Aphasiology
ISSN: 0268-7038 (Print) 1464-5041 (Online) Journal homepage: https://www.tandfonline.com/loi/paph20
Returning to work with aphasia: A case study
Julie Morris , Sue Franklin , Fiona Menger & GD
To cite this article: Julie Morris , Sue Franklin , Fiona Menger & GD (2011) Returning to work with
aphasia: A case study, Aphasiology, 25:8, 890-907, DOI: 10.1080/02687038.2010.549568
To link to this article: https://doi.org/10.1080/02687038.2010.549568
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APHASIOLOGY, 2011, 25 (8), 890–907
Returning to work with aphasia: A case study
Julie Morris1 , Sue Franklin2 , Fiona Menger3 , and GD1
1
University of Newcastle, Newcastle upon Tyne, UK
University of Limerick, Limerick, Ireland
3
North Tyneside Primary Care Trust, North Tyneside, UK
2
Background: For some people with aphasia, returning to work will be their eventual goal.
While there are reports in the literature of incidence of return to work, and general discussion of success, there are few documented in depth studies of what this might entail
for the individual with aphasia.
Aims: This paper explores returning to work with aphasia, and examines the complex
relationship between the person, the aphasia and the demands of employment.
Methods & Procedures: This is a detailed case report, describing and reflecting on the
experiences of GD, who returned to work following his stroke and aphasia. Therapy
focused specifically on work requirements is described and the factors affecting GD’s
return to work explored. An interview was used to elicit GD’s reflections on his
experiences.
Outcome & Results: GD’s language skills improved over time and with therapy, and he
developed several strategies that facilitated his communication. He was able to return to
work (part-time) in a modified role and this was successful initially. After an extended
period (∼19 months) his employment was terminated and GD explored other options.
He moved on to a volunteering and charity trustee role.
Conclusions: The success (or not) of returning to work with aphasia is multi-faceted and
does not rest solely with the person with aphasia. The nature of the work may have a
strong bearing on success, as will the ability and willingness of the employer to engage in
the process. Partnership with the person and constant review of goals and management
is of overwhelming importance. We need to consider what “success” may mean in this
context and the need to consider therapeutic and rehabilitation needs over a longer time
frame.
Keywords: Vocational; Work; Aphasia; Treatment.
The National Stroke Strategy (Department of Health, 2007) states as one of its quality
markers that “people who have had a stroke . . . are enabled to participate in paid, supported and voluntary employment” (QM16). However, it is unclear how many people
do return to work following stroke. Reports in the literature show the number may
be low, with estimates varying considerably. Vestling, Tufvesson, and Iwarsson (2003)
state that these proportions vary from 3% to 84%, with Treger, Shames, Giaquinto,
Address correspondence to: Julie Morris, Speech & Language Sciences, University of Newcastle,
Newcastle upon Tyne, NE1 7RU, UK. E-mail: Julie.morris@ncl.ac.uk
We would like to thank students and staff at the North East Aphasia Centre who contributed to this
work and the Tavistock Trust for Aphasia who funded the Centre during this study and continue to support
its work.
© 2011 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business
http://www.psypress.com/aphasiology
DOI: 10.1080/02687038.2010.549568
APHASIA AND RETURN TO WORK: A CASE STUDY
891
and Ring (2007) also reporting a large range (19–73%), the difference attributable in
part to what is classed as return to work.
Within these varied figures it is even more difficult to estimate the number of people with aphasia who return. Hinckley (1998) found 26% of her sample had returned
to work (although never in full to their previous status) whereas Parr, Byng, Gilpin,
and Ireland (1997) report that of their sample of 50 people, 36 of whom had worked
prior to their stroke, only 14% returned to work (5 of the 36). Only one of these was
to full-time employment as before. Caporali and Basso (2003) in their study found
that 23% of the sample who were working prior to their aphasia continued to do so
(9 of 38). This was approximately 31/2 to 7 years post onset. Of these, five were reported
to have returned to their previous roles and four were unable to do the same level of
work. Rolland and Belin (1993) conclude from their survey (of 63 people) that it is
“extremely rare that patients return to a job that is equal to the one they previously
held” (p. 227).
Gil and colleagues (Gil, Cohen, Korn, & Groswasser, 1996) also look specifically
at “vocational outcome” for people with aphasia. However, the detail given is scant;
for example work is classified into four overall categories (skilled, unskilled, sheltered,
and unemployment). The first two categories are considered “well recovered”; the latter two “poorly rehabilitated”. This type of research, while offering us some insight
into overall patterns, provides little information about working with an individual and
the complex issues that arise. Overall what appears to be missing is an in-depth exploration of the rehabilitation involved, the progression of events and an evaluation of
the long-term outcome (rather than simply that the person returned to work/did not).
Hinckley (2002, p. 546) reports that
. . . the few published studies on ultimate employability of adults with aphasia limit our
ability to appropriately counsel clients about long-term expectations. While many adults
with aphasia do not return to work, some do, and it would be important to be able to
describe the factors that contributed to successful return to work.
She later states, “detailed case reports with both positive and negative vocational
outcomes should be disseminated” (p.556), and it is this we seek to do within this
paper. We felt it important to discuss the issues that arose in relation to working
with one client (GD) and supporting him in his return to work. GD himself has
been involved in the preparation of this paper, and provides important insights and
understanding of the challenges and barriers involved in returning to work with
aphasia.
Hinckley (2002) reviews five studies related to return to work with aphasia. She
concludes from these that several factors influence return to work including workplace flexibility, social support, motivation, motor impairment, and cognitive abilities.
