Episode #73: Promoting Conversation and Positive Communication Culture: In Conversation with Marion Leaman

Aphasia Access Conversations

Ellen Bernstein-Ellis, Co-Director of the Aphasia Treatment Program at Cal State East Bay, speaks with Dr. Marion Leaman about how personal experience of social isolation during COVID might be leveraged as a catalyst for change in how we provide services in long term care settings. They also discuss Dr. Leaman's work on promoting the value of conversation as a clinical goal across the continuum of severity in aphasia.

Marion Leaman, recipient of a 2021 Tavistock Trust for Aphasia Distinguished Scholar, is an assistant professor at the University of Kansas Medical Center, where she is the director of the ALL-CAN-Converse Lab. she conducts research focused on aphasia intervention that has the goal to improve real world everyday conversation for people with aphasia and their families. Before returning to school in 2015 for her PhD, Marion had practiced as a speech-language pathologist specializing in aphasia for 22 years.

Listener Take-aways

In today’s episode you will:

• Learn how experience of social isolation during Covid can help SLPs personalize their communication partner training in SNF settings
• Hear about individual and system changes that can contribute to creating a more positive communication culture in SNF settings
• Learn how conversation can be a viable and important clinical goal across the continuum of aphasia severity
• Hear about the search for clinical tools to help SLPs reliably and meaningfully measure conversation

Show notes edited for conciseness

Ellen Bernstein-Ellis (interviewer):

Welcome to the Aphasia Access Aphasia Conversations podcast. Welcome to the episode Marion.

Guest: Marion Leaman

Thank you. Hello, It’s so nice to be here.

Well, congratulations again on being selected as one of the 2021 Tavistock Trust for Aphasia Distinguished Scholars this year. It was exciting to have that announced at the Clinical Aphasiology Conference. And it's early in your award. But what do you see as the benefits of being a Tavistock scholar?

Marion Leaman: It's been really terrific so far, and I could not be more honored for this recognition. I'll say even in this short time since May, the Tavistock Scholar Award has given me so many opportunities to talk with more clinicians, researchers and even people outside the field--personal friends, other people in other disciplines at my university, to explain to them why therapy that addresses everyday conversation for people with aphasia is so urgent.

We're going to be exploring that more today. It's going to be a wonderful conversation about conversation. I'd like to start with asking you if you have a favorite clinical experience, that points to the value of incorporating life participation approach to aphasia, or LPAAA, into your clinical work?

Marion Leaman: I actually have two small stories that I would really love to share with you. So we often hear about big and exciting LPAA experiences, but I want to highlight how small LPAA moments can also have big therapeutic impact. These two people whose stories I'm going to share, we're each living in different skilled nursing facilities. They each had nonfluent aphasia, which was quite severe. They had each been labeled as noncompliant because after working with their SLPs for several sessions, they refuse to allow their SLPs back in their rooms and SLP services were then discontinued. Importantly, these people were at different facilities with different SLPs and none of these people knew each other.

So the first person had global aphasia, and he loved following the stock market. So in my best LPAA clinician mode, I thought I was very clever, and I made laminated logos of his favorite stocks. For our first session, when I proudly showed them to him, he pushed them aside and took out the box where he kept his hearing aids. Just then, I heard his wife sigh in the background. She verbally and with frustration told me that he kept taking out those hearing aids, and that she and the nurse had to keep putting them away to redirect his attention to physical therapy, or tasks like dressing and grooming. She was angry that he, once again, was noncompliant with speech therapy when he pushed away my materials. She commented with annoyance that she changed the batteries the day before when he was sleeping. I signaled to her to not say anything more just then and to let me interact and communicate with her husband regarding his concerns. I followed his lead and trained my attention on his hearing aids engaging intensely and trying to understand what he wanted to tell me in that very moment. And in this highly nonverbal conversation, which took a good 10 minutes or so, he communicated to me that he wanted more than anything else that day, to have the batteries of his hearing aids changed. So we changed the hearing aid batteries.

