Wednesday, January 10, 2018

Reading :: A Cognitive Neuropsychological Approach to Assessment and Intervention in Aphasia: A clinician's guide

A Cognitive Neuropsychological Approach to Assessment and Intervention in Aphasia: A clinician's guide
By Anne Whitworth, Janet Webster, and David Howard

Although I was worried that this clinician's guide to aphasia would be too technical, I found it to be readable and well organized. Maybe it's all that Luria I've been reading recently.

The authors proffer the cognitive neuropsychology approach, which "first emerged as a coherent discipline in the 1970s as a reaction to the then dominant approach [to diagnosing aphasia] in neuropsychology," the "classical approach," which "sought to characterize the performance of people with aphasia by defining them in terms of their localisation of lesion" (p.3). Recall that Luria argued in Higher Cortical Functions of Man against a hard localization thesis (ex: a "speech center" of the brain, a "writing center," etc.), but Luria did accept a weaker version of the localization thesis—a fact that is not belabored here, but discussed in some of the other neuropsychology books I'll be reviewing soon.

In any case, the authors of this book discuss how to diagnose types of aphasia, identifying variations by different types of impairment. They also discuss therapy approaches, which typically "draw on compensatory strategies (other language and communication skills) to take over those impaired functions" (p.89). I especially appreciated Table 9.1, which lays out different therapy approaches:

  • Reactivation
  • Relearning
  • Brain reorganisation
  • Cognitive-relay
  • Substitution
  • Compensation (p.92)
For our purposes, a couple of these are particularly interesting. The authors describe the cognitive-relay approach's aims this way: "To seek an alternative route or means of performing the language function, i.e. use intact components of the language system to achieve the impaired function through indirect means (Luria, 1970)." The citation is to Luria's Traumatic Aphasia, which I haven't read, but I can see the connection to Luria's other books—especially Higher Cortical Functions of Man and The Man with a Shattered World. Perhaps importantly, the contrast of this approach with the other therapy approaches helps me to think through Miller's argument in Vygotsky in Perspective: that Vygotsky's approach focused on sign mediation and self-mastery, not tool mediation and labor, as later activity theorists did. Luria arguably continued this approach, finding ways to reconfigure cognition to restore functionality. One famous example from Man with a Shattered World: he counsels the patient not to try to spell out words but to write them without thinking. What could not be done with conscious attention could be done via "kinetic melodies."

Compare that approach with another one on the list. Substitution aims "to encourage the adoption of an external prosthesis to promote communication." That is, it turns to physical mediators—tools—distributing part of the job to parts of the environment. One example, although not related to aphasia, might be the approach that Leontiev and Zaporozhets took in Rehabilitation of Hand Function and Leontiev's later works, in which external tools (grids, kymographs) were integrated into the rehabilitation activity, providing an additional feedback loop. Such physical mediators are a common focus in activity theory and, as Miller notes, are typically not well distinguished from psychological mediators (i.e., signs). 

In any case, this book is a solid, generally accessible discussion of how aphasia can be assessed and treated. If you're new to neuropsychology, this might not be the place to start, but it's still pretty readable.

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