Of interest is that, in the studies Hinckley cites, the severity of the aphasia does not
influence whether the person returns to work or not. The fact that the factors identified by Hinckley are about not just the person but also their environment is important.
If we use a framework such as the A-FROM (Kagan et al., 2008), four sectors or factors are seen as important in working with someone with aphasia: the severity of the
aphasia, the communication and language environment, the person’s participation in
life situations and personal identity, attitudes, and feelings. Lock, Jordan, Bryan, and
Maxim (2005) discuss enablers and barriers to work in their study where people who
had had a stroke discussed their experiences of work. What is clear is that the demands
(linguistic, emotional, physical) placed on the person, the expectations, flexibility in
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the workplace, and attitudes may all have a strong effect on whether return to work is
possible and successful.
In their study of attitudes to return to work with aphasia, Garcia, Barrette, and
Laroche (2000) looked at perceived barriers. These were from people with aphasia,
speech and language therapists, and employers. All groups identified barriers relating
to productivity, unfamiliar speakers, electronic tools, and the lack of education about
communication disorders. Of course it is important not to focus only on the impact
of the aphasia on return to work. Parr et al. suggest that the person must become
“familiar with the limitations imposed by aphasia together with other consequences
such as physical weakness and fatigue, and understanding that these are likely to be
long term problems” (1997, p. 28).
This paper will present a detailed case report of one person’s experiences of return
to work. We aim to describe therapy for high-level aphasic deficits, targeted specifically around the requirements for work. We then describe what happened when GD
returned to work, specifically looking at his experience of the process. Finally we consider the issues that need to be considered in preparation for return to work, both with
the benefit of hindsight and using the AFROM as a framework.
GD: A CASE STUDY
We will first describe GD’s medical and work history. We will then present assessment
findings and describe the therapy given. A brief factual description of what happened
when GD returned to work will be followed by the results of an interview carried out
with GD where he reflects on his experiences.
Case history
GD’s aphasia followed a left hemisphere cerebro-vascular incident (CVI) in April 2000.
A CT scan showed a large infarction in the left parieto-occipital junction, likely to be
extending into the left planum temporale. GD reported minimal physical difficulties
following the CVI (slight leg weakness) but this resolved. At the time of the CVI, GD
was working in full-time employment. This was for a large insurance firm where he
worked with corporate financial clients. GD, age 45, lived with his wife and two children
(in their late teens). GD was a very active man both at work and in leisure time. GD
had left school at 16 and had later completed a diploma in management studies.
In terms of communication GD was reported to have mild receptive and expressive
aphasia. The most prominent aspect at this time was a difficulty with auditory
processing, leading to difficulties with comprehension, particularly within group or
noisy situations and with telephone use. He struggled to follow programmes on
television without using context to aid understanding, and needed peace, quiet, and a
one-to-one situation to converse with his family. GD also described (later confirmed
by testing) having difficulties with word finding (especially longer or unfamiliar words)
and with his written language both in terms of spelling and syntax. It was evident
from early sessions that return to work was a possibility and one that GD was actively
considering and discussing at home, in therapy and with his company directly. GD
states, “I was really, as you know, very enthusiastic to go back to work, in whatever
shape or form.”
GD was discharged from hospital very early post CVI (within the same week) and
from then on the contact was mostly with speech and language therapy (SLT). Once
APHASIA AND RETURN TO WORK: A CASE STUDY
893
at home, GD was seen twice weekly and sessions involved discussion of his communication difficulties and their implications, exploration of issues surrounding work,
assessment, goal setting, and direct language therapy (focused on word finding and
written language). See Graham, Morris, and GD (2002) for further information.
Work environment and requirements
In order to consider the significance of his aphasic deficits we needed to understand
GD’s communication environment further and the demands it placed on him. As
stated, GD was employed by a large insurance company as an accounts and development manager. He worked from home but with extensive travel. GD reported he
was very used to communicating while on the move and through teleconferences. He
also made extensive use of computers at work.
When asked to describe his position, he reported that it involved several main
activities: managing and supervising performance and development of an insurance
product, troubleshooting client insurance issues, managing marketing initiatives, and
regular contact visits nationally. Everyday activities included use of e-mail, phone
contact with manager and client, managing client databases, chairing meetings,
presentation design and implementation, reading documentation, memo/document
writing, and travel.
Assessment findings
These findings combine information obtained from formal assessment with observation and self-report. Formal assessment findings are presented in the Appendix for
information. These will not be discussed in detail, since most results were within normal limits, reflecting the high level nature of GD’s aphasia. They are from a period
3–5 months post onset.
Auditory comprehension. While earlier testing of auditory comprehension had
revealed subtle difficulties, by the time of these assessments, GD was performing
within the normal range on tests of auditory comprehension, with the exception of
tests of humour and inference. Despite this GD continued to report, and observation
confirmed, that he had problems understanding when there were groups of people or
when background noise was present.
GD reported that when face-to-face with people he had little difficulty. He was
aware that he watched the speaker’s lips and that this helped him. He reported difficulties if people turned away, on the telephone, and with background noise present. The
phone presented particular difficulties and he reported having difficulties distinguishing voices. While watching TV had been difficult, he reported that this was resolving.
However, listening to music remained an issue with the enjoyment derived from this
considerably diminished. In relation to his listening generally, he reported that “it feels
like there is an echo” and that it “makes things a bit wavy when I receive it”. An audiology report concluded that “hearing was either normal or close to normal for most
of the speech frequencies in both ears” (moderate high frequency loss reported).
Written comprehension. Written information provided a useful support to GD if
clarification of a spoken message was needed. GD reported that while he was able
to read complex material, his reading was not as it would have been. He felt that he
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MORRIS ET AL.
understood newspaper articles but that more complex information would need reading
two or three times. However, again, on assessments used, GD was within the normal
control performance range on the tests used.
