A-FROM in Action at the Aphasia Institute

Aura Kagan, Ph.D.1

ABSTRACT

Aphasia centers are in an excellent position to contribute to the

broad definition of health by the World Health Organization: the
ability to live life to its full potential. An expansion of this definition by
the World Health Organization International Classification of Func-
tioning, Disability and Health (ICF) forms the basis for a user-friendly

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and ICF-compatible framework for planning interventions that ensure
maximum real-life outcome and impact for people with aphasia and
their families. This article describes Living with Aphasia: Framework
for Outcome Measurement and its practical application to aphasia
centers in the areas of direct service, outcome measurement, and
advocacy and awareness. Examples will be drawn from the Aphasia
Institute in Toronto. A case will be made for all aphasia centers to use
the ICF or an adaptation of it to further the work of this sector and
strengthen its credibility.

KEYWORDS: Aphasia, aphasia centers, ICF, A-FROM, intervention

Learning Outcomes: As a result of this activity, the reader will be able to (1) situate the work of aphasia centers
within an outcome-driven framework for intervention that is grounded in the World Health Organization’s
International Classification of Functioning, Disability and Health; (2) use key Living with Aphasia: Framework
for Outcome Measurement (A-FROM) principles to broaden thinking about intervention and outcome; and (3)
adapt illustrative A-FROM examples to his or her own setting.

T he Aphasia Institute in Toronto, Can- into hope. The current multiplicity of aphasia
ada began in Pat Arato’s basement in 1979. centers across North America and internation-
Unwilling to accept the hopeless scenario ally, many directly or indirectly influenced by
painted by medical specialists who told her Pat’s vision, is testament to what she has
that her husband Oscar would not make any achieved. Many of these centers have been
more improvement, Pat gathered a few families started by speech-language pathologists and/or
and volunteers together to try and turn hopeless family members determined to ensure ongoing

1
Education and Applied Research, Aphasia Institute, BC-ANCDS
Toronto, Canada. Semin Speech Lang 2011;32:216–228. Copyright #
Address for correspondence and reprint requests: Aura 2011 by Thieme Medical Publishers, Inc., 333 Seventh
Kagan, Ph.D., 73 Scarsdale Road, Toronto, ON M3B Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
2R2, Canada (e-mail: [email protected]). 4662.
Aphasia Centers: A Growing Trend in North DOI: http://dx.doi.org/10.1055/s-0031-1286176.
America; Guest Editor, Nina Simmons-Mackie, Ph.D., ISSN 0734-0478.
216
 A-FROM IN ACTION AT THE APHASIA INSTITUTE/KAGAN 217

support and growth opportunities for individu- BACKGROUND TO LIVING WITH

als with aphasia. Like the Aphasia Institute, APHASIA: FRAMEWORK FOR
many have been founded at a grassroots level OUTCOME MEASUREMENT
with minimal funding and resources. In other Aphasia centers offer a diverse array of pro-
cases, administrators have had to be persuaded grams but have a common underlying belief
to allow an aphasia group to be offered as a system regarding the potential for learning to
service. Pat’s ideas are captured in the current live successfully with aphasia. Expert opinion as
vision of the Aphasia Institute—‘‘no barriers to well as an emerging research literature suggest
living successfully with aphasia.’’ Although the that this potential is reached by offering inter-
vision of ‘‘no barriers’’ seems distant, those of us ventions that may include, but go beyond,
who work in aphasia centers know, based on addressing the language impairment itself—
extensive firsthand experience, that individuals interventions that target life with aphasia.2,3
and families living with aphasia can regain a Because of the nontraditional and innovative
meaningful quality of life (QOL) with appro- nature of this intervention, administrators, pol-
priate intervention, despite the fact that lan- icy makers and funders are often unfamiliar
guage impairment has not been ‘‘cured.’’ with potential benefits and unclear about the

