This article was downloaded by: [University of Cambridge]On: 09 October 2014, At: 16:27Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

AphasiologyPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/paph20

Diversity in aphasiology: Crisis orincreasing competence?Brain Petheram a b & Susie Parr ca Frenchay Hospital , Bristol, UKb University of the West of England , Bristol, UKc City University , London, UKPublished online: 29 May 2007.

To cite this article: Brain Petheram & Susie Parr (1998) Diversity in aphasiology: Crisis orincreasing competence?, Aphasiology, 12:6, 435-447, DOI: 10.1080/02687039808249542

To link to this article: http://dx.doi.org/10.1080/02687039808249542

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information(the “Content”) contained in the publications on our platform. However, Taylor& Francis, our agents, and our licensors make no representations or warrantieswhatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions andviews of the authors, and are not the views of or endorsed by Taylor & Francis. Theaccuracy of the Content should not be relied upon and should be independentlyverified with primary sources of information. Taylor and Francis shall not be liablefor any losses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly or indirectly inconnection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden.Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

APHASIOLOGY, 1998, VOL. 12, NO. 6,4355487

Clinical Forum

Diversity in aphasiology : crisis or increasing competence ?

B R I A N P E T H E R A M t S and S U S I E PARRS t Frenchay Hospital, Bristol, UK $ University of the West of England, Bristol, UK §City University, London, UK

Aphasia the ‘fashion victim’

In a recent discussion of developments within the discipline of aphasiology, aphasia was described as a fashion victim, prey to ever-changing vogues in the analysis of language impairment (Parr e t al. 1995). Such a term suggests the eclecticism of the discipline but does not convey the richness and diversity of approaches to the analysis of aphasia which have built up over decades of study and clinical work. Howard and Hatfield (1987) have reviewed a number of approaches in terms of ‘schools ’ whose concerns seem sometimes conflicting and sometimes comp- lementary. In general, they are based on widely varying constructions of aphasia, which inform not only therapy but assessment and research. Practitioners will be familiar with the schools reviewed, and the different representations of aphasia upon which they are based. They include the ‘stimulation school’, pioneered by Schuell (1965) which represents aphasia as a unitary disorder varying only in severity and types of sensory-motor impairment and the ‘ neo-classical school ’, concerned with the relationship between linguistic deficits and specific, neuro- logically-located lesions (Goodglass and Kaplan 1972). In contrast, advocates of the ‘functional school’ argue for a focus on real-life use of language and communicative effectiveness in aphasia (Holland 1980). More recent developments within the discipline include the use of information processing models to pinpoint language breakdown (Byng e t al. 1990); the use of methods pioneered in conversation analysis, to assist analysis of aphasic interactions (Lesser and Milroy 1993), and approaches which go beyond the functional and psychosocial concerns in finding ways to support aphasic communication (Kagan and Gailey 1993, Lyon 1996).

Contributions from practitioners and researchers in other fields, including psychology, linguistics, neurology, systems science and psychotherapy, have continued to enrich and diversify the study of aphasia. But relationships between the various approaches are not always harmonious. The practitioner may be stimulated by the diversity, but may also become bemused by the apparently conflicting views of the treatment and assessment process, whether they are explicitly expressed or not. In terms of the therapeutic endeavour, the clinician may feel overwhelmed by choice and unable to select and combine approaches in a useful way. Indeed, the positive aspects of theoretical diversity may become

026&7038/98 $1200 0 1998 Taylor & Francis Ltd

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

436 Ciinicai Forum

obscured, as a question addressed by a recent ASHA Clinical Consult indicates : ‘How can all this theory be useful for treatment?’ (Albyn Davies 1994).

In terms of policy, the very diversity of constructions of aphasia bedevils those whose job it is to measure and account for therapy services. Frattali (1992) describes the increasing pressures of accounting to those who commission therapy services and who wish to base decisions on evidence that therapy works in functional terms. Focusing on functional measures, she argues that such pressure reveals a fundamental and damaging theoretical incoherence.

This paper discusses the discipline of aphasiology in terms of these internal tensions and the external pressures. It explores some of the damaging consequences as well as the potential of diversity, and traces the philosophical roots of different approaches. This paper will argue that, by making explicit the beliefs which underlie various approaches, diversity within the discipline can be properly understood and creatively used. The contribution of similar debates made within other disciplines is examined, and the necessity for an explicit, over-arching and unifying framework is argued.

Internal pressures

Internal pressures have resulted in tension between interests and approaches to assessment and therapy. This is evident, for example, as cognitive neuropsychology rubs shoulders with more traditional, less empirical clinical procedures, and as the move towards empowerment causes therapists to question the motives and practices of rehabilitation, in line with work in other related disciplines (French 1994).

