In this episode, we focus on a crucial yet often overlooked area: mental health services (e.g., psychotherapy, counseling) for individuals who use augmentative and alternative communication (AAC). Our special guest, Adrianna (Anna) Noyes, a doctoral candidate at Penn State University and recipient of the Changemaker Award at ASHA 2023, shares her invaluable insights and research.
We discuss how AAC impacts the psychotherapeutic process, exploring the unique communication dynamics of AAC users in therapy settings. We explore effective communication strategies therapists can adopt and the critical role speech-language pathologists play in supporting AAC users' mental health.
This episode is not just for professionals in the field but also for caregivers and anyone interested in understanding and supporting the wellbeing of individuals with communication challenges. Anna gives us many practical tips, along with recommendations for further resources on AAC in mental health services. Tune in to broaden your understanding and contribute to building a more inclusive and supportive community for AAC users.
Resources and Links:
Communication First: The Words We Use
Noyes, A. M., & Wilkinson, K. M. (2022). Supporting access to mental health services for patients who use augmentative and alternative communication: A proposed framework and suggestions for future directions. American Journal of Speech-Language Pathology, 1–15. https://doi.org/10.1044/2022_AJSLP-22-00089
Hagiliassis, N., Di Marco, M., Gulbenkoglu, H., Iacono, T., & Watson, J. (2006). Beyond speech alone: Guidelines for practitioners providing counselling services to clients with disabilities and complex communication needs. Scope (Vic).
Watson, E., Raghavendra, P., & Crocker, R. (2021). Mental health matters: A pilot study exploring the experiences and perspectives of individuals with complex communication needs. Augmentative and Alternative Communication, 1–11. https://doi.org/10.1080/07434618.2021.1921845
Na, J. Y., & Wilkinson, K. M. (2018). Communication about emotions during storybook reading: Effects of an instruction programme for children with Down syndrome. International Journal of Speech-Language Pathology, 20(7), 745–755. https://doi.org/10.1080/17549507.2017.1356376
Burns, M. I., Baylor, C. R., Morris, M. A., McNalley, T. E., & Yorkston, K. M. (2012). Training healthcare providers in patient–provider communication: What speech-language pathology and medical education can learn from one another. Aphasiology, 26(5), 673–688. https://doi.org/10.1080/02687038.2012.676864
Keywords: Speech-Language Pathology, Audiology, Psychology, AAC, Augmentative and Alternative Communication, Psychotherapy, Mental Health, Communication Challenges, Adaptive Communication Techniques, Ecological Systems Theory, ASHA, Adrianna Noyes, Speech Therapy Research, Inclusive Therapy Practices.
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And I think it just starts with thinking about it, right? That's right. I don't want it to end there. I don't want the end result to just be thinking, but we have to start somewhere. And if thinking is where we start, thinking can lead to action. So it's a great place to be, to be here. to be listening to this.
I appreciate everyone who is here to talk about this and to think about it.
Welcome to the speech, language and therapy podcast. Where we unite speech, language, pathology, audiology, and psychology to support the wellbeing of individuals facing communication challenges and their families. I'm really excited that you've joined me for today's discussion. Many of us have experienced the benefits of mental health counseling, a supportive space, regain insights, and find balance in our lives. But what about those who communicate differently? Today, we're diving into a really important and fascinating subject. And that is access to psychotherapy for individuals who generally don't use spoken language, but rather express themselves using augmentative and alternative communication, which we often abbreviate as AAC.
This topic has been on my mind quite a bit recently, but I've had some difficulty fully grasping the unique barriers that AAC users face in mental health counseling. as well as the practical applications that can enhance the effectiveness of therapy for these individuals. Fortunately, there are some incredibly thoughtful and insightful individuals who are making significant strides in this area. One such person, Adriana noise graciously joined me not long ago for a discussion that was both enlightening and practical. Helping to. Clarify many aspects of this complex subject.
We start our conversation by discussing some frameworks for understanding some of the unique dynamics that are part of the psychotherapeutic process for AAC users. These really set the stage for Anna's thoughtful and practical strategies for effective therapy. She gives us some really great communication strategies that therapists can use with AAC users. We also discussed the role of speech-language pathologists and how they can contribute to supporting mental health services for AAC users. I don't want you to wait any longer to hear this conversation. So let's introduce our guest.