Spoken production. GD was aware that he had some difficulties producing what
he described as “harder” words. He frequently noted words that he found difficult
in a book he carried. Some slight hesitation was evident in his speech, as were some
close phonological errors. If unable to find a word, GD was usually able to find an
acceptable alternative. Standard assessments of word retrieval again failed to detect
these difficulties GD was reporting; it was only more taxing assessments that began
to reveal difficulty (e.g., word fluency, naming from definition; see Appendix). Spoken
production in a sentence context, as measured by picture description was within the
normal range, as was production of narrative.
Written production. GD reported that he was writing in everyday life but that this
was considerably slower than it would have been. He reported taking 3–4 hours to
write a two-page letter, which he had to re-edit. He was also attempting crosswords
that he would have done previously, but reported that this was very slow and he
was unable to complete them. Again, these difficulties were not revealed by standard
assessments.
Other cognitive skills. Cognitive skills as measured by a general screen within the
Comprehensive Aphasia Test (CAT) (Swinburn, Porter, & Howard, 2004) were shown
to be normal. GD did report that his memory concerned him, and that he felt he did
not always remember details. He used memory aids from an early stage, always carrying an appointments diary, as he recognised he was forgetting things. It is of course
difficult to work out the contributions his language problems had in this instance (e.g.,
not understanding the material initially). To this end, a referral to clinical psychology
was made. Their findings indicated working memory, or ability to attend to and mentally track information, was good. However when a task involved large amounts of
spoken information then detail was lost. They suggested that this was a result of the
amount of processing capacity GD had to devote to understanding words.
Summary. In summary, it appeared that at 3–5 months post onset GD continued
to experience difficulties with auditorily presented information. However, this was at a
very high level and difficult to detect on language measures normally employed. This
led to difficulties in particular situations (e.g., on the telephone). Complex spoken and
written output could also present difficulties, with slight word-finding errors emerging
in speech when GD was under pressure, tired etc. Writing was subject to slight errors
and took GD far longer than he was used to. GD’s return to work was taken into
consideration when interpreting these findings and developing therapy goals.
A work directed therapy programme
GD attended an intensive aphasia clinic for 3 days per week for 12 weeks, where he
received a mixture of individual and group therapy. Collaborative goal setting with
GD focused on his overarching goal of return to work. Combining GD’s self-report,
knowledge of work tasks, and conclusions from assessment, led to specific goals. The
APHASIA AND RETURN TO WORK: A CASE STUDY
895
content of therapy was constantly discussed with GD and modified as a result. Much
of the discussion revolved around his insights into problems and into helpful strategies.
Therapy focused on auditory processing, writing and presentation skills, memory,
and increasing confidence. These areas will be briefly discussed. It is not intended
to provide a comprehensive description of each facet of therapy, but rather a broad
overview of approaches taken.
Auditory processing. Several possible foci for therapy were identified. These
included listening to and recording messages, telephone use, dealing with background
noise, and listening within meetings, including recording minutes. In order to address
these areas activities within therapy included listening work beginning with lip-reading
allowed then lip-reading withdrawn but with voice still “live”. Following this tape
recordings were used and finally telephone practice was introduced. GD reported
that both in person, but particularly on the phone, he often missed important initial information and that recorded messages were particularly difficult to understand.
To address this, therapy including tasks listening to messages and recording details of
meeting dates, venues, content etc. Initially information was checked collaboratively
in the session. Later GD was required to e-mail the information to a third party and
this was checked in a subsequent session.
GD was required to listen to sentences where the important information fell initially, followed by more conversational and largely redundant language. For example,
“The train leaves on Monday 27th November at 13.00. Hope that’s OK. They had a
limited choice of trains, but I thought that one best suited your requirements.” Later
stimuli were designed so that GD was unable to predict where the important information would be. Additionally, different speakers were used (via tape recordings) because
GD had reported that different voices confused him. GD and the therapist then collaboratively examined his success and discussed important elements to focus on and
how to identify these.
GD had identified numbers and names to be particularly difficult so part of therapy included on this. For example, he was required to listen and record the kind of
message left on an answerphone. For example, “This is Debbie Carter calling GD on
Tuesday 18th November. Could you ring me back please on 01629 237105.” Feedback
consisted of repetition of the stimuli with emphasis, joint evaluation, and discussion
of strategies for improving accuracy. It was suggested he chunk the numbers and this
was practised. A useful strategy to check heard information was to repeat it back to
the speaker for verification. A role-play situation was used in many instances, in an
attempt to make the task as meaningful as possible.
Approximately halfway through the therapy period, GD identified an additional
difficulty of listening with background noise present. It was decided to incorporate the
use of background noise in an attempt to desensitise him to it and/or help him develop
strategies to overcome the difficulty. Work began with speech-type background noise
(e.g., recording from radio), traffic noise (busy road in rush hour), and internal car
noise (since this was where GD often communicated). Later, train station noise, noise
from small groups (e.g., restaurant), and large groups (e.g., pub) were incorporated.
The competing “noise” was played out as GD was required to listen to information.
Initially the information he had to listen to was relatively straightforward with low
volume, with complexity and volume increasing over time.
Therapy also provided GD with some practice in taking minutes, by recording contributions within the group setting. This was challenging for GD (different
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speakers, background noise, auditory processing etc), and in retrospect insufficiently
utilised as a therapeutic task (this was done quite informally with little systematic
feedback).