Those who have followed debates in the Clinical Forum section of the journal Aphasiology will be aware that relationships between and within schools, both new and old, and not always harmonious. Thus, Sacchett and Marshall (1992) challenge the usefulness and validity of the traditionally functional approach to therapy and put forward a cogent argument for the functional gains which can be made following therapy based on cognitive neuropsychological principles. Some virulent responses to Byng et ai.’s (1990) apologia for cognitive neuropsychology by those with more locationalist and generalist orientation must make that exchange one of the land-marks of debate within the discipline. In more recent debates, champions of the cognitive neuropsychological and grammatical analysis of aphasic language pit themselves against a proponent of more ‘holistic’ accounts of interaction breakdown (Bastiaanse and Prins 1994, Garman, 1994, Leiwo 1994). Similarly, a theoretical reappraisal of the therapeutic approach to literacy disability in aphasia is bracketed with much earlier, and quite different, arguments supporting a functional approach (Parr 1996).

Not all commentators contribute to the conflicts and tensions. In a move towards theoretical cohesion, David (1990) suggests that the World Health Organisation framework of impairment, disability and handicap may enable disparities of interest to be unified. Lesser and Milroy (1993) suggest ways in which seemingly diverse approaches can usefully co-exist. Indeed, Byng e t a/ . (1990) describe cognitive neuropsychology as one of a range of approaches which may be adopted by the practitioner, and which does not necessarily preclude others. The therapeutic endeavour can therefore be seen to involve the selection of and combination of a number of therapies from a ‘portfolio’ or ‘toolbox’.

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

Clinical Fortlm 437

External pressures

Clinical aphasiologists are finding themselves under increasing pressure to account, in straightforward and quantifiable terms, for what they do. This can lead to the devaluing of therapeutic practices which are difficult to measure. Holland and Beeson (1993) comment that practitioners in the US have been ‘influenced to believe that there is something essentially wrong in taking time out from therapy to interact with patients on a more personal level’. They attribute this phenomenon to the demands of third party reimbursement practices which have a low tolerance of some less quantifiable clinical practices such as the exploration of the clients’ feelings. In the UK, external pressures include perceived threats to quality and equity of service as a result of health service changes (Jordan 1991).

The tendency toward enhanced quantification is also evident as a result of the demands of the medical marketplace, for example in the purchasing of therapy which will have measurable functional outcomes (Frattali 1992). Purchasers of therapy services themselves expect guidelines which will ‘indicate simple, manageable achievable and realistic targets ’ (North Western Regional Health Authority 1995). If the therapy process is not to be limited to a subset of what is currently practised, ways of evaluating the full range of processes involved in the therapeutic endeavour will need to be developed. If these measures are to be acceptable to third parties, they will need to be supported by the profession as a whole. A culture of mutual respect within the profession for the full range of approaches will enable a more united and effective response to third party pressures. However it is argued that a false consensus driven by a fear of sanctions is not a healthy or desirable state for the profession. This paper seeks to stimulate a constructive debate which will foster increased mutual respect amongst the proponents of the various approaches to therapy, and a more unified framework for the discipline.

Whilst the trend towards clarity of outcome and clinical accountability is to be welcomed, it seems difficult to streamline a complex discipline such as aphasiology which has developed over many decades of study and clinical practice. But those coming to aphasiology from outside the discipline, those who are entering it as aspiring clinicians and those who are commissioning and managing aphasia therapy services need to be able to accommodate the considerable range and complexity of the subject and to communicate in terms which are broadly agreed and understood. This study agrees with Worrall(l992) that the development of a broadly-agreed framework for research, therapy and evaluation is not simply an academic concern. She suggests that theoretical incoherence and fragmentation may plunge clinical practice into a state of crisis:

If the discipline of aphasiology does not decide soon on how communication should be measured, it will be decided for us. The end result may be that few if any speech pathologists may be around in the 21st century to provide any service to aphasic clients (Worrall 1992, p. 11).

