20Q: Mental Health, Aphasia, and the SLP’s Role

From the Desk of Ann Kummer

From the desk of Ann Kummer…

Speech-language pathologists who work with adults, and those who work in medical facilities, commonly see patients with aphasia, which is an inability to comprehend or formulate language. Aphasia can be caused by a neurological insult, such as a stroke, tumor, or neurodegenerative disease. It can also occur following an injury that results in head trauma. Aphasia can affect all aspects of communication, including auditory comprehension, verbal expression, reading, and writing.

The ability to communicate with others is a crucial skill necessary for fulfilling human relationships and a sense of well-being. Therefore, it is not a surprise that individuals who lose this ability experience anxiety, stress, depression, and other characteristics of compromised mental health. To help us to understand this issue more fully, Dr. Rebecca Hunting Pompon has provided this article, which will answer your questions and help you to provide support to affected patients.

Rebecca Hunting Pompon, PhD is an Assistant Professor in the Communication Sciences and Disorders Department and Director of the Aphasia and Rehabilitation Outcomes Lab at the University of Delaware. She has a clinical background in adult mental health and counseling. Her research focuses on the measurement of biopsychosocial factors in individuals with aphasia, and the influence of these factors on aphasia treatment response. She trains clinicians in counseling skills and interpersonal communication strategies across the allied health disciplines.

I think you will find this article both interesting and informative.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors

Contributing Editor

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Mental Health, Aphasia and the SLP's Role

Learning Outcomes

After this course, readers will be able to: 

• List common mental health challenges experienced by individuals with aphasia.
• Identify 2-3 evidence-based mental health/wellbeing screening assessments available for SLP use and related administration methods.
• Describe a set of basic counseling skills that SLPs can use across clinical populations and settings to foster trust-based interactions with clients.

Rebecca Hunting Pompon

1. What is the impact of the stress of living with aphasia for my clients?

Clinicians who work with individuals with aphasia (IWA) are well aware of its consequences. IWA often face altered relationships and roles, employment status, goals, plans, and day-to-day functioning. These changes lead to long-term stress and social isolation, even as individuals recover some of their language abilities and learn communication strategies. In other words, living with aphasia is a major life shift that is often chronically stressful, and the persisting stress can lead to physical and mental health consequences. In general, chronic stress is associated with decreased immune function, increased risk of cardiovascular disease and stroke, and increased depressive symptoms. Additionally, both chronic stress and depression are associated with diminished cognitive function, particularly attention and memory processes (American Psychiatric Association, 2013; McEwen & Gianaros, 2011).

2. Is depression more prevalent in post-stroke aphasia than in stroke survivors with no aphasia?

Yes. Depression after stroke has been examined fairly extensively, and depressive symptoms are more prevalent for stroke survivors as a group compared to the general adult population. Furthermore, studies that have included IWA among their stroke sample have reported that depressive symptoms are greater for IWA compared to stroke survivors without aphasia. The general adult population has a rate of major depression of about 8% compared to about 30% for stroke survivors in general and 40-60% of stroke survivors with aphasia (Ashaie et al., 2019; Hunting Pompon et al., 2019, in press; Kroenke et al., 2009; Mitchell et al., 2017). These research findings support what many clinicians have observed: living with aphasia is often associated with significant mental health-related challenges.

3. Do depressive symptoms tend to increase with the level of aphasia severity or decrease over time since stroke?

Logically, we may expect that when language impairments are a more significant communication barrier, the IWA may experience greater frustration, stress, and, therefore, depressive symptoms. However, there appears to be no significant relationship between chronic stress or depression and aphasia severity overall (Ashaie et al., 2019; Hunting Pompon et al., 2019), though a few research reports have identified associations between depression and varied modality-specific impairments (see Hunting Pompon et al., accepted). Intense stress has been documented in individuals on the milder end of the aphasia severity spectrum as well as those with moderate and severe communication challenges (e.g., Cavanaugh & Haley, 2020; Silkes et al., 2021). Other individuals seem to thrive with aphasia regardless of the severity of their impairment.