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Currently, the Aphasia Institute is a rationale for our services. Therefore, to advo-
teaching and learning center that operates as cate for our sector or our own individual
a synergy of direct service, education and agencies, it is helpful to be able to articulate
training, and research and development. In what we do and the results we achieve in a way
addition to acting as an information resource, that is clearly understandable and has credibil-
in any given year we provide direct service to ity with decision makers. Providing a solid
over 200 people with aphasia and family conceptual base for our work will help to
members within the Greater Toronto Area. strengthen our case for support and help plan
A range of direct services is offered including intervention in a way that ensures outcomes
professionally supervised volunteer-led con- with real-life impact for individuals and fami-
versation groups, a professionally led intro- lies living with aphasia. Living with Aphasia:
ductory program that includes a parallel Framework for Outcome Measurement (A-
curriculum for families, exercise, various rec- FROM) was developed with this in mind. A-
reational and educational activities of choice, FROM is a user-friendly version of the ICF
and a variety of education, training, and re- that has been adapted for aphasia and been
search programs. previously described.4 In line with the values of
As our programs have evolved over the the Life Participation Approach to Aphasia,5
past three decades, we have struggled with a A-FROM captures the domains of interven-
simple method of communicating what we tion and outcome that are relevant for aphasia
do to potential clients, funders, administra- centers and is presented in an accessible and
tors, and even prospective staff members. explicit format that allows for easy practical
Our solution has been the adoption of a application. A-FROM makes an explicit state-
broad, common, nonprescriptive outcome ment about the contribution of four domains to
framework relevant to the real-life impact QOL with aphasia (see Fig. 1 and Table 1).
of aphasia and grounded in the International The use of overlapping circles rather than
Classification of Functioning, Disability and separate boxes with arrows is deliberate and
Health (ICF).1 The current article describes suggests the real-life overlap and interaction
how this simple framework can potentially between the four domains and overall QOL
further the work of individual aphasia centers with aphasia.
and the aphasia center sector as a whole. Although not prescriptive in relation to
Applications discussed will include direct specific interventions or outcome measurement
service, outcome measurement and evidence, methods/tools, A-FROM does emphasize the
and finally awareness and advocacy, with importance of focusing on outcomes relevant to
illustrative examples drawn from the Aphasia living with aphasia. It provides clinicians, cli-
Institute. ents, funders, and other stakeholders with a
218 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 3 2011

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Figure 1 Living with Aphasia: A Framework for Outcome Measurement (A-FROM). (Reprinted with
permission from Taylor & Francis Ltd. Kagan A, Simmons-Mackie N, Rowland A, Huijbregts M, Shumway
E, McEwen S, Threats T, Sharp S. Counting what counts: a framework for capturing real-life outcomes of
aphasia intervention. Aphasiology 2007;22:258–280.4)

Table 1 Description of A-FROM Domains

Domain Description

Language and related impairments Equivalent to ‘‘impairment’’ in the ICF and includes traditional
areas such as talking, understanding, reading, and writing
Environment Anything outside of the person that facilitates and/or acts as a
barrier to communication including individual/societal attitudes,
partner attributes, physical factors, and language barriers
Participation Actual involvement in relationships, roles, and activities of
choice—situations that form part of daily life
Personal factors Inherent characteristics of the person, feelings, emotions,
attitudes, and identity or sense of self
A-FROM, Living with Aphasia: Framework for Outcome Measurement; ICF, World Health Organization International
Classification of Functioning, Disability and Health.
 A-FROM IN ACTION AT THE APHASIA INSTITUTE/KAGAN 219

guideline for thinking about the outcomes of helping us understand what outcomes were
various interventions. Without defining suc- relevant for the individual with aphasia. The
cess in terms of meaningful outcomes, the framework kept us focused on the client as
definition of a successful intervention outcome the best judge of what was ‘‘meaningful’’
can be too narrow. For example, the speech- change for them. (Quote from Jane Brenne-
language pathologist might work on the do- man Gibson, Board Chair)
main of language impairment using a neuro-
linguistic treatment for writing; however, the Most recently, A-FROM has been offi-
meaningful outcome is actually change in how cially included in our strategic plan and is
writing is used in daily life (participation currently in the process of being fully inte-
domain) as well as related changes in areas grated into our daily operations. In addition,
such as motivation, sense of autonomy, and we now routinely use A-FROM and its com-
confidence (personal domain). In other words, patibility with the ICF in all funding requests
the most critical outcomes are those of partic- to the government as well as in grant appli-
ipation (relationships, roles, and activities of cations so that decision makers can easily
choice) and personal factors (feelings, atti- situate our work within something that is

