The Importance of Aphasia Communication Groups

Chronic aphasia is linked to poor functional recovery, depression, and social isolation. In the exploration of the above factors, the role of aphasia communication groups has evolved. Aphasia communication groups for stroke survivors with chronic aphasia and their communication buddies are gaining clinical importance. Communication buddies can be family members, friends, carers, health professionals, and speech and language therapy students who serve as communication facilitators for each group member. Group members share experiences on stroke and aphasia by using technology/tablets and the total communication approach. The benefits or outcomes of group involvement are measured by assessment of functional communication, individual self-ratings of the impact of aphasia on communication, and quality of life after stroke. The use of the communication buddy system, total communication approach, and systematic evaluations enables therapists to measure the effectiveness and efficacy of communication groups in terms of functional communication, social inclusion, and quality of life.


Introduction
Aphasia is an acquired communication impairment that impacts the ability to speak, understand, read, write, and carry out mathematical calculations [1]. It is caused by damage to the language networks in the brain usually after stroke but not only [2]. Aphasia is linked to poorer functional recovery [3], return to work [4], activities of daily living [5], depression [6], and social isolation [7].
Functional communication and social participation are impaired in aphasia, which brings about reduced confidence in communication [8]. This leads to reduced interactions with family and friends [9] and smaller social networks [10]. Although maintaining social interactions and friendship networks in the chronic phase of aphasia (greater than 6-months post brain injury) has been identified as an important goal in aphasia rehabilitation, this is not regularly addressed by aphasia clinicians [9].
Historical models of aphasia assessment and treatment have focused mainly on the person's linguistic competence [11]. Even though people with aphasia (PWA) may have successfully achieved their therapeutic goals in individual speech and language therapy sessions, they still struggle to use their new communication skills successfully in natural environments, e.g., with family members, close friends, and their therapist outside of the clinic/treatment environment [12]. Contemporary Loneliness and social inaccessibility in chronic aphasia lead to poor community and public engagement [9]. Aphasia communication groups are an opportunity for social participation [28] that promote community integration, broaden friendship circles, and improve social connectedness [29]. Without prospects for good communication, PWA struggle to learn about their condition, to achieve personal goals, make friends, and interact meaningfully -all fundamental for citizenship and humanity and central to improving quality of life [27]. All these principles are offered to PWA in a communication group setting as they are given opportunities to exercise their human right on how to be involved with decisions about their care, make choices about their daily life, create opportunities to communicate their needs and thoughts, understand and express their necessities in relation to their health and wellbeing whilst being treated with respect and dignity [27].
ACGs are important to PWA as they have a common purpose: to become familiar with aphasia symptoms, to share personal experiences, support and encourage each other, and get trained on how to establish successful functional communication [25]. In a review by Attard and colleagues [30] on consumer perspectives on community ACGs, the findings revealed that group attendance formed positive relations for PWA with others, gave purpose in life, promoted environmental mastery, autonomy, personal growth, and self-acceptance. According to Lanyon and colleagues [31], PWA perceive community aphasia-group participation to be beneficial to their ability to live well with aphasia. Peer-to-peer communication strategies, shared roles and responsibilities, and consultation regarding group objectives and processes provide group members with the opportunity to become active contributors, demonstrate competence, and have positive influence over the group [31]. During the qualitative investigation of the factors impacting participation and integration of PWA in aphasia community groups, Lanyon and colleagues [31] revealed seven important features: 1. Balanced interactional patterns: reflects the balance and equal share in interactions between group members and leaders. It is associated with equal turntaking opportunities and the promotion of the appropriate sensitivity of the group leader toward group members.
2. An open and non-hierarchical group environment: relates to the maintenance of an interactional space that provides active consultation between peers and opportunities for the members to share roles and assume responsibilities (such as activities planning, assisting in message transfer, and organizing coffee breaks).
3. Communication awareness and education among members: demonstrates the need for group members to learn communication support strategies and aphasia training to understand and interact respectfully with their fellow members.
4. Meaningful activity: shows the constant need of group members for authentic interactions related to day-to-day life situations and life-sharing experiences with socially-focused activities.
5. Ritual and structure: group rituals such as formal welcomes, opportunities for sharing information, and involvement in the preparation of a coffee break are considered the foundation for enabling members, regardless of their prior experience with group processes, to intergrade within the group and feel that they participate in a relaxed and nonthreatening environment.
6. Composition and group size: both size and composition are central to the involvement of PWA within the group and may function as a bridge or barrier to their positive participation experience. ACGs with a mixed composition of people with a range of communication abilities are considered more beneficial for PWA with more severe communication difficulties. Also, smaller group size (3-4 members) fosters the creation of individual identity of each group member and promotes family and friendship-like endeavors. On the contrary, large groups (15 members) are challenging for PWA to interact with.