Today we're honored to have with us, Adrian and Noyce, who is a doctoral candidate at Penn state university. Prior to pursuing her PhD. She earned a master's degree from the university of Wisconsin. Eau Claire. Her contributions to the field of speech, language pathology have recently been recognized with the prestigious changemaker award. Which she received at the most recent American speech language and hearing Association's national convention.
I'm feeling very grateful today that she's agreed to join me on the show.
welcome to the show, Anna. Just really glad you're
here. Thank you so much for having me. It's really exciting to meet other people who are passionate about this topic.
Oh, yes, exactly. I agree completely. Could you start by just giving us a little background on your journey and what sparked your interest in AAC and mental health?
Sure. So, my first introduction to AAC was really during my master's program, and we were required to take a course on AAC. And it was really eye opening for me, because prior to that point, had not explored the way that using AAC impacts communication and conversation. And in my class, we did not specifically talk about mental health.
But when I learned about AAC, I kind of compared it with my own experiences as well as many members of my family. And just kind of, I know many people in the U. S. and in the world go to therapy. That's right. It's a very normal thing. Yes. And so I started to think about, wait a minute, if there are So many significant impacts to conversation and communication when you use AAC.
What does that mean for mental health services like psychotherapy? And I discovered that no one was really talking about that. So I wanted to do something about that. And that's what led me to come back. to come to Penn State and to explore emotional development and mental health supports for AAC users.
That is absolutely amazing. You know, it is, it it's such an important topic for so many people and. I've been trying to wrap my head around this topic as well. So maybe you could lay some groundwork here for us and talk about your framework for understanding mental health and AAC. You've written about an ecological model. And so could you explain a little more about this and how it can be useful?
Sure. So before I get into the answer to that question, I want to preface it with a little bit of a disclaimer per se about the terminology that I'm going to use in this discussion as well as the terminology that I used when I wrote the paper that you're referencing.
So when I wrote the paper, it was. Common practice to use the term individuals with complex communication needs. and so in the paper I talk about individuals with complex communication needs however, that was published In 2022, and in 2023, Communication First came out with their statement titled, The Words We Use, and they specifically indicate that we should not be using the term complex communication needs.
They give a list of many terms. I'm going to be using AAC users or patients who use AAC. So I just want to mention that I do recognize that in my paper, I do say that complex communication needs, it was Prior to the statement,
. The other terminology I want to talk about is both from the American Psychiatric Association and the American Psychological Association.
When I was writing the paper, I was very careful to follow preferred terminology. And both of those organizations have indicated that we should refer to individuals who receive mental health services like psychotherapy, we should refer to them as a patient, because it is a health care service, so you should avoid using the term client, and then we We should also refer to the provider with a very specific term that indicates the service being provided.
So I will do my best to refer to the provider as the psychotherapist because in this paper I do focus on psychotherapy. And then oftentimes I will talk about the patient or the patient who uses AAC because this is a healthcare service. And so I want to use that terminology.
That sounds wonderful.
Good to know. Great. Thanks for
clearing that up. Yeah, so let me get into the framework that you were talking about. So, it is Bronfenbrenner's ecological systems framework or model if you're familiar with that. And I do recognize that many clinicians May not be familiar with that because I was not familiar with it when I was an SLP.
So I thought about how I could frame this in much more simplistic terms that people would be familiar with. So really, if you can think of anything that has layers, like an onion or one of those nesting dolls, that's what we're talking about. We're talking about something that has multiple layers. So I'm going to be talking about some of the things that we need to consider in order to really approach this situation with a comprehensive perspective that addresses all of the factors that might be impacting the psychotherapy for patients who use AAC.
If we start at the very center, the core, the innermost layer, we're looking at the interaction between the psychotherapist and the patient who uses AAC. And there may be various factors that impact that interaction, but it's not enough when we're thinking about this topic, it's not enough to just focus on that setting.
We actually need to be thinking about other persons that may be involved in this model. So there may be a communication assistant. Now that may be a family member, a significant other, a friend, a paid professional. It could be anyone who is involved in various aspects of supporting the communication of an AAC user.