Writing and presentation skills. Much of GD’s work involved various types of written tasks, which he now found difficult. He was required to write reports, e-mail,
and prepare PowerPoint presentations. Within therapy working with e-mails, GD was
given verbal instructions about what to e-mail (so also addressing auditory processing, comprehension, and memory) and was asked to e-mail the information. This was
checked and discussed in a later session.
At work GD had been involved in the development of a communication database
and he was keen to be involved in the launch of this, which would require a presentation. With this specific work aim as the focus, GD independently wrote a presentation
about the database and gave the presentation initially to one person and then to a
small group. Their role was to provide an audience and to give feedback on the presentation as a whole. Later in therapy GD was given a topic and asked to prepare
a brief presentation for later in the week. He was asked to e-mail details of the date
and venue of the presentation. This was in an attempt to bring together several different aspects of therapy in something resembling a work situation. Following the
presentation he was asked to review his time management, clarity, formality, and
appropriateness.
Memory. GD reported problems remembering details of what he had done in the
previous week, and was concerned by this. Clinical Psychology had reported memory
to be good except when following of large chunks of auditory material. We decided
not to assess this further, but took his insights at face value and looked at strategies
to support him. The most useful of these was a hard copy of a full diary, which GD
developed consistent use of. GD was asked to record (post-hoc) the details of the day
that he felt were pertinent. At a later date he was asked to discuss the information and
evaluate how effective the diary was as a prompt/aid memoir. Discussion included
what kinds of information might have been more useful and what other strategies
might help him remember detail. Once use of the diary was established then GD used
it independently.
Increasing confidence in communication. Throughout all aspects of therapy there
was of course the overarching aim of improving GD’s confidence in his communication skills. This was done by ensuring levels of success and careful gradations of task,
use of feedback to support successful communication, and ensuring strategies were
in place. Throughout therapy GD’s goals changed as he improved within the therapy tasks themselves, but also as he identified barriers and goals relating to return
to work.
During the course of therapy it was felt that some of the issues discussed,
for example, return to work and feelings of panic associated with certain situations (e.g., if particularly noisy, travelling by car), might be better dealt with by
other professionals. Following discussion, GD agreed to be re-referred to clinical
psychology. GD was offered sessions at a later point (post the therapy described
here). GD reported that he found these sessions helpful, especially in relation to
the panic attacks he was experiencing and personal issues, particularly relating to
family life.
APHASIA AND RETURN TO WORK: A CASE STUDY
897
Outcome of therapy
Goals within therapy were constantly renegotiated and tasks changed to accommodate new goals and/or developments (often from observations/from GD’s insights).
For example, messages became more complex over time, the use of background noise
within therapy was introduced (when GD realised how much of an issue this was
across situations), and presentations were introduced. Use of formal assessments to
measure outcome was problematic, since GD performed within the normal range
on most assessments. Levels of difficulty within therapy progressed, as GD was able
to cope with more difficult tasks, indicating improvement. It is vital to consider
the person’s perception of change and in order to examine this GD completed the
Disability Questionnaire from the CAT. These results are presented in Figure 1 and
indicate changed perception of his difficulties in many areas (with a lower number indicating the person perceived themselves having less difficulty or being less
concerned).
Return to work
From when he first started therapy, GD reported that his employers were being very
supportive. He enlisted their support regarding his attendance at the intensive aphasia
clinic. The benefits of contact between SLT and the company were discussed with GD.
However, GD was very clear that he preferred contact to be made by either himself
or at the company’s request and his views on this were respected. A single report was
requested by Occupational Health, and this was provided.
While engaged in therapy GD remained in contact with work, attending occasional meetings, sending e-mails, and making sure he kept himself updated. This
also fulfilled the function of GD maintaining his identity as a working person.
There was exploration of GD attending a vocational rehabilitation setting, but
GD was keen to get back to work directly and did not want to explore that
option.
By the time GD returned to work, the company he worked for had merged with
another large company, and restructuring and changes of management began to occur.
Figure 1. Responses pre and post therapy on the CAT Disability Questionnaire.
898
MORRIS ET AL.
Despite this, GD returned to work (as planned) 2 days per week, working flexibly
both in time and location. His role was described as “project work”, managing a client
database with travel kept to a minimum (i.e., significantly different from his previous
work, where he would have worked directly with clients). Then 19 months after he
resumed work, GD was made redundant, and an exit package was agreed 8 months
later.
He subsequently decided that he would take on some volunteer work. He began
working with an intensive aphasia group, both helping with activities and with
the organisation of the group, for example making refreshments. In addition to
this, GD became a leading trustee in a relatively new charity that aims to support people with aphasia and their carers. He put forward many initiatives and
used his business knowledge and interpersonal skills to develop these. Throughout,
GD continued to use some of the strategies he evolved within therapy, particularly
requesting written material prior to meetings/sessions and always preferring to be
well briefed. He has not ruled out taking up some kind of paid employment in the
future.
Reflections from GD
During the preparation of this paper GD was asked to reflect on the course of events.
This reflection was elicited via interview. The interview was given limited structure by
using time references to elicit reflections (e.g., can you tell me about when you had
therapy, when you first returned to work, when you left work, when you started volunteering). Relevant extracts were taken from the interview and these were discussed with
GD as to whether they were appropriate and represented his perceptions. Alaszewski,
Alaszewski, Potter, and Penhale (2007) highlight that “the accounts of individual who
have had a stroke are an important and relatively neglected source of data which provide insight in the importance of work and the factors which impede or facilitate
work” (p. 1860).