7.
Group leadership: Group organizers and leaders play a crucial role in shaping the pattern of interaction, encouraging an engaging space, and modeling effective interaction. ACGs should equalize the power and status between leaders and the members by elevating the position of member peers to group leaders.
Aphasia communication groups' positive participation promotes patient involvement (PI) and elevates discussions on how aphasia impacts activities of daily living, social integration, and participation [32]. Azios et al. [9] propose a codesign model of intervention and research on friendship maintenance within aphasia communication groups, as a means of addressing the issues of social isolation and other personal concerns of PWA. The Quality of Communication Life Scale [33] suggests that "the more positive the personal and environmental factors, the more successful the [person's] communication acts, the better the quality of communication life" (p. 2). Taking into consideration the perspectives, needs, and experiences of PWA, as service users in ACGs, it is critical to use PI approaches and activities that will accelerate translation to real-world activities and promote functional interventions and strategies for living successfully with aphasia (activity and participation level 0 [14]). Positive effects of ACGs where PWA are actively involved in decision making, build confidence in PWA to express their needs, whereas research evidence demonstrates positive health benefits of building interpersonal relationships and community while being part of an ACG [20].

Establishing ground rules
Before establishing an ACG, members should discuss and agree on the group's ground rules using a SIMPLE approach. The ACG and each group member should be: Supportive -Ask caring questions; listen attentively to responses/others. Inspirational -Reassure others that life gets better and not to give-up. Motivational -Encourage action and acknowledge improvement. Practical -Offer options, helpful tips, and information and access to resources. Life-affirming -Not deny or devalue/trivialize the feelings of others. Educational -Talk about what's worked for them and others; offer guidance/ counsel, but without giving prescriptive advice.

Inclusion criteria
The general inclusion criteria for ACGs are that PWA: • are living in the community.
• have been discharged from acute and sub-acute rehabilitation.
• are in the chronic stage of aphasia.
• do not need additional medical support while being at the group.
• have given written informed consent to participate.
• have signed a confidentiality contract so they do not share the personal experiences and narratives of other group members with people outside the group.
• present with various types and severities of aphasia.
The inclusion criteria are usually adjusted according to the setting and the purpose of each ACG [21].

Group features
A successful group requires several features to be efficient: the members, the group, and the tasks/activities, the context [34]: • The Members: ○ work cooperatively and not competitively.
○ support each other and show empathy. ○ is relatively small (maximum five people).
○ is autonomous to address its activities and tasks.
○ has an effective leader/facilitator. ○ operates in the context of a supportive organization or community.
• The Tasks/Activities: ○ are accessible to all members.
○ are designed considering the individual skills of each member.
○ promote the active engagement of all members.
○ have precise objectives.
○ have a beginning and a defined end.
○ have measurable indicators of success.
• The Context: ○ The physical environment should be accessible.
○ Time schedule and agenda should be defined.
○ Resources should be allocated before enrolment.
○ External factors should be taken into consideration (traveling, financial issues).

