AJSLP

Research Article

Embedding Aphasia-Modified Cognitive

Behavioral Therapy in Script Training
for Primary Progressive Aphasia:
A Single-Case Pilot Study
Kristin M. Schaffer,a William S. Evans,b Christina D. Dutcher,c
Christina Philburn,d and Maya L. Henrya,e

Purpose: This study sought to determine the initial feasibility cohort that received script training without counseling
and benefit of a novel intervention that combines speech- (Henry et al., 2018). At post-treatment, the participant
language treatment with counseling treatment for an individual demonstrated stability or improvement on all measures of
with the nonfluent/agrammatic variant of primary progressive psychosocial and communicative functioning, with stability
aphasia (PPA). documented on seven out of 11 scales at follow-ups through
Method: Using a single-case experimental design, we 12 months post-treatment. A phenomenological analysis
evaluated the utility of modified script training paired with revealed pervasive themes of loss and resilience at both time
aphasia-modified cognitive behavioral therapy. The study points, and emerging themes of positive self-perception, sense
employed a multiple baseline design across scripts for the of agency, and emotional attunement following treatment.
primary linguistic outcome measure and a mixed methods Conclusions: Results indicate that script training with
approach for analyzing counseling outcomes. Psychosocial aphasia-modified cognitive behavioral therapy is a feasible
and communicative functioning scales were administered in treatment for an individual with the nonfluent/agrammatic
conjunction with a phenomenological analysis of semi- variant of PPA, with immediate and lasting benefits to
structured interviews. speech-language production and psychosocial functioning.
Results: The participant completed all study phases and These findings are the first to support the integration of
participated in all treatment components. She met the personal adjustment counseling techniques within a speech-
criterion of 90% correct, intelligible scripted words on language treatment paradigm for PPA.
all trained scripts through 12 months post-treatment. Supplemental Material: https://doi.org/10.23641/asha.
Treatment outcomes were comparable to a comparison 14925330

I
t is well-documented that individuals with aphasia are et al., 2016). The majority of individuals with aphasia are
vulnerable to negative psychosocial repercussions in- stroke survivors; however, a subset present with aphasia
cluding low mood, social isolation, and clinical de- caused by neurodegenerative disease, or primary progressive
pression (Brumfitt, 1993; Simmons-Mackie, 2018; Worrall aphasia (PPA; Gorno-Tempini et al., 2011). Individuals with
PPA may experience a compounded susceptibility to threats
a
Department of Speech, Language, and Hearing Sciences, The
to their emotional well-being. They face not only a devastat-
University of Texas at Austin ing loss of language, but also the knowledge that their aphasia
b
Department of Communication Sciences and Disorders, University will become significantly more severe over time (Rogalski &
of Pittsburgh, PA Khayum, 2018) and will progress to a global decline in func-
c
Department of Psychology, The University of Texas at Austin tioning and, ultimately, death. By contrast, individuals with
d
Austin Mindfulness Center stroke-induced aphasia typically follow a trajectory of stability
e
Dell Medical School, The University of Texas at Austin or even recovery in communicative functioning over time
Correspondence to Kristin M. Schaffer: (Demeurisse et al., 1980; Plowman et al., 2012).
kristin.schaffer@austin.utexas.edu
Individuals with PPA demonstrate a relatively isolated,
Editor-in-Chief: Julie Barkmeier-Kraemer progressive deterioration of speech-language functioning
Editor: Anastasia Raymer
(Mesulam, 1982) that evolves to a more global dementia
Received November 23, 2020
Revision received February 25, 2021
Accepted March 25, 2021 Disclosure: The authors have declared that no competing interests existed at the time
https://doi.org/10.1044/2021_AJSLP-20-00361 of publication.

American Journal of Speech-Language Pathology • Vol. 30 • 2053–2068 • September 2021 • Copyright © 2021 American Speech-Language-Hearing Association 2053
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 syndrome, with associated cognitive, motoric, or behavioral as this may interact subtly or clearly with communication.
impairments (Harciarek et al., 2014). Clinical consensus cri- Communication-centered counseling falls within the pur-
teria for PPA outline three distinct phenotypes: semantic, view of speech-language pathologists (American Speech-
logopenic, and nonfluent/agrammatic subtypes (Gorno- Language-Hearing Association, 2016) and includes both
Tempini et al., 2011). The nonfluent/agrammatic variant informational counseling, wherein the speech-language
(nfvPPA), which is the focus of this study, is associated pathologist educates the patient regarding their disorder,
with the core features of agrammatic language production and personal adjustment counseling, which addresses a
and/or apraxia of speech (Ash et al., 2010; Gorno-Tempini patient’s thoughts, feelings, and behaviors surrounding their
et al., 2011). Additionally, secondary features of this pheno- disorder (Luterman, 2020). Given that counseling within
type include at least two of the following: impaired compre- speech-language pathology is not a single, uniform entity,
hension of syntactically complex sentences, intact single-word research examining the application of different counsel-
comprehension, and spared object knowledge. Other diag- ing techniques is needed to provide empirical support for
nostic indicators of nfvPPA include neuroimaging findings evidence-based practice in the context of specific clinical
of prominent left posterior fronto-insular atrophy and tau- diagnoses. To this end, a modest body of research exists
positive pathology at autopsy (Gorno-Tempini et al., 2011; pertaining to counseling for individuals with aphasia more
Grossman, 2012; Spinelli et al., 2017). broadly. These papers primarily take a survey approach
(i.e., gauging clinicians’ counseling competency when treat-
ing individuals with aphasia; Lawton et al., 2018; Northcott
Treatment Research in nfvPPA et al., 2017), a “commentary approach” (i.e., offering gen-
A growing body of literature supports the utility of eral counseling guidelines; Holland & Nelson, 2007), or
speech-language treatment for PPA (Cadório et al., 2017; comprise counseling tutorials within the discipline of psy-
Carthery-Goulart et al., 2013; Cotelli et al., 2020; Volkmer chotherapy (provided by licensed psychologists; Kneebone,
et al., 2020), with most interventions targeting naming defi- 2016a). However, to our knowledge, studies that examine
cits (e.g., Henry et al., 2019; Meyer et al., 2016). Interven- counseling as a direct adjuvant to speech-language treat-
tions designed to address the nonfluent speech-language ment in this population are limited (Simmons-Mackie &
profile in nfvPPA include sentence production training to Damico, 2011), with only one study describing the use of
treat grammatical deficits (e.g., Hameister et al., 2017; CBT for individuals with severe stroke-induced aphasia
Machado et al., 2014), multisyllabic word production and their care partners, in the context of communication
training to target motor speech impairment (Henry et al., activities (Akabogu et al., 2019).
2013), and script training to address both the linguistic and The literature is even further constrained for PPA,
motor speech deficits that are core features of this variant with only two studies to date describing interventions that
(Henry et al., 2018). Video-Implemented Script Training incorporate speech-language and counseling components.
for Aphasia (VISTA) is a script training program that has Rogalski et al. (2016) describe the Communication Bridge
been primarily used with individuals with PPA (Henry web application for progressive aphasia, which includes
et al., 2018; Mahendra & Tadokoro 2020; Schaffer et al., restitutive and compensatory speech-language intervention
2020), but has also been used in an individual with stroke- along with counseling and care partner training. The counsel-
induced aphasia (Grasso et al., 2019). This intervention is ing component of this treatment includes informational
designed to promote speech production and fluency via struc- counseling regarding diagnosis and prognosis, as well as
tured, clinician-guided intervention sessions and daily unison application of general counseling skills (e.g., listening, dem-
speech production (or “speech entrainment;” Fridriksson onstrating empathy, and validating emotions; Rogalski &
et al., 2012) home practice. In PPA, VISTA has been ob- Khayum, 2018) by the treating clinician. Results from this
served to result in significant improvement in the production pilot study confirmed the intervention’s feasibility and showed
of correct, intelligible scripted words as well as increased statistically significant gains in communication confidence
grammatical complexity, mean length of utterance (MLU), for participants with PPA. In another study, Jokel et al.
and speech rate, and a reduction in fluency disruptions for (2017) piloted a group intervention for individuals with PPA
trained scripts (Berstis, 2020; Henry et al., 2018). Addition- and their care partners, which included informational counsel-
ally, results indicate generalized benefit to untrained scripts, ing provided by multidisciplinary health care experts and
with improved intelligibility and a reduction in fluency dis- breakout sessions targeting lexical retrieval intervention for
ruptions at post-treatment (Berstis, 2020; Henry et al., 2018). individuals with PPA. Following treatment, participants
with PPA demonstrated significant improvements in quality
of communication, PPA knowledge, and coping abilities
Counseling in Aphasia/PPA compared to a control group that did not receive treatment.
Despite a growing literature base supporting speech- Compounding the limited evidence base for counsel-
language interventions for PPA, research investigating ing techniques in aphasia is a lack of counseling training for
effective counseling interventions that address the emo- speech-language pathologists. While many speech-language
tional sequelae of this disorder is lacking. The presence pathologists regard counseling as a valuable component of
of either low mood or depression within the context of treatment, they often report reduced confidence in deliver-
PPA/aphasia is important to address through counseling, ing these services (Holland & Nelson, 2007). Northcott

