Speech language pathologists providing therapy services to persons with aphasia in medical settings are confronted today with two seemingly incompatible grim realities: 1) Persons with aphasia often have limited access to rehabilitation due to limited visits allowed by managed care insurances and; 2) third party payers, supervisors and families of persons with aphasia expect 'functional outcomes' as a result of treatment regardless of the time frame allowed. At the same time ASHA's revised Scope of Practice for Speech Language Pathology (May, 2001) now states that the ultimate goal of speech-language therapy intervention is to improve quality of life via increased participation in life.
The call to increasing 'life participation in aphasia' was initially sounded by some of the top aphasiologists in the country (Lyon, 1992; Chapey, et al, 2000). Increasing 'participation in life' may seem like a lofty task to the average clinician toiling away in a medical setting when, with shorter treatment sessions, the number of patients seen in a day has increased, paperwork has doubled, and obtaining even six to twelve consecutive visits for treatment can require a Herculean effort from clinicians already short on planning time.
Facing up to why it is important to "do more with less"
Doing "more with less" for people with aphasia begins with the SLP's recognition that months and months of individual speech and language therapy possibly never has necessarily been the road to increased communication opportunities, communication success, and/or participation in life for persons who have aphasia. The profession shares some responsibility in not clearly demonstrating the functional effectiveness of therapy in the typical medical setting under typical conditions. How, for example, can it be suggested that twelve individual therapy sessions are too few, when it has not been fully demonstrated that 40 sessions produced real life meaningful changes in persons' lives? (Threats, 2002)
One response to the constraints imposed by today's healthcare system is to do as Roberta Elman has suggested (1999) and provide treatment "outside the box." The "box" that clinicians may need to step out of could be what Jon Lyon (1999) calls the box of 'reimbursable care'. Both Elman and Lyon are dedicated aphasiologists who actually did step "out of the box" to forge new frontiers in meeting the communication needs of people with aphasia. Elman and her colleagues Bernstein-Ellis and Ewing, left paying jobs as speech language pathologists to begin the Aphasia Center of California in Oakland, which offers group therapy to people with aphasia five days a week without billing third party payers. Lyon partners with community agencies to train "communication partner volunteers" to provide services to people with aphasia through his nonprofit organization, Living with Aphasia. He also provides long term specialized services to couples coping with aphasia that would be unavailable in traditional treatment settings. ( Lyon, 1999) Providing services that empower couples coping with aphasia to learn more efficient communication strategies is to be applauded and hopefully taken up by more speech-language pathologists. For example, Boles (1998, 2000) has reported measurable changes in communicative success for couples who received Solution Focused Aphasia Therapy in the university setting. It is crucial, however, that clinicians in traditional medical settings are also able to show the effectiveness in facilitation of real life functional changes in the lives of those with aphasia. The current reduced treatment time situation for speech-language pathologists is precarious since not achieving functional goals with decreased therapy time could be used to declare that therapy does not really work. The continuing challenge for clinicians providing aphasia therapy in the medical arena will not only be to advocate for patients to receive the appropriate amount of treatment visits, but also to initiate at least beginning guidance for coping with the long term consequences of aphasia on daily life. This process can begin through family education and training in the initial stages of therapy, but will also need to address ensuring that persons with aphasia have access to meaningful communication opportunities such as that provided by participation in group conversation programs that focus on facilitating satisfying interactions with peers and trained volunteers.
