"What I Mean Is..." A Structured Program to Improve Mild to Moderate Retrieval/Fluency Problems 3rd Edition

By Hilary J. Dibben B.Sc M.Sc S-LP(C) and Anita Kess B.A. M.A. Dip.App.Ling

The first and only speech therapy book for adults, offering speech rehabilitation for those with high functioning speech disorders. (Important to note is that you may not even realize that you have a speech disability: I didn't.)

If you have been speaking normally all your life, suddenly to be saddled with a speech impairment is a terrible blow to the self-esteem. It's also unspeakably frustrating not to be able to express yourself and be understood.

I think the 'feeling misunderstood', continually, is one of the worst things.

This book made a wonderful difference to me and I know it will do the same for you!
Julie

• Language: English
• Publisher: Lulu.com
• Release date: Mar 30, 2011
• ISBN: 9781257244836

Book preview

What I Mean Is…

A Structured Program to Improve Mild to Moderate Word Retrieval/Fluency Problems

3rd Edition

Written and compiled by:

Hilary J. Dibben, B.Sc., M.Sc., S-LP(C) Anita Kess, B.A., M.A., Dip.App.Ling.

What I mean is…: A Structured Program to Improve Mild to Moderate Word Retrieval/Fluency Problems, 3rd Edition - Hilary Dibben and Anita Kess.

Copyright © 2003 by Hilary Dibben and Anita Kess

ALL RIGHTS RESERVED.

Book layout by Julie Taylor and Marilyn Carr-Harris.

Cover design by Marilyn Carr-Harris.

A ReBuildingYou Publication

www.ReBuildingYou.com

Acknowledgments

To all the patients past and present with whom I have had the privilege to work during their courageous journey towards recovery.

To Butch, Jennifer and Adele for their generous and unwavering support.

Hilary

With thanks to my adorable husband, Dr. Joseph F. Kess, for his generous assistance with the materials on ambiguity and for his support of this project.

Anita

About the Authors

Hilary Dibben, B.Sc., M.Sc., SLP (C), has been working as a speech pathologist in Victoria, British Columbia, Canada since 1987. She works with a variety of neurologically impaired in- and out-patients at Victoria General Hospital Neuro-Rehabilitation Department and formerly with the Gorge Road Rehabilitation Hospital. Hilary has self-published two other compilations of speech therapy treatment materials, The Barrier Book and Listening Activities.

Anita Kess, B.A., M.A., Dip.App.Ling. is currently an instructor in the division of Arts and Science at Camosun College in Victoria, British Columbia, Canada. She teaches English to international students. She also maintains a private practice which caters to head injured patients who are not native speakers of English. She has published a number of articles in general and applied linguistics and has published two textbooks.

Foreword

Mild, moderate and even severe word retrieval/fluency problems in the presence of what appears to be functional expressive language is a frequent occurrence after neurological injury, most commonly head injury and stroke. This population is often not a priority for speech pathology intervention as the more severe interruptions of expressive and receptive language tend to take a higher priority. However, these clients consistently complain of difficulty coming up with the right words with which to explain themselves. They feel that they are not clear and are frequently misunderstood. This problem causes patients considerable distress and has serious implications for their return to work, school and previous social interactions. As a speech pathologist working with patients in a high level Out-Patient Head Injury Program, I find that most patients being treated report this same problem. Improving their ability to express themselves becomes one of their major goals in the therapy program.

I was unable to find a structured treatment approach that addressed word retrieval deficits at this level of ability. I was not satisfied with just generating word lists and categorization exercises because patients soon became bored with these tasks. In addition, mere word lists and categorization drills did not seem to improve (a) the scores on objective measures, (b) the functional fluency of their expression or (c) their selfrating of their ability. I started to use the definition task and soon discovered its usefulness for patients who repeatedly report, I have difficulty coming up with the right words in order to explain what I mean. I slowly adapted it into a structured program and have been using it in one-on-one as well as group therapy settings since 1992. It has since proven itself to be highly effective in remediation and compensation of word retrieval/fluency problems with this population. Success has been measured not only by standardized tests but also by patient report and self-ratings (using analog scales). An added bonus is that patients report enjoying the activity!

The What I mean is… program uses a common therapy exercise of definition, combined with a comprehensive collection of material demonstrating verbal ambiguity ‘that must be explained’. It has been structured in such a way that the patient becomes immersed in a process that:

Improves awareness of their listener’s point of view and encourages them to take responsibility for transmitting what they mean.

Teaches a structure upon which explanations can be organized that through practice becomes internalized and automatic.

Improves word retrieval and word fluency.

Teaches a compensatory strategy (i.e. structured circumlocution) to be used during moments of word finding difficulty.

Assists in the more generalized treatment goal of reorganizing language.

Assists with flexibility of thought by helping the client to search for other possible meanings to ambiguous verbal material.

Coming up with the right words to express the intended meaning and fluency of expression are not only important to the neurologically impaired but also of interest and concern for other non-injured populations like students, ESL learners, administrators, etc. The What I mean is… program can be used in any of these settings to improve verbal expression.

