HOW REHABILITATION MODELS SHOULD ADDRESS THE PSYCHOSOCIAL IMPACT OF APHASIA
· HOW REHABILITATION MODELS SHOULD ADDRESS THE PSYCHOSOCIAL IMPACT OF APHASIA
- UNIVERSITY OF ESSEX, DEPARTMENT OF LANGUAGE AND LINGUISTICS, GRADUATE PROGRAMME IN LANGUAGE DISORDERS
Aphasia is an acquired language disorder which affects the language (reading, writing, comprehension, expression) and the speech. Apart from these fields it also has an impact on the patients’ everyday lives, their relationships with the other people, their family, their work, their cultural values and their social interactions. So aphasia should be considered as a “multi-facet disorder which demands a flexible and integrated therapy and support”. (Pound C., Parr S., Lindsay J. & Woolf C., 2002, p 1) The choice of the rehabilitation model is being done according to the aims of the intervention and the patients’ response to the treatment method. Different kinds of rehabilitation have different impact on the patients’ impairment and degree of change. Rehabilitation refers to “services concerned with: education, physical functioning, psychological adjustment, social adaptation, vocational capacities or recreational activities”. (Sussman M.B. 1965, p 1) This essay will be focused on the psychosocial change that can be achieved with the appropriate rehabilitation models.
· The psychosocial impact of aphasia
Aphasia is also characterized as a social problem which affects the patients’ daily activities and interactions, resulting in serious social and psychological ramifications. Increased attention has been paid nowadays to the psychosocial effects of aphasia and the emotional needs of the patients as it has been realized that they play a significant role in the rehabilitation and the treatment. Many aphasic patients face great difficulties in coping with their lives because of their impairment. Lewis and Rosenberg cite that these patients experience “two main psychological disturbances: anxiety and problems with identity and self-esteem”. (Brumfitt S. 2002, p 20) Depression, low self esteem, behavioral alternations and changes may also be present. The emotional dimensions of aphasia can affect all the aspects of the patients’ social and daily lives, as the loss of normal communication and linguistic impairment can lead to a different life style with isolated activities. Most of the aphasic patients express “feelings of isolation, loneliness, sensitivity, psychological impoverishment that caused them to avoid and reject people, in fear of rejection”. (Sarno M.T. 1991, p 500) Moreover, they suffer from hopelessness, grief, discouragement, denial, embarrassment because of their inability, futility, despair, anger and they use to have regressive, aggressive and anti-social behavior because they cannot adapt themselves to their new life. So, we reach to the conclusion that the emotional devastation, the frustration, the panic and the gray period of aphasia are the main characteristics of the behavioral changes in the psychology of the aphasic patient. (Howard D. & Hatfield F.M. 1987)
All these feelings are the result of the changes that have taken place in their lives so suddenly. These patients lose the accustomed roles they used to have before, in their home, their job, their community, their company. Many of them lose their jobs, with consequent financial problems, they may also lose the role they used to have in their family and in the society and sometimes they lose their physical health and capacity. (Perkins W.H. 1977) For example, in case of hemiplegia, the psysical difficulties can affect the sexual interest and the relationship between the patient and his/her partner, as many aphasics suffer from fear that sex can cause harm. Thus, it is very difficult and hard for them to face the reality from another point of view, which they cannot accept, as they have lost their favor of the life. Such feelings of depression and emotional disturbances may have as a result catastrophic reactions e.g.: denial to eat, poor motivation to participate in the therapy plan, suicide attempts, weight change, delusional behavior, psychical destructiveness, panic attacks, violence. (Myers R. “Notes from the lesson”, 2004)
Furthermore, aphasia affects the relationship between the aphasic patients and their spouses. Many of them experience “ a variety of negative reactions including shock, guilt, bitterness, depression, loneliness and irritability. The spouses of the aphasic patients have to face role changes and altered social lives”. (Sarno M.T. 1991, p 511) So the lives of the aphasics and their family members are completely changed.
Apart from these problems, aphasics also suffer from fears, phobias and embarrassment because of their inability to speak properly and communicate. This is so important because speech is one of the most vital and significant functions of the human beings. The impairment they have with their speech, their memory, their comprehension influences their whole lives as they have difficulties with ordinary activities such as: making calculations, answering the telephone, go for shopping, etc. (Ender by P. & Emerson J. 1996) In addition to this, they are unable to do the hobbies they enjoyed or do something independently. Consequently they withdraw from their friends, their social and leisure activities, and their jobs and live a pessimistic, hopeless, lonely and miserable daily routine.