The second person's story that I want to share with you she had severe transcortical motor aphasia. At my first visit, she allowed me to administer some formal and informal testing. But when I came back, she began wheeling herself out of the room in her wheelchair the instant she saw me. But, she gazed over at me and gestured to me to come with her. I followed her lead, leaving my well planned out therapy materials behind. She wanted me to push her wheelchair around the facility, visiting the garden, the patio, the music room, the cafe. While we did this, we conversed verbally and non-verbally about the locations and activities. I shared some of my interest in music and she gestured to me that she was a cellist. And in fact, she was an accomplished professional cellist, which I had not known until that moment.

So I want to share with you that neither of these individuals ever refused speech therapy again. This was not in any way something special or unique about me. This happened because with each of them, I demonstrated through my behavior that I was engaged and interested communication partner who valued what they wanted to do and say that day, how they wanted to participate in their own therapy, and in their own lives. I'll also add that the man's wife, and later the woman's family, in observing my engaged behaviors that supported participation and real world conversational desires, immediately changed their behaviors as well. Each of these families adopted approaches that valued the individual, communication, and importantly, that provided each person with opportunities for directing their own participation,

Marion, those are really powerful stories. And for me, it really harkens back to what has been transformative to me as a clinician---thinking about the work focused on relationship-centered care, which seems like a high value for you. I refer our listeners to some of the wonderful work done by Felicity Bright in this area. I know there's an article by Worrall and colleagues in 2010, and a recent one in 2020 by Cohen-Schneider, Chan and McCall, that focus on the value and critical importance of relationship-centered care. So thank you for sharing that.

Before we explore your passion for starting conversation treatment. I want to share a quote from a recent impactful article in AJSLP that you co-authored with Jamie Azios, exploring how our personal experience with COVID-related social isolation might help us to promote change in long term care settings. You say, “We now have an audience with direct personal experiences of social distancing and the harmful feelings associated with being excluded from everyday interactions. Therefore, the time is ripe to overcome barriers to culture change and increase the value of communication and social inclusion in long term care.” That's on page 321 of your article that you co-authored with Jamie. I found that really powerful. What do we know about the negative consequences of social isolation?

Marion Leaman: Yeah, that's a great question, because there are really some very significant consequences when people are socially isolated. So this includes things like depression and other mental health concerns that can also be related to reduced communication opportunities and communication. But there even can be very significant medical consequences, such as increased risk of heart disease, diabetes, and even death.

Your article lays out some of these factors. You refer your readers to the Aphasia Access White Paper authored by Nina Simmons-Mackie that does a beautiful job of laying out some of the consequences of social isolation. In your article, you mentioned the work by Page and colleagues that highlights the benefits of a Communication Training Plan that can assist staff in completing their patient ADLs in less time and with improved caregiver or resident relationships--going back to that relationship-centered care again. Can you describe this tool for our listeners?

Marion Leaman: Sure, absolutely. Page, along with several colleagues extended the idea of using a written communication plan for optimizing communication between CNAs and residents of skilled nursing facilities that had originally been innovated by Généreux and colleagues. The plan includes things such as how the person communicates, how to communicate with the person, the person's habits, and their behaviors. But key to Pages work with these communication plans, was adding a residence life section to the plan and including brief and regular hands on training in the room with the CNA and the resident, in little five or 10 minutes spurts. And most importantly, in my mind, taking an approach that highly values the insight, expertise and experience of the CNA, so that the SLP and CNA would collaboratively develop the plan together.

Wow, that’s really a great example. It reminds me that to improve communication culture in long term care, it's going to require both individual and system level changes. The system level changes are something that Aura Kagan is always reminding us of-- that we have to look at this broader piece. You and Jamie Azios lay out an action plan. What are some of the things that SLPs can do to take immediate action?

Marion Leaman: So first and foremost, I think something that we can do that's easy and very important, is to consistently model Person-Centered or LPAA interactions by being interested and engaged with our residents in skilled nursing facilities during our own physical care routines that we have to do as SLP. For example, if you're readying a lunch tray for a bedside swallow evaluation, there's no reason that we can't engage the individual on a really personal level by asking about food preferences, or even sharing of ourselves in small comments, like “my dad used to make the worst meatloaf”, because it engages the person and lets them know us as individuals and opens the door for that person to also share related kinds of stories.

So again, even if you're connecting over meatloaf, sometimes that's just so valuable.

Marion Leaman: I know. Well, and you laughed, right? We just had a connection over meatloaf, fictitious meatloaf.

