6 Interactional aphasia

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Interactional aphasia Principles and practices oriented to social intervention Jack S. Damico, Martin J. Ball, Nina N. Simmons-Mackie and Nicole Müller

One of the real accomplishments during Chris Code’s tenure as Editor in Chief of Aphasiology: An International and Interdisciplinary Journal has been his consistent advocacy of psychosocial issues and social models of aphasia treatment. This chapter is intended to advance his efforts and those of numerous other social scientists in clinical aphasiology by advocating a more direct focus on interactional aphasiology as a sub-discipline of clinical aphasiology. In the nineteenth century there was a flourishing of research and clinical experience that gave way to the first major focus on the human brain and its disabilities (Eling, 1994). Led by physicians and researchers who are now the recognized founders of medical and clinical aphasiology (e.g., Gall, Broca, Wernicke, Freud, Jackson), there occurred a great accumulation of knowledge regarding the brain and the consequences of brain damage. It took some time, however, before these data were placed within acceptable frameworks for various medical and clinical applications. John Hughlings Jackson, one of the founders of modern neurology, once discussed this problem of data overload. He suggested that although we have multitudes of facts, we require, as they accumulate, organizations of them into higher knowledge. He felt that we needed some better generalizations and working hypotheses (1882). Over the 125 years since this assertion, we can recognize both the problem that Jackson stated and several solutions that were eventually employed. With the formulation of neuropsychological approaches of brain functioning and damage pioneered by Lashley (1929) and Luria (1947), the focus on medical aphasiology led by Geschwind (1965), and the development of clinical aphasiology according to Schuell (1953), Darley (1975), and Porch (1967), the accumulated data over the last hundred years have been (somewhat) successfully applied to clinical populations. Despite these successes, however, there are problems with the ways in which the accumulating data are organized and employed within clinical populations. To an even greater extent than occurred in the nineteenth century, we are accumulating data and research findings that require additional generalizations and working hypotheses that are somewhat different from those that have preceded us. As suggested by Jackson, we have to organize our data into

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higher levels of knowledge to create effective working hypotheses of how these data fit within the framework of individuals who are trying to negotiate the impact of aphasia. This chapter proposes one way to better organize some of the data that currently confront us, an orientation that will assist our understanding and focus on language, interaction, and aphasia. In this chapter, we propose that we move toward a more formal, explicit, and high profile focus within our discipline of clinical aphasiology. A focus on authentic interactions in aphasia utilizing the research methodologies appropriate to these phenomena and the applications and practices drawn directly from theories and investigations directed to face-to-face interactions. We propose the creation of a sub-discipline of Interactional Aphasiology. Given the recent advances in clinical aphasiology toward a greater acceptance of qualitative research methods (e.g., Damico, Simmons-Mackie, Oelschlaeger, Elman, & Armstrong, 1999; Goodwin, 1995; Klippi, 1991; Wilkinson, 1999), and a growing focus on the functional and social considerations of aphasia (e.g., Ferguson, 1996; Holland, 1991; LeDorze & Brassard, 1995; Penn, 1987; Worrall, 1992), this proposal may not seem unusual or bold. Indeed, there have been a number of efforts over the past few years toward a focus on aphasia as a clinical and practical impairment that results in extensive interactional consequences. Despite these recent advances within the history of aphasiology, attention to authentic interactional data and how they impact on social consequences has only minimally been advanced. It certainly has not been a major focus within the organized efforts oriented toward clinical aphasiology. For example, in the loosely structured organization that holds the Clinical Aphasiology Conference every year, the vast majority of research papers presented have not focused on authentic interactional data or social consequences. Further, a reading of the current trends within the United States and within Europe shows they are far more oriented toward linguistic and processing approaches to intervention and to modular cognitive models, both to explain aphasia and to provide interventions. Those researchers who focus on authentic interaction in aphasia are certainly in the minority in the professions oriented to clinical aphasiology. This lack of orientation to interactional issues is surprising when the pervasiveness of the social and interactional consequences of aphasia is considered. One reason for this neglect appears to be that the issues of interaction in aphasia and of the social impact of aphasia are complex and involve numerous variables and considerations. When viewing this complexity, it is not surprising that the discipline of aphasiology with its medical and experimental orientations has not focused extensively on these issues. There are many areas of significance still to be investigated within the realm of aphasia. Aphasia, however, is a large field, capable of entertaining diverse orientations. The time is right for an explicit orientation embracing the complexity of authentic interaction and social action rather than ignoring it.