However, the concerns discussed above are by no means unique to aphasiology. Indeed they can be seen as characteristic of many fields of study in the late 20th century. In considering the nature of similar ‘crisis states ’ reached within analogous disciplines, and how these have been addressed, it may be possible to extract some useful guidelines for aphasiology. This paper seeks to learn from the experiences in another field, that of Information Systems, and to apply concepts developed there

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

438 Clinical Forum

to aphasiology. This is seen as reasonable because whilst the concerns of the disciplines are very different, there are sufficient fundamental structural similarities to make the attempt worthwhile. Both are ‘applied’ rather than ‘pure’ sciences; that is to say their main focus can be seen as supporting effective intervention in problem situations involving people, rather than the discovery of objective truths in the manner of chemistry, physics, or astronomy. Both are also characterized by a range of approaches which differ in their approach to the field of study at the fundamental levels of ontology and epistemology. Ontology in this context is concerned with the nature of the subject and what falls within its boundaries; and epistemology with what constitutes a legitimate intervention or counts as an increase in knowledge. These issues are discussed in more depth below.

1:

Aphasiology as a discipline

A clinical profession is often preoccupied with dispensing and absorbing information about the pathologies encountered and approaches to them which are going to be useful in practical terms. Time spent considering the philosophical bases of the profession may be considered wasted. Such reflection may be viewed as adding nothing to the accumulation of professional skills. Yet a consideration of the philosophical bases of research, as in Eastwood’s (1988) discussion of qualitative methodology in speech and language therapy, has direct practical application. Alternatives to quantitative methods are, it is suggested, possibly more appropriate to the exploration of a process which is partly linguistic and cognitive and partly social. However, such debates range beyond practical applications of more sensitive research methods. They imply the need for a reappraisal of the very philosophical foundations of the profession. These can be realized in terms of two questions. First, what kind of discipline is aphasiology ; and, secondly, what are its legitimate concerns and objectives? For the purposes of this discussion one would define ‘discipline’ as the body of knowledge which supports the practice of a profession.

There has been much discussion and debate in the professional literature about whether speech pathology (which we may take to include aphasiology) is a fully fledged ‘science’. Established definitions of what constitutes a science have been invoked and the current state of the art compared to these standards. Thus, Ringel et al. (1984) characterize the established sciences, such as physics and biology as having a:

central fore of conceptions about its discipline and each possesses unifying paradigms that control the direction of work and impose, in very broad terms, conceptual constraints on the field.

They go on to conclude that: the human communication sciences have not thus far developed any unifying, integrating or dominating paradigms that encompass the whole range of investigations being carried on under their rubric.

Siege1 and Ingham (1987) set out to further the discussion by arguing that communication sciences are part of a group that ‘might very well be exempt from the requirement of paradigm status ’ since they have more in common with ‘ fields such as medicine, technology, and law, which are organized in response to a social need’. They go on to conclude that ‘we are part of a community of scientists, in particular the behavioural sciences’. In response, Bench (1989) points out that

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

Clinical Fomm 439

‘ communication disorders places considerable emphasis on the biological sciences of physiology, anatomy, neurology ’ and that behavioural science itself fails most of the accepted tests of a science-imprecise concepts, lack of unifying theory, low replication of findings, dispute over constructs, and positing of unobservable variables. He concludes that ‘the prospect of a unifying theory for communication disorders seems as remote as it is for behavioural science’. Rutting e t al. (1989) argue for the acceptance of a broad basis for clinical practice :

science is a multifaceted enterprise involving many hammers chipping away at the ontological stone. Conceptual and methodological diversity characterises the scientific enterprise.

It would be understandable if many practising members of the profession regarded such debates as rarefied ‘logic chopping’ which has little relevance to the practice of aphasia therapy. However the nature and structure of the body of knowledge on whtch intervention is based has very direct implications. This is because it determines not only what is a legitimate object of study but also what is excluded and thus not studied and developed. If there is no broad consensus about the knowledge base of a field of study, there is a danger of dogmatic disputes about the legitimacy of the aims or methods of a given study rather than its potential usefulness. This is not intended as an argument for an ‘anything goes’ approach to research, or an excuse for studies with poorly designed methodologies. Rather, it arises from concern at the amount of scarce research energy and publication space which is taken up with criticisms of particular studies which can be seen to be rooted in deep seated disagreements about philosophy. One argues that there is a need for proponents to be more explicit at the level of ontology, what they take the nature of the endeavour to be. Only from this basis can meaningful discussion of epistemological and methodological issues be conducted. It is to be hoped that surfacing these issues will lead to more respect for the range of theoretical positions and thus a move to a more constructive, if no less rigorous critique.

In this paper it is argued that the internal dissension apparent in aphasiology can be resolved in ways that not only avoid the fragmentation into different ‘camps ’, but also offer a more effective basis for meeting external challenges. Aphasiology encompasses a wide range of activities including specific therapy focused on the impairment itself; work with aphasic people on the development of strategies to minimize the communicative limitations, and assistance in coping with the psychosocial impacts of the impairment. The nature of acquired aphasia is such that for the foreseeable future there is no likelihood of a ‘cure’ for aphasia and thus it can be expected that aphasiology will continue to encompass this variety of concerns.