How about an example of near term action?

Marion Leaman: Moving out a little bit on the trajectory, I think about the closest people we can train and get on board with this is likely PTs and OTS and our own Director of Rehab who are likely going to value communication and how that impacts the person's interactions on an everyday basis. So we can just start really close to home by doing a little bit of training with PT and OT, and that can go a long way.

That leads us to what long term action might look like?

Marion Leaman: So for long term action, we really want to start advocating at an administrative level, to be given a little bit of time, it doesn't even have to be a lot of time, to begin training facility wide staff. And when I talk about facility wide, I'm including everybody who interacts with that patient. So it can include housekeeping staff, secretarial staff, everybody can make a difference in the lives of the people who are residents in the skilled nursing facility.

Marion, you also emphasize both the importance of interprofessional practice in improving communication culture, and the role of the SLP in incorporating experiential learning about social isolation into their communication partner training. Can you give an example of how you might do this?

Marion Leaman: Sure, experiential learning is really based on the premise that when we experience something firsthand, we better learn the information and can better apply it throughout our lives. So the idea in this paper was that many of us now have experienced social isolation at a level that's never been seen before. So if we have staff, even in a brief 20 minute training, reflect on their own experiences of isolation during the COVID pandemic, and what that felt like--why it was hard, and then supporting those staff people to connect these personal feelings of social isolation to the experiences of social isolation experienced by people in skilled nursing facilities who have communication disorders. This can open the door for more empathy and understanding and help all of the staff understand the critical importance of learning how to create social connections for the residents.

Thank you, I was so really impressed with that article, the reference will be in our show notes for our listeners. Thank you for sharing that with us.

I really want to shift now to your work that explores the value of conversation as a clinical goal. In fact, when we were preparing where we would head with this interview, you told me, “Conversation, that's what I'm all about.” How do you connect this to a Life Participation framework?

Marion Leaman: How is conversation anything but a life participation framework? It's the primary way that every single one of us participates with other people in our everyday lives all day, every day. In my mind, it's absolutely critical to our lives. It's essential to participate in connecting with others. I always try to remember that I need to share that my concept of conversation is perhaps a little bit broader than that of other people. I want to remark that conversation for me is all of the communication and interaction that occur between two people, and it doesn't depend on language at all, as you could even see in the story I told about the gentleman with the hearing aids, that was really a nonverbal conversation.

In talking about conversation and how we may take what we understand about that for granted. We may not be as aware of all the factors that are involved with it. You shared with me a story about one of the first graduate students you supervised as a clinical instructor. Could you share the question he asked you before starting his therapy session? I think it's really illustrative.

Marion Leaman: Yeah, well, this is one that stuck with me for about 12 or 14 years at this point. But I had this absolutely terrific student. He was enthusiastic and nervous about his first session with a client in our university clinic. And this gentleman happened to have a very severe nonfluent aphasia. I shared my approach with the student for using conversation as a medium of therapy. I just have never forgotten this question he asked right before he entered the session. He said to me, “How do you have a conversation with someone who can't talk? And I thought it was a great question. But honestly, it had never even occurred to me before, which is probably why I've remembered at all these years, because I have conversations with people who can't talk all the time. And his question reminded me of the need to be explicit when talking about conversation, to make it clear that conversation encompasses and occurs through many different and complementary nonverbal and verbal channels.

You explained that you had originally planned to do your doctoral research on conversation therapy, something that you've really embraced and pursued across the years, but you had to make a really hard decision to select another starting point, what did you decide had to come first, and why?

Marion Leaman: So throughout my more than 20 years of practice, people with aphasia have taught me how to deliver therapy through conversation. As a clinician, I learned that such an intervention can drive change in many aspects of communication, including language production. But what I realized really quickly when I began my PhD, is that to demonstrate these changes, we need reliable and stable measures of language and conversation,

Marion, since we want to put success in conversation as a high clinical value across all aphasia severity levels, tell us a little bit about how we currently assess conversation.

Marion Leaman: So when I started my PhD, we already had some really nice strong measures of participation, and ways to measure patient reported outcomes, and we could also measure efficacy of strategy use. But at that time, there were no measures of language production in conversation. Instead, typically, when we measure language at a discourse level, we tend to use a picture description tasks such as the Western Aphasia Battery picnic scene.