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tudes, identity). Outcomes in the domains of understandable, credible, and internationally
impairment (language) and environment accepted.
(communication barriers and supports includ-
ing awareness, attitudes, and skills of others)
are important to capture as potential enablers Outcome Measurement and Evidence
of participation, positive sense of self, and Many speech-language pathologists would
overall QOL. agree that our field as a whole is undervalued
within the health care system. Aphasia inter-
vention has suffered particularly in recent times
APPLICATIONS OF A-FROM with dysphagia services introduced instead of,
FOR APHASIA CENTERS rather than in addition to, language and com-
munication treatment.6 Within the field of
A Mandate for Our Work clinical aphasiology itself, the advent of aphasia
In line with the broad definition of health groups and centers focusing on outcomes that
referred to earlier, most aphasia centers include include but go far beyond language impairment
services beyond traditional language treatment. is increasingly accepted and growing, but there
A-FROM can help to clarify for administra- is a large gap in the provision of evidence to
tors, policy makers and funders the range of support best practice. The use of a common
services and, more important, the rationale for map and terminology in measuring outcome
services offered. Depending on the location of can lead to research that facilitates evidence-
aphasia groups and centers within the overall based practice and that supports collaboration
health care system, the need for an official to benefit our entire sector.
mandate for a broader approach to outcome In line with the idea of ‘‘outcome-driven
measurement and/or indicators of success dif- practice,’’ this section will be followed by direct
fers. In the case of the Aphasia Institute, a service applications rather than vice versa. In
broad approach has been a de facto reality for other words, clarity around desired outcome is
many years; however, it is only recently, with an excellent starting point when planning in-
the advent of A-FROM, that our board of tervention. The following guiding principles
directors has formally acknowledged its place are useful when thinking of how to document
and importance. and capture outcomes of interventions at apha-
sia centers4 (pp. 270–271):
When the board of directors was de-
veloping the present strategic plan with the 1. The client him- or herself is the most
Institute staff, volunteers, and external stake- appropriate person for judging ‘‘meaningful’’
holders, A-FROM was very instrumental in life change.
220 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 3 2011

2. The client should have an opportunity to programs and that all A-FROM domains are
determine and choose what outcomes are tapped in one way or another (see Table 2).
relevant from his or her perspective. The recently developed Assessment for Living
3. A-FROM domains are appropriate to all with Aphasia (ALA) covers all A-FROM do-
aphasia severity levels. mains within one tool (Simmons-Mackie N,
4. Outcomes in the participation domain Kagan A, Victor JC, Carling-Rowland A, Mok
should relate specifically to actual function- A, Hoch JS, Huijbregts M, Streiner D. The
ing in everyday life as opposed to capacity to assessment for Living with Aphasia: Psycho-
perform tasks or carry out activities. metric Evaluation. 2011; In submission). The
5. Activities or tasks can be measured under Aphasia Institute will begin using the ALA as
the participation domain but should be part of our intake assessment process so that we
understood as important components of have a baseline for measuring progress. The full
real-life participation rather than as a sepa- ALA is necessary for formal research purposes
rate domain. because it has established psychometric proper-
6. A-FROM encourages multidirectional ties, but we may use selected questions for less
thinking and questions (for example, impact formal outcome measurement required by some