The authors regard the integration of these endeavours into a coherent discipline as one of the main challenges currently facing aphasiology. Such a discipline should support the coexistence of the various theories in a way that their relevance and contribution to the problem area can be established and they can be appropriately applied in practice. It should also support the evaluation of the outcomes of practice and thereby the propositions on which it is based. In an attempt to contribute to the cohesion of the field, this paper looks at ways in which another discipline has attempted to cope with these demands, and also draws on aspects of the philosophy of science.

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

440 Clinical Forum

Theory and meta-theory

There is a tendency to see the coexistence of differing theories and approaches as a ‘crisis’ and in some disciplines much energy has been devoted to argument and debate with the aim of determining a consensus around a particular methodology. Reflection at this level in another context (that of Systems Science applied to human organisations) has offered an alternative interpretation which sees the multiplicity of approaches in an applied discipline as being a sign of increasing competence rather than a crisis (Jackson 1991). It can be argued that those who seek to intervene effectively in real world situations involving human activity (such as organizational problem solving or, indeed, communication rehabilitation) will need access to a variety of methodologies to reflect the variety of situations with which the practitioner will be confronted. Given a recognition of the richness and variety of human life, any approach which purports to cope with all situations will either be so general as to be vacuous, or impossibly complex. Thus the emergence of a range of approaches is welcomed as increasing the likelihood of achieving a match between the intervention and the needs of particular situations. Jackson further argues tht this ‘ complementarist ’ (recognition of the complementary virtues of differing paradigms) approach is the most healthy for the development of applied disciplines.

He identifies three alternative structures which represent different responses to diversity. First, ‘isolationism’, in which the discipline consists of discrete groups of practitioners who each adhere to a single approach. Secondly, ‘imperialism’, in which a single approach becomes dominant and may subsume aspects of the former alternatives. Thirdly, ‘pragmatism’, in which the focus is on that which works in practice and no attention is paid to theory. It is possible to discern these structures in the significant debates within aphasiology which were described earlier. For example, some responses to Byng et d . ’ s (1990) discussion of the merits of cognitive neuropsychology denote an isolationist stance :

. . . present procedures go far towards meeting possible goals of assessment and therapy and the alternatives do not appear to be clinically viable. (Goodglass 1990, p. 95).

Instances of imperialist views also occur in the literature :

... treatment of pragmatic aspects of language should only be used in conjunction with a psycholinguistically orientated type of therapy ... such a therapy can only be effective when it is based on a detailed psycholinguistic analysis of the underlying cause(s) of the language disorder ... (Bastiaanse and Prins 1994).

Each of these three responses to diversity within a discipline have significant disadvantages. An isolationist discipline remains fragmented and the approaches are not able to learn from each other. In addition, much energy tends to be wasted on arguments which attempt to ‘prove’ that one approach is better than another. If an imperialist discipline evolves then new ideas tend to be evaluated in relation to the extent to which they are compatible with the dominant paradigm, which may stifle innovation. Those elements of other approaches which are subsumed may well be ‘denatured’ when divorced from their underpinnings and thus less effective. A purely pragmatic approach would lead to idiosyncratic practice and deny the opportunity of the transfer and development of learning and experience which a body of theory provides.

In Jackson’s terms a ‘ complementarist ’ discipline would include a range of

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

Clinical Forum 441

methods which might span more than one paradigm. These would be required both to address the different problem types encountered, and to meet the needs of multiple problems or issues within a single situation. This accords with rephrasing the question ‘does therapy work?’ to ‘what works for whom?’ (Wertz 1984). This makes heavy demands on practitioners not only due to the need to master a range of methods, but also to apply the most effective choice or mix of methods in particular circumstances. Jackson sees the latter as problematic and suggests that a complementarist discipline needs to develop a meta-theory which is concerned with supporting the analysis of problem situations and guiding the choice of method(s).

In aphasiology, such a meta-theory would consist of a coherent approach to assessment and treatment, which draws on different theoretical constructions of aphasia in accord with the perceived needs of the aphasic person. This is, indeed, what many therapists do already, but a meta-theory would offer a theoretical underpinning for this process. It would make the process of selection and combination of approach explicit, and directly link this process with definitions of clinical expertise. It would champion clinical diversity and offer a resistance to reductionist constructions of therapy. In relation to the problem of fragmentation within the discipline, an overarching meta-theory would offer a framework within which constructive debate could take place and would also present a more coherent image to those outside the profession.

