Drama therapy offers an authentic medium through which people with aphasia can interact and share their experiences. We describe the rationale and procedures of a drama therapy class for individuals with chronic aphasia, focusing on the patient-reported outcomes of a representational group of seven participants.  Subscales of the Burden of Stroke Scale (BOSS) and the Communication Confidence Rating Scale for Aphasia (CCRSA) were administered before and after participation in the 18-week class.  Means, standard deviations, and effect sizes were computed.  Results indicated perceived improvements in both communication and mood (medium effect sizes), but not in social relations

Cherney, Leora

Oehring, Ann

Rubenstein, Ted

Whipple, Keith

The Aphasiology Archive

1  Patient-reported outcomes following a drama class for individuals with chronic aphasia   INTRODUCTION  Despite linguistic gains following treatment, people with aphasia (PWAs) experience residual communication problems that significantly impact their daily lives. They report social isolation, loneliness, loss of autonomy, restricted activities, role changes, and stigmatization.1,2 As a result, there has been increased emphasis on approaches that focus on enhancing the “living of life with aphasia”. The major goal of these “Life-Participation Approaches to Aphasia" (LPAA) is to facilitate participation in personally relevant activities to help PWAs achieve and maintain a good quality of life.3 Consistent with the goals of the LPAA, we used drama and drama therapy to create an innovative communication experience in which individuals with chronic aphasia conceptualized, wrote and produced a play addressing their experiences of having, living with and coping with the effects of aphasia.  Drama therapy has been defined by the National Association of Drama Therapy as the systematic and intentional use of drama/theater processes, products, and associations to achieve the therapeutic goals of symptom relief, emotional and physical integration and personal growth.4 Drama therapy is an active, experiential approach that facilitates the client's ability to tell his/her story, solve problems, set goals, express feelings appropriately, achieve catharsis, improve interpersonal skills and relationships, and strengthen the ability to perform personal life roles while increasing flexibility between roles.  Since drama therapy emphasizes the interplay between thought and speech, and allows communication of ideas through both non-verbal and verbal means, it offers an important authentic medium through which people with aphasia can interact and share their experiences.    In this poster, we describe the rationale and procedures of this creative arts therapy class for aphasia, with a focus on the patient-reported outcomes of a representational group of seven participants.    METHODS  Participants in the drama class met once weekly for 90 minutes over 18 weeks. Sessions were co-facilitated by a speech-language pathologist and a drama therapist.  Each session was audio- and videotaped and then transcribed for use in planning and script development. Initially, general theater games and activities provided the foundation to maximize communication opportunities and communication exchanges. Intermediate sessions incorporated improvised storytelling, scene generation, and script development and revision. Later sessions incorporated practice and rehearsal, culminating in performance of a production in front of a live audience.     Subjects Core group members included 14 (9 male; 5 female; 12 white, 2 black) individuals with chronic aphasia. Mean age was 55.85 years (range: 31-76 years). Etiology was predominantly stroke, with a range of physical residuals and aphasia classifications. Educational, vocational, ethnic, 2  and socio-economic backgrounds were diverse. Mean time post onset was 6.1 years (range:11 months - 27 years).    A representative sample of seven participants (5 male, 2 female; 6 white, 1 black) were evaluated before and after participation in the theater class.  Mean age was 56.7 years (SD=9.71; range 41-73 years). Mean time post onset was 8.29 years (SD=8.6 years; range 3-27 years). Clinically, three participants were characterized as having a mild anomic aphasia (all recovered from Broca’s aphasia), while four participants were characterized as having a moderate Broca’s aphasia.  Etiology was stroke in 6 participants and a gunshot wound in one participant.  All but one of the participants was right-handed premorbidly. Mean education level was 15.7 years (SD=3.4 years, range 12-21 years) and premorbid occupations included the following: history professor; janitor; actor; retail store owner; housewife; lawyer; commercial real estate manager.  Patient-Reported Outcomes Measures of patient-reported outcomes were administered before and after participation in the theater class using selected subscales of the Burden of Stroke Scale (BOSS)5 and the Communication Confidence Rating Scale for Aphasia (CCRSA)6.  