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To continue developing this line of research and its clinical implications, and more importantly, to get clinicians and researchers, professors and students to employ the work based on strong research and the principles and practices that result from this research, it is necessary to extend the awareness that the long-term consequences of aphasia are generally linked to the interactional realm. For, as Garfinkel (1967) and Goffman (1974) have stated, the genesis of society and social action is in the face-to-face interactions between individuals.

An operational framework To create the needed orientation, an operational framework is required. There are several reasons for such a framework. First, it will enable the development of an effective set of principles or guidelines to direct future work and application within this proposed sub-discipline. To establish a disciplinary study, one must have a set of principles or constraints within which to operate. Second, once the framework is proposed and the principles developed, researchers oriented to this area can become more improvisational in their approaches to research and clinical application, and still be directed by the framework. This should enhance the creativity and originality of the research and clinical initiatives. Finally, an operational framework that represents an enhanced orientation will serve as an impetus to professionals interested in this area, so that they can adjust to the needs and opportunities of interactional aphasiology. Frankly, to incorporate people into a movement, you need a direction, people to advance and implement the movement, and, in effect, a flag or banner that others outside the vanguard will follow. The sub-disciplinary structure and its operational framework will supply such a “banner.” A sub-discipline of interactional aphasiology should consist of a set of principles and practices not just oriented to the social components or consequences of aphasia per se, but primarily to the interactional aspects that involve a focus on authentic face-to-face activities and the abilities and variables of interest within such authentic activities. The need to focus on face-to-face interaction can be accomplished in many ways; directly via methodologies like conversation analysis and other products of ethnomethodology, and indirectly as when we investigate the motivations, impact, and affective issues involved with authentic interaction and when we set about creating applications generated by the data collected. Further, this framework – even as a working endeavor – should be advanced in ways that will enhance the objectives, data, implications, and applications of research regarding authentic interaction to other aphasiologists and to those interested in clinical aphasia. To formulate this framework, we can draw from a large knowledge base. Other realms of social science have targeted interaction as social action in all its authenticity and complexity, and have focused on how social action is effectively established, negotiated, and

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sustained. Consequently, we can adopt some of this cross-disciplinary work into a study of social action that can enrich our appreciation of interaction in aphasia. This chapter discusses some of the social science research that may be outside the clinician’s typical experience, but is relevant to the establishment of interactional aphasiology. As a starting point, the following ten principles are suggested as the guiding values for the sub-discipline of interactional aphasiology.

Principles for interactional aphasiology Given the complexity of authentic interaction in all its various manifestations, it is important to have a set of principles available when engaging in data collection, analysis, and interpretation. These principles can guide how data are treated and what importance the data or patterns of data might hold. Further, a set of principles can inform the framework from which we operate to construct values, strategies, and techniques that can assist in increasing our knowledge and the applications of this knowledge in interactional aphasiology. Based on our research and a survey of the literature, there appear to be a number of interactional principles of social action that should be considered. Here is a list of those considered most important at present: Principle one: Authentic face-to-face interaction For the initial purposes of a framework in interactional aphasiology, there must be a clearly distinguished focus for our research and clinical endeavors. This focus should consist of a continual orientation of activity toward authentic face-to-face interaction in its various forms. That is, within this sub-discipline, the topic and context of interest should revolve around face-to-face interaction in terms of how it is systematically accomplished, what variables impact on face-to-face interaction, and the implications of neurological damage to this social dyad. In their classic sociology text, The Social Construction of Reality, Berger and Luckmann wrote, “The most important experience of others takes place in the face-to-face situation, which is the prototypical case of social interaction. All other cases are derivatives of it” (1967, p. 28). This principle suggests that people construct the meanings of objects and situations through their interactions with one another. That is, through their face-to-face interactions, individuals socially construct their behaviors, expectations, and beliefs (Gergen & Davis, 1985; Goffman, 1974; Rogers, 1980; Scheff, 1990). This belief and its applications provide an effective guide to determining what should be investigated, and what should become the object of descriptive assessment and compensatory intervention. The focus on face-to-face interaction is the basis for interactional sociology and it can serve us as a first principle as well in interactional aphasiology.