However, those kinds of tasks are really quite different than conversation and so they may not provide the information we need that's specific to what's actually going on in conversation for people with aphasia. When I began my PhD, there was no possible way to demonstrate that any intervention, either the one I had in mind or any other intervention would have impact on language production in conversation. I set out to determine if measuring language and conversation was even feasible, so that we could show real world impact of our current and future interventions on conversation because it's usually the desired outcome for most people. As it turned out, of course, that first year PhD project was much larger than I'd expected. I ended up spending the last six years developing language measures for conversation.

In searching for tools that allowed you to measure conversation in life participation contexts, you develop the Social Conversation Collection Protocol, which I think you call the SCCP. Do you want to describe this for the listeners?

Marion Leaman: One of the challenges with measuring what happens in real world conversation is that anything can happen. Further complicating things, there are all different kinds of interactions that get described as conversation. For instance, there are interviews, there are conversations where the topic is already pre-determined and there are spontaneous social conversations, just to name a few. The problem with all of this is that the language behavior and interaction are very likely to be restricted or encouraged in different ways in these different subtypes of conversations. Because my interest was in measuring language in unstructured social conversations, I developed this Social Conversation Collection Protocol as a way to optimize the likelihood that all of the conversation samples used for assessment purposes would have this in common. I developed this protocol using what we know about how adults interact with each other in social conversations, largely coming out of the conversation analysis literature in people without aphasia. As I start to talk about this protocol, I'd be absolutely remiss not to mention the contributions to my thinking about this that came from my PhD mentor, Lisa Edmonds, and from my dissertation committee member and mentor, Julie Hengst, that have been really important for developing this protocol.

Marion, let me just jump in briefly. When we were preparing for this last week, you mentioned there was another mentor that really had impactful influence on your thinking about this. Do you want to mention one more person?

Marion Leaman: Absolutely. I need to give a shout out to Gloria Olness, who has been a tremendous and generous mentor to me since the day I met her in 2017. She's contributed to so much of my thinking, most especially about the importance of personal narrative in the therapeutic process and how we can support opportunities for storytelling in therapy. But that's a whole other subject I'd love to talk about one day.

Absolutely. Let’s get back then to the SCCP.

Marion Leaman: Some key features of the Social Conversation Collection Protocol are the very same kinds of features we find in conversations between adults without communication disorders. For instance, we know from Conversation Analysis that there is a preference for all of us to correct our own speaking errors. We don't go around correcting one another, typically. In this protocol, the person with aphasia is also given unpressured time to self-correct their errors. Likewise, adults don't instruct each other as to how to communicate, we all make those decisions for ourselves. So we don't instruct people how to communicate, whether they use writing or gestures or verbal. Likewise, adults don't cue each other, so we don't use cueing (in the protocol). Along with all of this, I want to be sure to highlight that the person with aphasia is given as much time as they need to communicate, just as adults without communication disorders tend to do what with one another, although delays for self-expression during communication are, of course, much, much shorter for people who don't have communication disorders. And so lastly, in social conversations, both people tend to share of themselves by telling little stories, and there's not usually a control of the topic or a controlled yes no question kind of format. So these are the kinds of characteristics we emulate in this Social Collection Protocol.

So when conversation is being assessed, as clinicians, we really want to be sure that our pre- and post-treatment conversations are as similar to one another in these ways as possible, even though the topics will differ because there are unstructured social conversations. So if we don't use a tool like the Social Conversation Collection Protocol, and instead base our assessments using conversations in which clinicians provide different amounts of cueing or supportive techniques, or in which the clinician controls the topic, asks a lot of closed ended questions, or conversely, engages in conversations in which the clinician only says yes or no, what we end up doing with all those different kinds of conversations, or conversation samples, is introducing a whole lot of potential variability to the sample that's actually really related to the behavior of the partner. And so this would make it potentially really difficult to compare one conversation to another.

Marion, you've published a series of articles based on this doctoral research. And there's another paper coming out in JSHR soon that you co-authored with Lisa Edmonds on assessing conversation, narrative, and aphasia. It offers a really careful description of the core measures that you use to analyze conversation. We're going to put the references all in the show notes.