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of participation intervention on impairment of our funders. Whatever the assessment tool
outcome and vice versa; reciprocal impact of used, when submitting outcome data, we have
outcomes in the areas of participation and found it useful to refer to A-FROM and its
personal factors). direct link to the ICF, making sure that the
recipient is aware of the broad range of out-
A-FROM can be thought of as a canvas on come domains captured and their relevance to
which to track progress and evaluate effective- the lives of individuals with aphasia and their
ness qualitatively and/or experimentally and families.
was originally motivated by the challenge of
capturing real-life outcomes frequently ob-
served and reported by individuals with aphasia Direct Service
and family members participating in aphasia A-FROM can be used to capture what goes on
center programs. There are many aphasia as- in an aphasia center as illustrated in the follow-
sessment tools available depending on personal ing selected examples. In addition to expanding
preference and purpose of the assessment. It is our own thinking, A-FROM helps explain the
important to ensure that the assessment process rationale for our range of services to others in a
captures the broad-based intent of aphasia way that is easy to grasp.

Table 2 A-FROM Domains and Sample Questions

A-FROM Domain Sample Question

Aphasia (language and How would you rate your talking/reading/writing/understanding?

related impairments) Overall how would you rate your communication?

Participation Are you satisfied with the number of people you see?
Do you get out as much as you want?
How are you doing with your roles and responsibilities at home?
Do you join in conversations at home?

Environment Does your family know how to help you with the aphasia?
Do your friends understand about aphasia—that you
know what you want to say?

Personal Do you feel that you are in charge of your life?

Do you think good things about yourself?
Do you have things you enjoy or look forward to?
A-FROM, Living with Aphasia: Framework for Outcome Measurement.
 A-FROM IN ACTION AT THE APHASIA INSTITUTE/KAGAN 221

Figure 2 The success cycle. (Reprinted with permission from Robbins Research International, Inc.)

FIRST CONTACT AND INITIAL ASSESSMENT difference between traditional assessments and
Anthony Robbins, a world leader in the areas of assessments at the Aphasia Institute (see

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business and personal development, makes Table 3).
reference to what he calls the ‘‘success cycle’’: Initial assessments at the Aphasia Institute
the importance of beliefs on perceived poten- consist of a semistructured conversation with
tial, actions taken based on this perception, and skilled conversational support—the purpose
results of the actions, which in turn influence being to assess the impact of aphasia on what
beliefs. When analyzing what we see happen- clients (individuals with aphasia and family) are
ing when individuals and families come into actually doing and feeling. One of our goals is
the Aphasia Institute, it is helpful to use his to provide an immediate experience of success,
simple diagram7 (see Fig. 2) and relate it to A- because with conversational support, there is
FROM. almost always dramatically increased opportu-
With reference to Fig. 2, we frequently see nity to participate in conversation and exchange
individuals and families come in to the Aphasia facts, feelings, and opinions on issues relevant
Institute with a fixed, often negative, belief to intelligent adults who find themselves living
about their communication potential and vastly with a language impairment. During the course
decreased confidence in the ability to commu- of this conversation, assessment staff (speech-
nicate and participate in life. In line with this, language pathologist and social worker) obtain
what we see is a decrease in actual participation a clear picture of life with aphasia from the
as indicated in the responses to questions asked perspective of the person with aphasia and the
in guided conversational interviews. According family member. The use of Supported Con-
TM
to the Robbins diagram, this leads to limited versation for Adults with Aphasia (SCA ;
results, which reinforce the belief in lack of Aphasia Institute, Toronto, ON)8,9 techniques
potential, creating a negative cycle. and sophisticated pictographic resources to ask
For many individuals and families living and elicit responses to questions, ranging from
with aphasia, the first contact with our field simple to extremely complex and abstract, en-
involves an assessment of language impairment ables the people with aphasia to tell their own
that highlights deficits. The obvious rationale story. Each story is particular to the individual
is that this gives us, as communication special- and his or her family member, but general
ists, a clear indication of where to begin treat- themes are common and include areas such as
ment; however, such assessments likely relationships, roles, activities of choice, atti-
contribute to negative beliefs about communi- tudes and skills of others, self-image, feelings,
cation potential. (As an aside, language assess- and, of course, the language impairment itself.
ments are sometimes part of research Without asking questions in each of the A-
conducted at the Aphasia Institute, but are FROM domains (see Table 2), the clinician
not part of our initial introduction to the does not have the information to discuss the
service.) A-FROM can be used to capture the broad range of options available to address the
 222