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 et al. (2017) found that 58% of licensed speech-language through follow-up at 1 year post-treatment. (2) Will the
pathologists who treated individuals with aphasia reported participant respond positively to speech-language treatment
reduced confidence in attending to their patients’ psychologi- and will the magnitude of treatment response be compara-
cal needs. Limited training at the graduate school level likely ble to a comparison cohort that received VISTA treatment
contributes to clinicians’ perceived lack of expertise in this without a counseling component (Henry et al., 2018)? We
area. Survey results indicate that approximately half of hypothesized that the participant would demonstrate a
speech-language pathology master's programs offer a dedi- positive treatment response, as indicated by significant
cated counseling course, which is often optional (Luterman, improvement on the primary language outcome measure at
2020). Likewise, only 20% of clinicians report that they post-treatment and follow-up assessments through 1 year
completed counseling coursework in their master's program post-treatment. Additionally, we predicted that the partici-
(Phillips & Mendel, 2008). When provided, speech-language pant’s treatment response would be comparable to an existing
pathology graduate coursework emphasizes informational VISTA cohort that received the speech-language intervention
counseling, but provides limited or no didactic training on in isolation. This finding would confirm that the addition
personal adjustment counseling that addresses the emotional of counseling procedures does not negatively affect speech-
consequences of living with a communication impairment language treatment response. (3) Will this participant dem-
(Luterman, 2020). onstrate improved psychosocial functioning following the
intervention, as measured quantitatively (using psychosocial
and communicative functioning scales) and qualitatively
Cognitive Behavioral Therapy (using pre- and post-treatment interviews)? We predicted
Among existing psychotherapeutic methodologies, cog- that the participant would demonstrate improved quanti-
nitive behavioral therapy (CBT) is the most widely investi- tative and qualitative psychosocial outcomes. Specifically,
gated (Chand et al., 2020; Hoffman et al., 2013). CBT in we predicted improved numerical ratings on psychoso-
both its traditional and modified forms has proven effica- cial and communicative functioning scales in areas not
cious in a variety of diagnoses (e.g., Butler et al., 2006; Cully already near ceiling at baseline, as well as an increase
et al., 2017; Hassiotis et al., 2013), and has been utilized in in positive-themed responses related to navigating life
neurodegenerative disorders such as Alzheimer’s disease (e.g., with PPA at post-treatment.
Spector et al., 2012; Stanley et al., 2013; Teri & Gallagher-
Thompson, 1991). CBT emphasizes the interconnectedness
among thoughts, feelings, and behaviors (A. T. Beck, 1964),
training individuals to identify, assess, and respond to mal-
Method
adaptive or unhelpful thoughts in order to optimize mood and Participant
behavior. Notably, Kneebone (2016a) created a modified CBT Study procedures were approved by the institutional
framework for use by psychologists, intended for individuals review board at The University of Texas at Austin and the
presenting with an emotional disorder status post-stroke, in- participant gave informed written consent to participate. The
cluding individuals with aphasia. Kneebone’s CBT frame- participant was a 78-year-old monolingual English-speaking
work recommends that more modifications to traditional female with 16 years of formal education (see Table 1). A
CBT are needed with increased severity of an individual’s retired real estate agent, she was diagnosed with nfvPPA
post-stroke cognitive or communication challenges. 1 year prior to enrollment in the study. The initial diagno-
sis was made by a neurologist subsequent to neurological,
Current Study neuropsychological, and speech-language testing. At the
time of the study, the participant presented with a 5-year
Although counseling falls within the speech-language history of a slowly progressive decline in speech and lan-
pathology scope of practice, studies that evaluate treat- guage skills.1 Pre-treatment speech, language, and cognitive
ment paradigms combining speech-language and counsel-
ing interventions are limited. This underscores the need for 1
This participant demonstrated an interest in participating in research
evidence-based counseling interventions in PPA to address with our lab 2 years prior to enrolling in this treatment study, before
this important gap in the literature and to guide best prac- she was formally diagnosed with PPA. At that time, her deficits were
tice for clinicians. very mild and she was diagnosed with mild cognitive impairment. Thus,
In the current single-case pilot study, we examined the the participant did not qualify for participation in ongoing PPA treatment
feasibility and utility of a novel intervention that combined studies with our lab. Instead, she participated in a script-based home
script training (VISTA) with aphasia-modified CBT (here- practice program, wherein she engaged in unison speech production
after labeled as VISTA+C to denote VISTA plus counseling) with training videos on a weekly basis and then recited scripts from
memory during once weekly meetings held with the researcher. The
for an individual with mild nfvPPA. Our research questions
participant was not provided with any explicit VISTA training (targeting
and hypotheses were: (1) Will an intervention that combines articulation, speech fluency, or grammatical production) during these
aphasia-modified CBT with speech-language treatment be sessions. She was, however, familiar with unison speech production
feasible? We predicted that the treatment would be feasible, practice prior to enrolling in the current study. For the current study,
as measured by intervention compliance with both speech- new script topics were developed relative to this early home practice
language and counseling procedures and study completion program.

