Guest blogger Megan Nosol shares her experience running a writing therapy group by offering 10 helpful tips for starting your own aphasia treatment program.
Think of all the ways we use our writing skills on a daily basis: to-do lists, emails, text messages, birthday cards – the list can go on and on! Acquired dysgraphia, a writing impairment resulting from a brain injury such as a stroke, can have a profoundly negative impact on a person’s ability to communicate with the world around them. Especially if their speech is impaired too, as is often the case with aphasia.
Using the Life Participation Approach to Aphasia (LPAA) and evidence-based therapeutic writing techniques, speech-language pathologists can help people with acquired dysgraphia expand their communication abilities. SLPs can help to make writing less effortful through compensatory writing strategies and impairment-based therapy. This can help to increase the chances of a successful return to work, to improve a host of cognitive, linguistic, and perceptual motor processes, and to enhance quality of life for people with writing impairments.
Based on my experiences as the SLP leader of a writing group at the Triangle Aphasia Project and a former high school writing teacher, I developed a list of practical tips that you can use to develop a therapeutic writing group for people with aphasia. You can also use these tips in individual treatment sessions with clients with dysgraphia.
1) Pick a location and time that are reliable and consistent for your writing therapy group.
This may sound like a no-brainer, but space reliability and a room with a large table and chairs are crucial in running a dependable writing group that is functional for people with disabilities. If you do not have space in the facility where you work, contact a local non-profit organization, library, university, community center, or independent living community for a room to hold your group therapy once a week. A room with a whiteboard or chalkboard is a big plus!
2) Collect materials for the writing therapy group.
- Gather a big box of pencils, erasers, rubber grips for pencils (for clients using their non-dominant hand), markers, clipboards, and index cards. And if you don’t have a room with a whiteboard, get a giant easel pad.
- You will need lots of paper! I gather any non-confidential paper thrown away in recycling bins to use the backs in my writing group therapy.
- Lined pads of paper are useful with clients who have handwriting problems. Look for these at dollar stores or in sale bins at office supply stores.
- While you’re at the dollar store, buy several photo books. I frequently have clients write notes on index cards that they keep in photos book sleeves so they can refer to them when they write.
- Lastly, collect file folders to hold client work so that you can track progress more easily.
3) Recruit SLP students to provide more 1:1 opportunities for clients during your writing therapy group.
Reach out to your local university program to enlist student support for your group. This is an excellent opportunity for graduate students to learn how to evaluate and provide skilled therapy to people who have acquired writing impairments. Many of your clients may have special needs that require more one-to-one attention to increase participation in the group.
4) Get to know your writing therapy group members.
The essence of LPAA is placing the client at the heart of the decision-making in terms of treatment objectives. What are their interests? What is important to each of them? What are their short-term and long-term writing goals? Their interests, values, and goals should inform the topics of your writing exercises.
5) Select your therapeutic goals for the writing therapy group.
Your clients have come to your writing group for a reason. Find these reasons and target them with relevant writing exercises. Through a written checklist with examples and pictures, ask your clients what they specifically want to work on. Some ideas include: sentence generation, spelling, numbers, grammar, word-choice, assistive technology to make writing easier, email writing, text message writing, writing for communication purposes, creative writing, letter writing, or perfecting writing to return to work. Make a list of their needs and rotate requested topics in your group therapy sessions. Save this list and return to it once a month to ensure you are targeting writing tasks based on their needs and interests. I recommend only targeting 2-3 per 1.5-hour group therapy session (or 1-2 targets per 45-minute session).
6) Obtain a baseline of writing skills from each of your clients.
A full assessment of writing includes looking at spontaneous writing, written naming, writing to dictation, and copying a written statement. Try using the Cookie Theft picture from the BDAE to get a writing sample that you can compare over time. Once you have a sample, you can look at organization, sentences structure, word choice, and spelling (Chapey, 2008). Standardized stimuli for assessing writing can come from the WAB-R or BDAE-3 aphasia assessment batteries. The best assessments of spelling come from controlled word lists, such as in the PALPA or Johns Hopkins University Dysgraphia Battery (1985, described in this book). Keep these assessments in client folders and re-assess clients at regular intervals (I do this every 8 weeks) to track progress and re-examine your treatment approach. Having a graduate SLP student is helpful in conducting these assessments so you can focus on the therapy.
7) Learn more about the different types of acquired dysgraphias to better understand how to treat them.
There are primarily 4 types of acquired dysgraphia: phonological dysgraphia, deep agraphia, surface dysgraphia, and graphemic buffer dysgraphia. Keep in mind that clients can fall on a spectrum of these deficits or have various combinations of these types of dysgraphias.
