Easing language barriers
4/10/2008 12:30:05 PM | by Nancy Allison
Helping bi-lingual aphasics is the work of this professor.
If you’ve ever tried to speak a foreign language, you know how tough it can be. The native speaker, unaware of your inability, rattles off a question. You hear the sounds but they don’t make sense. Or they do, sort of, and you know that somewhere in your brain is the answer. “Spit it out!,” you tell yourself. But the moment has passed. The questioner has given you that, “Are you deaf, or just stupid?,” look, and moved on.What a relief it is to get back to your own language.
But what if you couldn’t? What if your native tongue suddenly didn’t compute and you couldn’t speak it? Right now, over a million Americans live with such a condition, and this year another 100,000 people will join them.
When a rupture or blockage in the brain deprives speech centers of oxygen, speaking and understanding one’s own language becomes the nightmare known as aphasia.
Aphasia buries our treasured relationship to words. Sometimes it takes years to recover a small piece of that treasure. For bilingual patients, it can take even more digging, says Maria Muñoz, speech-language pathologist and director of Harris College’s new bilingual clinic.
Long known as one of the few programs in the nation that offers bilingual Spanish-English training for speech-language pathologists, TCU’s new clinic is one of a handful devoted to treating bilingual aphasic adults.
Clinical studies have shown that bilingual patients benefit from assessment and treatment that takes both languages into account, says Muñoz. Her research focuses on improving the English-centered state of the art.
“We want to understand patterns in the medical community that impact decisions about assessment and treatment of bilingual clients. We need to find out more about what clinicians are doing when faced with a bilingual aphasic patient. What kind of treatment is being provided, what are the goals of treatment, and how are these being goals met?”
Muñoz teaches in-service workshops to local practitioners to raise awareness of the differences in treating bilingual patients. The first step is to begin with a systematic assessment of all languages known by the aphasic patient prior to the incident, using the Bilingual Aphasia Test (BAT). This is essential to the rehabilitation plan and to charting progress in recovery.
Monolingual clinicians and family members assume that the language the aphasic person spoke before the injury or stroke occurred is the one that will surface in recovery. But often, says Muñoz, it’s just the opposite.
Muñoz tells the heartbreaking story of one long-married couple. The husband was bilingual, but his wife only spoke English. When the man woke up after his stroke, he had great difficulty speaking at all. But when he began to talk, the only language he recalled was Spanish.
“We don’t understand why one language becomes more dominant than the other in patients with aphasia,” says Muñoz. “In the case of Spanish-English bilinguals, Spanish seems to hang on better than English. That happened with this gentleman.”
The wife was devastated that she could no longer communicate with her husband. However, family participation is crucial to patients relearning how to speak. “The best strategy I could recommend in this case,” says Muñoz, “was for the woman to start learning Spanish.”
Why are some bilingual patients able to communicate in one language more effectively than the other after acquiring aphasia? “We don’t know if the brain is inhibiting one language, or over-activating one language, or if it’s a switch in the brain,” says Muñoz. Sometimes, with bilingual patients, English can be dominant one day, and Spanish the next.
Although neuroimaging techniques can show which areas of the brain are active during a particular activity, they don’t fully explain the mystery of how we learn languages, or how we will recover from brain events such as stroke.
“The front left hemisphere of the brain, known as Broca’s area, directs language production,” Muñoz says. But her research is less about why aphasia happens than how to address it in bilingual speakers when it does. “I want to investigate how bilingual patients are being treated, and how we may need to change things in order to maximize functional outcomes.”
Existing treatments are based on the English language, but the differences between Spanish and English are great. As Muñoz made clear in a recent speech at the National Aphasia Association conference in New York City, treating aphasia in bilingual and Spanish speakers is much different from treating it in English speakers.
“Syntax, word length, inflection, tense, mood and gender are all very different for Spanish and English speakers,” said Muñoz.
One treatment found useful in those with Broca’s aphasia is melodic intonation therapy. This technique uses singing to get patients back into producing speech. However, Spanish has a different intonation pattern from English, Muñoz says.
“So my question is, how effective is it to use the same program for both English and Spanish speakers?” Muñoz’ goal is to find out how well MIT works for Spanish speakers, and what, if any, modifications need to be made to make it more effective for them.
There isn’t much reported research to draw upon and few who are qualified to help Spanish bilingual aphasics. The majority of speech-language therapists in the community are non-Spanish speaking. “We’re trying to change that, by improving the training of Spanish speakers, or if the therapist is monolingual, by directing them how to help Spanish speakers as best they can,” Muñoz says.
The idea is to find out what works best for each patient, “to maximize function,” Muñoz says. “The client is not going to get back to the skill level he or she had before the event. There will be some residual effects: everything from minor word-finding difficulty to being able to say only two or three understandable words three years after the event.”
Muñoz has seen both cases, and everything in between. Her job? “To figure out how to maximize the best recovery I can.” Finding a way to do that takes more than an understanding of how the brain processes language; it also requires communication skills beyond the norm.
Aphasic patients feel isolated and trapped inside a body that won’t cooperate. As one patient, who can’t speak but can still type, writes: “I can talk to myself not say out. when say out it not word i want to use. sentence hard. it like be locked in own world of silence, yet you can hear. you word is perfect conversation in head. not when talk. so angry. hard not shout hard not whisper.
For most of us, patience is a fleeting virtue. For a speech-language therapist, it’s a job requirement. Hurrying or interrupting an aphasic person as he or she tries to speak isn’t helpful. But you have to know when to stop waiting, and when to try and elicit a response.
It must be very frustrating. No, says Muñoz: “I never feel frustrated with patients. They are all very motivated, and thrilled with any improvements made. They have a real desire to keep working. I do get frustrated with myself at times, when I feel I don’t know how to help, or if I feel I’m not providing clients what they need.”
Sensitivity to the whole person is paramount, Muñoz says. “Communication is much more than language. Humans can communicate well without words by using gestures, laughing, smiling. It’s astounding how effective some people are who can’t use many words.”
Muñoz, the first in her family to go to college, was born in the U.S. to immigrants from Mexico. Working to help bilingual patients with aphasia, she says, is a way of “giving back to the community.” Switching between Spanish and English is something that Muñoz can do without thinking — a relationship to language that she tries never to take for granted.
Invited to the Universidad de Talca in Chile last summer as a visiting lecturer, Muñoz presented her research to students and faculty, spoke at a conference on international approaches to managing healthcare, read, ate, slept, and dreamed in Spanish. “There were times when I got so tired of speaking in Spanish, that I had no words left. I was making up words. There was a void in my brain. It was terrifying.”
If she had to lose a gift, Muñoz says, losing the gift of speech would hit her hardest. “Words are my thing. I’m definitely a language person. Being without speech would be very, very hard for me.”
Contact Muñoz at email@example.com.
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Maria L. Muñoz, Ph.D, CCC-SLP is associate professor and director of the Emphasis in Bilingual Speech-Language Pathology in the Department of Communication Sciences and Disorders at Texas Christian University. She received her doctorate from the University of Texas, Austin as a participant in the Multicultural Leadership Development Program and completed a post-doctoral fellowship at the University of Arizona. She teaches and conducts research in treatment outcomes in aphasia, the manifestation of aphasia in Spanish/English bilinguals, and multicultural pedagogy. Muñoz has presented her work at national and international conferences, and published in scholarly journals such as Brain and Language, Aphasiology, and the American Journal of Speech Language Pathology.