Return to work. In fact, while GD had been aware that he was unlikely to assume
his role as before, he felt that the first 2 months’ return were very unstructured, he
had little or no face-to-face interaction with colleagues and therefore relied on phone
use, which remained a struggle. He saw the project work as a way of “managing” him,
since information technology was not his specialism. Three months into his return GD
was asked to attend a regional meeting and he describes this as an extremely taxing
situation. He reports struggling to cope, listening to 10–12 people with the noise of a
projector. He reports being quiet and unconfident, a marked contrast to his pre-stroke
style. GD reflects:
I tended to be quiet . . . because I think really I still had . . . I was confident, but nowhere
near as I was before . . . I was worried I might stumble my words . . . sound foolish, what
have you.
Some of his colleagues did not realise he had had a stroke, and therefore made
no allowances. GD frequently chose not tell people he had had a stroke, but that
he had problems with “hearing”. GD often commented that having a visible form
of disability (e.g., using a stick) would, in many ways, have been easier to manage.
Difficulties were exacerbated by changes in line management. He reports having to go
APHASIA AND RETURN TO WORK: A CASE STUDY
899
over explanations, and there being a lack of understanding of aphasia or stroke. His
new manager rarely made contact as GD reflects:
where once upon a time I would be expected to have some sort of contact with my line
manager every day, this guy who hadn’t a clue how to cope with me, he rarely spoke to me
. . . it was sort of like, in a way I thought, erm, I felt a wee bit shunned.
Coping and changing. GD reports changing strategies in relation to work; preparation began to be pivotal in every aspect. He reports:
I had to be organised, checklists were like a key . . . putting into black and white my travel
arrangements . . . it was like, it was a slow process.
GD suggests his focus became preparation rather than delivery, again a contrast
to pre-stroke. He was able to give PowerPoint presentations (prepared) but found it
extremely difficult to deal with any questions, which generated anxiety and panic. He
also discusses this preparation as “Catch 22” as, if his preparation was too good, then
colleagues believed he had no difficulty and therefore no allowances/adjustments were
made. GD also reports difficulties with some colleagues, and almost a year into his
return to work he was selecting only the “friendly or sympathetic” colleagues to deal
with. GD remembers thinking, around 15 months after his return to work, that it was
likely the company would either terminate his employment or offer a different kind of
position. He reports:
I thought they would either offer me something else or say enough is enough and save the
money.
Ending. GD himself felt frustrated at the lack of progress, and a further change
in management meant his project work was not a priority. Then 19 months after his
return, the company did indicate they wished to terminate employment. He reflected:
they just basically said . . . erm, it’s about time to say cheerio . . . erm which it wasn’t a
surprise but on the other hand thought I still felt I had some sort of value and they could
have said, look GD, we’ll give you another job, but by the way you’re not on X, you’re on X
minus, and I would have accepted that, but they didn’t.
However, there was an 8-month period during which the financial details of this
were resolved to both GD’s and the company’s satisfaction. GD reports that in the
interim his feeling of purpose diminished, he experienced mood swings, and felt bitter
about his employer. Reflecting on the overall experience of returning to work, GD
reported that he felt threatened going back and that people could not see his disability.
He reflects:
the sort of job I had was all to do with communication really . . . and because I couldn’t
communicate as I could did before . . . well, I felt threatened, I think that I was always a
scare that they would pull the plug on me at anytime. Eventually they did.
What next. Reflecting on working in the voluntary system, GD feels he is regaining
some purpose in life but that he still has some way to go. He does tend to get frustrated,
but sees himself as having turned a corner. He reports a period of hiding his feelings
and frustrations. He states:
I knew there was no future with my employer or other employer, the penny was dropping big
time . . . a bit of a low ebb.
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He reported comparisons with other people with aphasia to be unhelpful; his aphasia may have been “mild” but that was irrelevant to him. GD reports reaching a crisis
point when his strategies for coping failed him and he looked for additional support.
He describes this period as
nothing at the end of the tunnel, just black. Got to open that door even though may not be
clear.
He felt the pressure of frustration, which he feels he was “bottling up”. He was
referred by the GP to a “life counsellor” and describes these sessions as pivotal
in reducing frustration and in improving mood. In GD’s view, best practice would
include the opportunity for these kinds of counselling sessions. However, he also
reflects that earlier sessions with psychology were of limited use to him; this may
relate to approach used and/or timing. It emphasises the importance of having options
available to the person throughout the rehabilitation process rather than at fixed
time points. This was all around the period that negotiations with work were being
finalised.
The future. Asked to think of the future, GD is very enthusiastic about his role of
trustee of a charity. He remains unsure whether he would cope with paid employment
or not; he says he just does not know. He sees the process as a long term one, with the
situation evolving over time:
I think my relationships with people, wife, family, were actually were in a very very difficult period . . . but I think now I’m quite happier . . . but it took . . . well 3 years
on . . . so it’s a sort of a long process isn’t it . . . maybe I guess . . . there’s no end to the
process.
Finally, asked to reflect on whether going back to work was important, he reflects
that it was “essential”; that he had to test himself. This remains his view even though
he feels the end result was not satisfactory. He reflects:
Had to test myself. I didn’t like the results over that period of time because that experience
wasn’t a successful experience but, have to do it . . . I think there was no option not to go
. . . it was worthwhile in a sense of going down that route, even though the end result wasn’t
successful, wasn’t, I wasn’t satisfactory about what happened.
DISCUSSION
In order to understand the factors that affected GD’s return to work, we will use
the structure of the A-FROM (Kagan et al., 2008). Analysis of GD’s circumstances
into the four factors (participation, personal identity, severity of aphasia, and communicative environment), and, more importantly, their interactions, gives structure
to a consideration of important influences on GD’s ability to return to his previous
employment.