Total communication
Group members practice total communication skills, i.e., gestures, singing, drawing, and writing, and/or a combination of all the above [20]. The main topics of discussion are learning about/refreshing knowledge on stroke and aphasia, linking the information to members' own experiences, asking questions, and discussing living with stroke and aphasia [21]. It is also important for members to share stories about life before the stroke [35]. Resources for total communication such as writing boards, notebooks, tables, communication books, aphasia friendly materials [36], and the Internet should be used to access information online [37].

Virtual aphasia communication groups
Group meetings can be established with face-to-face contact or digitally. Virtual group meetings and videoconferencing are a growing trend in aphasia rehabilitation with a major impact [38]. Online groups favor the person with mild to moderate aphasia, the member who is well motivated to participate and seeks interaction despite the means. In online ACGs, it is mandatory that members know how to operate a tablet, mobile phone, or a laptop independently and understand the ethics and procedures behind video conferencing [39]. Realistically, ACGs via video conferencing compared to face-to-face interaction need more time to plan and prepare. When technical problems occur, and they often do occur, they cause anxiety and frustration to the group. Some members become diverted into "fixing" the problem where others "switch off " from participating, factors that make the interaction dysfunctional. The experience of engaging in an online meeting is more mentally demanding as members must concentrate simultaneously on the content of the meeting, the visual material, and the constant input from several sources. Additionally, nonverbal cues are not detected easily, and the facilitator must be proactive in giving cues and prepare digital material to promote engagement.

Setting client-centered goals in the aphasia communication groups
According to Worrall and colleagues [40], goal setting in ACGs with PWA can be challenging because of members: • persisting language impairment that makes expressing needs and discussion of experiences a long and demanding process.
• cognitive difficulties that create struggles with decision-making, • strain in understanding the abstract concept of aphasia.
• poor awareness of their overall condition.
• feelings of disempowerment that arise when communication is distracted.
• age as members that are often older expect to be directed in one-on-one therapy rather than group treatment.
A further challenge is related to the setting that may reinforce a culture in which SLTs focus on the language impairment and are in control.

SMART short-term goals
At the beginning of each ACG, goals are discussed with the members of the group, which are more likely to be their long-term goals for aphasia rehabilitation in general. The facilitator along with the communication buddies needs to support the members of the group to break down these goals into SMART short-term goals that can be addressed in the group. These goals should be SMART: Specific, Measurable, Attainable, Relevant, and Time-based (Figure 1).

The SMARTER framework
In combination with the SMART goals, the SMARTER "Shared, Monitored, Accessible, Relevant, Transparent, Evolving, Relationship" framework encourages aphasia rehabilitation specialists engaged in group therapy to share the goal-setting process with the person with aphasia [41]. The procedure of setting SMARTER goals should be accomplished in a way that is accessible to the members of the group and ensures that the goals evolve with the needs of the clients. Within this framework, the person with aphasia is actively engaged in monitoring their own progress on the goals and each activity in the group ensuring transparency (see Figure 2).
All goals are relevant to the person with aphasia, and care is provided in a way that builds rapport within the group. Personalized and qualitative therapeutic objectives enable group members to gain more insight into their communication barriers, individually and within the group.
For ACGs to achieve a SMARTER goal setting, the facilitator must read through the framework extensively and then answer the questions for each domain reported below in Table 1 c.

The communication buddy system
A communication buddy is a communication and conversation partner assigned for each person with aphasia within the group. Their main goal is to facilitate the understanding and output (not necessarily verbal) for PWA within the group. Communication buddies should establish mutual support, promote learning about aphasia, facilitate communication, and promote communication skills enhancement [21]. Pairing in groups is based on Bion's theory of "containment" or "container and contained." According to Bion, the theory of containment is the capacity

Shared
• Has the person with aphasia and their family been able to prepare before attending the session?
• Have family members, carers, and significant others been involved in goal setting?
• Has the information been presented in a comprehensible way?
• Is the information relevant to the person with aphasia?
• Is the relationship between group members a trusting and collaborative one?
• Have all people involved in goal setting understood the purpose of the procedure?
• Have all people involved been able to express their individual needs and personal expectations? Relationship-Centered • Have the established goals been client-centered?
• Has good rapport and trust been developed between the group members and facilitators?