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Principle two: The constructive nature of interaction Within the social sciences there is a pervasive idea that both orients our attention to the social world and, consequently, must serve as the actual rationale for our endeavors within the sub-discipline of interactional aphasiology. This is the principle of social constructivism. It suggests that the major work and accomplishment of face-to-face interaction is the construction of the meanings of objects and situations based on our interactions with one another. That is, through face-to-face interactions, individuals socially construct their behaviors, expectations, and beliefs. Based on this principle, many of the human behavioral traits and psychological processes like self-identity, competence, and the capacity and reactions to intimacy are viewed less as stable internal constructs and more as the products of external interactions with others (Berger & Luckmann, 1967; Kemper, 1991; Shotter, 1984). The significance of this principle for interactional aphasiology lies in the fact that it provides one with a theoretical framework relating to the creation and preservation of both social and psychological behaviors. Rather than assuming that a particular trait or a specific behavior is due solely to a psychological construct or neurological module outside the social realm, this principle places the genesis of any trait, belief, or behavior squarely within the social sphere. Who we are and how we react is partially and importantly based on our previous and concurrent social interactions. In effect, this principle provides us with the rationale for why we should study face-to-face interaction. There is a social component to all human behaviors and traits, and to understand this phenomenon in aphasic patients, to understand how this phenomenon is modified and re-constructed, we must study where the social construction occurs – within face-to-face interaction.

Principle three: Local negotiation of social action Consistent with the first two principles, a third interactional principle also places the emphasis on the actual activities that occur during face-to-face interaction. This principle is based on the widely documented finding within ethnomethodology that successful social action is accomplished at the local level (Duranti & Goodwin, 1992; Garfinkel, 1967; Heritage, 1984). This means that any social phenomenon as it unfolds is locally and immediately constituted through the observable activities of the participants. This principle is consistent with the expectation that an individual’s “common-sense” knowledge during interaction is employed on an instance-by-instance basis to construct social action. In this sense, what participants in a social interaction will do in their next interactive turn is related to what their partners have done in the immediate prior turn. This reliance on the immediate and local actions and context such that one action helps determine the next creates a conditional relevance, so that a first action helps determine what may occur as a second action, and the second

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actually depends on what occurred as the first action (Goodwin & Heritage, 1990; Wilkinson, 1999). In any social action the importance of this local negotiation can be generally stated as a condition where actions project next actions. Said another way, the presence and impact of participants in an interaction impinge on each other as the face-to-face situation continues. In effect, authentic interaction is constructed through a continuous reciprocity of expressive acts. Consequently, when researchers and clinicians orient to face-to-face interaction, they can focus on the actual behaviors and possible interpretations as revealed in the actual data before them. This provides a mechanism for understanding social action without having to delve too far outside the actual interactional dyad. For our part in interactional aphasiology, we should orient the aspects of the local management of interaction to discover how and when this occurs. Principle four: The complexity of face-to-face interaction The fourth guiding principle provides us with a realistic set of assumptions regarding our task of trying to study, account for, and understand the impact of aphasia on face-to-face interaction. We should expect, recognize, and embrace the complexity of the authentic interaction as a human phenomenon. In authentic contexts, the reactions and interactions, the personalities and beliefs, the objective behaviors and subjective interpretations are emphatically close and local. During face-to-face activities, the skills, traits, and behaviors of each participant are continually interacting, and we must attempt to describe and account for them as best we can. Indeed, that is the objective of a research agenda focusing on interaction in aphasia. Without attention to the complexity, our efforts, our implications and our applications will fall short of the needs of our patients and clients. Damico et al. (1999) have discussed this issue, and the fact that one of the problems with much of the current experimental research in clinical aphasiology is that it doesn’t account for the complexity of the neurological and social phenomenon known as aphasia. The experimental research in the field is effective – as far as it goes – but it is simply not sufficient to account for authentic social interaction. In the sub-discipline of clinical aphasiology, the complexity must be recognized and various ways to account for the impact of aphasia in all its complexity must be a priority when designing and carrying out any research agenda. Principle five: The multiplicity of manifestations Keeping with the complexity theme, the fifth principle strives to emphasize and then guide the investigation of all the potential manifestations of semiotic, cognitive, social, and psychological activity that make up the tapestry of face-to-face communication. Within authentic interaction, we should expect that there are a number of potential manifestations needed to create the