· Rehabilitation models
Regarding the personality and the emotional and psychosocial disturbances, the rehabilitation should start as soon as possible, since the therapeutic plan can lead to positive outcomes and improve the patients’ condition. But, although there are three separately approaches to the treatment of aphasia: the medical, the behaviorist and the holistic model of rehabilitation, effective management can be achieved by the interaction and the participation of medicine, psychology, counseling, psysical and social intervention. The choice of the appropriate method should be done according to the needs and the adaptation of the individual patient.
The main goals of the therapeutic models are: “the enhancement of communication, the identification and dismantling barriers of social participation, the adaptation of identity and the promotion of a healthy psychological state”. (Pound C., Parr S., Lindsay J., Woolf C. 2002, p 19).
· Medical model
The medical model reinforces the traditional approach of aphasias’ rehabilitation. Historically, medicine was the prior method they used for the patients’ treatment and the recovery. The medical model is focused on “the functional inabilities and limitations of the individual patient”. (Pound C., Parr S., Lindsay J., Woolf C., 2002, p 4) As far as it concerns the role of medicine in the psychosocial rehabilitation of aphasia, it is very valuable. The medical model is based on the concept that the patients’ problems and depression are the result of the brain injury. Its’ aim is to diminish the aphasics’ difficulties and emotional disturbances (depression, anxiety, fear, pessimism, denial, etc) and restore his independence and self esteem with the appropriate medication. For example, “the use of drugs, anti-depressants and muscle relaxants has shown a significant improvement for walking and activities of daily life”. (Enderby P. & Emerson J. 1996, p 25) The medical model provides “a well organized setting in which all services are mobilized for the patient with aphasia”. (Sarno M.T. 1991, p 558) So, the patients are able to live a more normal life and overcome many difficulties of their impairment. But, nowadays this model is used in cases that “the interaction between the patient and the therapist is not possible”. (Sarno M.T. 1991, p 516)
· Holistic model
The development of a carefully designed and effective therapy plan for the patients’ future is very important and prominent. Many aphasic patients cannot realize their problem and so they don’t accept their impairment. Thus their denial of the illness or the therapy plan should be examined in terms of the psychological impact as it delays the rehabilitation and results in deep depression. The holistic model can contribute satisfactory in the improvement of this situation.
The holistic model is more involved with the socio-cultural, psysical and bio conditions of the society and the human problems. “The holistic concept stresses an organic and functional relationship, a continuity interaction and a fundamental interdependence among the traditionally defined parts or areas of human behavior”. (Sussman M.B. 1965, p 31) The human environment, the social impact and interaction with groups and the cultural effect, play a significant role in the holistic rehabilitation. Its’ purpose is to restore the abnormalities and the troubles that are related to the patients’ personality, feelings, way of thinking and acting, as “it is focused on the consequences of the impairment, on social and intellectual domains”. (Crystal D. & Varley R. 1998, p 18) Thus, the psychotherapy, the family support, the group therapy and the counseling are all considered to be components of the holistic model.
· Psychotherapy
The main characteristic of psychotherapy (or “talking cure” Brumfitt S. 2002, p 26) is that it helps the aphasic patient “to express distress and direct his attention on the preserved abilities in order to make a connection with the past and present self. Also it allows time for the patient to mourn the lost self before a new one can emerge”. (Brumfitt S. 2002, p 20) So the aim of this approach is to help the patient go through the destructive feelings of depression and anxiety, reduce his confusion and panic and finally get rid of them. The imaginary psychotherapy, the drama therapy, the art therapy and the dream therapy are being used for such purposes and are considered as helpful rehabilitation methods because they give the chance to the aphasic to experience all his senses and reveal all his unexpressed feelings. (Brumfitt S. 2002, p 27) For these reasons, the role of the therapist is considered to be very important and essential for the patients’ recovery. But in order psychotherapy to be effective the relationship between the therapist and the patient should be friendly and trustworthy so as the aphasic to feel safe and comfortable to express his inner world and his emotional pain. The patient will be willing to do the psychotherapy if he realizes that the therapist is the one who can help him relieve his distress and improve his communicational skills.
· Family therapy
The family therapy is also another alternative way of aphasias’ rehabilitation. Its’ purpose is to release the patients and the family members from some bad experiences. It also targets to the emotional needs of the aphasics in order to understand what makes them suffer, so as to help them organize and programme their new lifestyle in a better way. The role of the therapist is to give information and direct the feelings of the patients and their family. (Lebrun Y. & Hoops R. 1976) It is very important the family members not to be overprotected or extremely anxious about the current condition of the aphasic because this may have a bad effect and outcome in his recovery. Encouragement and hope are the basic components of the linguistic and psychological rehabilitation. The family therapy is one of the most effective methods “to stimulate and support the patient through the various stages of recovery”. (Sarno M.T. 1991, p 559) The positive and encouraging side of the family members can contribute to the improvement of the patients’ depressed and isolated feelings. In terms of the family therapy, it is suggested that the spouses and the other members of the family should treat the patient as before the injury.