Meta-analyses of general stroke research reports show no significant association between time since stroke and prevalence of depression, though, importantly, the majority of post-stroke depression research is conducted with individuals during the first year after stroke (Mitchell et al., 2017). Aphasia-focused research on depression, though limited, has included participants with chronic aphasia and also shown no relationship between time since stroke and depressive symptoms (Ashaie et al., 2019; Hunting Pompon et al., in press). In other words, depressive symptoms do not appear to significantly increase or decrease from the onset of aphasia, but more research is necessary to further examine the prevalence of depression over time for IWA.

4. What’s the difference between grief and depression? How do I know if my client is in a state of grief or is depressed?

Living with aphasia includes loss in several ways, even as the individual adjusts and adapts to new ways of communicating and approaching day-to-day activities. Grief often accompanies these major changes and adjustments and may trigger depression. Grief and depression share a primary feature – sadness/low mood – which may be perceived by the clinician through a client’s affect or behavior. And although grief and depression share some characteristics, they are also different in some key ways.

Major depressive disorder, according to the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2022), includes 1) depressed mood and/or loss of interest or pleasure, accompanied by 2) some combination of symptoms, including change in appetite, slowing of thought or movement, fatigue, feelings of inappropriate guilt or worthlessness, difficulty with concentration, and recurrent thoughts of death (may or may not include a specific plan or action).

Grief is also characterized by depressed mood and/or loss of interest or pleasure and may include a change in appetite and difficulty sleeping. Typically, grief does not include feelings of inappropriate guilt, worthlessness, or suicidal thoughts. Although grief can trigger a depressive disorder, it is a separate psychological experience, especially when most of its symptoms resolve in the months to a year following the loss event. Like depression, grief is complicated, including grief related to the onset and adjustment to chronic impairment. For more information on differentiating grief and depression, visit https://www.verywellmind.com/grief-and-depression-1067237.

In addition to acknowledging and validating the loss and grief that may surround the communication impairment, the clinician can periodically check in with the client about their emotional experience related to aphasia and its consequences, described further below.

5. What does ASHA say about SLPs’ scope of practice related to working with clients who are experiencing depression?

ASHA describes the role of the SLP in “personal adjustment counseling” to “address feelings, emotions, thoughts, and beliefs expressed by individuals and their families/caregivers (e.g., realization of the pervasive impact of a communication disorder on day-to-day life)” (ASHA, n.d.; https://www.asha.org/practice-portal/professional-issues/counseling-for-professional-service-delivery/). In other words, addressing mental health and wellbeing as it relates to communication-related change and adjustment is an important part of the SLP’s work.

6. What can I do if I suspect my client is depressed? As an SLP, can I screen for depression?

Yes, as an SLP, you can screen for depressive symptoms, though you cannot diagnose depressive disorders. Several evidence-based screening tools are available for SLPs to use with clients and family members. Two tools that may be used with IWA with mild to moderate aphasia are the Patient Health Questionnaire (PHQ) depression scales (Kroenke et al., 2009; Kroenke & Spitzer, 2002) and the PROMIS Emotional Distress-Depression scales (Pilkonis et al., 2011). These brief and simply worded scales inquire about the features of depression and provide Likert-scale response options for each item (e.g., “Never,” “Rarely,” “Sometimes,” etc.). Both the PHQ and PROMIS scales are open-access for clinicians (www.PHQScreeners.com, https://www.healthmeasures.net/search-view-measures).

Visual analog mood scales are often used with clients with more severe impairment (e.g., Barrows & Thomas, 2018), though studies of these measures report conflicting evidence of their validity (Kontou et al., 2012; Torrance et al., 2001). Alternatively, mood scales may be given to a family member or other observer of the client to complete as a proxy reporter, though research reports on the degree of agreement between self- and proxy-report on assessments are varied (e.g., Haley et al., 2019; Hernandez et al., 2021). Several versions of the Stroke Aphasia Depression Questionnaire (SAD-Q; Sutcliffe & Lincoln, 1998) were developed for family members and other proxy reporters, and a related study reported a high degree of agreement with other scales that assess similar symptoms via proxy report (Laures-Gore et al., 2017). The SAD-Q scales are open-access (https://www.nottingham.ac.uk/medicine/about/rehabilitationageing/publishedassessments.aspx).