Participation
Issues around participation (other than participation in work) did not figure largely in
GD’s construal of his aphasia, perhaps because he had sufficiently good communication to be able to talk to people socially, and because work had always been a huge part
of his life and therefore return to work was his main priority. It is interesting, however,
APHASIA AND RETURN TO WORK: A CASE STUDY
901
that further on in his recovery GD understands that his communication impairment
has affected his family relationships.
Personal identity
It is clear from GD’s description of his experiences around returning to work that the
initial loss of work and his communication deficit severely affected his confidence. He
also found it difficult to explain to his work colleagues that he had aphasia, and spent
a good deal of time in work preparation in order to hide this fact. It was interesting
to note that GD found the fact that his disability was largely “hidden” was a source of
difficulty.
He also felt that the lack of contact from his manager made him feel a “little bit
shunned”. The eventual loss of his paid employment effected his mood severely (seeing
a “black future”), and it is a testament to his strength of purpose that he was able to
recover from this and take up the voluntary roles that have allowed him to regain
much of his lost confidence. He found life counselling to be particularly useful in this
respect.
Severity of aphasia
Assessment indicated that GD had only mild aphasia. However he had very real
communicative difficulty in terms of the requirements of his job. Therapy was targeted specifically at developing strategies for work, and he had an unusually intensive
amount of intervention. He did work for 19 months (part-time), but it is clear that
he was doing superhuman amounts of work and expending huge amounts of effort to
maintain his position.
Communicative environment
The communicative environment is clearly pivotal in the case of returning to work
and it is clear that there were both barriers and facilitators in GD’s workplace. His
firm were prepared to change his role at work and employ him for 2 days per week.
However, expectations of the employer and demands on GD could be perceived as
barriers. GD was still required to travel, attend large meetings, use mobile phones,
communicate rapidly etc. GD reported a lack of structure in his revised post and found
that they had given him a project in an area where he was not a specialist. Because of
the position that the firm was in, he had many changes in line management and little
contact from his manager.
The demands placed on GD’s language (through work for example; the environment) were immense and revealed issues of competence that may not have otherwise
been seen. It is likely that his level of aphasia would have had a more minimal impact
had he worked in a different environment. Parr et al. (1997) suggest that people whose
work relies on communication skills “may find that they quickly reach the understanding that return to the same form of work is unlikely” (p. 28). Lasker, LaPointe, and
Kodras (2005) state that posts which are communicatively and cognitively demanding may be especially difficult. Garcia et al. (2000) make the important point that
many jobs now require rapid communication, often in group situations, and mastery
of many different technologies. This was clearly the case for GD; his position required
all these things.
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Interactions between factors
Most importantly, it is likely that it was the interaction of the above factors that particularly contributed to GD’s difficulties at work. At the point of returning to work
he had not come sufficiently to terms with his identity as a person with aphasia. This
led to GD’s choosing to communicate with his line manager himself without direct
SLT involvement with the employer. This was clearly a weak link in the chain; it
is impossible to tell how much more engaged his workplace would have been with
more information and support. We, and GD, would now argue this should have been
explored and renegotiated at different junctures as GD’s perception of his identity
changed over time. Perhaps more focus should have been placed on the added value
this would offer, the benefits it would bring. We chose to respect the person with
aphasia’s wishes, but GD was perhaps under informed in making these choices.
Possible interactions would have included providing education for colleagues, supporting GD in making clear agreements, facilitating on-going support, monitoring
etc. Instead, what happened was that GD was put in situations that were particularly
difficult and which generated anxiety, reinforcing ideas around identity. It is interesting to note his very perceptive comment of the “Catch 22” of spending so much time
preparing things to give the appearance of coping that he would appear not to require
support. Vocational rehabilitation specialists could have had a role, as might disability
employment advisors. These could have provided an alternative bridge between GD
and his employer and would have brought expertise about work place negotiations
that are beyond the remit of SLT. Specific vocational rehabilitation was discussed with
GD as an option but was not taken up.
The National Stroke Strategy (Department of Health, 2007) discusses that return
to work may not always be immediate, but people may be able to return to work longer
term and therefore “can benefit from arrangements to give access to rehabilitation and
support for return to work weeks, months or years post-stroke, as appropriate for the
individual” (p. 48). In GD’s situation, because he had done so well in recovering from
aphasia he was expected to return to work relatively quickly, but it might have been the
case that being given more time to come to terms with his aphasia could have meant a
more open, planned, and successful return.
“Success” in returning to work
What might constitute success in terms of return to work? Clearly GD was successful at many levels. He negotiated and made a return (albeit part-time). In a study
reporting statistics regarding success, GD would have made a successful part-time
return. However, the situation is much more complex than this. After ∼19 months
GD’s employment was terminated, but he had feared this for much longer and was
questioning the value placed upon him, his role, and his future.
Levack, McPherson, and McNaughton (2004) interviewed people who had
returned to work following traumatic brain injury (TBI). They reported that for three
of the people studied, while they initially returned to work successfully, eventually this
was “unsustainable”. They too emphasised the need to study factors over time and the
possibility of the need for on-going support. For some individuals this was perceived
as failure with associated feelings of frustration and, for some, depression.
It was not clear that GD was being unrealistic in returning to work (other than
in the very early stages). Parr suggests motivation to return to work may depend
APHASIA AND RETURN TO WORK: A CASE STUDY
903
somewhat on stage of life and role of work. GD had an established career, a strong
identity with work, linked social life, and established patterns of long work hours.
Parr et al. suggest “the drive to return to work may be overwhelming” (1997, p. 29).