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social action. That is, there might be linguistic resources, various types of cognitive skills and traits, social strategies and knowledge resources, verbal and non-verbal behaviors, neurological traits, and other potential semiotic systems that might be employed to create the emergent phenomena that we know as social action within face-to-face interaction. As an individual attempts to negotiate within face-to-face interaction, he or she employs a number of these manifestations to accomplish the desired objectives and the resultant interactional behavior – one that creates comprehensibility, predictability, and successful expectations – is most likely to be the emergent property of interactions between some of this multiplicity of manifestations (Perkins, 1998, 2001, 2002). To use a metaphor employed by Janet Emig (1983), the individual uses these manifestations to “weave a web of meaning.” For our purposes, then, we must be prepared to engage in an objective and detailed analysis of our data to determine what variables or manifestations produce the observed social actions (e.g., Simmons-Mackie & Damico, 1997). Principle six: Orient to the functional goal In order to best address the complexity and to keep a handle on the plentitude of symptoms and manifestations in face-to-face interaction, it is best to maintain that the catalyst for interaction is to accomplish social action. We should orient our first question to “how was an interaction (or an aspect of it) accomplished?” If we adopt this functional and strategic approach, then we can better handle the complexity of the phenomenon and its potential emergence via the resources available to the interactants in the dyad or social group. This focus on the functional aspects of face-to-face interaction is consistent with a emerging emphasis in clinical aphasiology over the past 15 years. Work by clinical researchers like Holland (1991, 1998; Holland & Thompson, 1998), Lyon (1996) and Elman (Elman & Bernstein-Ellis, 1995) have advocated a more functional approach to the description, assessment, and intervention in aphasia and these initiatives have greatly influenced the field. Within the sub-discipline of interactional aphasiology, a practical and functional orientation to face-to-face interaction and how it impacts on effectiveness should serve as the medium within which the data are interpreted. Principle seven: Social action as collaborative Another interactional principle necessary in interactional aphasiology is a reasonable consequence of most of the principles discussed thus far – social action is always a collaborative enterprise. In effect, face-to-face social action is always collaborative and so we should always remember to incorporate this characteristic. Indeed, it should be our watchword. If social construction is accomplished at the local level, then all social actions are active and dynamic

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enterprises wherein (at least) two participants are involved in a process of coconstruction. Social actions of all sorts (e.g., conversation, arguments, fights, nonverbal posturing) are not a series of discrete behaviors or messages that pass from an active individual to a passive one. Rather, all face-to-face interaction is a process of participants actively constructing and negotiating meaning in a coordinated and joint manner as the social action proceeds. In practice, we can focus on the aphasic or the non-aphasic interactant, the dyad or the group, but eventually any analysis or its interpretation should orient to the collaborative impact needed to construct an interaction (Goodwin & Heritage, 1990; Oelschlaeger & Damico, 1998; Perkins, 1995). Principle eight: The dynamic character of interaction Building on the previous point, the construction of our relations with others – especially due to the local management of the interaction – is highly flexible. Whatever patterns and strategies are introduced during an interaction, they will always be dependent on the interactions and reactions of the other participant. Consequently, the behaviors and goals, interactions and reactions will be continually modified through the exceedingly variegated and subtle interchange that goes on when accomplishing social action. We must always be aware of this fact. It is possible that this characteristic will eventually limit the wholesale applications of some of our research. But it is equally possible that we may find that, although individual manifestations change across contexts, individuals, and over time, general and underlying principles will be discerned. For the moment, however, the dynamic character of face-to-face interaction should serve as the caveat of the sub-discipline. Principle nine: Contextual impact Although some social researchers have tried to focus exclusively on conversation as the prime face-to-face interaction, there are other equally valid and authentic social dyads and groupings that may also require investigation depending on various contextual issues. Harvey Sacks (1992) and others (e.g., Goodwin & Heritage, 1990; Scheff, 1990; Schegloff, 1968), focusing on conversation, acknowledged this in their writings and their research foci. To determine which social dyads should be the focus of attention, one must recognize the contextual relevance of social action. Not only do the various manifestations of social action change depending on the local context, but, as with all aspects of human semiotic systems, context determines the prime social dyads and groups from one interactional opportunity to another. Therefore, we should employ an awareness of contextual relevance when determining what kind of face-to-face interaction should be the focus of our attention in various settings.