Importantly, SLPs who suspect depression should refer their clients to their primary care provider or a qualified mental health provider as available. We will discuss this more below.

7. What about anxiety and aphasia?

Like depression, anxiety disorders are also associated with persisting high stress and may occur following the onset of impairment (Brenes et al., 2008). Anxiety has been studied less than depression in stroke and with IWA. Research reports describe relatively high rates of anxiety in IWA; specifically, the rate of anxiety disorders may be greater than 40% for IWA compared to 18-25% for stroke survivors with no aphasia (Campbell Burton et al., 2013; Kneebone et al., 2012).

SLPs can screen for anxiety symptoms. One evidence-based, open-access measure of anxiety is the Generalized Anxiety Disorder scale (GAD-7; Spitzer et al., 2006) (www.PHQScreeners.com).

8. Are there measures developed specifically for people with aphasia that assess mental health?

There are several mental health-related measures developed for IWA in addition to the SAD-Q mentioned above. One is the Modified Perceived Stress Scale (mPSS), a measure of chronic stress based on the widely used Perceived Stress Scale (Cohen & Janicki-Deverts, 2012) that we modified and validated with IWA (Hunting Pompon et al., 2018). This scale has ten items that are written simply (below a 6th-grade reading level) and includes both example and practice items, and graphically supported response options. Study of the mPSS showed a significant link between level of chronic stress and depression and anxiety symptoms in IWA. Separately, the Assessment of Living with Aphasia (ALA; Simmons-Mackie et al., 2013) assesses the Personal domain of the A-FROM framework (Kagan et al., 2008) with simple and graphically supported questions about the client’s mood, self-perception, and identity.

Our lab is currently validating a modified measure of resilience for IWA. Working with the developers of the University of Washington Resilience Scale (Amtmann et al., 2020), we systematically modified this evidence-based scale and its components to be maximally accessible to IWA. This 8-item measure assesses an individual’s ability to manage challenge and stress through items like “I stay positive even when bad things happen” and “I do what is important to me, even when stressed.” Preliminary results of this validation study show significant associations between IWA-reported resilience, chronic stress, depressive symptoms, and anxiety (Hunting Pompon, Mach, & Stroker, 2022). In other words, this scale appears to validly capture the degree to which an individual responds to challenge and stress in a positive way, though additional data is needed. Once validation of this measure is complete, it will be a useful clinical tool to identify clients’ strengths and challenges specific to adjustment to life with aphasia.

9. Most mental health measures are not necessarily aphasia friendly. How can I use them with a client with aphasia?

There are a few ways to support the administration of a patient-reported outcome measure with an IWA, starting with general strategies to support communication (Simmons-Mackie & Kagan, 1999), providing both visual and auditory presentation of the scale items (i.e., inviting the person to read along silently while the clinician reads aloud), presenting only one item at a time to minimize visual distraction, and gathering qualitative responses to verify and confirm the client’s response choice (Engelhoven et al., in press). Additionally, Tucker and colleagues have described a 5-step hierarchy of communicative support to use during measure administration. In short, if any item is not understood: 1) repeat the question and response options, 2) restate the question simply, 3) restate the question and provide examples of each response option, 4) add a yes/no choice for each response option and finally, if these steps have not been successful, 5) skip the item and administer the next one (Tucker et al., 2012). Other information on patient-reported outcome measures and their administration with IWA is available from Engelhoven, Bislick, Gray, and Hunting Pompon (in press).