You know, it involves, it could be turning the device on. mounting it to the wheelchair, charging the device, you know, troubleshooting, whatever the case may be. So there, there is a role of a communication assistant. And then if an individual uses AAC, they probably are currently, or in the past, have interacted with a speech language pathologist.
And so, there's also room to consider the role of the SLP in this model, and how the SLP, hopefully, is a facilitator to the interaction between a psychotherapist and a patient who uses AAC. But then we need to go even broader. So that's why I'm talking about this layered approach, and that's why we use Bronfenbrenner's systems.
So there are other factors outside of that patient psychotherapist system that we need to consider. For example, billing codes. Okay, so as far as I know, and I'm not a mental health professional by any means, there is a billing code for like a one hour session with a patient. And I would imagine that In some ways, service provision is constrained by these billing codes.
We we have to be billable. That's just the reality that we live in. And in order to do that, we have to follow the service that the code is billable. So, is there any flexibility, or could there be flexibility, could we encourage payers to incorporate a code that would allow more accessibility for AAC users.
So that's something we need to consider, for example. Also, we need to be thinking about factors such as training and education of psychotherapists. So both pre service training as well as any continuing education that they might have the opportunity to participate in.
And then another factor we need to consider is ADA accommodations.
In theory, it creates a situation where AAC users should find mental health services accessible. But I don't think in reality that is occurring. Mm. Mm hmm. I think that ADA is really good at accommodations for things like mobility. I don't know if it has addressed communication disorders as well as it has other factors.
Yeah. I just really love that model. It's holistic and it takes into account a number of factors that we can use to make these services more accessible. Could you talk a little more about how AAC affects the psychotherapeutic process?
Okay, that is a great question. So, in order to understand how AAC affects the psychotherapeutic process, we first need to talk about what the psychotherapeutic process is and what that looks like. So, One thing that we need to understand is that yes, it is a type of conversation. It is a therapeutic conversation.
But there is a key difference. It is an asymmetrical conversation. It's not a conversation with equal contributions from both parties. It is a conversation where one party, the psychotherapist, might ask a question, and then the patient gives this long, lengthy response where they explain their feelings or whatever the case may be.
So that's the first thing we need to understand is the asymmetry of a psychotherapeutic conversation. And I've briefly just mentioned it, but we also need to understand that the psychotherapist is going to implement various communication techniques prompting techniques, elicitation techniques, clarifying information, things of that nature.
And that doesn't necessarily occur in a typical conversation, right? It's just kind of a natural back and forth. Whereas in psychotherapy one party is really soliciting information from the other party, and that's a little bit different as well. So now that we have talked about psychotherapy and the way it is asymmetrical that can prepare us to think about AAC and how AAC impacts psychotherapy.
So, we also need to consider that there are different types of AAC. There are speech generating devices. There are communication books, there are systems that are generative, where the individual types or spells out what they would like to say, and there are systems where the individual uses icons and messages that have been pre programmed into their device.
So when we start to think about that, we can realize that the way that an AAC user is going to be able to respond to the communication techniques of the psychotherapist, is constrained by the type of system that they have access to. So if they use a generative system, it does have a drawback, it is slower to communicate that way, but they can essentially convey any message that they would like to, whereas if they have an icon based system, it may have the benefit of being faster, but it has the drawback of limited availability of messages.
We also need to consider The fact that AAC users are different. Being an AAC user does not mean that you have a language disability or disorder. being an AAC user just means that you use AAC, but some AAC users do have a language disorder. Some AAC users do have an intellectual disability.
So we also need to be considering the AAC user themselves and how their situation differs. What their skills are, what they bring to the table what their preferences are, their abilities, things of that nature. Now, with that in mind, there's kind of a two pronged approach here that I'm thinking of there is also the difference of physical abilities, right, and you would think that physical abilities would not impact psychotherapy, We would think it's simply communication, but this is the reason I was saying it's a, two pronged approach is because there are all of these different abilities that an AAC user can bring to the table, communication abilities. Physical abilities. And why does that matter?
