frequently than they provide negative responses about other aspects of treatment. This pattern is also seen in the subject group whose spouses have moderate aphasia. In addition to frequent negative responses in the verbal production category, negative responses also often appear in the auditory comprehension questionnaire category. It appears from the data that the majority of subjects expressed positive opinions regarding treatment. Those responses that were other than positive were concentrated in response type two (negative opinion) in question categories of verbal production (for both subject groups) or auditory 53 comprehension (for the subject group whose spouses have moderate aphasia). Many responses by spouses of persons with mild aphasia reflected uncertainty or not applicable rather than negative opinions. By contrast, subjects whose spouses had moderate aphasia did not often select responses of uncertain or not applicable. Subjects in both groups showed negative opinions about their spouses' verbal production skills, but only spouses with moderate aphasia also showed negative opinions about their spouses' auditory comprehension skills. One speculation for these results may be depression among persons with moderate aphasia, contributing to lack or perceived lack, of change as a result of treatment. Moderate aphasics may be mourning the loss of communication abilities and limitations which in turn may lead to depression. Feelings of depression may affect the outcome of treatment sessions as well as participation in unstructured environments, in that patients may not wish to participate in communication situations. Perhaps they are grieving the loss of communication abilities or are unwilling to engage in communicative interaction unless they can be assured of success or are not motivated to participate in treatment sessions. Regardless of the reason, the result is that patients either do not change or their spouses perceive that they do not change. Another possible explanation for an increase in negative opinions among women whose communication partners have severe 54 aphasia may be unrealistic expectations on the part of those women. Rosenbeck, LaPointe, and Wertz (1989) suggested that family members tend to judge rehabilitation improvement based upon a patient's expressive skills which are often dependent upon auditory comprehension skills. Women may expect their husbands to regain communication skills to a premorbid level and may be very dissatisfied when that does not happen. These results support the continued need for counseling and explanations regarding the consequences and treatment of aphasia, in an effort to increase awareness and create realistic expectations for recovery of communication ability. This is particularly important for spouses of persons with moderate aphasia. Correlation of Spousal Self Ratings of Participation in the Treatment Program and Opinions of Treatment Subjects' responses on the two portions of the Treetment Eartioipation Qnestienneire were correlated with responses on the Communioation Abilities Questionnaires No correlation was significant. Subjects were also grouped according to their husbands' level of severity, and correlation coefficients were computed between questionnaire responses. Once again, no correlation was significant. It can be concluded that the amount of time a subject spends in the treatment program of her spouse is not related to her opinion of treatment. SUMMARY AND CONCLUSIONS The following conclusions can be drawn from this research. First, the majority of subjects expressed positive attitudes toward their husbands’ treatment program. Most subjects believed the Speech-Language Pathologists managing the treatment program of their spouses’ exhibited good clinical skills and that their spouses’ improved in auditory comprehension and verbal production abilities as a result of enrollment in a treatment program. Although the majority subjects expressed positive opinions about all aspects of treatment, the greatest number of positive opinions was observed in the clinical skills category. Second, severity of aphasia did not appear to influence subjects’ opinions about their spouses’ treatment program or perception of improvement in auditory comprehension or verbal production skills. Third, Observed responses in the verbal production category were lower than expected. Subjects in both severity groups expressed negative opinions about their spouses’ verbal production skills. Last, perceived amount of subject participation in the treatment program and in self-regulated home treatment sessions was not related to subject’s opinions about their spouses’ treatment program. 55 56 On the basis of these data the research hypotheses have been accepted or rejected as follows. Hypothesis one is rejected. There is a significant difference between spouses’ response according to questionnaire category on the Qommunioation Abilities Questionnairel Hypothesis two is accepted. Despite the significant chi square, pattern analysis and means comparison show no significant difference in subject responses grouped according to aphasia severity level. The significant chi square is a result of difference in frequency of response across response types. Hypothesis three is rejected. There is a significant difference in subject responses according to a combination of aphasia severity and questionnaire category. Hypotheses four and five are accepted. There is no relationship between subjects re8ponses on the Communication Abilities.Questionnaire and Treatment Eartioioation Questionnaires APPENDICES APPENDIX A 57 Appendix A Clinical Skills Please circle the answer that you believe best describes the clinical services that your relative received during the duration of treatment. 1. The clinician used teaching activities that seemed appropriate to your relative’s level of therapy. yes uncertain no not applicable *******************************ti**************************** 2. During treatment the clinician presented task instructions in a organized manner that seemed easy for your relative to understand. yes uncertain no not applicable ****************a******************************************** 3. The clinician spoke to your relative in a respectful manner. yes uncertain no not applicable ************************************************************* 4. The clinician assigned homework activities that seemed appropriate to your relative’s level of treatment. yes uncertain no not applicable ************************************************************* 5. The clinician provided feedback on your relative’s responses during treatment tasks. yes uncertain no not applicable **********************t************************************** 58 Appendix A 6. The clinician explained homework assignments in a manner that seemed easy to understand yes uncertain no not applicable *******************************t***************************** 7. The clinician explained the results of the initial evaluation to you and your relative. yes uncertain no not applicable ****************w4**4******t4***a4*************************** 8. Over the course of treatment the clinician and your relative developed a good working relationship. yes uncertain no not applicable ************************************************************* 9. During the early therapy sessions the clinician defined your relative’s communication problem and discussed a plan of treatment. yes uncertain no not applicable ********************t**************************************** 10. The clinician presented activities that were of personal interest to your relative. yes uncertain no not applicable ************************************************************* 59 Appendix A Auditory Comprehension Before beginning this portion of the questionnaire it is crucial for you to think about your relative’s comprehension abilities after his stroke and his present comprehension abilities. Please circle the answer you believe represents the changes you have observed. If you believe a question does not apply to your relative or believe that services were not necessary to improve a particular communicative aspect, please circle not applicable. 