· Group therapy
The group therapy is the method that is used most in the recovery of the brain-injured patients. It is focused on making the patient feel better by the support of the group therapists. The aphasic has the opportunity to express all his anger, his anxiety, his violence and hostility in order to feel released and so to develop and built a new stronger and independent self. Moreover in a psychotherapy group the aphasic patient can talk about his experience and his emotional needs in a positively environment where he has time to think and express his views. In a therapy group like this, the patient can feel that he is understood and safe with result to become more open to the physical and psychological healing. (Murdoch B. E. 1990, p 94-97) Thus, this approach is considered to be very valuable and helpful in many ways because it helps the aphasic “break down some of the barriers which had been built up since the aphasia had occurred and also because it allows the exploration of conflicts in a controlled setting with professionals available to give appropriate support”. (Code C. & Muller D. 2002, p 23) Apart from this, self worth and restoration of self-esteem is regained from the conversations, the verbal interactions and mutual understanding from the other members of the group. Great attention should also be paid to the skills of the group leader as he has to be experienced and capable in order to be able to operate effectively the emotional, behavioral and perceptual deficits of the patient. (Lebrun Y. & Hoops R. 1976) Although the fact that the group therapy may be a very useful intervening method for the psychological rehabilitation of the aphasics, it can also be significant and necessary for their wives of the patients and their family members. As it has been referred previously, the social and the sexual life of the couple after the stroke or the TBI incident, changes completely. The spouses of the patients may also feel stress, isolation, frustration and anxiety. (Lebrun Y. & Hoops R. 1978) The group therapy gives them the chance to get rid of all these pessimistic feelings, make them feel better and improve their relationships with their partner.
· Counseling
Counseling is one of the most substantial parts of the holistic model and it can be a really effective mean of treatment when it is combined with other rehabilitation approaches. Counseling is not only beneficial for the aphasic patient but also for their family members and relatives. The therapist is aiming to improve the quality of life, the relationships and the linguistic ability of the aphasic. The supportive behavior and environment which the therapist creates, can change the patients perception and emotional grief. The counselor can change the patients’ discouraging feelings of disbelief, anger, hopeless, through a complex process. In the beginning, “he allows the patient to grieve and share with him his pain and afterwards he tries to install new emotions that help the aphasic accept the current situation and cope with his loss”. (Repper J. & Perkins R. 2003) The therapeutic process of counseling can repair the psychological damage and help the patient discover his self in order to built a confident and strong identity. Moreover the counselor helps the patients face the reality and understand their problem, as many aphasics have the tendency to overestimate their abilities because they cannot realize the severity of their condition.
· Behaviorist Model
The behaviorist model is another aspect of the psychosocial therapy of aphasia. It is based on the Skinner’s theory of “behavior modification through the operant conditioning, which stresses the importance of reinforcement in producing a certain behavior, useful for the rehabilitation”. (Code C. & Muller D. 2002, p 191) The therapists use this rehabilitation model in order to manipulate the patients’ behavior. So they change the depressed and anxious behavior of the aphasic with the help of a specific stimulus. This way of treatment is considered to be “ a programmed instructional approach, an educational process which applies to operant conditioning methods”. (Sarno M.T. 1991, p 551) The behaviorist model is very effective for the aphasic as the providing feedback from the therapist can change the patients’ psychosocial problems and the emotional disturbances. Furthermore, it gives the opportunity to the aphasic to retrieve information about him. In summary, it shows the patient the strategy, the way in order to modify his response –negative emotions- when another similar occasion happens.
· Conclusion
The overall conclusion we arrive at is that the aphasic patient exhibit neuropsychosocial deficits apart from the linguistic impairment. Aphasia is deemed responsible for psychological, social, familial and professional changes in the patients’ daily life. For these reasons, great emphasis has been put on the importance of rehabilitation to the social and emotional functioning. “Current trends in the concept of rehabilitation and in related forces of social change suggest that in the future, rehabilitation of the disabled will be cast in a broader social frame reference”. (Sussman M. 1965, p 34) So, this field needs further and deeper investigation in order new techniques or improvement of the current psychosocial approaches and methods of treatment to be developed.
Living with aphasia is a difficult and painful experience. In this dark trip the aphasic patient needs encouragement, hope and support from the therapist, the family members and relatives. The good psychology and positive thinking may be the most efficacious rehabilitation method.
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