Schaffer et al.: Counseling and Script Training in PPA 2055

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 Table 1. Demographics for the VISTA+C participant and the original
counseling, n = 10; Henry et al., 2018). The participant
VISTA cohort (Henry et al., 2018; n = 10).
demonstrated intact cognition, with a score of 30/30 on the
Demographics VISTA+C Participant VISTA cohort
Mini-Mental State Examination (MMSE; Folstein et al.,
1975), and mildly impaired performance on the Western
Age 78 M (SD): 67.7 (5.5) Aphasia Battery–Revised (WAB-R; Kertesz, 2006; see Sup-
Gender F 4 M; 6 F plemental Material S1 for WAB-R subtest scores at each
Education (years) 16 M (SD): 15.6 (2.1) time point), the Motor Speech Examination (MSE; Wertz
Handedness Right Right (all participants)
et al., 1984), and the Northwestern Anagram Test (NAT;
Note. VISTA = Video-Implemented Script Training for Aphasia; Thompson et al., 2012). The participant’s MLU in words
VISTA+C = VISTA plus counseling; M = male; F = female. during the WAB-R picture description task was 8.60 and her
MLU during her initial script development probe was 10.00.
Despite relatively spared utterance length, she exhibited
testing, conducted by the treating speech-language pathologist, occasional agrammatic productions during connected speech
supported the nfvPPA diagnosis per clinical consensus criteria (e.g., “We did a tour of Van Gogh exhibit.”) and writing
(Gorno-Tempini et al., 2011). The participant presented with (e.g., “The boy is standing on a stool which about to tip
mild motor speech impairment (apraxia of speech and dysar- over.”). The participant demonstrated a high level of accu-
thria) characterized by reduced prosody, slow rate, inconsis- racy during oral reading tasks, achieving 97.22% accuracy on
tent speech sound errors (particularly on multisyllabic words single words and 94.44% accuracy on single pseudowords
and consonant clusters), and articulatory imprecision, as on a modified version of the Arizona Battery for Reading
well as mild agrammatism in connected speech and written and Spelling (Beeson et al., 2010), and 98.44% accuracy on
language. In accordance with nfvPPA diagnostic criteria, she oral reading of The Grandfather Passage (Van Riper, 1963).
exhibited intact single-word comprehension and spared The participant met inclusion criteria for enrollment
object knowledge. in VISTA, based on the following guidelines that were also
Results of standardized speech, language, and cogni- applied in the comparison VISTA study (Henry et al., 2018):
tive testing are presented in Table 2, alongside the mean an nfvPPA diagnosis, an MMSE score of ≥ 15, and intact
performance of the comparison cohort (VISTA without repetition of at least three syllables on the WAB-R Repetition

Table 2. Speech, language, and cognitive assessments at pre-treatment, post-treatment, and follow-up time points.

VISTA+C M (SD) from

Assessment Time point participant VISTA cohort

Western Aphasia Battery–Revised Pre 96.6 84.3 (6.4)

Aphasia Quotient (out of 100) Post 95.8 85.7 (6.1)
3-month 96.8 81.7 (8.3)
6-month 96.8 79.9 (8.9)
12-month 92.5 75.5 (11.9)
Mini-Mental State Examination Pre 30 26.8 (2.3)
(out of 30) Post 30 27.3 (1.8)
3-month 29 27.0 (2.4)
6-month 30 26.5 (2.1)
12-month 30 23.3 (5.9)
MSE Apraxia of Speech rating* Pre 2 3.7 (1.3)
(0 = none, 7 = profound) Post 2 4.3 (1.3)
3-month 2 4.9 (1.3)
6-month 2 4.9 (1.1)
12-month 2 5.4 (.9)
MSE Dysarthria rating* Pre 1 2.9 (1.7)
(0 = none, 7 = profound) Post 1 3.1 (1.9)
3-month 1 3.3 (2.7)
6-month 1 3.4 (2.5)
12-month 2 3.1 (2.5)
Northwestern Anagram Test Pre 90.0 63.7 (21.5)
(% out of 30 items) Post 86.7 74.3 (20.0)
3-month 96.7 66.5 (27.1)
6-month 86.7 54.3 (34.3)
12-month 86.7 42.6 (37.6)

Note. Mean scores and standard deviations from the Video-Implemented Script Training for Aphasia (VISTA) cohort reported in Henry et al. (2018)
are included for comparison. Unstandardized difference tests (Crawford & Garthwaite, 2005) comparing the VISTA plus counseling (VISTA+C)
participant to the VISTA-only cohort showed no significant differences in magnitude of change from pre-treatment to subsequent time points.
MSE = Motor Speech Examination.
*From Wertz et al. (1984).

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 Table 3. Video-Implemented Script Training for Aphasia plus
subtest. Additionally, the participant was deemed an appro-
counseling (VISTA+C) treatment regimen, adapted from Henry
priate candidate for this intervention given that she endorsed et al. (2018) and J. S. Beck (2011).
and demonstrated emotional distress in the context of her
PPA diagnosis. Prior to enrollment, the participant became
Probing: Participant completes trained and untrained script probes
tearful during phone calls with the clinician and stated that at the start of each session. If criterion is met (during Sessions 1
her communication challenges had a negative impact on her and 2 for a given script) on primary linguistic outcome measure
overall quality-of-life. and participant successfully engages in unison speech production
for trained script, then speaking rate of VISTA video is increased
by 10% for home practice.
Experimental Design VISTA Treatment Steps:
The VISTA+C intervention, which comprised both 1. Recall/ Participant chooses
speech-language treatment (VISTA) and counseling (aphasia- recognize each correct script
sentence from four
modified CBT), included treatment sessions and daily home- foil sentences
work (see Table 3 for treatment regimen). Sessions were held 2. Organize/ Participant puts script
twice weekly for 6 weeks. Each session included VISTA construct sentences in order
training (45 min to 1 hr) and the additional counseling 3. Read Participant reads script
aloud
procedures were included every other session (approximately 4. Respond to Participant produces
30 min). Treatment was conducted by the first author, a questions in scripted sentences
licensed speech-language pathologist who had completed scripted order from memory in
graduate-level coursework in family-centered counseling and response to
questions (in order
CBT in adults. of script)
All stages of treatment were conducted remotely, via 5. Produce script Participant recites
telerehabilitation, as the participant did not live in close from memory entire script
proximity to the research site. Telerehabilitation has in- 6. Respond to Participant responds
questions to questions with
creasingly become an accepted alternative to face-to-face with scripted scripted sentences
treatment in speech-language pathology. Outcomes from sentences (not in order of
VISTA were found to be comparable when treatment was script)
delivered remotely versus in person for individuals with
PPA (Dial et al., 2019) and telerehabilitation in aphasia Structured conversation: During the second treatment session for
and/or apraxia of speech caused by stroke has also shown each script, participant engages in unscripted conversation with
promise (Furnas & Edmonds, 2014; Goldberg et al., 2012; a naïve communication partner regarding the script topic.
Lasker et al., 2010). Of note, half of the participants in the Aphasia-modified CBT: Clinician-guided hierarchy conducted
comparison VISTA cohort also received treatment via tele- every other session.
rehabilitation (Henry et al., 2018). In the current study,
1. Mood check Establish frequency, duration, and
treatment procedures mirrored those in the comparison intensity of overriding mood that
cohort, with the exception of the additional counseling week
component. We will briefly describe the speech-language 2. Review previous Ensure that homework was attainable
treatment, which is described in depth elsewhere (Grasso homework and conducted appropriately
3. Prioritize the agenda Collaboratively select most concerning
et al., 2019; Henry et al., 2018), and then outline the novel communication problem to
complementary CBT procedures in greater detail. address
4. Aphasia-modified CBT Clinician guides participant through
skills training CBT techniques to respond in a
Speech-Language Intervention more helpful manner to maladaptive
For VISTA, a multiple baseline design across scripts communication-centered thoughts
5. Create new homework Collaboratively create tailored daily
was utilized. During pre-treatment, the participant identi- homework
fied topics that were functional and meaningful in her 6. Session summary and Clinician summarizes session and
life. Six scripts were then developed via a collaborative feedback participant provides feedback
process between the participant and clinician. Scripts were Weekly phone call: On a nontreatment day, participant engages in
designed to be challenging yet attainable, with sentences structured conversation pertaining to script-in-training for 5–
constructed to be a few words longer than the participant’s 10 min with clinician.
MLU (mean MLU [in words] across scripts was 11.47) Homework: 1. Participant engages in daily unison speech
and with multisyllabic words included sparingly. During production home practice with script-in-training. 2. Participant
the initial probe, the participant was prompted to speak at completes tailored CBT homework.
length about each of her selected topics. This probe in- Note. CBT = cognitive behavioral therapy.
formed the content that would be included in the script
and also provided the clinician with samples of the partici-
pant’s word choice, so that the scripts were both natural
and personalized.