Table 3 A Comparison of Traditional and A-FROM-Based Aphasia Assessments

Communication Explicitly
Support Giving Hope
Actual Life Provided to about Potential Family Explicitly Value
Functional Tasks Participation Maximize to Live Involvement the Perception
or Activities (Performance Impact of Personal Overall Success in Successfully as Client Not of the Person
Impairment (Capacity in ICF) in ICF) Environment Factors QOL Conversation with Aphasia Only Caregiver with Aphasia

Many traditional H H
aphasia
assessments
(and initial
contact with
SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 3

the person
with aphasia
2011

and family)

Aphasia Institute H H H H H H H H H H
initial contact
and assessment
in line with
A-FROM
Relevance: Experiencing some success in communicating and indicating that this is a service which addresses the depth and breadth of impact of aphasia appears to change beliefs about
potential for positive change for the person with aphasia and the family member.
A-FROM, Living with Aphasia: Framework for Outcome Measurement; ICF, World Health Organization International Classification of Functioning, Disability and Health; QOL, quality of
life.

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 A-FROM IN ACTION AT THE APHASIA INSTITUTE/KAGAN 223

impact of aphasia on daily life. Clients invar- regarding the effectiveness of conversation
iably leave the assessment feeling more opti- groups.
mistic about the potential for positive change. For conversation groups, participation is
The fact that areas explored range far beyond the major intervention domain because the
the impairment explicitly acknowledges the activity provides actual opportunity for conver-
depth and breadth of the impact of aphasia sation (opportunities to establish real relation-
on daily life. In effect, by focusing on all A- ships, taking on different roles within the
FROM domains, we begin to change the group, and engaging in an activity that is the
client’s beliefs and to expose possibilities for most basic form of human interaction), as
increased action (broad life participation). The opposed to ‘‘preparing’’ clients within a context
positive results reinforce more positive beliefs, that is removed from real-life situations. Con-
thus engaging the individual and family in versation groups also involve intervention in
what can be termed a ‘‘positive’’ as opposed to the environment domain because there is ex-
‘‘negative’’ cycle. In other words, assessments at plicit focus on reducing language barriers and
the Aphasia Institute are designed to highlight increasing communicative access. Thus, as with
potential for positive growth and change and all Aphasia Institute activities, volunteer facil-

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give hope in addition to identifying challenges. itators receive formal training focused on both
attitudes and skill, sophisticated pictographic
CONVERSATION GROUPS resources are available to get around language
A second example where A-FROM can be barriers, and the culture of the agency is one
used to clearly indicate the conceptual under- where inherent competence of people with
pinning for our work relates to the concept of aphasia is assumed.
conversation groups. Although only formally Potential outcome domains, on the other
named ‘‘conversation groups’’ in the late 1990s, hand, include all domains. Areas that can be
these groups have been in existence at the measured include improvements in the aphasia
Aphasia Institute since 1979. A-FROM can itself (impairment), skill of the facilitator in
be used to clearly indicate the relevant domains reducing language barriers and increasing access
of intervention and expected outcome (see to conversation (environment), increased con-
Fig. 3). This provides context for studies by fidence (personal factors), and obvious partic-
Elman and others10,11 that provide evidence ipation outcomes related to friendships, normal

Figure 3 Conversation groups intervention and outcome domains.