There is evidence of movement towards this position. Code (1994) has proposed such a framework based on a metamodel of recovery in aphasia. This includes neural, cognitive, behavioural, and psychosocial/emotional aspects of recovery. He argues that ‘we need to examine the interactions between cognitive, communicative and psychosocial functions in individual patients ’. The emphasis on interactions between aspects of recovery supports the concern of this study about fragmentation within the discipline. The British Aphasiology Society document which offers advice to purchasers of aphasia therapy, states :

Aphasia rehabilitation is a complex, multi-faceted process which changes over time. (BAS 1992).

Following this statement, a number of aspects of aphasia therapy are listed. These include the lessening of linguistic disability, the development of alternative communication strategies, maximization of language use, facilitation of ad- justment, support for relatives and friends, education and information giving. Continuous assessment of communication skills and the communication en- vironment is needed for selection of appropriate measures. In this document, the British Aphasiology Society overtly resists pressures on the production of simplistic and reductionist measures of outcome and efficacy. It moves towards meta-theory in embracing complexity, within a clear and relatively simple framework.

The BAS taxonomy of aphasia rehabilitation maps closely onto the WHO categories of Impairment, Disability, Handicap, and Distress and onto other definitions of impairment and disability made by disabled people themselves (for example Finkelstein and French (1993) and the British Council of Disabled People, as discussed in French (1994)). It may be that such classification systems offer a suitable framework within which a meta theory could be developed. Such a framework would encompass theories about : the problems faced by aphasic people

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

442 Chical Forum

and the barriers surrounding them; the aims and rationale of treatment ; the strengths and weaknesses of the various methods ; and the assessment and evaluation of therapy. The construction of such a meta theory is beyond the scope of a single paper and is indeed an evolutionary process which must involve a wide cross section of the profession if it is to be a useful and relevant exercise. As a contribution to this process there follows a consideration of the implications of this broad view of aphasiology for the evaluation of the processes and outcomes of therapy. Legitimation is a generic term for the procedures by which a discipline accepts or rejects propositions as a valid part of its body of knowledge, and thus the range of acceptable legitimation processes largely determines the nature and content of the discipline.

Legitimation: what kind of science?

In order to study this process it has been found useful, by Ulrich (1992) amongst others, to consider science in terms of whether it is ‘pure’ or ‘applied’. In pure sciences such as physics and anatomy, the theories are justified by the traditional scientific method of experiment and refutation or falsificationism (Popper 1968). The propositions aspire to the status of objective truth which is valid independent of context. In the applied sciences, such as economics and politics, the aims are more to do with supporting effective intervention than a search for ‘truth’, since it has been found that methods or axioms applicable to one situation may not have the same relevance in another context.

In aphasiology, the applied paradigm is arguably dominant since the main concern is to offer rehabilitation to people with aphasia. Advances in ‘pure’ knowledge are pursued as means to that end rather than ends in themselves. However, there are within most applied sciences, elements of pure science. In aphasiology these would include linguistics, neurology, and cognitive neuropsy- chology. In aphasiology, the focus mainly falls on the ways in which insights from these fields can be applied to linguistic rehabilitation.

The very nature of applied sciences is such that the ‘truth’ of many propositions is not able to be established by repeated experiments within controlled environ- ments. This is because situations involving people are by definition not repeatable. Only limited predictions can be made about the full complexity of individuals’ reactions to situations, so the homogeneity within a group or between groups is problematic. Repeated experiments on the same group are also compromised since the experience of each experiment will change the participants. An added dimension is that applied sciences address issues of outcome and behaviour in the ‘ real world ’ rather than in a laboratory, so the results of controlled experiments may not be applicable.

It is certainly true that a great deal of knowledge has been gained about the relative effectiveness of treatment techniques on particular aspects of language recovery, using techniques such as randomized controlled trials. In recent years there has been an increase in the reporting of single case studies which is arguably a response to the individualized nature of aphasic impairments. There seems to be no emerging consensus about the relative merits of these approaches but both are likely to continue to make a contribution to the knowledge of how best to treat the patient. However the extent to which such improvements are affecting the communicative behaviour outside clinic is still uncertain.