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 Linguistically balanced scripts were created and pre- Figure 1. An example of aphasia-friendly written and visual content
utilized during aphasia-modified CBT training.
sented to the participant for her approval before treatment
began. Four scripts were randomly selected for training
and two scripts remained untrained (see Supplemental
Material S2 for linguistic parameters and Supplemental
Material S3 for the participant’s script characteristics).
After scripts were finalized, videos were created for
home practice. Videos featured a healthy female adult speaker
(with only mouth and lower face visible) producing scripted
content using exaggerated articulatory gestures to provide
salient visual targets for production (see Supplemental
Material S4 for script rate details). After scripts were fi-
nalized but before treatment began, two baseline probes
were collected, wherein the participant was given the
prompt, “Tell me about (specific topic).” After baseline
probing, the participant engaged in preliminary unison
speech production practice, consisting of prompts to feelings, and behaviors) in relation to communication. This
watch and listen to the mouth model while attempting to was followed by goal-setting with the clinician, to tailor the
speak in unison. Subsequently, the participant was provided intervention toward a specific area of change that the partici-
with a home practice video for the first script, with instruc- pant deemed important to address. This participant’s stated
tions to practice unison speech production for at least goal was “to think about myself and my communication in a
30 min daily. Frequency and duration of home practice more positive way.”
were recorded throughout the study via a computer track- Aphasia-modified CBT sessions closely resembled
ing system (Qualtrics). the format of traditional CBT sessions (J. S. Beck, 2011),
One script was trained per VISTA session, with each and included activities such as a mood check, homework
script trained for a total of three sessions (see Table 3 for setting and review, CBT training to evaluate and respond
treatment regimen). During VISTA sessions, the clinician to communication challenges, session summary, and elici-
provides visual, verbal, and phonetic placement cues, as tation of participant feedback (see Table 3; for a mock
needed, to address articulatory, grammatical, and word CBT clinician/patient sample, see Supplemental Material
choice errors. With this participant, visual and verbal cues S5). The ultimate goal in this process was for the partici-
targeting articulatory and word selection errors were used pant to observe maladaptive or unhelpful thoughts as they
most frequently. As with the original VISTA cohort, gener- arose, notice how these thoughts related to her emotions
alization tasks (see Table 3) were integrated as a comple- and behaviors, and work toward responding to this triad
ment to structured speech-language procedures. of thoughts, feelings, and behaviors more adaptively. To
At the end of the formal treatment phase, the partici- tailor the intervention to the unique needs of a person
pant was provided with a home practice link that included living with a progressive disorder, treatment addressed
all four trained script videos. Like participants in the original maladaptive thoughts, while promoting acceptance of
VISTA cohort, she was encouraged to engage in ongoing the reality of life with PPA. This involved creating ways
unison speech practice in order to promote maintenance of to frame one’s mindset to think realistically, yet in a more
treatment gains. adaptive manner. For example, if the participant identified
an automatic unhelpful thought of “I can’t speak,” through
Counseling Intervention collaborative CBT training, this statement may shift to “I
As a complementary treatment component, aphasia- can’t speak as well as I used to, but I can still try my best.”
modified CBT was formally incorporated during every other Additionally, homework was collaboratively developed
treatment session. The frequency of counseling was intended each session as a natural extension of discussions that took
to approximate an ecologically valid proportion of time place during the session. Daily homework included activi-
that a speech-language pathologist could feasibly engage ties such as writing down “Thought Records” that outlined
in counseling in a standard clinical setting. Additionally, communication-centered situations along with associated
if the participant demonstrated emotional distress during thoughts, feelings, and behaviors; reading positive mantras
speech-language treatment, aphasia-modified CBT tech- regarding communication; and completing behavioral en-
niques were employed as teachable counseling moments. The gagement tasks for activities that were previously avoided
CBT intervention was designed to be “aphasia-modified” by the participant (e.g., speaking on the phone).
in that communication-centered challenges were addressed
and aphasia-friendly written and visual materials (for an
example, see Figure 1) were used to maximize comprehension Follow-Up Testing
of key CBT concepts. During the first counseling session, In addition to pre- and post-treatment evaluations,
the participant was provided with psychoeducation about the the participant engaged in speech, language, cognitive, and
core tenets of CBT (i.e., the connectedness among thoughts, psychosocial assessment at 3, 6, and 12 months following

2058 American Journal of Speech-Language Pathology • Vol. 30 • 2053–2068 • September 2021

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 treatment in order to evaluate longitudinal stability of significantly in a single individual relative to the distribution
treatment outcomes. During follow-up assessments, the of differences found in controls. Importantly, the procedure
participant was also asked to produce trained and untrained controls Type I error rate, even with a small compari-
scripts from memory. son group (n = 10).