Can you please briefly summarize a couple key outcomes of your doctoral research, and maybe even give a nod towards any surprises or disappointments, because that happens.

Marion Leaman: There's always a few of those in a dissertation. Using the SCCP that we just talked about to collect conversations, we found that language and conversation can indeed be measured. For most of the measures that we evaluated, there was good to excellent reliability and stability. Just to give a quick list of the kinds of measures we looked at, some of them were the complete utterance, correct information units, global coherence, communicative success, and grammaticality.

My surprise and disappointment was that one measure, a measure of referential cohesion, in other words, the ability to use pronouns accurately to specify nouns, really wasn't stable at all. And we found this across two different studies with two different sets of participants. As I spent time thinking more and more about this, my surprise did lesson, because using pronouns is actually a really interactional language structure. If the person with aphasia uses an empty pronoun, the way they often do, such as “it”, and the partner happens to provide a noun, suddenly the “it” is no longer empty.

So the measure of this pronoun usage was unstable for a number of reasons. But this really was one of them-- that some partners provided a lot of nouns to clarify the empty pronouns and others did not. And so that made the measure unstable. Fnding this finding actually really disappointed me quite a lot, as Lisa Edmonds can attest to. Although pronouns are seemingly a very small grammatical structure, and they might appear to be quite unimportant, my experience as a clinician doing a lot of conversationally focused therapy was that when people with aphasia use vague pronouns, it oftentimes can contribute to derailing the conversation significantly, especially if the person is trying to tell a story, or tell about something like their family history. I'd really hoped to find a way to measure this, so that when we address it in therapy, we can demonstrate change.

A positive aspect came out of this disappointment, however, and that was that we also collected data from people without aphasia, and we found that they very, very, very rarely ever make pronoun errors like this, it was something like three errors out of 2500 occurrences. It was like .003 or something. So we now have research that will be published in the article you mentioned, showing that these kinds of pronoun errors can warrant treatment if the person with aphasia wants to address that, because the errors do reflect the impact of aphasia, and they're not just part of a typical day to day fluctuation.

And then the other important finding I want to share with you, is that for the most of those measures that we looked at, the language that was produced in a story monologue using a picture book, so sort of like those picture descriptions we were talking about earlier, although I use picture books. So it was more complex. The measures were not highly correlated between the language in a picture task and the language in conversation.

That finding really suggested to me that if our interest is in changing language through therapy, as it's used in conversation, then what we really need to be doing for at least as part of our evaluation, is evaluating conversation. We really can't use proxies, such as structured picture monologue, to learn about all of the conversational treatment needs of people with aphasia. These kinds of picture tasks also can't be assumed to capture post-treatment change or gains that may be occurring in conversation, because the kind of language that's used in conversation, for most measures, is not similar to the kind of language used in at least that picture story tasks that we evaluated. Those are two brief findings, but they were long.

I think you did a phenomenal job of trying to cover six years of research in this short response. But I just want to comment that it seems to me that it proves that your decision to study these measures first, instead of doing what you want it to do, really paid off, because it's going to hopefully impact some of the tools and some of the ways we think about measuring conversation and outcomes that are meaningful for our clients. I really thank you for digging in like that, and trying to explore and establish these base measures. So really meaningful work, Marion, thank you.

Marion Leaman: Thank you. I really appreciate it. And I really did think I was going to finish it in about six months.

As we wrap up this conversation, do you want to give a brief description of Conversation Therapy? I know, that's your next piece of research.

Marion Leaman: I'm really, as you could imagine, very excited, I'm just getting this under way, actually. I have my first participant coming in less than two weeks for the Conversation Therapy. It makes use of spontaneous conversational interactions, using many of the principles of that Social Conversation Collection Protocol that we talked about in detail today, as well as some techniques for repair, that optimize independent self-expression for the person with aphasia. So not over helping them. We really believe that this kind of therapeutic self-repair, when those moments happen, word retrieval difficulty, can be really helpful for people and have some generalization, hopefully, come out of that.

So we'll look forward to that. And maybe in a future podcast, a follow-up on that research.

Marion Leaman: Hopefully, it won't be six years from now.