GD reflected that it was “essential” to return and indeed, if rehabilitation had indicated he would be unlikely to succeed, this might have been disastrous in terms of
impact on his social wellbeing. Some of the difficulties could be seen as environmental
rather than personal, but GD was faced with limits about how far the environment (in
particular his work) was able or willing to adapt and this led to some of the difficulties
faced within work. Clearly the degree to which an organisation/employer is prepared
and/or able to adapt will influence success. GD himself sees this interaction between
individual and their employer as of major importance and feels the organisation had
no “best practice” in how to deal with this situation, let alone support him. He feels
there should be more emphasis placed on supporting and improving the situation for
the individual and potentially on employer education.
From an SLT perspective, this case also highlights the question of how we measure
success in therapy for someone returning to work. Many standard assessments were
inadequate since GD’s performance was within the normal range. Is it sufficient to set
goals and then examine if these are achieved? In this instance this was always done collaboratively with GD, and often the success or difficulties he encountered gave a very
direct evaluation of the success of therapy. Levack et al. (2004) make the important
point that studies of vocational outcome (in traumatic brain injury) usually measure
outcome at one point in time and that this may not be representative. Success, or not,
is far more complex than this and varied for their participants.
Facilitating return to work
Treger et al. (2007) conclude from their review of the literature that there is a lack of
research on vocational outcome and that “rehabilitation professionals” have a key role
both in terms of service and influencing policy. Radford and Walker (2008) conclude
that “returning people to work should be an integral part of the rehabilitation process
rather than an afterthought. The barriers in returning to work are many and complex
and each needs to be addressed by a trained individual. Top-down and bottom up
strategies are both needed” (p. 167).
There are issues raised concerning the role of the SLT in facilitating return to work.
In a situation such as this, who should the multi-disciplinary team be? Clearly, alongside the person themselves, the SLT has a role in assessing communication, examining
linguistic/communicative demands of the employment situation, directing therapy,
developing strategies (etc.). As discussed, active engagement of the employer is considered very important, but there may be issues here for the individual. The employer
needs to understand what may affect return to work (consider those cited by Hinckley,
2002) and needs guidelines on how to support the individual. GD advocates that,
where possible, the employer should be part of that multi-disciplinary team; the purpose not least, education of the employer. However, GD reached this view several
months after his return to work; he had initially wanted limited contact between SLT
and work. There is a clear need for close working with the employer, the person
with aphasia, and also someone with an understanding of the individual’s position.
This person may need to become a negotiator and/or advocate for the person with
aphasia, potentially facilitating modifications to ensure the client’s skills are utilised
appropriately. We need to consider timing and acceptance of different therapeutic
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interventions, and revisit decisions over time, re-presenting opportunities. Clinical psychology and counselling also had an important role for GD, but he made different use
of them at different times, demonstrating the need for flexible services that the person
can access as required.
CONCLUSION
Having left work, GD became quite despondent initially, and then began to consider other options. He currently gives a great deal of time and energy in supporting
other people with aphasia. The outcome for GD is still evolving, and emphasises the
importance of considering the longitudinal aspects of outcome. At the centre of such
discussions should be the perception of the person with aphasia of personal success.
From the interview, GD clearly stills feel a disappointment that his work finished and
a frustration that his employers did not explore other options with him. However, his
position appears to have moved on from when he felt “bitter” about the company and
how he had been dealt with. At times GD had felt he was “shunned” and an “outcast”
and this reinforces the importance of work in our lives. This is emphasised by Vestling
et al. (2003) who state “work fulfils basic human needs, such as financial, societal and
intrinsic needs, and returning to work after stroke is of significant importance for quality of life and life satisfaction” (p. 35). We would like to argue that GD’s story (to date)
is one of success and achievement, but not necessarily in his original goal—return to
work. GD’s situation emphasises the importance of the combination of factors that
might influence return to work, not least the demands and flexibility of the employment situation. It also demonstrates the immense motivational drive needed by the
person with aphasia and their support networks in achieving this. The need for flexible timely services is clear and the complexity of the individual situation a challenge
to rehabilitation professionals.
Manuscript received 6 August 2010
Manuscript accepted 16 December 2010
First published online 4 March 2011
REFERENCES
Alaszewski, A., Alaszewski, H., Potter, J., & Penhale, B. (2007). Working after stroke: Survivors’ experiences and perceptions of barriers to and facilitators of the return to paid employment. Disability and
Rehabilitation, 29(24), 1858–1869.
Bird, H., Franklin, S., & Howard, D. (2000). Why is a verb like an inanimate object? Grammatical category
and semantic category deficits. Brain and Language, 72, 246–309.
Bird, H., Howard, D., & Franklin, S. (2003). Verbs and nouns: The importance of being imageable. Journal
of Neurolinguistics, 16, 115–149.
Bishop, D. V. M. (1983). The Test for Reception of Grammar (1st ed.). Published by the author and available
from Age and Cognitive Performance Research Centre, University of Manchester, UK.
Bryan, K. (1995). The Right Hemisphere Language Battery. London: Whurr.
Caporali, A., & Basso, A. (2003). A survey of long-term outcome of aphasia and of chances of gainful
employment. Aphasiology, 17(9), 815–834.
Department of Health. (2007). National Stroke Strategy, London, UK: Author.
Franklin, S., Turner, J. E., & Ellis, A. W. (1992). ADA Comprehension Battery. London: Action for
Dysphasic Adults.
Garcia, L. J., Barrette, J., & Laroche, C. (2000). Perceptions of the obstacles to work reintegration for
persons with aphasia. Aphasiology, 14(3), 269–290.
APHASIA AND RETURN TO WORK: A CASE STUDY
905
Gil, M., Cohen, M., Korn, C., & Groswasser, Z. (1996). Vocational outcome of aphasic patients following
severe traumatic brain injury. Brain Injury, 10(1), 39–45.
