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Individualized (Re)engagement Plans 

An individual with aphasia likely has been introduced to the rehabilitation continuum…he/she has had physical, occupational and speech therapy, has been motivated by the recreational therapist and supported by the case manager.  A team of cheerleaders who know the game and recognize the potential barriers to the goal of returning to their role in their family, their social networks and their community helps guide their journey through rehabilitation.  So, what’s next?

The world around us has embraced the concept of accessibility.  Handicapped parking, wheelchair ramps and rails allow for access to restaurants, theatres, places of worship and businesses…opening the door for return to vocational and social pursuits.  But what ramps are available if an individual’s greatest barrier is his/her communication?  And, why, do we suppose, is it so difficult for an individual with aphasia to return to the things that he/she loved to do, to their career?  to their community service?  to their roles as spouse, parent, student, friend, etc.?

Think about it… Communication is the connector, the link between one human being and another.  It is the means by which we introduce, establish and maintain relationships.  It is the power we call upon to pursue, to challenge, to persuade and to advocate.  It is the tool we rely on for teaching, emoting and inspiring.   Communication defines us.  How many times have you heard, “He has great communication skills”, “They had a communication breakdown”,  “We are working on our communication”… these phrases reveal the great emphasis and weight that understanding and expression has in our lives.

But it’s more than that…the defining nature of our communicative abilities suggests that impairment in those skill areas can, and will, significantly impede our success in those roles.  Not surprisingly, the result of deficits in speech and language is a withdrawal from those roles that require this power of communication…the extent can range from avoiding a ringing phone to becoming socially isolated.  The cause, in part, can be attributed to a strike to one’s communicative confidence.  An individual with aphasia can question, doubt and even deny his/her communicative power, and as with any other measure of confidence,… avoidance or withdrawal of attempts, will only serve to reduce it further, creating a cycle feeding itself with untested perceptions.  But, as the saying goes, “perception is reality” …an individual’s view of his/her communication skills and challenges will influence the person’s direction and outcome.

Thus, the power of Individualized (Re)engagement Plans!  A personalized approach to the individual’s communicative profile, their goals and careful attention to perceptions and confidence as it relates to communication!

The IRP begins with a functional assessment of communicative strengths, opportunities and a measure of success with the use of supports, be it a trained individual, resources/props or an augmentative communication system.   Personalizing the plan also requires that we, the client, family and speech pathologist, discuss the individual’s interests, roles, and life objectives.  Knowing that “what were your loved one’s fundamental preferences, likes, and dislikes, still are.” (Lyon, 1998), TAP at WakeMed Rehab helps reinforce your hope in returning to all of those things in your life that make you uniquely you.  Together, we create a plan.  A set of individualized hierarchies to assist you in returning to those goals, one step at a time.

The result of the IRP should be a recognition that it is not adaptation OR rehabilitation…it is NOT compensating for what was lost, putting off plans for life until some arbitrary time when an individual feels “completely ready”, and it is NOT forsaking your hopes, dreams and aspirations.  It IS, rather, a realization that this challenge of aphasia will require a plan, lots of support and a basis in hope.  Likening the journey to one taken on a two lane road, a dotted line allowing constant movement back and forth between compensation and rehabilitation, with full appreciation for the scenery, the side trips and opportunities to enhance your life and ensure happiness.

Compensation Rehabilitation

The next step in the IRP is brainstorming, a process that allows for do-able ways to address the life goals of the individual.  What supports need to be in place to make it happen?  What environmental modifications can be suggested to support an individual in the return to social pursuits, a vocational goal or a role in the family?  For example, can the person return to the role of bill-payer if we use the aid of a computer program, or copying vs. writing the checks?  Can a person go back to their civic club or weekly bridge game if the other members are trained to “speak aphasia”?  The possibilities are endless; there are no right or wrong…just supported attempts and lots of feedback on how to modify the process.

The key to this aspect of intervention is variability (different tasks every day), frequency (every day w/ respect for fatigue) and multimodality (something that involves listening and then reinforced with visual methods).