224 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 3 2011

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Figure 4 Aphasia Institute direct service interventions and ideas.

adult conversational roles, and enjoyment in an activity. It does, though, make us consciously
activity for its own sake. A-FROM is a simple aware of what is implicit and often taken for
way to convey these multifaceted outcomes with granted. We found that using this framework
real-life impact to administrators, funders, and generated enthusiastic and creative discus-
policy makers and/or others in decision-making sion. Staff thought more deliberately about
positions. how to achieve maximum outcomes in as
many domains as possible for each interven-
PROGRAM PLANNING tion. Even the most experienced among us
In our efforts to maximize the benefits of using had new insights and ideas. This initial
A-FROM as part of planning for the upcoming brainstorming session was followed by an
year, we recently asked direct service staff at the intensive program planning day to ensure
Aphasia Institute to allocate every direct service that we address all A-FROM domains to
we provide to individuals and families living the extent possible.
with aphasia to the appropriate domain. We
then reviewed this as a group, specifically CLIENTS AS EQUAL TEAM MEMBERS IN DIRECT
focusing on gaps and where we might consider SERVICES
adding additional programs or a different mix A-FROM is available in pictographic format
of programs (see Fig. 4). For example, in noting (see Fig. 5) and can be used to create a shared
interventions and outcomes per domain, staff intervention and outcome agenda with individ-
noted that although all our activities generally ual clients and with clients as a group. It is
contribute to outcome in the area of personal empowering for clients to understand the ra-
factors, there is a gap in range of choices related tionale for various aphasia center activities. It is
to direct intervention, for example, ongoing a means of expanding ideas on what is possible
support groups and individual counseling for for them to achieve.
our clients with aphasia and for family mem- The pictographic version of A-FROM is
bers. now posted on our walls for quick reference by
A-FROM is not being suggested as ‘‘the clients and volunteers, and it is not unusual to
answer’’ to program planning or any other find a person with aphasia looking at or asking
 A-FROM IN ACTION AT THE APHASIA INSTITUTE/KAGAN 225

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Figure 5 A-FROM in pictographic format. (Reprinted with permission from Taylor & Francis Ltd. Kagan
A, Simmons-Mackie N, Rowland A, Huijbregts M, Shumway E, McEwen S, Threats T, Sharp S. Counting
what counts: a framework for capturing real-life outcomes of aphasia intervention. Aphasiology
2007;22:258–280.4.)

about the schematic. The pictographic version In a recent family group during our 12-
can be used to explain intervention methods session Introductory Program, the discussion
and to help clients ‘‘see’’ progress in domains revolved around how one can measure suc-
other than impairment. This is relevant for cess and that with aphasia, progress is so
both the person with aphasia and the family hard to see. We used the A-FROM sche-
member. It is useful to do this separately for the matic, which depicts the Language Impair-
person with aphasia and family member be- ment circle with words describing aphasia, to
cause, although the domains remain constant, help make an abstract concept real and to
what the domains cover and user perspective help illustrate the importance of engaging
can differ. For example, family is part of the and participating in life. The group listened
environment for the person with aphasia but and questioned, and one family member,
the person with aphasia is part of the environ- who had been quite passive, seemed to gain
ment for the family member/significant other. a better understanding about aphasia and
The following actual scenarios provided by what he should be expecting and striving
staff, illustrate the potential for direct use of for. The following was discussed in relation
A-FROM with clients. to each domain:
226 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 3 2011

 Language and impairments: impairment- not only for the general public but for the
level work is done primarily in inpatient health care community members, who need
hospital settings and rehabilitation. to see themselves as part of the environment
 Our focus is where the circles all meet— for people with aphasia. For example, we re-
living with aphasia. cently worked with a graphic artist to create
 Our focus is QOL, and A-FROM domains online ‘‘living A-FROMs’’ as we chatted to
are a means to think about progress and to health care policy makers, administrators, re-
have an opportunity to be an active partici- searchers, and frontline staff at an Innovations
pant in decisions and conversations involving Expo held in Ontario and attended by the
the life of the person with aphasia. Minister of Health, who visited our booth.
 Members of the family group represent a We had extremely limited time to get complex
part of the communication and language concepts across and found A-FROM helpful in
environment of the person with aphasia, doing so as it is an instantaneous and obvious
and the environment is impacted by their snapshot of key challenges related to aphasia.
increased knowledge, their support, and Awareness and advocacy are as important
their advocacy in the bigger environment. within an aphasia organization as outside of it.