Absolutely. You've done the hard work of establishing your measures. Hopefully, this next chunk will be even more fun. Marion, I'm going to just close the interview today, not only thanking you, because I so appreciate this conversation, but I'm wondering if you could just reflect on if you had to pick just one thing that we need to achieve urgently as a community of providers, professionals, life participation practitioners, what would what would that one thing be?

Marion Leaman That's a hard question. So for me, I really passionately believe that we quite urgently, every single one of us as speech pathologists and researchers and clinicians, need to ensure that the interventions that we're choosing to deliver, meet the real world communication needs of the person. And that conversation moves from around the edges of intervention to front and center. And I always think of a quote from Audrey Holland that was so eloquently stated in one of her journal articles about 25 years ago, was that conversation is not something we do before or after therapy. Conversation is the very reason for therapy.

Thank you. Well, you quoted one of my favorite mentors.

Marion Leaman: And mine too.

Absolutely great way to close this wonderful interview and conversation about conversation, Marion. Thank you again for being our guest for this podcast.

Marion Leaman: Thank you so much. And thank you for inviting me here. It's wonderful to have the opportunity to share some of these ideas in my research with you and with the audience at large. I really appreciate it.

Absolutely. It was our pleasure, my pleasure. For more information on Aphasia Access, and to access our growing library of materials, go to www.aphasia access.org and if you have an idea for a future Podcast Series topic, email us at [e-mail] and thanks again for your ongoing support of Aphasia Access.

On behalf of Aphasia Access, we thank you for listening to this episode of The Aphasia Access Aphasia Conversations podcast. For more information on Aphasia Access, and to access our growing library of materials, go to www dot aphasia access.org. If you have an idea for a future podcast series or topic, email us at info at aphasia access.org. Thanks again for your ongoing support of Aphasia Access.

References and Resources

Généreux, S., Julien, M., Larfeuil, C., Lavoie, V., Soucy, O., & Le Dorze, G. (2004). Using communication plans to facilitate interactions with communication-impaired persons residing in long-term care institutions. Aphasiology, 18(12), 1161-1175.

Leaman, M. C. (2020). Establishing Psychometrically-Sound Measures of Linguistic Skills in People With and Without Aphasia During Unstructured Conversation and Structured Narrative Monologue (Doctoral dissertation, Teachers College, Columbia University).

Leaman, M. C., & Azios, J. H. (2021). Experiences of social distancing during coronavirus disease 2019 as a catalyst for changing long-term care culture. American Journal of Speech-Language Pathology, 30(1), 318-323. https://pubs.asha.org/doi/pdf/10.1044/2020_AJSLP-20-00176

Leaman, M. C., & Edmonds, L. A. (2021). Measuring global coherence in people with aphasia during unstructured conversation. American journal of speech-language pathology, 30(1S), 359-375.

Leaman, M. C., & Edmonds, L. A. (2020). “By the way”… How people with aphasia and their communication partners initiate new topics of conversation. American journal of speech-language pathology, 29(1S), 375-392.

Leaman, M. C., & Edmonds, L. A. (2019). Revisiting the Correct Information Unit: Measuring informativeness in unstructured conversations in people with aphasia. American journal of speech-language pathology, 28(3), 1099-1114.

Leaman, M. C., & Edmonds, L. A. (2019). Linguistic measures of conversation in aphasia: The Global Coherence Scale and The Complete Utterance. In Poster presentation at the Clinical Aphasiology Conference, Whitefish, Montana.

Leaman, M. C., & Edmonds, L. A. (2018) Measuring Informativeness in Conversation Using Correct Information Units (CIUs) in People with Aphasia. In Poster presentation at the Academy of Aphasia Conference, Montreal, QC.

Page, C. G., Marshall, R. C., Howell, D., & Rowles, G. D. (2018). Use of communication plans by certified nursing assistants: Little things mean a lot. Aphasiology, 32(5), 559-577.

Simmons-Mackie, N. (2018). Aphasia in North America: A white paper. Archives of Physical Medicine and Rehabilitation, 99(10), E117. https://doi.org/10.1016/j.apmr.2018.07.417

Simmons-Mackie, N., & Cherney, L. R. (2018). Aphasia in North America: highlights of a white paper. Archives of Physical Medicine and Rehabilitation, 99(10), e117.