Graham, F., Morris, J., & GD. (2002). Return to work: Issues facing the client and the therapist. “I want
a vanilla life”. Paper presented at the British Aphasiology Society Therapy Symposium, Swanwick,
Derbyshire, UK.
Hinckley, J. J. (1998). Investigating the predictors of lifestyle satisfaction among younger adults with chronic
aphasia. Aphasiology, 12(7/8), 509–518.
Hinckley, J. J. (2002). Vocational and social outcomes of adults with chronic aphasia. Journal of
Communication Disorders, 35(6), 543–560.
Kagan, A., Simmons-Mackie, N. S., Rowland, A., Huijbregts, M., Shumway, E., McEwen, S., et al.
(2008). Counting what counts: A framework for capturing real-life outcomes of aphasia intervention.
Aphasiology, 22(3), 258–280.
LaPointe, L. L., & Horner, J. (1998). Reading Comprehension Battery for Aphasia-2. Austin, TX: Pro-Ed.
Lasker, J. P., LaPointe, L. L., & Kodras, J. E. (2005). Helping a professor with aphasia resume teaching
through multimodal approaches. Aphasiology, 19(3/4/5), 399–410.
Levack, W., McPherson, K., & McNaughton, H. (2004). Success in the workplace following traumatic brain
injury: Are we evaluating what is most important? Disability and Rehabilitation, 26(5), 290–298.
Lock, S., Jordan, L., Bryan, K., & Maxim, J. (2005). Work after stroke: Focusing on barriers and enablers.
Disability and Society, 20(1), 33–47.
Lum, C. (1996). Nonpropositional and propositional speech in aphasia. Unpublished PhD thesis. Psychology
Department, The University of York, York, UK.
McKenna, P., & Warrington, E. K. (1983). Graded Naming Test. Windsor, UK: NFER-Nelson.
Morris, J. (1997). Word deafness: A comparison of auditory and semantic treatments. Unpublished DPhil,
The University of York, York, UK.
Nelson, H. E. (1982). National Adult Reading Test (NART). Windsor, UK: NFER-Nelson.
Nickels, L., & Howard, D. (1994). A frequent occurrence? Factors affecting the production of semantic
errors in aphasic naming. Cognitive Neuropsychology, 11, 289–320.
Parr, S., Byng, S., Gilpin, S., & Ireland, C. (1997). Talking about aphasia: Living with loss of language after
stroke. Buckingham, UK: Open University Press.
Radford, K. A., & Walker, M. F. (2008). Impact of stroke on return to work. Brain Impairment, 9(2),
161–169.
Rolland, J., & Belin, C. (1993). The person with aphasia and the workforce. In D. Lafond, Y. Joanette,
J. Ponzio, R. Degiorani & M. Taylor Sarno (Eds.), Living with aphasia: Psychosocial issues (pp. 224–242).
San Diego, CA: Singular Publishing.
Swinburn, K., Porter, G., & Howard, D. (2004). The Comprehensive Aphasia Test. Hove, UK: Psychology
Press.
Treger, I., Shames, J., Giaquinto, S., & Ring, H. (2007). Return to work in stroke patients. Disability and
Rehabilitation, 29(17), 1397–1403.
Vestling, M., Tufvesson, B., & Iwarsson, S. (2003). Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. Journal of Rehabilitation Medicine, 35(3),
127–131.
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APPENDIX
Assessment results
Test
GD
Norms
Comprehensive Aphasia Test (CAT) Spoken
word to picture matching (Swinburn et
al., 2004)
30/30
25–30
Spoken picture verification (Morris, 1997)
98/100
92–100
Spoken ADA synonym judgement
(Franklin, Turner, & Ellis, 1992)
155/160
152–160
68/8015 blocks
16–19 blocks
28/30
27–30
Auditory comprehension
TROG; Test for Reception of Grammar
(Bishop, 1983)
Written comprehension
Written word to picture matching (CAT)
Written picture verification (Morris)
Written ADA synonym judgement
Written sentence–picture matching (CAT)
RCBA: Reading Comprehension Battery for
Aphasia (LaPointe & Horner, 1998)
Section VII: Paragraph picture
Section VIII Paragraph factual
Section IX: Paragraph Inferential
Right Hemisphere Language Battery
(Bryan, 1995)
Metaphor (written)
Humour
Inference
Not available
154/160
Within normal range
(Lum, 1996)
25/32
24–32
28/30 (5 minutes in total
to complete)
8/10
10/10
10/10
No norms
10/10
7/10
7/12
9.53 (SD 0.63)
9.70 (SD 0.47)
9.16 (SD 0.56)
121/130
91–122
115
46
Mean 124; SD 27
Mean 48; SD 21
23/30
Mean 22
Spoken production
Nickels naming test (Nickels & Howard,
1994)
Extended category fluency bird (Bird,
Howard, & Franklin 2003)
High imageability categories
Low imageability categories
Graded Naming Test (McKenna &
Warrington, 1983)
Naming from definition (Bird, Franklin, &
Howard, 2000)
(Continued)
APHASIA AND RETURN TO WORK: A CASE STUDY
907
APPENDIX
(Continued)
Test
GD
Norms
15/25
15/25
Mean 19.79; SD 3.56
Mean 20.50; SD 2.87
12 animals
12 “S”
12–56
Single word repetition (CAT)
31/32
30–32
Single word reading (CAT)
46/48
44–48
National Adult Reading Test (Nelson, 1982)
29/50
Predicted full IQ of 102
(Verbal IQ 101;
Performance IQ 104)
80
33–87
60
18–66
Nouns
Verbs
Word fluency (CAT)
CAT spoken picture description
Written production
CAT written picture description