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Principle ten: Adopting methods suitable to the phenomena we study The last principle I want to discuss as necessary for the sub-discipline of interactional aphasiology involves the tools and methods that we should use to investigate authentic face-to-face interaction. That is, what kinds of research methodologies are adequate for conducting research on complex and authentic social action like this? For a host of reasons, the answer is that we should adopt qualitative research methodologies. Over the last few decades, there has been a trend in the philosophy of science to recognize that research and systematic investigation becomes scientific by adopting the methods of study appropriate to its subject matter. This stance is called “scientific realism” and is currently a dominant philosophical position rather than the formerly dominant neo-positivistic approach (Okasha, 2002; Papineau, 1996). Among other things, scientific realism suggests that science is defined by the results and findings not the methodology. Within this focus, qualitative research – by definition – appears to be the most appropriate research paradigm for interactional aphasiology. Basically, qualitative research refers to a variety of analytic procedures designed to systematically collect and describe authentic, contextualized social phenomena with the goal of interpretive adequacy (Damico et al., 1999). The idea of interpretive adequacy – what Graham Button has described as explication of social action – should be the goal of interactional aphasia, and so qualitative research methodologies are best employed within this subdiscipline. Of course, this qualitative research paradigm involves a number of traditions of inquiry. While we may be most familiar and even prefer – within this context – to employ the most analytic of the qualitative methodologies – conversation analysis, it is not the only tradition of inquiry we should employ. In fact, to completely investigate and understand authentic interactional data, its variables, complexity, and implications, conversation analysis is not sufficient by itself. Other qualitative traditions of inquiry are more appropriate in some instances. Other traditions of inquiry include biographical study, case study research, ethnography and ethnographic methodologies, grounded theory, historical methodology, and other types of naturalistic data collection strategies like participant observation, ethnographic interviewing, discourse analysis, artifactual analysis, focus groups, and lamination research and phenomenology (Damico & Simmons-Mackie, 2003; Damico el al., 1999). Within a sub-discipline of interactional aphasiology, this paradigm and these traditions of inquiry and the various naturalistic data collection strategies can assist us in achieving the other nine principles within the previously described operational framework.

Conclusion These ten principles should help orient us to an understanding of how social action is achieved in face-to-face interaction, and how it impacts on the social

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accomplishments and consequences of individuals with aphasia. Of course, we still have to develop the implications and applications that might arise from the sub-discipline of interactional aphasiology. For example, we must ask: “How do we get others to understand and focus on the interactional complexity of face-to-face interaction?” and “How can the practices resulting from this research be applied in clinical settings?” It is certainly possible that the principles proposed in this chapter are preliminary and naïve. In the final analysis, however, whether we adopt an approach consisting of these or other principles, whether we strive to create a sub-discipline or not, there is a need to embrace the complexity of aphasia and its implications within a social action framework. For, when addressing the issues and concepts in clinical aphasia, regardless of what we theorize and discuss about language and processing, grammar and modular cognitive systems, the real significance of all of these areas means nothing unless we see these abstract conceptions played out in the arena of authentic face-to-face interaction. After all, that is where the human creature exists.

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