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

Clinical Forum 443

This raises the issue of the range of views within the discipline on the ontological status of ‘language’ and ‘communication’. An objectivist view of language can call on concepts and methods relating to it being a body of skills and knowledge, mastery of which can be measured and evaluated in relation to agreed standards. However the concept of communication is related to the more subjective processes involved in the transmission of meaning. Attributes such as ‘understanding’ and ‘functional ’ are mainly susceptible to indirect measures of their effects since the phenomena themselves are not directly accessible to others. Clearly language in its broadest sense is the means of communication, and thus linguistic ability determines communicative ability to a large extent. However the relationship between linguistic skills and communicative competence is neither straightforward nor necessarily linear. Examples of this include : academic treatises which demonstrate a high level of linguistic capability but which are only comprehensible to a few people because of syntactic complexity and extensive use of low frequency vocabulary ; and, conversely, many individuals with no neurological impairments who only ever use a fraction of the language capabilities that most people would consider necessary.

It is interesting to note that some functional assessments relate performance to the aphasic person’s premorbid level of competence rather than a notional absolute or ‘normal’ capability. More recently, there has also been a movement from correlation of functional measures with linguistic tests : CADL (Holland 1980) with BDAE (Goodglass and Kaplan 1972) and PICA (Porch 1973); Speech Questionnaire (Lincoln 1982) with WAB (Kertesz 1982) ; to correlation with the ratings of spouses or significant others (CETI (Lomas e t al. 1989)). Reflection about the type of phenomena being measured by functional assessments as opposed to linguistic assessments gives rise to concern about the usefulness of trying to correlate scores on a relative scale with those on an absolute scale. The assessment processes relating to clinical performance are rooted in different paradigms from those measuring functional performance. If the paradigm shift is incomplete then the measuring instruments deployed are likely to be misleading.

Whilst traditional scientific methods are appropriate for assessing the extent and recovery of linguistic capability, a broad view of aphasiology will need to draw on a range of approaches to legitimation depending on the nature of the particular activity being considered. It is suggested that here again the WHO taxonomy, together with other classifications of impairment and disability (such as that developed by disabled people themselves) may be helpful. Figure 1 shows how the continuum of methodologies for evaluation may be mapped on to this.

To the right of the continuum, the legitimation of qualitative approaches to issues of disability, handicap and well-being is important if the profession is to move beyond a general well-meaning supportiveness. If applied in its true spirit, the qualitative approach involves a fundamental change in the therapist/patient relationship from expert and client to a more equal partnership. The therapist becomes a facilitator, learning from rather than teaching the aphasic person. The focus of qualitative investigation falls on the perspective, views and experiences of the aphasic person, rather than those of the clinician. The ‘fact’ of aphasia as a linguistic impairment becomes absorbed and transformed by the aphasic person’s own particular circumstances, sets of meanings and beliefs, and mechanisms for coping. Thus, the idiosyncratic nature of what someone understands by and does with their aphasia can be described, not as a fact but as ‘fiction’ or narrative. This

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

444 Clinical Forum

WHO‘ classification:

BCODPZ c iassi f i in :

science paradigm:

research methods:

measures:

impainnent disability handicap well-being

impainnent disability

pure applied

q u a n t i i e qua l i v e

absolute relative

4

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

Clinical Forum 445

between qualitative and quantitative approaches, as a recent series of articles in the British Medical Journal demonstrates :

Although the more qualitative approaches found in certain of the social sciences may seem alien alongside the experimental, quantitative methods used in clinical and biomedical research, they should be an essential component of health service research-not just because they enable us to access areas not amenable to quantitative research, such as lay and professional health beliefs, but also because qualitative description is a prerequisite of good quantitative research, particularly in areas that have received little previous investigation. (Mays and Pope 1995)

Conclusion

The impetus for writing this paper has come from many sources. The over- riding concern is the need for a framework of discourse for the discipline. This should stimulate constructive interchange, critique of ideas and approaches, and promote understanding of how these can relate to clinical practice. This paper does not claim to have accomplished the task of providing such a framework. Its aim has been to stimulate reflection within the discipline and make explicit the need to surface beliefs about principles and methods which form the foundation of clinical work and research. The emphasis has deliberately been at a philosophical and conceptual level since if there is a lack of agreement about fundamentals there is a danger that debate will become dogmatic and destructive.

One of the main benefits of developing a conceptual framework and meta-theory would be that new approaches could be developed and adopted without being seen as a threat to those that are already established. This is not a call for the uncritical acceptance of new treatments but for a recognition that there is a need for a range of approaches to meet the needs of aphasic people and that there are other bases of critique and evaluation than those traditionally employed by the discipline. Concomitantly, those advocating innovative approaches should understand the need for a level of rigour at the methodological level that is no less demanding than that applied to existing approaches even if based on different paradigms.