Psychosocial Outcomes
Outcome Measures and Statistical Analyses
To address Research Question 3, evaluating psycho-
Treatment Feasibility social status before and after treatment, we used mixed
In order to address Research Question 1, to determine methods analyses to comprehensively capture the VISTA+C
the feasibility of the VISTA+C intervention, we measured treatment response. These analyses included both quantita-
the participant’s intervention compliance and completion tive (participant and family-reported ratings on psychosocial
of study phases. Intervention compliance was defined and communicative functioning measures) and qualitative
as engaging in all aspects of the intervention, including (phenomenological analysis of pre- and post-treatment in-
speech-language and counseling components during tele- terview transcripts) data. Psychosocial and communication
rehabilitation sessions as well as homework. Study comple- scales or subscales were administered by the treating clini-
tion was defined as participating in all phases of the study, cian at pre-treatment, post-treatment, and each follow-up.
including pre-treatment, during treatment, post-treatment, As a general screen for depression and anxiety, the Patient
and 3-, 6-, and 12-month follow-ups. Health Questionnaire (PHQ-9; Kroenke et al., 2001) and
the Generalized Anxiety Disorder (GAD-7; Spitzer et al.,
Speech-Language Treatment Outcomes 2006) scales were administered. The Positive and Negative
To answer the first part of Research Question 2, re- Affect Scale (PANAS; Watson et al., 1988) was adminis-
garding the participant’s response to speech-language inter- tered to evaluate emotional state. While there are no dedi-
vention (VISTA), we calculated percent correct, intelligible cated psychosocial scales for use in PPA, stroke or aphasia
scripted words for each script during probes. Two probes scales or relevant subscales were administered to the par-
were conducted at pre-treatment and post-treatment, and ticipant. These included the Adaptive/Full Length Aphasia
a single probe was conducted at each follow-up time point. Communication Outcome Measure (ACOM; Hula et al.,
Consistent with the original VISTA cohort, criterion perfor- 2015), the Communication, Social Relationships, and Posi-
mance on a trained script was established as production of tive and Negative Feelings subscales of the Burden of Stroke
90% correct and intelligible scripted words. Statistical com- Scale (BOSS; Doyle et al., 2004), and the Communication and
parisons were derived from simulated distributions (Dial & Psychosocial subdomains of the Stroke and Aphasia Quality
Martin, 2017) to assess the significance of changes from of Life Scale-39 (SAQOL-39; Hilari et al., 2003). Finally, per-
pre- to posttreatment and each subsequent follow-up time ception of mood was rated by the participant’s daughter via
point. For the simulation analyses, random sampling was the Stroke Aphasia Depression Questionnaire (SADQ-21;
conducted item-by-item, using probabilities of correct and Sutcliffe & Lincoln, 1998) at pre- and post-treatment.
incorrect responses to create simulated data sets that mirrored A phenomenological research approach was used to
the actual data. Each simulation was run 10,000 times to qualitatively analyze pre- and post-treatment semi-structured
generate 10,000 simulated distributions of performance per interview transcripts (Creswell & Poth, 2017). The partici-
time point (two pre-treatment probes, two post-treatment pant engaged in a 15- to 20-min interview with the clinician,
probes, and a single probe at 3-, 6-, and 12-month follow- responding to open-ended questions pertaining to thoughts,
ups) for trained and untrained scripts. To calculate p values, feelings, and behaviors associated with the experience of
the distributions from two time points within a trained or living with PPA. The interviews were transcribed and then
untrained condition were compared. Bonferroni correc- independently coded by two researchers with training in
tion was used to control for familywise error (p < .0125). qualitative research, using phenomenological procedures.
Additionally, the simulated data were used to obtain differ- With this approach, individuals’ lived experiences of a con-
ence scores to determine 95% confidence intervals (CIs). cept or phenomenon are examined, so that the core essence
The second part of Research Question 2 aimed to es- of that experience can be uncovered (Creswell & Poth, 2017).
tablish whether the participant’s treatment response on The transcript data were analyzed via horizonalization (iden-
the primary linguistic outcome measure was comparable tifying significant statements within the discourse data)
to an existing VISTA cohort that did not receive counseling and theme generation (creating distinct clusters of meaning
(Henry et al., 2018). Specifically, we sought to confirm that from observing general trends in the significant statements).
VISTA+C is equally efficacious from a speech-language The two researchers reviewed their preliminary themes
perspective relative to VISTA alone. To do so, we compared and reconciled any discrepancies in the analytic coding pro-
the magnitude of change in performance in our participant cess via discussion and re-examination of significant state-
from pre-treatment to post-treatment and each subsequent ments in order to reach consensus on finalized themes.
follow-up time point (i.e., 3, 6, and 12 months) to the mag-
nitude of change in the comparison group using unstan- Interrater Reliability and Treatment Fidelity
dardized difference tests (Crawford & Garthwaite, 2005). Interrater reliability was established for the primary
This test evaluates whether the change in score differs linguistic outcome measure (correct, intelligible scripted words)

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 by the treating clinician and a trained undergraduate research 66.91] at the 6-month time point; and p < .0001, 95% CI
assistant. The treating clinician recorded the participant’s [52.94, 65.07] at the 12-month time point). Performance on
performance during all assessment (i.e., pre-treatment, post- untrained scripts was not significantly different from pre-
treatment, and follow-up time points) and treatment sessions, treatment to any follow-up. This indicates that there was
while the research assistant observed video recordings and re- not a significant improvement or decline in performance
corded performance data while blinded to treatment condition longitudinally, compared to baseline.
(trained vs. untrained scripts). The research assistant viewed To provide context for the participant’s treatment re-
video probes from 25% of assessment and treatment sessions, sponse over time, we report her standardized speech, lan-
transcribed the participant’s response to probes, and marked guage, and cognitive test scores from all treatment phases
each word as intelligible or unintelligible relative to the script (see Table 2). While the participant demonstrated consistently
target. Interrater reliability was measured using point-by- high performance on trained scripts through the 12-month
point agreement, wherein the total number of agreements follow-up, results from standardized testing indicate decline
was divided by the total number of agreements and dis- in some areas of speech and language functioning during
agreements and the sum was multiplied by 100 (Kazdin, this period. That is, the participant demonstrated increased
1982). Interrater reliability was high, at 98.88%. motor speech impairment on the MSE for dysarthria, with
Treatment fidelity was assessed by two trained under- a rating of 1 at pre-treatment to a 2 at the 1-year follow-up
graduate research assistants, who viewed session recordings (using a severity scale of 0 = no impairment to 7 = severe
and indicated the clinician’s consistency in following each impairment), with stability in apraxia of speech status (MSE
step of the treatment protocol. The research assistants rating of 2 longitudinally). Linguistically, the participant’s
independently watched 33.33% of randomly selected treat- global language performance on the WAB-R Aphasia Quo-
ment sessions. Fidelity was high, at 99%. tient (AQ) declined from a 96.6 at pre-treatment to a 92.5 at
the 1-year follow-up and sentence production performance
on the NAT was relatively stable, as evidenced by 90% ac-
Results curacy at pre-treatment and 86.7% accuracy at the 1-year
Treatment Feasibility follow-up. Cognition remained grossly stable longitudinally,
With regard to Research Question 1, the participant with the participant scoring 30/30 on the MMSE at pre-
attended all scheduled treatment sessions and consistently treatment and the 1-year follow-up.
participated in both speech-language and counseling inter-
vention components. Regarding intervention completion, Speech-Language Performance Relative
the participant completed all phases of the study, from to Comparison Cohort
pre-treatment through the 12-month follow-up. During the
treatment phase, she engaged in 19.42 hr of unison speech To address the second part of Research Question 2,
production home practice, as well as daily counseling home- unstandardized difference tests (Crawford & Garthwaite,
work. She missed 7 days of home practice due to personal 2005) were used to compare the magnitude of change in
reasons. After treatment concluded, the participant contin- the participant’s performance on the primary linguistic out-
ued to engage in periodic practice with her videos through come measure to that of the existing VISTA cohort (Henry
the 12-month follow-up, completing an additional 14.15 hr et al., 2018; see Table 4). Results indicated no significant
of home practice. difference for change in performance on the primary lin-
guistic outcome measure between the VISTA+C participant
and the comparison cohort for trained or untrained scripts
Speech-Language Response to Treatment from pre- to post-treatment (trained scripts: t(9) = −.47, p =
To address the first part of Research Question two, .647; untrained scripts: t(9) = .79, p = .450) and from pre-
pertaining to speech-language outcomes, we measured the treatment to all follow-up time points (3-month time point:
participant’s performance on the primary linguistic outcome trained scripts: t(9) = −.57, p = .582; untrained scripts:
measure of percent correct, intelligible scripted words across t(9) = .26, p = .804; 6-month time point: trained scripts:
all time points. The participant reached the 90% criterion t(9) = −.79, p = .448; untrained scripts: t(9) = .06, p = .950;
for this measure on all trained scripts through 12-months 12-month time point: trained scripts: t(9) = −.71, p =
posttreatment (see Figure 2). Simulation analyses indi- .499; untrained scripts: t(9) = .16, p = .873).
cated a significant difference from pre- to post-treatment Comparing change on speech, language, and cognitive
(p < .0001, 95% CI [55.15, 66.91]) for trained scripts. Per- scores between the VISTA+C participant and the existing
formance on untrained scripts was not significantly differ- VISTA cohort more broadly across all time points, unstan-
ent from pre- to post-treatment (p = .752, 95% CI [−15.11, dardized difference tests indicate that the magnitude of
7.19]). Additionally, simulations were conducted to determine change in the participant’s performance did not differ signif-
stability of performance on the primary linguistic outcome icantly from the comparison cohort on standardized assess-
measure from pretreatment to each follow-up time point. ments from pre- to post-treatment (WAB-R AQ: t(9) = .75,
Maintenance of gains was confirmed for trained scripts p = .474; MMSE: t(9) = .18, p = .859; apraxia of speech rat-
through 12 months post-treatment (p < .0001, 95% CI [56.25, ing on the MSE: t(9) = 1.04, p = .327; dysarthria rating on
67.65] at the 3-month time point; p < .0001, 95% CI [55.15, the MSE: t(9) = .46, p = .654; NAT: t(9) = .85, p = .416)

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 Figure 2. Multiple baseline data showing the Video-Implemented Script Training for Aphasia plus counseling (VISTA+C) participant’s
performance for trained and untrained scripts over time. Vertical lines indicate treatment phase, which includes pre-treatment, treatment,
maintenance, post-treatment, and follow-up phases. Tx = treatment; Mo. = month; F/u = follow-up.