Relevant
• Do the goals take into account the client's everyday life?
• Have the client's family members and carers been involved in the goal-setting process?

Accessible
• Are goals written in an accessible aphasia-friendly format?
• Can extra support be provided to ensure understanding?
• Do PWA understand that they can change their goals if they wish to?

Transparent
• Are PWA and their carers aware of which goals will be worked on and how these will be assessed?
• Is it clear how their personalized goals and the processes used to achieve these are linked?
• Have they been able to assess what they will learn about during the group based on their current needs and goals?

Monitored
• Have the goals been written in a way that allows for ongoing evaluation?
• Have the goals been written in a way that allows modifications?
• Can these goals be used to review improvements or no improvements?

Evolving
• Are PWA and their carers aware that they can review the goals?
• Are PWA and their carers aware that they can change the focus of the activities if they like? Table 1. Specific questions involved in SMARTER goal setting framework as adapted from Hersh et al. [41].
of one individual to receive in himself/herself projections from another individual, which he/she then can sense and use as communications (from him/her), transform them, and finally give them back (or convey back) to the subject in a modified form (see Figure 3) [42]. Communication buddies can be: • health care professionals.
• allied health rehabilitation students, e.g., speech and language therapy students.
• the client's carer, a family member, or friend.
• volunteers from aphasia and stroke support organizations.
Communication buddies should be identified and assigned by the person with aphasia or by the setting where the group is taking place, e.g., students in a university setting. Communication access, social contact, and active participation are crucial elements in aphasia group work. The person with aphasia, the group facilitator, and the communication buddy must collaborate to find the means and strategies that are most useful for the particular client during communication breakdowns. These may include gestures, drawing, picture support, simplified text, writing keywords, clarification statements, verification questions, eliminating environmental distractors, and summarizing (see Table 2). It is mandatory to work closely as a team to identify and tailor these strategies to the person with aphasia. The "essential" people that makeup ACGs.

Communication partners training
It is crucial that communication buddies, before their involvement with the group [41]: • receive education on group therapy principles.
• practice scenarios via role-play and home assignments.
• watch videos and work on communication repair (i.e., how to modify, repeat or revise a message when the first communication attempt has failed) and facilitation strategies (i.e., active listening, good preparation, prompting, visual and verbal cues).
• receive training on feedback techniques, problem-solving, conversation skills, and self-reflection.
It is mandatory that communication partners learn how to implement the communication strategies within the group, communicate their message in simplified and accessible ways and assist the person with aphasia to get their message across [43].

Peer-led aphasia communication groups
Peer-led support groups for PWA are run by a person with aphasia and/or family member, with the assistance of their communication buddies, which aim to increase social interaction and peer support [44]. Peer-led models in aphasia communication groups provide access to constant peer support and may address some of the limitations of professionally-led support groups that may use formal agendas and have a strict group structure [45].
Studies examining peer-led support groups in other chronic conditions, that is, cancer survivors, have shown peer-led support groups (72.1%) are greater in the community than professionally led support groups (27.9%) [46], and there is a larger preference for peer than professional health care leaders [47]. For example, by reducing professional resources and interventions, peer-led ACGs can provide extensive, long-term opportunities for functional communication, social contact, friendship, and peer support [48]. Aphasia Connect has successfully expanded the range of services available for PWA across the UK by utilizing PWA as service providers (group leaders) as well as receivers (group members) [49]. Additionally, members of peer-led ACGs share a greater sense of empowerment and ownership as they provide and receive support [45]. In most UK aphasia peer-led groups, PWA receive training and ongoing support from speech-language therapists and trained volunteers to co-facilitate and codesign support groups [48]. Similarly, in other community-based ACGs such as Speakability UK, professional facilitators support the initial development of self-assisted groups for PWA, for example by suggesting resources and tips, and provide additional support upon request from group members [47].
Tregea and Brown [45] found that the features that are important for the successful functioning of a peer-led aphasia support group are: • Friendship: instant bonds, feelings of belonging, and close friendships that resulted from shared experiences and mutual understanding.
• Informality: the sense of casualness, a relaxed environment with no pressure to communicate, and no formal agenda.
• A supportive communication environment: mutual support to participate, the need for patience, and encouragement to communicate.
• Providing support: a support base for PWA and their families to feel accepted, provision of resources, and information about aphasia.
Additional factors that facilitated peer leaders to start and run groups include informational support, practical support, attracting new members, time, venue and organization, and a pleasant communicative personality [45].