An explicit and integrated theory of therapy, which forms the basis for all aspects of intervention, and which respects the varying paradigms and constructions from which these arise, could strengthen the foundations of therapeutic endeavour. Seeing aphasia and functional and psychosocial impact only as ‘facts ’ or objectifiable phenomena, may be to limit understanding of the subjective, changing, narrative aspects of the condition. The strengths and limitations of both concerns, their links with appropriate and relevant methodologies and the relationship between them need to be made explicit. If underlying philosophical principles are made clear, much of the destructive factional warring within the discipline could become unnecessary. Confusion about the conceptual basis of aphasia therapy and the resulting tendency to adhere to dominant paradigms must have the effect of diminishing the service which can be offered to aphasic people, and weakening any claim on resources made by those seeking to assist them.

References

ALBYN DAVIS G. 1994, Theory as the base on which to build treatment of aphasia American Journal

BASTIAANSE, R. and PRINS, R. 1994, Communicative speech therapy in aphasia: what does it mean, of Speech-language Pathology, 3, &lQ.

can it be effective and how should it be done? Aphasiology, 8,482-488.

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

446 Clinical Forum

BENCH, R. 1989, Science and theory in communication disorders : A response to siege1 and ingham.

BRITISH APHASIOLOGY SOCIETY 1992, Advice to purchasers. Society Publication. BURY, M. 1991, The sociology of chronic illness: a review of research and prospects. Sociology of

BYNG, S., KAY, J., EDMUNDSON, A. and SCOTT, C. 1990, Aphasia tests reconsidered Aphasiology 4,

CODE, C. 1994, Mechanisms underlying recovery from aphasia. Proceedings of 24th Clinical Aphasiology

DAVID, R . 1990, Aphasia assessment: the acid test. Aphasiology, 4, 103-109. EASTWOOD, J. 1988, Qualitative research: An additional research methodology for speech pathology?

British Jo~rnaf of Disorders of communication, 23, 171-184. FINKELSTEIN, V. and FRWCH, S. 1993, Towards a psychology of disability. In J. Swain, V.

Finkelstein, S. French and M. Oliver (Eds) Disabling Barriers, Enabjing Environments (London : O U Publications and Sage), pp. 26-34.

Journa f of Speech and Hearing Disorders, 54, 296-298.

Health and Illness, 13, 451-468.

67-93.

Conference, 5-8 June 1994,

FRANK, A. 1991, At the Will of the Bo& (Boston: Houghton M a n ) . FRATTALI, C. 1992, Functional assessment of communication : merging public policy with clinical

FRENCH, S. 1994, On Equal Terms: Working with Disabled People (London: Butterworth Heinemann). GARMAN, M. 1994, Aphasia and communicative speech therapy: the potential of grammatical

GOODGLASS, H. 1990, Cognitive psychology and clinical aphasiology. Aphasiofogy, 4, 93-97. GOODGLASS, H. AND KAPLAN, E. 1972, Assessment of aphasia and related disorders (Philadelphia:

Lea and Febiger). HOLLAND, A. 1980, C A D L : Communicative Abilities in Daih Living (Baltimore : University Park

Press). HOLLAND, A. and BEESON, P. 1993, Finding a new sense of self: what the clinician can do to help.

Aphasio fogy, 7, 58 1-584. HOWARD, D. and HATFIELD, F. 1987, Aphasia Therapy: Historicaland Contemporag Issues. (Hove, UK:

Lawrence Erlbaum Associations). JACKSON, M. C. 1991, Systems Methodofogies for the Management Sciences (Chichester UK : John Wiley),

pp. 264-270. JORDAN, L. 1991, A profile of aphasia services in three health districts. British /ownu/ of Disorders of

Communication, 26, 293315. KAGAN, A. and GAILEY, G. 1993, Functional is not enough: training conversation for aphasic

partners. In A. Holland, and M. Forbes (Eds) Aphasia Treatment: World Perspectives (San Diego: Singular Publishing Group), pp. 199-225.

views. Aphasiofogy, 6, 6385.

analyses. Aphasiofogy, 5, 491-496.

KERTESZ, A. 1982, Western Aphasia Battery (New York: Grune & Stratton). KLEINMAN, A. 1988, The I /hss Narratiues: SNffering Healing and tbe Human Condition (California: Basic

LEIWO, M. 1994, Aphasia and communicative speech therapy. Aphasiofogy, 8, 467-506. LESSER, R. and MILROY, L. 1993, Linguistics and Aphasia: Psychofinguistic and Pragmatic Aspects o j

Znteruention (Longman : Essex). LINCOLN, N. 1982, The Speech Questionnaire: an assessment of functional language ability.