Introduction

Examples of subjective complaints from patients:

I can’t express myself the way I used to.

I have trouble finding the right words.

I have trouble getting across what I really mean.

I tend to ramble on and on.

By the time I’ve figured out how to say something, I’ve forgotten what it was I was trying to say.

I speak more slowly.

I’m really vague.

People keep finishing my sentences.

"I use more words like um, a, you know, like, than ever before."

I’m self-conscious about the difference in the way I talk so I go out less…I’m afraid people will thing I’m stupid.

I don’t talk anymore, I just listen.

I feel dumb, less intelligent.

I feel boring.

Comments from people who know these clients well suggest they:

are more wordy or talkative,

are much quieter than they used to be,

participate less in conversation,

get noticeably frustrated when conversing.

I. Theoretical Background

General conversation relies heavily on rules that are retrieved from past learning (remote memory) and are more reflective of the individual’s pre-morbid social skills. Thus, conversation on a social, automatic level may occur without interruption. However, when the conversation becomes abstract or lengthy or requires detailed explanations, rules are broken. This type of narrative requires the use of many strategies and processes, including:

strategies for organization/connection of thoughts and ideas,

selection of appropriate items to include or exclude,

word retrieval,

word order,

deductive and abstract thinking,

drawing conclusions.

These processes are integrated in a new manner for each narrative. (Hagan and colleagues, 1979; Malkmus and colleagues, 1980; Becker, 1984).

"Disorganization and lack of specificity in meaning are frequently the result of a combination of inattentiveness to the communication act and its parameters, a lack of attention to feedback given by the listener, and word retrieval problems. Prigatano and colleagues (1986) stated that the repetitions and revisions within messages actually serve to clarify the message for the speaker, not the listener. The verbalization of a message assists in focusing or structuring the speaker’s own thoughts. Thus the speaker is attempting to compensate for his or her disorganization by imposing a self-generated strategy, similar to the use of echolalic speech in individuals who experience delays in processing." (Kennedy and Deruyter, 1991)

Kennedy and Deruyter (1991) describe five pragmatic (i.e. how the patient uses language in context) disturbances to expressive language:

disorganization of the message

impaired message selection and modification

incomplete messages or absence of detail

excessive information included in the message

disruption of paralinguistic features (e.g. intonation, facial expression, gesture, proxemics, eye contact)

Others have also documented pragmatic disturbances such as the use of irrelevant information [due to selective filtering] (Geschwind, 1964), non-aphasic disturbances of disorganization, vague terminology, rambling (Levin and colleagues, 1981; Holland, 1982) and excessive detail or excessive talking (Holland, 1982).

According to Prigatano and colleagues, 1986, communication can be tangential as a result of a lack of integration of many processes. For example, retrieval of words and word order, connection/organization of thoughts and ideas and abstract thinking.

II. Objective Findings on Standardized Tests

The clients who fit the description in the preceding section usually present with functional expressive language skills. Frequently, performance on some standardized tests will appear adequate because of the insensitivity of such evaluation methods to pragmatic disturbances. Therefore these problems can be overlooked and not identified in formal reporting.

The battery that I use for pre- and post-testing of word retrieval/fluency deficits in patients treated through our therapy program is as follows:

Woodcock Language Proficiency Battery: Picture Vocabulary

Expressive Vocabulary Test

Peabody Picture Vocabulary Test

The FAS

An analog scale measuring the client’s self-rating of the impact of this problem (a copy is provided at the end of this book)

The scores on these standardized tests will often be significantly lower than the scores on tests for other areas of expressive and receptive language skills. However, even if the scores fall within the range of normal, frequently the pattern of scores is revealing.

III. The Task of Formulating Definitions

The ability to define words with precision and clarity is important for effective spoken and written communication. Speakers must be able to articulate the meanings of key terms to avoid misunderstandings and to resolve conflicts. Successful word definition requires an understanding of words and the ability to express that knowledge unambiguously – a combination of cognitive, linguistic and meta-linguistic competencies (Nippold, Hegel, Sohlberg, Schwarz, 1999).

IV. How to Use This Program: A Quick Overview

The What I mean is… program works on the principle of doing a repetitive task (i.e. the defining meaning task) over a large volume of targets. During this immersion, clients frequently report that they are beginning to think more about what they are saying and starting to think more about their listener’s perspective.

Section 1 gives the client practice with category naming. Naming the best category is integral to the definition task in Section 2. For lower level patients, the therapist may need to do even more preliminary work on categories like category naming for groups of 4, 3 then 2 words, adding members to a category and/or listing members within categories. These exercises are readily available in many therapy workbooks.

Section 2 teaches the definition task and will be applied to a large volume of words. Section 3 introduces another important strategy for explaining meaning which is using synonyms and synonymous phrases. This method is often easier for explaining meaning of verbs (action words) and modifying words (adjectives and adverbs). Section 4 continues the explaining meaning task to homonyms. Homonyms are words that have more than one meaning. If the client is having difficulty with the multiple meaning task (which relies heavily on flexibility of thinking), switch to the lexically ambiguous sentences in Section 5. In this section the homonyms have the added contextual information of the sentence they are