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 Table 4. Script production performance for trained and untrained topics in the VISTA+C participant and the original
VISTA cohort.

Primary linguistic outcome measure: percent correct intelligible scripted words

Condition Time point VISTA+C participant mean Original VISTA cohort M (SD)

Trained Pre 37.5 38.0 (13.7)

Post 98.5 89.8 (14.7)
3-month 100.0 87.5 (19.5)
6-month 99.3 79.9 (21.2)
12-month 97.2 68.6 (35.1)
Untrained Pre 37.4 36.1 (14.7)
Post 33.4 43.1 (19.9)
3-month 37.1 35.6 (19.7)
6-month 30.1 30.1 (20.1)
12-month 28.3 31.1 (26.1)

Note. Unstandardized difference tests (Crawford & Garthwaite, 2005) revealed no significant differences in magnitude
of change from pre-treatment to subsequent time points for the VISTA+C participant relative to the original cohort.
VISTA = Video-Implemented Script Training for Aphasia; VISTA+C = VISTA plus counseling.

or from pre-treatment to any follow-up time point (3-months: pre-treatment and 12 at post-treatment, out of 50 points, with
WAB-R AQ: t(9) = −.77, p = .463; MMSE: t(9) = .43, p = lower scores indicating a less negative affect. These scores in-
.677; apraxia of speech rating on the MSE: t(9) = 1.07, p = dicate low negative affect.
.314; dysarthria rating on the MSE: t(9) = .23, p = .826; NAT: Results from additional scales and subscales provide
t(9) = −.21, p = .836; 6-months: WAB-R AQ: t(9) = −.87, contextualization specific to aphasia. Of note, these measures
p = .409; MMSE: t(9) = −.14, p = .890; apraxia of speech are all normed for individuals with stroke-induced aphasia.
rating on the MSE: t(9) = .96, p = .363; dysarthria rating on As such, we cannot compare the participant’s scores directly
the MSE: t(9) = .06, p = .950; NAT: t(9) = −.31, p = .767; to other individuals with PPA. Scores from the BOSS range
12-months: WAB-R AQ: t(9) = −.57, p = .584; MMSE: from 0 to 100, with 100 indicating the least desirable health
t(9) = −.65, p = .531; apraxia of speech rating on the state. On the Communication subscale, the participant’s score
MSE: t(9) = 1.04, p = .325; dysarthria rating on the MSE: improved from a 25 at pre-treatment to a 14.29 at post-
t(9) = −1.62, p = .139; NAT: t(9) = −.77, p = .462). treatment. On the Social Relations subscale, the participant’s
score improved from a 15 at pre-treatment to a 0 at post-
treatment. For the Positive Emotions subscale, the partici-
Psychosocial Outcomes
pant’s score improved from 31.25 at pretreatment to 18.75
To address Research Question 3, evaluating psycho- at post-treatment. On the Negative Emotions subscale, the
social outcomes from pre- to post-treatment, we used participant’s score was stable at 25 across both time points.
mixed methods analyses, including quantitative and quali- On the SAQOL-39, which measures quality of life for individ-
tative approaches. uals with stroke-induced aphasia, the highest possible mean
score for a subdomain is 5. The participant’s Communication
Quantitative Results subdomain score was generally stable from pre- (3.86) to post-
Participant ratings from psychosocial and communica- treatment (4.43). Similarly, her Psychosocial subdomain
tive functioning scales and subscales administered at pre- score was also stable across pre- (4.6) and post-treatment
treatment, post-treatment, and follow-up time points (3, 6, (4.93) time points. Of note, the Physical subdomain was
and 12 months) are displayed in Table 5. Stability or numeri- not administered (was not relevant for this individual) and,
cal improvement in ratings of psychosocial and communica- as such, an overall score could not be obtained. Results from
tive functioning was observed from pre- to post-treatment on the ACOM, which measures communicative functioning in
all 12 scales or subscales. Additionally, of the 11 scales and daily contexts for individuals with stroke-induced aphasia,
subscales administered during follow-up time points, results are indicated via T-scores, along with the standard error, and
indicate stability or improved psychosocial or communicative standard deviation. During pre-treatment, the participant’s T-
functioning status longitudinally on seven scales. score was 55.30 (95% CI [52.35, 58.25]), with a standard error
Results from the PHQ-9 and GAD-7, which screen of 1.51. This score was .5 deviations above the mean (of indi-
for the presence of a mood or anxiety disorder (i.e., clinical viduals with stroke-induced aphasia). At post-treatment, the
depression or generalized anxiety disorder) were not indic- participant’s T-score was 59.16 (95% CI: [56.26, 62.03]), with
ative of a clinical disorder at any time point. Regarding a standard error of 1.46. This score was .9 SDs above the
emotional state, scores from the PANAS indicated a high mean (of individuals with stroke-induced aphasia).
positive affect score of 48 out of 50 at both pre- and post- Stability was demonstrated through the 12-month
treatment. The participant’s negative affect score was 13 at follow-up in positive self-perceptions of quality-of-life on

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 Table 5. Pre-treatment, post-treatment, and follow-up scores on psychosocial and communicative functioning scales for the VISTA+C participant.

Total
3-month 6-month 12-month possible
Scale Normative data (mean; SD) Pre-treatment Post-treatment follow-up follow-up follow-up points

Personal Health Questionnaire (PHQ-9) Healthy adults (3.3; SD ± 3.8) 4 2 3 4 3 27

Generalized Anxiety Disorder Scale (GAD-7) Healthy adults (4.9; SD ± 4.8) 2 2 5 2 1 21
Positive and Negative Affect Scale (PANAS): Healthy adults (33.3; SD ± 7.2) 48 48 49 43 43 50
Positive scale
PANAS: Negative scale Healthy adults (17.4; SD ± 6.2) 13 12 15 15 10 50
Burden of Stroke Scale (BOSS): Communication Stroke survivors (30.6; 25.0 14.0 25.0 35.7 39.2 100
subscale SD ± 23.7)
BOSS: Social Relationships subscale Stroke survivors (17.5; 15.0 0.0 5.0 20.0 20.0 100
SD ± 21.0)
BOSS: Positive Emotions subscale Stroke survivors (34.8; 31.3 18.8 18.8 31.3 31.3 100
SD ± 20.8)
BOSS: Negative Emotions subscale Stroke survivors (38.4; 25.0 25.0 25.0 25.0 18.3 100
SD ± 22.0)
Stroke and Aphasia Quality of Life Scale Stroke-induced aphasia: N/A 3.9 4.4 4.0 3.9 4.1 5
Schaffer et al.: Counseling and Script Training in PPA