10. What counseling skills should SLPs use when working with people with aphasia?

In my clinical training in psychotherapeutic counseling, I was taught a large set of basic counseling skills used moment-to-moment during the counseling interaction. I adapted this set of skills to suit the work of allied health professionals, including SLPs working with IWA. These basic skills can help the clinician gather important personal information – like depressive symptoms and other psychosocial experiences – useful for treatment planning, as well as provide information about adjustment to life with aphasia. The skills are grouped into 5 categories: Self-awareness, Attending, Gathering information, Providing information, and Promoting change.

This framework and its primary counseling skills are summarized briefly below. Additional information and education in this area are available through a recent article (Hunting Pompon, 2021).

11. Why is “Self-awareness” a fundamental counseling skill?

Self-awareness is the first set of counseling skills for a reason. If clinicians are not aware of their own internal reactions and outward responses, it is difficult to adapt their verbal and non-verbal communication that stem from these reactions. Self-awareness helps us become more intentional in our communication and respond in an authentic and empathetic way. Responding inauthentically and non-empathetically can be a barrier to building an environment of trust necessary to discuss difficult experiences and emotions. Overall, the better we know ourselves, the more we can engage with the client in a genuine and empathetic way to create a trust-based therapeutic partnership.

12. What specific counseling responses are included with “Attending?”

There are two major skills within Attending: active listening and empathy. Active listening is a simple but effective communication technique that may be the most important of all counseling-related skills. It communicates that the client has been both heard and understood, which is essential to promote an atmosphere of trust and emotional safety. When used with IWA, active listening techniques can also serve to confirm a message if/when the client struggles to communicate. Active listening can involve responding with a single word or paraphrase that underscores the most important component of a client’s message or a brief summary (a phrase or sentence) to bring several components together. Typically, we use a number of verbal and non-verbal responses to affirm that we are listening in everyday conversation, clinically or otherwise, from a nod of the head to non-specific utterances like “I see,” “interesting,” or “Uh-huh.” These responses are reasonable affirmations in conversational turn-taking, but replacing some of these non-specific responses with a brief paraphrase can be an effective way to demonstrate that the clinician has heard and acknowledged themes important to the client, including emotional reactions or other responses that may heighten the client’s sense of vulnerability. For clients with more severe impairment, key word writing while listening can serve as a visual paraphrase (see also Kagan, 1998).

Empathy comes easily for some and requires more explicit effort for others. It includes our ability to understand the experience and emotions of another person, and in the present context, communicate that understanding to the other person. Experiencing and expressing empathy to our client helps to build trust, rapport, and connection with our client.

13. “Gathering information” is what we do as clinicians. What makes it a basic counseling skill?

There are a number of skills that can help us as effective gatherers of information, including potentially sensitive information about psychosocial perceptions and experiences. Active listening, as described above, is one tool that can help yield high-quality, personally relevant information from the client. Other strategies that help clinicians gather information are asking open-ended questions to elicit the client’s perception of primary daily challenges, priorities, and well-being. Questions like “What part of your daily activities is most challenging?” and “Tell me about how you are coping day-to-day?” paired with active listening responses can help the clinician gather deeper information on the client’s experience than most closed-ended questions. Open-ended questions can be useful when paired with scales used to assess mental health or well-being, as discussed above. The clinician can ask about specific measure items to gather additional information and assess the importance of that item for the client.

Clients with more severe impairment may struggle to understand or respond to open-ended questions. Clinicians can add a fixed choice to these questions to explore these themes with the appropriate level of communicative support. For example, “Tell me how you are coping day-to-day?” can be followed with “Good,” “Okay,” “Not great,” thumbs up/thumbs down, etc.

14. “Providing information” is also fundamental to clinical work – what’s new here?

Of course, providing information is a fundamental role of any clinician. When considering conversations about potentially sensitive information like the client’s emotional state, ways of providing information are important to consider. Describing emotions or difficult experiences may increase the client’s sense of vulnerability, stress, and/or anxiety in the moment. These heightened emotional states may diminish memory retrieval, encoding (Guenzel et al., 2013; Jafari et al., 2017), and the client’s baseline communication abilities (Cahana-Amitay et al., 2011). Given these potential challenges, the clinician can provide multi-modal support when relaying information, such as writing key words, a list, or drawing a diagram that connects key points, and provide other supports for information encoding, such as summarizing information and anticipating clarifying questions.