All testing was conducted by a speech-language pathologist who was independent of the treating speech-language pathologist.  The BOSS is a comprehensive, patient-reported measure of functioning and well-being. It is a 64 item scale, comprising 12 internally consistent and unidimensional scales.7  The Communication Difficulty (CD) subscale consists of seven items; the Social Relations subscale consists of 5 items, and the Mood subscale consists of 4 items representing a negative mood (lonely, anxious, angry, sad) and 4 items representing a positive mood (confident, happy, calm, optimistic about the future).  Each of these subscales has an associated psychological distress scale (communication associated distress; social relations associated distress; mood associated distress). BOSS subscales and questions are listed in Appendix 1.     The CCRSA is a 10-item self-report scale that assesses the PWA’s confidence in communication in various situations. Participants indicate their degree of confidence on a horizontal visual analogue scale with markings from 0-100.  Preliminary analyses indicate that the CCCRSA is internally valid and reliable.6 The CCRSA items are included in Appendix 2.    Analysis Means and standard deviations of each BOSS subscale and CCRSA score were calculated at each assessment period. Because of the small number of subjects, effect size measures were computed from pre- to post-participation in the drama class. Effect size measures the magnitude of a treatment effect and, unlike significance testing, is independent of sample size. Cohen's d  was calculated for dependent measures using the original means, standard deviations, and correlation coefficient.8  Effect sizes were benchmarked against Cohen’s (1988) definition of effect size as “small, d=0.2,”, “medium, d=0.5,” and “large, d=0.8.”9  RESULTS  Table 1 shows the means, standard deviations, and effect sizes. On the CCRSA and the BOSS mood subscale (positive), a positive effect size represents improvement.  On all other BOSS 3  subscales, a negative effect size represents improvement as indicated by a decrease in burden or associated distress.    None of the effect sizes were large; however, several effect sizes demonstrating perceived improvements following participation in the drama class could be benchmarked as medium.  These included responses on the BOSS communication burden and communication distress scales and the positive mood scale.  Perceived improvements that could be benchmarked as small included increased communication confidence as measured by the CCRSA and decreased negative mood and mood distress.   DISCUSSION AND CONCLUSIONS Participation in a drama class for aphasia resulted in perceived improvements in both communication and mood.  Communication changes were indicated by decreases in both communication difficulty and the distress associated with communication, as well as small, but increased communication confidence.  Mood changes were determined by moderate increases in positive feelings, and small decreases in negative feelings and the distress associated with these negative feelings and emotions.    Notable improvements did not occur on all BOSS subscales. Interestingly, there were no perceived changes in the participants’ difficulty with social relations or associated distress.  Such findings are not surprising given the chronicity of the aphasia, and the fact that the PWAs were all living in the community and had previously attended other sessions of community aphasia groups.  However, the lack of perceived change in social relations serves to highlight the impact of the drama class specifically on communication and mood.  Factors contributing to perceived changes in communication and mood, including use of specific drama therapy techniques that focus on communication skills and the success associated with the live performance, will be discussed.   Finally, patient-reported outcomes have been called the new “gold standard” for many chronic conditions, and there is broad agreement on the importance of incorporating the patient’s own perspectives about the impact of treatment.10,11 Given that aphasia is a chronic condition, the value of the PWAs own self-report and perceptions of their condition should be considered.     REFERENCES  1.  LeDorze, G. & Brassard, C. (1995).  A description of the consequences of aphasia on aphasic persons and their relatives and friends based on the WHO model of chronic diseases.  Aphasiology, 9, 239-255. 2.  Parr, S. (1994). Coping with aphasia: Conversations with 20 aphasic people.  Aphasiology, 8, 457-466. 3. Chapey R, Duchan JF, Elman RJ, Garcia LJ, Kagan A, Lyon J, Simmons-Mackie, N. Life Participation Approach to Aphasia: A Statement of Values for the Future. Retrieved April 4  5, 2009: American Speech-Language and Hearing Association website: http://www.asha.org/public/speech/disorders/LPAA.htm 4. National Association of Drama Therapy.  