That matters for conveying emotional states. So, here's another problem with current AAC. It doesn't necessarily allow for the acoustic and prosodic cues. That come with spoken communication. That is a limitation, I would say, across the board of all, Types of AAC. I just mentioned various types and Generally speaking all of them are limited when it comes to acoustic and prosodic cues
so we start to think okay. How can we get around that? What? other modalities are there and physical body based communication methods are an alternative to those acoustic and prosodic cues. However, sometimes AAC users also have physical limitations, in the way that they are able to use their body.
So It really becomes tricky for some patients who use AAC because they may have difficulty conveying their emotional states through their device, their system, their communication method. And for some AAC users, they may also have difficulty conveying their emotional states using their body based methods.
Their posture, their facial expressions, their gestures, things of that nature. So, it can really be challenging due to the device, and then also if that individual has any physical limitations. That make conveying emotions difficult as well. Exactly. And then the last difference that I wanted to bring up, something that may impact psychotherapy, is the use of a communication assistant.
So typically, individuals go to therapy, psychotherapy, alone. And there's this whole component of privacy and confidentiality. That's present with that. Whereas an AAC user, for various reasons, may use a communication assistant and that communication assistant may Attend therapy, with them.
And that can really change the whole dynamic. of the psychotherapeutic process. Mm-Hmm. , because now there's this third party involved, the a a c user may not feel comfortable sharing personal right information in front of this person. And then also it introduces this dynamic, and I will talk more about this later, but. The psychotherapist may have an inclination or a tendency to communicate with the communication assistant rather than the patient themselves. And so it introduces this other dynamic that also needs to be addressed.
Those are amazing considerations, Anna. So important. That makes so much sense. So tell us a little bit more about the ways that communication methods of AAC users differ in a therapy setting and what challenges this might create for therapists.
Sure.
So I have already touched on one of those, which is a huge challenge, which is conveying emotional states. And that can be problematic for psychotherapists as they are trying to evaluate the patient or determine next steps or determine an appropriate intervention plan. It can be really challenging for them if they're unable to accurately determine the emotional state of the patient, but there are also other Differences that we need to talk about.
So one of the key differences is time this is huge and I do have some ideas on how to address this but I do feel like a more comprehensive Um, and I think that that approach is needed in other words, I think we need to kind of revolutionize the whole healthcare billing system and I just don't think that's going to happen, but typically these therapy sessions are an hour long, but what we know is that AAC users communicate 15 to 20 times slower than individuals who use spoken communication.
To do the math, let's think about it, an AAC user potentially needs 15 hours, 15 sessions to communicate the same information that would be conveyed in a one hour session with somebody who uses spoken communication. That is huge. Additionally, sometimes Third party payers, health insurance, puts a limit on the number of sessions that you get.
They don't just limit the length of the session, they limit the number of sessions you get. So, that is why I said the time is so huge. I'm really concerned, and I don't have the data to back this up, but I'm really concerned about adequate accessibility to Mental health supports like psychotherapy for AAC users, because I'm really concerned that, you know, a one hour session is not enough, maybe they need a longer session.
And then I also have concerns that they are able to get enough sessions to kind of make up for that time difference.
Oh, definitely. Those are some really important considerations and they make so much sense. So we definitely have some roadblocks here and we can see the road in front of us in terms of making incremental changes in trainings and. making this more accessible. Let's talk about some strategies that we can use. What are some effective communication strategies that therapists can use with AAC users?
Sure. So the first one that I'm going to talk about is asynchronous communication. this idea that not all communication needs to happen in the therapy session. Which really ties into the issues with time that I was just talking to you about. So, asynchronous communication really, I think, is one way to make mental health services more accessible to AAC users.
This can take the form of providing The patient who uses AAC with questions, like at the end of a session, providing them with a list of questions to answer in preparation for the next session. It can take the form of maybe the AAC user could journal daily or regularly. about their mood and fluctuations and things of that nature.
And then the psychotherapist or even a psychiatrist could check that journal and see what has been happening, kind of this ongoing tracking. I also want to mention though, and I think this might be a really overlooked point. But the importance of asynchronous virtual scheduling, I think it's so important for AAC users to have privacy in seeking out mental health supports.
And maybe they don't want to ask someone to make an appointment for them. So wouldn't it be great if more psychotherapists and mental health professionals had online? scheduling, that didn't require somebody to call them up on the phone, and that way AAC users could be more independent, have more privacy.