The role of the facilitator
Aphasia communication group facilitators should not necessarily be qualified SLTs but individuals who have been trained by professional SLTs and/or the research team, in case the group is part of a randomized controlled trial (RCT), ahead of the intervention or trial, with a particular focus on meaningful and effective communication with PWA [49]. Facilitators should be provided the National Aphasia Guidelines [50] for communication with PWA and be trained on partner conversation skills [43]. Facilitators should assist PWA to co-facilitate the group, and complete checklists at the end of each group session to evaluate fidelity to group content [49]. In a recent pilot feasibility RCT by Tarrant et al. [51] examining group signing intervention in PWA, the facilitators identified several benefits that they attributed to the intervention, starting with the prospect for PWA to meet peers and share personal experiences and the development of warm, empathetic friendships.
In contemporary clinical aphasiology, facilitated conversation in aphasia communication groups is a popular exercise but only a small number of published studies have documented how interactions occur in such group settings [51,52]. One aspect of ACGs that has been mentioned in the recent literature, but that has not yet been the focus of intensive study, is participation management [51]. Facilitators report that finding ways to help people with limited expressive language participate in the conversation and the group, in general, is one of the central challenges faced by the clinicians and volunteers who lead these groups [51][52][53].
The study of Archer and colleagues [52] documents common approaches to assisting PWA to participate meaningfully within the group discussions. Results revealed a set of conversational practices used by facilitators and by group members with verbal output difficulties. Archer et al. [52] stated that "these practices took the form of two sequences viz. floor transfers and question-answer series" (p. 15). The identified sequences contributed to promoting meaningful conversational participation by group members with non-fluent aphasia.
After a national survey of third sector ACGs facilitators in the UK by VandenBerg et al. ( [54], p. 25), results revealed that the factors described as important to supporting members' attendance in aphasia support groups were as follows: • A kind induction (29%); • Members' confidence in their communication skills (24%); and.

Evaluating the benefits of aphasia communication groups
Aphasia communication groups offer many advantages over traditional individual therapy models in the chronic stage [55]: • Provides naturalistic communication opportunities and practice: the group setting facilitates provides a safe nonjudgmental environment for participants to practice and improve pragmatic skills, such as turn-taking, topic initiation, and maintenance [56]. Conversation practice and the use of spontaneous utterances may assist with the generalization of language skills to everyday interactions rather than the use of overlearned therapy targets [57].
• Is cost-effective: the session cost for each individual member can be reduced while maintaining a per-hour reimbursement that is similar to one-to-one session.
• Has positive psycho-social outcomes: PWA experience social isolation and reduced meaningful social engagements [42].
Group evaluation has three fundamental purposes [57]: 1. To validate and gain approval and acceptance of the status of the group. This process gains justification both for the choice of activities of the group and the continuing of its actions.