15. “Promoting change” is our primary role as clinicians – how is it a counseling skill?

When considering a client’s mental health and well-being, there are a few counseling skills that may help seed change. Among them, clinicians can underscore the clients’ strengths and opportunities for growth, help them reframe challenges, encourage the importance of connection with others, such as the benefits of joining an aphasia community, and throughout our interactions, demonstrate empathy and unconditional positive regard. Helping clients manage and move through chronic stress, depression, and anxiety is not dependent on the SLP alone, and usually, a combination of the individual’s experiences over time leads to improvements in mood and overall well-being. Separately, clinicians often experience concern and worry for their clients, especially when they wonder how IWA will cope with the complex challenges of life with aphasia over time. Since each clinician interacts with each client for a relatively brief time period in the scope of life, we can only do our best to be authentically supportive, empathetic, and realistic optimists, and provide individualized opportunities for communicative recovery and resources for personal growth. 

16. It is difficult to find mental health professionals with knowledge or expertise in aphasia or communication disorders in general. What can I do for my clients who need mental health support?

Few counseling professionals familiar with aphasia and communicative support strategies exist in the U.S. Although there are some conversations now underway among clinical aphasiologists about counseling education for SLPs, aphasia and communicative support training for mental health professionals, and other mental health-related initiatives for IWA, current mental health resources are limited in the U.S.

Until we have more support and referral options for IWA who are struggling with mental health challenges, there are a few things the clinician can do:

• assess, discuss, and revisit challenges around adjustment to life with aphasia, identifying priority concerns of clients and family members;
• refer clients with depressive and anxiety symptoms to their primary care provider to explore pharmacological intervention as appropriate;
• provide information on conversation/life participation groups for IWA (see DeDe et al., 2019) and caregiver support groups for caregivers, including online options as appropriate (more on this below);
• discuss and encourage client engagement in physical and other activities they enjoy as a regular part of their day. In essence, “doing more of what you enjoy” is at the core of the psychotherapeutic approach called Behavioral Activation (Martell et al., 2022), currently being researched with IWA.

17. Are there treatments available that address mental health for people with aphasia?

Currently, there are several treatments in various stages of development that address the cognitive, emotional, and/or mood-related behavioral responses to living with aphasia. A few of these forthcoming individual treatments include Acceptance and Commitment Therapy or ACT for Aphasia (Evans et al., 2022), Communication and Low Mood, or the CALM Trial (Thomas et al., 2012, 2013), and Solution Focused Brief Therapy in Post-stroke Aphasia, or SOFIA Trial (Northcott et al., 2019). ACT and SOFIA are treatments intended to be administered by an SLP in collaboration with a mental health professional; CALM is administered by a psychologist. As mentioned above (Martell et al., 2022), another individual treatment in development called Behavioral Activation Therapy for Depression after Stroke, or BEADS (Thomas et al., 2016, 2018), is intended for stroke survivors, including those with mild to moderate aphasia, administered by a psychologist or “low-intensity psychological wellbeing practitioner.”

There are a few group interventions that target mental health and well-being of IWA as well. One approach examined in a small pilot study in our lab is Resilience Skills for Aphasia (Stroker & Hunting Pompon, 2022). This 12-session group program was based on the structure of the Relaxation Response Resiliency program (Park et al., 2013) to promote three primary elements of resilience: stress reduction, cognitive-emotional reappraisal, and personal growth. This program will continue to evolve in the coming years.

Keep an eye on conference presentations and research literature for updates on these and other evidence-based mental health and wellbeing-related interventions for IWA.