1. My relative is better at following spoken directions. yes uncertain no not applicable ********************a**************************************** 2. My relative responds with appropriate actions during conversation with other people. yes uncertain no not applicable ************************************************************* 3. My relative seems to have an easier time understanding spoken conversations involving three or more peOple. yes uncertain no not applicable ************************************************************* 4. My relative seems to understand yes and no questions. yes uncertain no not applicable ***************t********************************************* 60 Appendix A 5. My relative remains on a tOpic of conversation for an appropriate amount of time. yes uncertain no not applicable ***ti******************************************************** 6. My relative is able to give appropriate responses to simple questions such as ”What is your name?". yes uncertain no not applicable ************************************************************* 7. My relative appropriately answers long and/or complicated questions. yes uncertain no not applicable ************************************************************* 8. My relative appropriately answers short/unfamiliar questions. yes uncertain no not applicable ************************************************************* 9. My relative seems to understand written information. yes uncertain no not applicable ************************************************************* 10. My relative seems to understand long and/ or complicated spoken directions. yes uncertain no not applicable ********************************************************R**** 61 Appendix A Verbal Production Before beginning this portion of the questionnaire, it is crucial for you to think about your relative's speaking abilities after his stroke and his present speaking abilities. Please circle the answer you believe represents the changes you have observed. If you believe a question does not apply to your relative or believe that services were not necessary to improve a particular communicative aspect, please circle not applicable. 1. My relative initiates conversations with friends and other family members. yes uncertain no not applicable ****************i******************************************** 2. It is easy to understand my relative when he speaks in short sentences of approximately 2 to 4 words yes uncertain no not applicable *********************************tt************************** 3. It seems that my relative is aware of his communication errors. yes uncertain no not applicable ************************************************************* 4. My relative participates in a variety of speaking situations. yes uncertain no not applicable ********************t**************************************** 62 Appendix A 5. It is easy to understand my relative when he speaks in sentences that are longer than 5 words. yes uncertain no not applicable *44********************************************************** 6. Assistive modes of communication have been discussed with me and my relative. yes uncertain no not applicable **************a********************************************** 7. It would be easier to talk with my relative if he used an assistive communication device. yes uncertain no not applicable *********************t*************************************** 8. My relative seems to become frustrated during conversations with friends and other family members. yes uncertain no not applicable ************************************************************* 9. My relative seems to become frustrated when he speaks in sentences that are longer than 5 words. yes uncertain no not applicable k************************************************************ 10. It seems easier to understand my relative when he uses nonverbal gestures (pointing) rather than speech. yes uncertain no not applicable ************************************************************* 63 Appendix A Participation In Treatment Program Think about your relative’s treatment program and how involved you were in the treatment sessions. Please circle the response that best represents the number of times you participated in your relative’s treatment session. A. Never participated in relative’s treatment sessions. B. Participated in C. Participated in D. Participated in E. Participated in F. Participated in less than 10% of the sessions. less then 25% of the sessions. approximately half of the sessions. approximately 75% of the sessions. approximately 90% of the sessions. G. Always participated in relative’s treatment sessions. 64 Appendix A Participation in Therapy Outside of Treatment Session Think about your relative outside of his/her treatment sessions. Please circle the answer that best represents how often you and your relative participated in treatment tasks outside of the treatment sessions. A. Never participated in treatment tasks outside of treatment sessions. B. Participated in treatment tasks outside of treatment sessions less than once a week. C. Participated in treatment tasks outside of treatment sessions approximately one to two times a week. D. Participated in treatment tasks outside of treatment sessions approximately three to four times a week. E. Participated in treatment tasks outside of treatment sessions daily. APPENDIX B Ease of Questionnaire Understanding 65 Appendix B Numerical ratings are defined as: l. Strongly disagree 2. Disagree 3. Uncertain 4. Agree 5. Strongly agree SUBJECT QUESTION 1 QUESTION 2 QUESTION 3 QUESTION 4 1. 5 5 4 5 2. 4 5 4 4 3. 4 4 5 5 4. 5 5 4 5 5. 4 5 5 4 6. 5 5 4 5 7. 4 4 4 4 8. 5 5 5 4 9. 5 4 4 4 10. 4 4 4 3 Average Average Average Average 4.5 4.6 4.3 4.3 Mean= 4.4 APPENDIX C 66 Appendix C Subject Response Type Across Questionnaire Category Subject Le¥el CS AC VP 0 Severity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etters A-V represent subject response types Questionnaire Category CS = Clinical Skil 3 AC = Auditory Comprehension VP = Verbal Production M = Mild aphasia according to BDAE S 2 Moderate aphasia according to BDAE 67 Appendix C Individual Mean Scores within Categories 68466633208276308126 33332331343333323333 3.30 AC 96833158339301081338 23222332332233323232 2.92 CS 902208470$0099040780 343343334L4433‘24334 3.74 Subject nus"SMISHIHMZSQSMQSHunQZSQZHcan .AnuCnuEnrGququruNnuanRmiUnv Mean Letters A-V Represent Subjects Questionnaire Category C8 = Clinical Skills AC = Auditory Comprehension VP s Verbal Production M = Mild aphasia according to BDAE s = Moderate aphasia according to BDAE fl Appendix C Subject Participation Within and Outside of the Treatment Program Subject Level Participation Participation of within Outside of Severity Treatment Treatment 3