2.
To improve by recognizing the importance of identifying any weak areas and how to improve these.

3.
To condemn the weak practices of the group and to highlight the group's inadequacies.
To proceed with an evaluation process of the ACG, one could choose to evaluate all or any of the following areas [19]: • The process: How were activities prepared and conducted? How was the method processed from the formation of the group to disbandment?
• The members: How did the members perform, either as individuals or within the group?
• The resources: Was the allocated venue, resources, room equipment, and time allocated sufficient?
• The organization: Did the group structure, context, content, and communication strategies, hinder or promote members' involvement?
• The objectives: Were the goals appropriate to the needs of the group? Were the goals sufficiently adapted to the individual needs of the group members?

The Aphasia Communication Team (TACT): a university-affiliated aphasia communication group
The TACT is a university-affiliated ACG in the Republic of Cyprus. The number of strokes in Cyprus range between 1200 and 1400 yearly [58]. If one considers a third of all stroke survivors have aphasia, this means, there are roughly 400 new cases of aphasia each year. About 61% continue to experience communication problems 1 year after stroke leading to fewer friendships and smaller social networks [59]. In the exploration of all the above factors influenced by aphasia, the idea of The Aphasia Communication Team -TACT emerged. TACT delivers benefits to PWA, families, and speech-language therapy trainees. TACT aims to provide stroke survivors support for learning and communication opportunities to promote living well with aphasia. TACT works on the barriers (areas of weakness of the person with aphasia and conversation partners that make communication difficult) and on what communication tools members could use to improve communication. TACT has a broad outlook for living well with aphasia and improving quality of life. Another goal targeted is the understanding that aphasia can be a long-term condition and that aphasia is a "family issue"-not just for the person with aphasia [60]. TACT promotes full participation and engagement in activities of interest. TACT encourages a safe, positive, environment, and is inclusive to all.
The Cyprus Stroke Association recruits stroke survivors and TACT is held at the premises of the Rehabilitation Clinic of the Cyprus University of Technology once a week, for 2 hours. Two groups have been established so far, with five stroke survivors with chronic aphasia and five communication buddies, for each group. Communication buddies are speech and language therapy students who serve as communication facilitators of each group member. The groups are supervised and coordinated by academic and scientific staff from the Department of Rehabilitation Sciences.
The Inclusion Criteria for participating in TACT is that PWA: Group members are assessed on psychometric measures (language, cognition, and quality of life) at the beginning and the end of each block of therapy. Therapy consists of a 12-week block of weekly sessions. The assessment procedure is based on the International Population Registry for Aphasia after Stroke (I-PRAISE) protocol [61] in combination with Attard et al's. [53] ICF-based assessment protocol. This is deemed necessary to measure improvement or change in behaviors post-therapy (see Table 3).
Group members are encouraged to share experiences by using technology and tablets. They also practice total communication skills, i.e., adding gestures, drawing, and writing to speech. The main topics of discussion are acquiring new knowledge on stroke and aphasia, linking the data to members' personal experiences, clarifying questions and misunderstandings about their condition, and sharing stories about their life before stroke, the incidence itself, and living with aphasia (see Figure 4).
Group member's outcomes consist of change or improvement in measures of functional communication, the overall severity of language impairment, auditory comprehension, spoken language (including naming), reading, and writing from  Table 3. ACGs outcome measures. *Address all correspondence to: maria.kambanaros@cut.ac.cy baseline, overall communication self-rating, and quality of life after stroke. Data gathered via assessment procedures are digitalized for each individual member on a database using the RELEASE protocol [61]. The use of the communication buddy system, the involvement of the total communication approach, the systematic assessment, and the collection of individual patient data (IPD) sets enable the TACT team to measure the effectiveness and efficacy of group therapy interventions for people with chronic aphasia in terms of use of functional communication, social inclusion [14], and quality of life [31].

Conclusion
There is no doubt that Aphasia Communication Groups (ACGs) are of great benefit for people with chronic aphasia. ACGs are associated overall with improvement in communication, social networks, and community access. To achieve this, ACGs facilitators, participating members, and communication buddies should have equal involvement in the realization of the group.