(SAQOL-39): Communication score for subdomains

SAQOL-39: Psychosocial score Stroke-induced aphasia: N/A 4.6 4.9 4.7 4.7 4.7 5
for subdomains
Aphasia Communication Outcome Measure Stroke-induced aphasia 55.3; 1.5; .5 59.2; 1.5; .9 68.0; 1.7; 1.8 62.4; 1.5; 1.2 62.9; 1.5; 1.3 N/A
(ACOM; T-score; standard error; standard (50; SD ± 10) SD above SD above SD above SD above SD above
deviation) mean mean mean mean mean
Stroke Aphasia Depression Questionnaire Stroke-induced aphasia (median 18 21 N/A N/A N/A 63
(SADQ-21) score: 23; interquartile range:
16–29)

Note. For the PHQ-9, GAD-7, Negative scale of the PANAS, BOSS subscales, and SADQ-21, lower scores indicate more desirable health state or affect. For the Positive scale of
the PANAS and the SAQOL-39, higher scores indicate more desirable health state or affect. VISTA+C = Video-Implemented Script Training for Aphasia plus counseling; N/A =
not applicable.
2063

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 the Communication and Psychosocial subdomains of the to speak with unfamiliar people I meet.”). Additionally, the
SAQOL-39, and low report of negative emotions on both participant often used emotion-centric language to express
the PANAS and BOSS subscales. Additionally, scores on that, within the context of daily life, she was attuned to her
the ACOM indicated improved communicative function- internal state (e.g., “The counseling was tough. And it made
ing of over 7 points from pre-treatment to the 12-month me realize that I had feelings about it [PPA].”) and that those
follow-up. While the participant indicated a 5-point de- varied emotions were observed within a larger context of
cline in positive mood on the PANAS from pre-treatment how she positively navigates life with PPA. At post-treatment,
to the 12-month follow-up, her scores were consistently four out of the five themes reflected positive attitudes and
greater than 1 SD above the mean. Notably, the partici- perceptions surrounding communication, amidst the on-
pant demonstrated an improved health state from pre- to going acceptance of loss.
post-treatment on the BOSS subscales in the areas of Com- Beyond interview data, qualitatively, the participant
munication, Social Relationships, and Positive Emotions; reported that she met her stated goal of thinking about
however, by the 12-month follow-up time point, her scores herself and her communication more positively. Anecdot-
either returned to pre-treatment levels or indicated a decline ally, during pre-treatment, the participant described several
in perceived health state. communication environments she avoided. By the end of
Finally, the participant’s daughter completed the treatment, she reported making phone calls to family more
SADQ-21 at pre- and posttreatment time points as an ad- frequently and accepting lunch invitations she may have pre-
ditional measure of mood. As with the other scales, this viously declined. Additionally, at the conclusion of treatment,
scale has been norm-referenced for individuals with stroke- her daughter reported, “I feel the counseling along with
induced aphasia. Scores on this scale range from 0 to 63, the speech sessions is extremely beneficial and I don’t
with 63 indicating the highest level of depression. The par- think there would be as much improvement without the
ticipant’s scores on this measure were grossly stable, with counseling.”
a score of 18 at pre-treatment and 21 at post-treatment.

Qualitative Results Discussion

Phenomenological analysis of pre- and post-treatment While there is substantial evidence supporting linguis-
interviews revealed several themes surrounding the lived tic treatments for PPA, research evaluating the benefit of
experience of having PPA. Two themes were pervasive during counseling interventions in this population is lacking. As
both interviews, while six additional themes were prevalent such, the current pilot case study constitutes a preliminary
either during the pre- or post-treatment interview. Specifically, step toward expanding the treatment literature in this under-
the themes of loss and resilience were present throughout both studied area. To our knowledge, this is the first study to
time points. The participant described various ways in which evaluate the integration of explicit personal adjustment
her lifestyle and relationships have changed in the context counseling techniques within a speech-language framework
of PPA (e.g., “I want them to know me before [the onset of for PPA. This study is also one of only a few studies in the
PPA]. And that’s not possible.”), yet she also stated quali- PPA literature to utilize mixed methods research to compre-
ties about her character that underscored her perseverance hensively capture treatment outcomes. Moreover, findings
when facing communication challenges associated with PPA lend supportive evidence regarding the feasibility of telere-
(e.g., “It’s not my nature to give up.”). habilitation as an alternative to in-person PPA treatment.
Beyond those ongoing themes, three themes that were Results indicated that, for an individual with mild
present during pre-treatment included value of communica- nfvPPA, the treatment was feasible and led to improved
tion, negative self-perception, and avoidance. The partici- speech-language and psychosocial outcomes. Specifically,
pant emphasized how meaningful communication is to her the participant demonstrated intervention compliance and
(e.g., “Communication is important. That differentiates us participated in all phases of the study through 1 year post-
between animals and us—people.”). She repeatedly expressed treatment. She met criterion on the primary language out-
that, given her challenges with communication, she perceived come measure of percent correct, intelligible scripted words
herself unfavorably (e.g., “I don’t feel like I’m a good, fun for trained scripts, and her response to treatment was com-
grandma. Because I can’t participate in the children’s dia- parable to an existing cohort that received VISTA without
logue.”) and actively avoided certain communicative situa- counseling (Henry et al., 2018). Despite reporting a reason-
tions such as talking face-to-face or on the phone (e.g., “I’m ably high quality-of-life and absence of frank depression
texting all the time.”). Of the five themes that were present or anxiety at baseline, our participant endorsed negative
during the pre-treatment phase, three themes reflected nega- feelings related to communication difficulty and described
tive attitudes and perceptions surrounding communication. avoiding specific social situations. We documented im-
By contrast, during the post-treatment interview, the provement in these domains following VISTA+C via quan-
following themes emerged: positive self-perception, sense of titative self-report measures of communication functioning
agency, and emotional attunement. The participant indicated and qualitative themes derived from interviews. The emer-
that she perceived herself in a positive light (e.g., “Well, gence of the themes of positive self-perception, sense of
I just talk to myself in my mind and I say, ‘I can do it.”’) agency, and emotional attunement at post-treatment suggest
and believed she had control over her actions (e.g., “Confidence that, as a result of VISTA+C, the participant learned tools