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 Participation in life situations is greatly im- A recent survey asking staff at the Aphasia
pacted by aphasia. Institute about A-FROM and their own use
 Personal identity, attitudes, and feelings are of it internally and externally elicited some of
areas of life that are diminished by aphasia the following comments:
and tend to be increased as individuals with
aphasia are able to reengage and be involved The visual schematic is helpful in ex-
in their lives. plaining the abstract work we do and also
highlights the systems theory factors in our
A speech-language pathologist (Introduc- work. (Clinical staff)
tory Program Leader) said, ‘‘The information Since we cannot be experts in all areas,
was very well received. We plan to include a it helps me determine where we fit and how
discussion on this topic in future Introductory we contribute to the other domains. (Clinical
Programs for both members with aphasia and staff)
the family support group.’’
A social worker (Introductory Program When I speak to people about what I
Leader) said, ‘‘In a one-on-one counseling do, after we get through what aphasia is,
session, a member was totally despondent inevitably the conversation turns to how we
about lack of progress in the impairment circle, help people speak. I then say that we don’t
repeatedly asking questions of what’s next and actually do that kind of therapy, but that we
what the future will be. It was helpful to help people live with their new situation.
acknowledge that the greatest loss was in the Although I don’t specifically say A-FROM,
impairment circle, and to explain that this is the I do say that speaking is one part of a whole
work he is still doing with a private speech- person, and there exists other areas that we
language pathologist. However, the A-FROM help work on, so people can return to living a
schematic helped to expand the conversation full and complete life, albeit with aphasia.
into an examination of progress already made (Administrative staff)
and the richness of the possibilities in the User-friendly for a lay audience . . . and
future.’’ not dependent on professional jargon. (Clin-
ical staff)

AWARENESS AND ADVOCACY It helps me identify areas that I need to

We are currently using A-FROM as an essen- work on: counseling of clients and families or
tial element of our aphasia advocacy campaign, getting familiar with medical terminology
specifically to increase awareness and knowl- when going through a referral form. (Clinical
edge of aphasia. As we know,12,13 this is needed staff)
 A-FROM IN ACTION AT THE APHASIA INSTITUTE/KAGAN 227

Over the past month, we have been help us in our efforts to make living successfully
looking at A-FROM with the volunteers. We with aphasia a reality for as many people as
took the time to break up each domain and possible.
understand what fits into each as well as how
they overlap. In subsequent weeks, following
the larger presentation on A-FROM, prior to ACKNOWLEDGMENTS
each presentation we looked at A-FROM and This article is the result of many conversations
reminded ourselves where the topic fit in and with staff, volunteers, and clients at the Apha-
to remember how it can impact all other areas sia Institute and is written in tribute to them
as well. . . . I think it helped the volunteers all. In addition, the author thanks Dr. Nina
understand our members more deeply and see Simmons-Mackie for her insightful comments
the entire person as well as the numerous on an early version of this article.
barriers they face. It was great to see how
excited the volunteers got, especially when
discussing the environmental factors and REFERENCES
how we can be doing so much more to

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advocate, etc. It was also good to look at tional Classification for Functioning, Disability
ourselves and see what things in our environ- and Health (ICF). Geneva, Switzerland: World
ment help or add barriers to our members. Health Organization; 2001;10
(Clinical staff) 2. van der Gaag A, Smith L, Davis S, et al. Therapy
and support services for people with long-term
Also useful to orient new staff, visitors, stroke and aphasia and their relatives: a six-month
and stake holders to our ‘‘common language.’’ follow-up study. Clin Rehabil 2005;19(4):372–
(Clinical staff) 380
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