What is drama therapy? Retrieved January 18, 2010: http://www.nadt.org/faqs.htm 5. Doyle, PJ, McNeil MR, Hula WD. (2003). The burden of stroke scale (BOSS): validating patient-reported communication difficulty and associated psychological distress in stroke survivors. Aphasiology,17, 291-304. 6. Babbitt, E., Cherney, LR, Heinemann, A., Semik, P. (2009). Using Rasch Analysis to develop the Communication Confidence Rating Scale for Aphasia (CCRSA). Clinical Aphasiology Conference, May,2009.  7. Doyle PM, McNeil MR, Mikolic JM, Prieto L, Hula WD, Lustig AP, Ross, K, Wambaugh JL, Gonzalez-Rothi LJ, Elman RJ. The burden of stroke scale (BOSS) provides valid and reliable score estimates of functioning and well-being in stroke survivors with and without communication disorders. Journal of Clinical Epidemiology 2004; 57: 997-1007. 8. Morris, S. B., & DeShon, R. P. (2002). Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychological Methods, 7, 105-125. 9. Cohen J. Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Earlbaum Associates; 1988 10. Wiklund, I. (2004). Assessment of patient-reported outcomes in clinical trials: the example of health-related quality of life, Fundamental & Clinical Pharmacology, 18(3), 351-363.   11. Fries, J. F., Bruce, B., & Cella, D. (2005).  The promise of PROMIS: Using item response theory to improve assessment of patient-reported outcomes. Clinical & Experimental Rheumatology, 23 (Suppl. 39):S53-S57.    Table 1.  Effect Sizes of Patient-Reported Outcomes Following Participation in a    Theater Class:   Test Pre-Participation Post-Participation   Mean SD Mean SD Effect Size BOSS        Communication  - Burden 12.29 4.99 10.21 3.83 - 0.46   Communication  - Distress 7.00 2.77 5.86 2.19 - 0.51   Social Relations - Burden 7.14 3.44 6.71 3.64 - 0.16   Social Relations - Distress 5.43 3.21 5.64 3.22   0.07   Mood (Negative items) 6.71 4.57 6.14 2.54 - 0.33   Mood (Positive items) 8.29 2.75 9.93 3.01   0.61   Mood  - Distress 1.57 1.13 1.71 1.38   0.22 CCRSA 71.71 14.12 74.43 9.13   0.38 Highlighted items indicate a medium effect size.   5  Appendix A.  BOSS items  Communication  Because of your stroke, how difficult is it for you to… 1 Talk? 2 Understand what people say to you? 3 Understand what you read? 4 Write a letter? 5 Talk with a group of people? 6 Be understood by others? 7 Find the words you want to say?    You indicated that you have some difficulties communicating. DM3 How often do difficulties communicating cause you to feel anxious, unhappy or frustrated? DS3 How much do difficulties communicating cause you to feel dissatisfied with yourself or your life? DR3 How much do difficulties communicating prevent you from doing the things in life that are important to you?  Social Relations  Because of your stroke, how difficult is it for you to… 1 Enjoy leisure activities with friends or relatives? 2 Keep old friendships going? 3 Maintain your role as a friend or family member? 4 Interact with people you’re meeting for the first time? 5 Interact with friends and family members?    You indicated that you have some difficulties in social situations or relationships. DM6 How often do difficulties in social situations or relationships cause you to feel anxious, unhappy or frustrated? DS6 How much do difficulties in social situations or relationships cause you to feel dissatisfied with yourself or your life? DR6 How much do difficulties in social situations or relationships prevent you from doing the things in life that are important to you?  Mood (Negative)  Since your stroke, how often do you feel… 1 Lonely? 2 Anxious? 3 Angry? 4 Sad?    You indicated that you experience some negative feelings and emotions. DR8 How much do your feelings and emotions prevent you from doing the things in life that are important to you?    6  Mood (Positive)  Since your stroke, how often do you feel…  1 Confident? 2 Happy? 3 Calm? 4 Optimistic about the future?    Appendix B.  CCRSA items  1. How confident are you about your ability to talk with people? 2. How confident are you about your ability to stay in touch with family and friends? 3. How confident are you that people include you in conversations? 4. How confident are you about your ability to follow news and sports on TV? 5.  How confident are you about your ability to follow movies on TV or in a theater? 6. How confident are you about your ability to speak on the telephone?  7. How confident are you that people understand you when you talk? 8. How confident are you that you can make your own decisions? 9. How confident are you about your ability to speak for yourself? 10. How confident are you that you can participate in conversations about your finances?  

Patient-reported outcomes following a drama class for individuals with chronic aphasia

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