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 to adaptively process and respond to her inner world, leading and commitment therapy, mindfulness-based cognitive
to increased awareness of her emotional state and enhanced therapy) could potentially be modified for individuals with
self-determination and self-image. The benefits derived from aphasia/PPA in future clinical research studies. Moreover,
jointly focusing on communication and counseling may to- it is important to acknowledge that elements of counseling are
gether drive the positive changes on the ACOM and BOSS often utilized by practicing clinicians. That is, although
subscales, suggesting that the holistic nature of this interven- many speech-language pathologists report reduced confi-
tion may be more impactful than the sum of its parts. These dence with providing counseling to individuals with aphasia,
findings suggest that individuals who do not meet clinical they also report that they use counseling microskills such as
criteria for a frank mood or anxiety disorder may still active listening and demonstrating empathy during patient in-
benefit from participating in an intervention that encom- teractions (Northcott et al., 2017). These “soft-skills” overlap
passes counseling alongside speech-language treatment. with our aphasia-modified CBT approach and are critical
Notably, this participant presented with a mild impair- elements in fostering strong therapeutic alliances with
ment of speech and language, without significant concomi- patients. In addition to these counseling microskills, CBT
tant deficits in cognition and behavior that may eventually draws from the cognitive theory framework to encourage pa-
emerge in PPA. Enrolling an individual with this profile tients to examine thoughts, feelings, and behaviors and make
was intentional, given the metacognitive requirements of adaptive adjustments accordingly. Future research examining
participating in all aspects of CBT. At its core, CBT trains the counseling skills in speech-language pathologists’ clinical
individuals to think about thinking, verbalize their inner toolkit are needed to identify how targeted counseling re-
world, progressively take steps toward becoming their own search may be used to augment current practices of clini-
therapist, and monitor and modify their thought processes cians in the field.
and behaviors in a way that highlights their autonomy and While counseling is included in the speech-language
self-efficacy. With this single-case pilot study, modifica- pathology scope of practice, clinicians must be aware of the
tions were made to traditional CBT to account for aphasia, boundaries of the counseling services they can ethically pro-
while preserving the basic premise of CBT, which requires vide. If depression or anxiety screenings signal the potential
a willingness and ability to engage in higher level thinking. presence of a mood or anxiety disorder or if a patient’s emo-
However, per Kneebone’s (2016a) framework for CBT tional challenges extend beyond the realm of communica-
after stroke, it may be possible to tailor this treatment ap- tion, cognition, or swallowing, the clinician should refer
proach for individuals with more severe cognitive and com- the individual to a licensed mental health professional for
munication deficits. Further modifications may involve a further clinical management. One helpful guideline that
more behaviorally-focused and less abstract, cognitively- may be applied from the stroke recovery literature is the
focused approach, including concrete examples, mnemonic “stepped care” model (Kneebone, 2016b). This model as-
supports, increased multimodal/environmental cues, weekly serts that psychological care is warranted for all survivors
“check-in” phone calls from the clinician, and care partner of a stroke and, by extension, progressive disease, and pro-
involvement. At this pilot stage, we believe that, with the poses that the type of psychological care and the appropri-
use of aphasia-friendly visual and written supports and sim- ate provider (e.g., allied health professional vs. licensed
plified language, aphasia modified-CBT may be successfully mental health professional) vary depending on the severity
implemented for individuals who present with any PPA var- of an individual’s emotional symptoms.
iant. In the future, our current protocol may be expanded The current study has several limitations. First, the
and modified to meet the needs of individuals with more treating clinician conducted the pre- and post-treatment in-
significant cognitive–linguistic impairment, as proposed by terviews and administered the psychosocial scales, intro-
Kneebone (2016a). However, we believe that, even with ducing the potential for bias in the participant’s responses.
more extensive modifications, this specific style of counsel- This limitation will be addressed in future replications of
ing may not be an ideal fit for individuals with lack of in- this study, and a separate researcher will conduct the inter-
sight regarding their deficits. views and administer the psychosocial scales. Additionally,
An additional treatment consideration is a patient’s we only obtained psychosocial and communicative function-
stage of grieving and degree of acceptance of their disor- ing ratings for the individual participant and not for the
der (Kübler-Ross, 1969). For example, if an individual is existing comparison cohort. Thus, we were unable to di-
experiencing denial of their disorder, engaging in aphasia- rectly compare psychosocial functioning across participants.
modified CBT may be perceived as obtrusive and counseling In the future, we plan to administer these scales to partici-
of this nature may be met with resistance. Therefore, obtain- pants receiving VISTA without counseling to enable this
ing a sense of a patient’s emotional state and their personal comparison. Notably, while some of the scales were appro-
conceptualization of their disorder is an important prelimi- priate for broad administration across individuals in the gen-
nary step before selecting a patient-centered intervention. eral population (i.e., PHQ-9, GAD-7, PANAS), several of
Returning to the topic of counseling interventions in the rating scales were normed for individuals with stroke-
speech-language pathology practice, CBT is one of a number induced aphasia. As such, these results should be interpreted
of evidence-based psychotherapeutic interventions. While with caution. One PPA-specific scale, the Progressive Apha-
this counseling intervention may be appropriate for some sia Severity Scale (Sapolsky et al., 2014), exists; however,
patients, other related types of psychotherapy (e.g., acceptance this is not a dedicated psychosocial scale and would likely

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 not be a sensitive estimate of potential treatment response Ash, S., McMillan, C., Gunawardena, D., Avants, B., Morgan, B.,
to the intervention used in this study. These challenges with Khan, A., Moore, P., Gee, J., & Grossman, M. (2010). Speech
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single individual, generalizability to the broader population (2nd ed.). Guilford.
of individuals with PPA is limited. Given the positive find- Beeson, P. M., Rising, K., Kim, E., & Rapcsak, S. Z. (2010). A
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participants from each PPA variant and will pair tailored of Speech, Language, and Hearing Research, 53(2), 450–468.
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Berstis, K. V. (2020). Investigating changes in connected speech in
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with aphasia-modified CBT to determine acceptability, fea- script training [Master’s thesis, The University of Texas at
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on quantitative measures, which aligned with themes from Cadório, I., Lousada, M., Martins, P., & Figueiredo, D. (2017). Gen-
qualitative interview data. We hope that these findings, eralization and maintenance of treatment gains in primary
alongside the extant literature, will serve to collectively progressive aphasia (PPA): A systematic review. International
demonstrate the value of providing holistic, person-centered Journal of Language & Communication Disorders, 52(5), 543–560.
care that addresses both the speech-language impairment https://doi.org/10.1111/1460-6984.12310
and the emotional components of navigating life with a Carthery-Goulart, M. T., Da Costa Da Silveira, A., Machado, T. H.,
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Acknowledgments Dementia & Neuropsychologia, 7(1), 122–131. https://doi.org/
Clinical and research infrastructure for this project came 10.1590/S1980-57642013DN70100018
from the National Institute on Deafness and Other Communica- Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2020). Cognitive
tion Disorders of the National Institutes of Health under award behavior therapy. StatPearls.
numbers R01 DC016291 and R03DC013403 (Principal Investiga- Cotelli, M., Manenti, R., Ferrari, C., Gobbi, E., Macis, A., & Cappa,
tor: Dr. Maya Henry) and 1F31DC019044 (Principal Investigator: S. F. (2020). Effectiveness of language training and non-invasive
Kristin Schaffer), and by funding provided to The University of brain stimulation on oral and written naming performance in
Texas at Austin by the Darrell K Royal Research Fund for Alzhei- primary progressive aphasia: A meta-analysis and systematic
mer’s Disease (Principal Investigator: Maya Henry). We thank the review. Neuroscience and Biobehavioral Reviews, 108, 498–525.
participant for the time and commitment that she devoted to our re- https://doi.org/10.1016/j.neubiorev.2019.12.003
search study. We also thank the members of the Aphasia Research Crawford, J. R., & Garthwaite, P. H. (2005). Testing for suspected
and Treatment Lab at The University of Texas at Austin, partic- impairments and dissociations in single-case studies in neuro-
ularly Sydney Hamilton and Kirsten Laursen, for completing psychology: Evaluation of alternatives using Monte Carlo sim-
speech sample transcription, reliability analyses, and fidelity analy- ulations and revised tests for dissociations. Neuropsychology,
ses. Finally, we thank Megan Young for her assistance with quali- 19(3), 318–331. https://doi.org/10.1037/0894-4105.19.3.318
tative research analysis and Gregory Hixon and Stephanie Grasso Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and re-
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