International Rehabilitation Medicine, 4, 114-1 17. LOMAS, J., PICKARD, L., BESTER, S., ELBARD, H., FINLAYSON, A. and ZOGHAIB, C. 1989, The

Communicative Effectiveness Index : development and psychometric evaluation of a functional communication measure for adult aphasia. Jomaf of Speech & Hearing Disorders, 54, 113-124.

LYON, J. 1996, Optimising communication and participation in life for aphasic adults and their prime care givers in natural settings: a use model for treatment. In G. A. Wallace (Ed.) Adrrlt Aphasia Rehabifitation (Newtown M.A. : Butterworth Heinemann).

MASON, J. 1994, Linking qualitative and quantitative data analysis. In A. Bryman and R. Burgess (Eds) Anahsing Qmlitatiue Data (London: Routledge), pp. 89-1 10.

MAYS, N. and POPE, C. 1995, Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. British Medical Journal, 311, 42-45.

NORTH WESTERN REGIONAL HEALTH AUTHORITY 1995, Breaking down barriers : guidelines for purchasers of services for disabled adults aged 16-64 with physical and sensory impairments (Warrington i North Western Health Authority).

Books).

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014

Clinical Forum 447

PARR, S. 1996, Everyday literacy in aphasia: radical approaches to functional assessment and

PARR, S. 1996, The road more travelled: whose right of way? A response to Pierce, Gonzalez.

PARR, S., POUND, C. and MARSHALL, J. 1995, A handful of power for aphasic people. R y a l College of

POPPER, K. 1968, Coqectures and Rejitations: The Growth of Scientgc Knowledge. (New York: Basic

PORCH, B. 1973, Porch Index of Communicative Abiiio (Palo Alto : Consulting Psychologists’ Press). PRUTTING, C., MENTIS, M. and NELSON, P. 1989, Critique of Siegel: The limits of ‘The limits of

RINGEL, R., TRACHTMAN, L. and PRUTTING, C. 1984, The science in human communication sciences.

SACCHETT, C. and MARSHALL, J. 1992, Functional assessment of communication: Implications for the

SCHUELL, H. 1965, Differential Diagnosis of Aphasia with the Minnesota Test (University of Minnesota

SIEGEL, G. and INGHAM, R. 1987, Theory and science in communication disorders. Journalof Speech

STAINTON-ROGERS, W. 1991, Explaining Health and Illness (Harvester Wheatsheaf: New York). ULRICH, W. 1991, Critical heuristics of social systems design. In R. Flood and M. Jackson (Eds)

WERTZ, R. T. 1984, Language disorders in adults: State of the clinical art. In A. Holland (Ed)

WORRALL, L. 1992, Functional communication assessment: an Australian perspective. Aphasiology, 6,

therapy. Aphasiology, 10, 469-479.

Aphasiology, 10, 496-503.

Speech and Language Therapists’ Bulletin, 527, 8-9.

Books).

science in communication disorders ’. Journal of Speech and Hearing Disorders, 54, 296-302.

Journal of American Speech and Hearing Association, December, 3 3 3 7

rehabilitation of aphasic people: reply to Carol Frattali. Aphasiology, 6, 95101.

Press : Minneapolis).

and Hearing Disorders, 52, 99-104.

Critical Systems Thinking: Directed Readings (Chichester : Wiley), pp.

Language Disorders in Adults (San Diego: College-Hill Press), pp.

105-1 11.

Address correspondence to : Brian Petheram, Speech and Language Therapy Research Unit, Frenchay Hospital, Frenchay, Bristol BS16 ILE, UK.

Commentaries upon this paper follow below and the response to these commentaries appears on pp. 481-487.

Diversity in aphasiology: a crisis in practice or a problem of definition?

ROELIEN BASTIAANSEt and SUSAN EDWARDS$ t University of Groningen, Groningen, Netherlands $ The University of Reading, Reading, UK

Aphasiology is the study of aphasia. It is a subject which has engaged neurologists, physicians, psychologists and linguists as well as clinicians who work directly with the language disorder, professionals known as speech and language therapists in the UK and by varied titles elsewhere. Increasing numbers of non-vocational university students study this subject and aphasia research is conducted in a variety of different settings. While the condition of aphasia is a personal tragedy, the study of the condition is lively, interesting, intellectually challenging and even fun, especially if one can handle the robust debates that occasionally evolve. Thus we are delighted to be invited to join in this debate with Petheram and Parr.

The study of aphasia, which is what we understand aphasiology to be, is a broadly based area of study in which a number of diverse disciplines are involved

Dow

nloa

ded

by [

Uni

vers

ity o

f C

ambr

idge

] at

16:

27 0

9 O

ctob

er 2

014