So it's a really simple strategy, but I think that online scheduling could be a really important accessibility feature for AAC users in mental health.
That's really a great point. Autonomy and independence are important for all including AAC users. So it's a really wonderful point.
Right. So, you did ask specifically about communication strategies, and I do want to talk about a framework.
I did not develop it. It is by Burns et al. It's called the FRAME framework. Oh, wow.
I
hope he patented that. And each letter stands for a different strategy. And it's really great. It was actually developed for communication.
between patients who use AAC and doctors, but right now I'm, I'm just a new researcher. I haven't figured it all out yet. I don't have any specific strategies for mental health professionals, but I think the FRAME framework is great. So I'm going to tell you. The five letters and what they stand for. So F stands for familiarizing oneself with the patient's communication modalities.
Really simple, but the provider, the psychotherapist, needs to understand how the patient communicates. Really simple, but super important. And then second, the R is for reducing one's own rate of speaking. Mm. We need to allow time for patients who use AAC to communicate, so we also need to reduce our own rate of speaking.
The A stands for Assisting with Message Construction. When necessary, we can try to kind of intervene and help with that. The M stands for using multiple communication modalities. , I think a really great thing that might benefit AAC users in mental health settings is using various communication modalities.
Such as A simple little sign. A little picture or something to say, wait, I'm still constructing my message to let the provider. No, don't move on. I still need more time. I'm working on it. So they could be constructing their message on their speech generating device, but then have some type of way. Maybe it's a body based method.
Maybe it's putting their hand up. Maybe it's something else. But I think something that definitely needs to be explored is the use of multiple communication modalities. To really support AAC users in mental health. And then lastly, is engaging the, engaging the patient in the process. And this goes back to the role of the communication assistant.
And the fact that when a communication assistant is present, Oftentimes the tendency is to kind of ignore the patient and rely on the communication assistant. And so I think the E for engage the patient is really important because If a communication assistant is there, the patient still needs to be the focus.
Mm hmm. Mm hmm. Fascinating. Interesting. Important. Mm hmm. Wonderful. So you've talked the interactions with a psychotherapist. What about SLPs? I know SLPs will be out there listening. And, you know, how could they contribute to mental health services for AAC users?
That is a great question.
And I wish that I had I will give you a little spoiler into my second paper that hopefully we'll be discussing. SLPs currently don't play as big of a role in this process as I would have hoped. So I do have many ideas on how SLPs can improve that. I guess just with a disclaimer that currently it's not happening to the extent that I think it needs to happen.
And also we are still working on the research to determine what the best practices are for SLPs. What I will say about this, we have a big push. For interprofessional education and interprofessional practice. And I think that is a great starting ground that SLPs need to get more involved and play a bigger role with collaborating.
I think SLPs in healthcare have done a better job of communicating with doctors, nurses. But we haven't explored mental health yet. So I think just encouraging SLPs even to just start thinking about this. I think anyone who is listening, I applaud you. Because many people, many SLPs don't recognize this as an important topic that needs to be addressed.
So just start thinking about it and thinking about how you can connect. With psychotherapists, that could be, social workers, psychologists, school counselors. Many SLPs work in schools, and there are also school counselors, so that's a great place to start collaborating.
I love that, you know, in terms of at least sparking more of these conversations, because in my experience it goes both ways. We can learn more what the mental health professionals are doing and they can learn from us and that generates more ideas that can bubble up to the top and eventually to research and more effective services for all.
Absolutely. And I think it just starts with thinking about it, right? That's right. I don't want it to end there. I don't want the end result to just be thinking, but we have to start somewhere. And if thinking is where we start, thinking can lead to action. So it's a great place to be, to be here. to be listening to this.
I appreciate everyone who is here to talk about this and to think about it. Awesome. So I have a couple more ideas. One is specifically for SLPs who work with children, and one idea is for SLPs who work with individuals of all ages. So for SLPs who work with children, we need to work on educating children about how to communicate about emotions.
We need to start this conversation earlier so that these children are able to communicate about their own emotions. They can hopefully identify the causes of their emotions. They can try to identify solutions to their emotions. And all of that starts, in childhood and having these conversations with children educating them, making sure that they have access to vocabulary about emotions.