18. I’m also concerned about my clients’ family members. How can I help them when my primary focus is their loved one?

Although the IWA is the SLP’s primary concern, family members are an important contributor to aphasia rehabilitation and overall quality of life. In general, family members provide more “treatment” than rehabilitation clinicians, and it has been documented that clients from high-functioning families have better long-term outcomes (Visser-Meily et al., 2006). In other words, caregivers’ well-being is important to the overall progress of the IWA in addition to their own health. The Caregiver Self-Report Questionnaire, created by the American Medical Association (2015), is a 17-item measure that can help family members reflect on how they are doing and can be a conversation starter for the clinician who would like to provide relevant support resources and referrals. The Caregiver Self-Report Questionnaire can be recommended for the family member to complete independently and is available in multiple languages and in online and print formats at https://www.healthinaging.org/tools-and-tips/caregiver-self-assessment-questionnaire.

A few helpful caregiver support resources that clinicians can share with their client families are the National Aphasia Association (www.aphasia.org), the National Alliance of Caregivers (www.caregiving.org), and Caregiver Action Network (www.caregiveraction.org), among others. The 211 information and resource line (call 211 in any U.S. state or visit www.211.org) is important to share with families needing essential services, including mental health, healthcare, financial, food, and housing resources.

19. Obviously, depression and chronic stress impact a person’s quality of life, but could they impact treatment response or rehabilitation outcomes?

Although it is important to acknowledge and act on the impact of these challenges on quality of life, there may also be consequences to rehabilitation. There is ample research evidence about the influence of persisting stress and depressed mood on cognitive processes, including attention and memory. In short, chronic stress and depression involve similar physiological processes and regions of the brain that impact attentional and memory over time (McEwen & Gianaros, 2011; Russo, 2012). Within the context of rehabilitation, this may translate to clients’ ability to engage, attend, and remember what they’ve learned in treatment. We do not yet have data to assess the impact of chronic stress and depression on treatment response, but this is an area of research that is underway in our lab.

20. Working with clients and families who struggle day-to-day can be difficult over time. What can I do to help prevent burnout?

Burnout is a risk for any clinical professional who helps clients facing life-altering change/challenges and has been one of many negative dimensions of the pandemic period across healthcare. According to social psychologist Dr. Christina Maslach, who has been studying burnout since the 1970s, burnout has three dimensions: mental or emotional exhaustion, depersonalization (cynicism), and diminished feelings of personal accomplishment (Maslach & Leiter, 2022). Burnout can have both physical and mental health consequences for the clinician and can serve as a barrier to optimal clinical care.

Just as self-awareness is an important fundamental ability among the counseling skills, it is also fundamental in burnout prevention. When you are aware of your unique challenges as a clinician, you will be better equipped to manage them and find the necessary support. Connecting and providing mutual support with other clinicians, managing day-to-day stress, and engaging in a healthy lifestyle and enjoyable activities outside of work can support both personal health and healthy clinical practice over time.

A number of resources are available for clinicians concerned about burnout, including assessment tools like the Maslach Burnout Inventory for Medical Personnel (Maslach et al., 1997; https://www.mindgarden.com/315-mbi-human-services-survey-medical-personnel), content provided by the Centers for Disease Control and Prevention (https://www.cdc.gov/mentalhealth/stress-coping/healthcare-workers-first-responders/index.html), and a relatively new publication for multi-disciplinary healthcare workers, especially regarding pandemic-related burnout, called the New Self-Care Protocol: Practice Guide for Healthcare Practitioners and Staff (Mollica et al., n.d.; www.hprtselfcare.org/).

In conclusion, mental health is a major concern for IWA, their families, and the SLPs who serve them. Although it can be uncomfortable and challenging to address depression, anxiety, and chronic stress in our clients, these conversations are within the SLP’s scope of practice and, importantly, may make a significant contribution to the rehabilitation, health, and well-being of clients and their family members. In addition to acquiring and using mental health screening tools and basic counseling skills in their practice, SLPs should also attend to their own needs and well-being to both prevent burnout and provide the best possible care to their clients.

Acknowledgments

I would like to thank Amy Engelhoven, Elizabeth Madden, JoAnn Silkes, and Reva Zimmerman for reviewing and providing thoughtful comments on this article.

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