- Phonological dysgraphia is characterized by poor phoneme-grapheme matching, or “sound-to-letter” conversion. Clients with phonological dysgraphia typically have a significant problem with spelling nonwords (made-up words like “flibbet”) and their spelling errors are often not phonologically plausible.
- Deep agraphia is characterized by both phonological dysgraphia and semantic errors. Nonword spelling is generally poor.
- Surface (or lexical) dysgraphia is characterized by a tendency to write phonetically. Homophones (words that sound alike such as “one” and “won”) are tricky for people with surface dysgraphia.
- Graphemic buffer dysgraphia is characterized by impairments in all writing tasks, a loss of letter ordering, and letter omissions, substitutions, transpositions, and additions. Many times, the initial letters are correct, but the middle and final letters of the words deteriorate.
8) Incorporate evidence-based therapeutic writing techniques into your client-centered writing tasks.
If you intend to treat these clients as an SLP and not as a writing coach or teacher, it is crucial that you use evidence-based therapeutic writing techniques to target writing deficits. Otherwise, you are not providing a skilled service. Unfortunately, we do not have a vast number of therapeutic writing techniques based on large, randomized studies examining methods for the rehabilitation of acquired dysgraphia. However, the following list captures all of the evidence-based, therapeutic writing techniques I frequently use with my writing therapy group:
- Phoneme-Grapheme Re-Training (Hillis and Trupe 1986)
- Written Naming Tasks (Hillis, 1991)
- Item-Specific Lexical Spelling Treatment (Clausen and Beeson, 2003)
- Anagram and Copy Treatment (ACT) (Beeson, Hirsch, and Rewega, 2002)
- Copy and Recall Treatment (CART) (Beeson and Rapcsak, 2002)
- Problem-Solving Approach to Spelling Training (Beeson, Rewega, Vail, and Rapcsak, 2000)
- Model-Driven Remediation of Dysgraphia (Hillis and Caramazza, 1987)
- Self-dictation strategy (Pound, 1996)
- Graphemic Buffer and Attentional Mechanisms (Hillis and Caramazza, 1989)
9) Develop a list of writing tasks that are based on client’s interests, can be adjusted in difficulty, and can work well for training therapeutic writing techniques and strategies.
Be prepared to differentiate tasks based on the client’s dysgraphia type and severity, fine motor restrictions, and strengths and weaknesses. I modify each group writing tasks to easy, moderate, and difficult levels so that all clients can participate in the group. To achieve task differentiation, the SLP needs to know the client and understand what writing techniques and strategies are effective for him or her. Here are some writing task ideas:
- Play Hangman
- Writing down phone messages
- Round Robin Text Messaging
- Emailing a partner
- Pen pals
- Grocery calculations for number writing
- Check writing
- Group-made birthday, thank you, or sympathy cards
- Find the Error (editing game)
- Complete the sentences with a word or phrase
- Complete the word for spelling
The Writing Therapy app can be used for fill-in-the-blank, copying, writing to dictation, and written naming tasks. Number Therapy has an activity devoted to typing number concepts that are heard or read. Reading Therapy has phrase and sentence completion activities that are valuable practice for writing.
Try all these apps for FREE by downloading the Lite versions, or find other apps that are right for your aphasia therapy needs with the Tactus App Finder.
10) Encourage home practice and the use of technology as a compensatory strategy.
To increase successful carryover of trained skills, I provide 1-2 home therapy tasks per week and provide clients with a list of situations in daily life where they can practice their newly trained skills. We know that technology can help, and apps can make therapy more enjoyable and make tracking progress easier. Voice dictation, spell check, word prediction, grammar check, abbreviation expansion, and stored messages can really improve functional writing.
However, the brain receives motor feedback during the physical act of writing. This is important for rehabilitating the brain’s ability to recognize letters and sounds again. Therefore, show clients how they can practice writing by hand first, and then check their work with an app. Or how they can spell a word using technology, then write it out by hand. If they are only dictating to their phones to create text messages or emails, or if they are exclusively using writing therapy apps on their tablets or laptops in place of written home therapy work, they are missing a critical piece of writing rehabilitation: the physical act of writing.
So put pen to paper and have fun! Running an aphasia writing therapy group can be a rewarding experience for all involved.
Further resources for writing therapy:
All of the articles linked above provide valuable evidence-based treatments for writing. Roberta Chapey’s 2008 book, Language Intervention Strategies in Aphasia and Related Neurogenic Communication Disorders, is another excellent resource for evaluation and treatment of people with aphasia.
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