That is huge. And then I think it's not enough just to give them access. They need to know how to access it. They need to know where to find the buttons. They need to know How to use them. They need to know what happy and sad and disappointed and frustrated and overwhelmed. They need to know what these words mean so that they can have effective conversations later if they need to pursue psychotherapy or something of that nature.
Great. Then, for SLPs working with individuals of all ages, we need to ensure access to adequate vocabulary for crisis situations. So that way, an individual in crisis has a way to say, I need help.
we might think about, you know natural disasters or other situations and we try to prepare, maybe have an alternative AC device in place for that if, you know, if the power goes out, we have a backup plan. Do we have a plan in place for a crisis situation where an individual is in crisis and needs mental health support?
A person who uses spoken communication, if they are in crisis, what can they do? They can call a phone number. I know that there are even texting services available, but if that's not accessible to an AAC user, they need something. So SLPs need to start thinking about all sorts of situations and making sure that AAC users have a way to reach out for help in instances of crisis,
Yes, so much, so much good stuff to do, Anna. And I'm so glad that you're on the forefront and moving this forward. I feel like everything you've given us has been practical. I'm wondering, are there any other practical considerations you'd like to give us?
Sure. The first takeaway that is so important to me, and I think it's obvious, but I just spent all this time telling you about How different the psychotherapeutic process is for AAC users.
I want to emphasize that it's still psychotherapy. So mental health professionals are still trained in psychotherapy. And yes, there may be some alterations. Communication may be different. It may be different. To evaluate the emotional state of an AAC user, but at the end of the day it is still psychotherapy So I don't want us to think of this as some totally different beast that we have to conquer.
This is still psychotherapy There are professionals out there trained in psychotherapy. Now, they don't have the training maybe for AAC But we can fix that we can address that. Yes, but at the end of the day, it's still psychotherapy And I really want to emphasize that point and then the other point that I want to emphasize This is for maybe caregivers It could be for speech therapists.
It could be for anyone. We also need to think about access to self regulating resources. So, that could be for example, everybody likes something different. Music, journaling, art, TV shows, books, going for a walk, taking a nap, taking a shower. And I bring this up because I do think that perhaps right now, mental health services for AAC users are not as accessible as I would like them to be.
So with that being said, we need to start thinking about what can we do to still support the mental health of AAC users while we are trying to figure this out. And one thing we can do, everyone can do, at home, in any environment, is to make sure that we know the preferences of the AAC user. We know, do they like certain music, do they like journaling art, whatever it is.
And that they have a way, a very easy way to request those activities. So that they can try to self regulate when there is a need.
Great point. Great point. For those people that might be looking for more resources, can you recommend any resources or further readings for people that are interested in this?
Yes, and I will send these to you so that you can post the references. Um, I already mentioned Burns et al. Mm hmm. Which is the FRAME framework resource.
I would also recommend, and I hope for this person I am pronouncing their name correctly, Hadjaliassis et al. They have a more mental health focused resource that I would highly recommend. I would also recommend looking at the work of Eleanor Watson. She is in Australia and she is doing phenomenal work.
She published a paper in 2021 that was really instrumental in helping me with my research and she is also on the forefront of exploring Mental health supports for a a c users. So Watson, et all is great. And then the last resource that I came up with when I was giving you recommendations for SLPs and I said that SLPs need to teach children how to have conversations about emotions.
They need to be able to talk about the reason for the emotion and the solution and what we can do. And a great resource for that is na. At all. They published papers in 2016 and 2018 and so that's a really great resource. It's not specifically about mental health supports for AAC users, but it is about how to teach children how to communicate about their emotions, which I think ultimately supports mental health later in life.
Absolutely. Great stuff. Anna, I just really appreciate your, perspective on this. Your care your thoughtfulness and just willingness to share your time with us So it's been a real pleasure talking with you and just want to say thank you so much for being on the
show It was great being here and having these conversations.
I'm so happy to share this information with anybody who wants to listen.
Thank you so much for listening to today's episode. I hope our conversation has been helpful. Offering new ideas and tools to support those with communication challenges. So until next time. I'm encouraging you to continue to do what you can to ensure every form of communication is valued. And to help build communities that honor the dignity rights and wellbeing of all.