An IRP suggests a starting point…a springboard for return to life goals.  And, as is evident from this program description, a crucial component to that plan is the supports one can access that will aid in a successful (re)engagement.   At TAP at WakeMed Rehab, we refer to the human supports as the Communication Support Team.  (© 2007, Silverman)  The Team is made up of individuals who are willing to work with the person with aphasia in either the Individualized Home Program or the Reengagement Plan, or both.  Perhaps the person will commit to an hour a week, to come to the individual’s home to read with him/her or an old colleague from work will take the individual to a club meeting or out for a round of golf.  This critical piece of the program establishes social (re)connections, offers language stimulation and even provides some much needed respite for the primary communicative partner.

For questions or referral to TAP:

Contact the Clinical Specialist

Maura English Silverman, MS, CCC/SLP

Triangle Aphasia Project at WakeMed Rehab

Phone:  919- 350-0981

Email:  msilverman@wakemed.org

Let’s create a program where one doesn’t exist… together we can creatively find solutions to the needs of individuals with aphasia!

Handout of Hints

Before we get started…

·        It takes two to tango; state the obvious “We’re in this together”; “We both know how to speak aphasia!”

·        Remember to take turns; slow yourself and your communicative partner down.

·        Do things collaboratively; share the communicative burden.

·        Be flexible; try a variety of ways to exchange info.

·        Don’t just use the techniques when communication breakdowns occur…use them habitually to help set the template and create a new way of communicating.

·        Remember that “key words” not only demonstrate the flow of the story/conversation, but they also provide a means of expression for the Person With Aphasia (PWA) and can be used during verification to be sure you are on the right track!

·        Rapport and sharing a sense of self, your humor, etc. are most important in a mutually satisfying conversation! 

Step One:  The setting…

1.      Know the situation…is this idle chit-chat, a sharing of stories or something more urgent?

2.      Do we need to modify the environment (turn TV off, etc.)?

3.      Do I need any tools (paper, props, etc.?)



Step Two:  The supports…

1.      Start with what you know…narrate the situation (i.e. “You look excited/worried/upset”); use facial expression, situational cues to help you start the conversation.

2.      Encourage the PWA to communicate first…comment on any and all techniques they use / give specific feedback on what helped and what you still need to know.

3.      Listen (and Watch) for a general theme, …write down and ask about that general theme.

4.      Write key words throughout the exchange; cross out any words that you have determined were an incorrect path.

5.      Ask the PWA to gesture, or “show” you if the verbal attempts are unsuccessful; comment on what you see, and write it down to confirm accuracy.

6.      Ask the PWA to draw or write something (you can put those options out as cue cards if that helps); don’t read the message too literally!

7.       Ask the PWA general and BROAD questions, always avoid asking narrow (20-question type) questions.

8.      Try drawing concurrently and label (in questioning tone) any drawing that the PWA makes.  Label yours also!

9.      Ask questions about the drawing or gesture, “Okay, is this a ___________?”; if you can’t figure out what the drawing is, ask the PWA to point out the most important part of the drawing. 

10.Provide choices to the PWA if you have narrowed your topic enough to do that (be sure you provide the choices in writing as key words!)

11.Give the PWA a yes / no card or write it on the paper for determining accuracy of what you are saying and what they are saying too.

12.Use visual scales, number sequences, props (newspaper, map, etc.) to strengthen the info going in and to provide an opportunity to help get the message out.

13.Ask WH- questions (written and verbal) to focus your attention on the message.  (i.e. “When did this happen?; “Who did that?”

14.If the PWA has a communication book, encourage them to see if the information is in there.



Step Three:  The rehearsal

1.      Verify, Verify, Verify!!  Use statements like, “Let me tell you what I understand so far”; “Wait, Joe, Let me make sure I am on the right track”.

2.      Review the key words and flow of conversation; restate those that you crossed out, saying “and you told me it wasn’t _________”.

3.      Label pictures, clarify and ask for additional detail on anything that you aren’t sure of.

4.      Double check yes/no’s, relationship words (wife, brother, etc.) and man/woman.  These are often incorrect and not realized.



Step Four:  The encore…

1.      Give feedback at the end of the exchange/story on what helped you and what didn’t;  Admit your mistakes and talk about breakdowns in communication for what they are…both listener and speaker errors. 

2.      Emphasize the positive and demonstrate by review what was actually communicated (Many individuals with aphasia are unaware that they got that much across!)

If you just can’t get the message exchanged, take a break, and come back to it.