Episode 139: Behavioral Activation with Deena Schwen Blackett

Show Notes: Episode #139

Behavioral Activation with Deena Schwen Blackett

Interviewer info

Lyssa Rome is a speech-language pathologist in the San Francisco Bay Area. She is on staff at the Aphasia Center of California, where she facilitates groups for people with aphasia and their care partners. She owns an LPAA-focused private practice and specializes in working with people with neurogenic communication disorders. She has worked in acute hospital, skilled nursing, and continuum of care settings. Prior to becoming an SLP, Lyssa was a public radio journalist, editor, and podcast producer. In this episode, Lyssa Rome interviews Deena Schwen Blackett about group treatment for aphasia.

Guest info

Dr. Deena Schwen Blackett is an Assistant Professor in the School of Communication Sciences and Disorders at the University of Central Florida and director of the Communication, Aphasia Recovery, and Emotion (CARE) Lab. Dr. Schwen Blackett's research focuses on understanding the relationship between emotion and language in aphasia, developing methods for improving psychosocial well-being in aphasia, and improving aphasia rehabilitation outcomes.

Listener Take-aways

Describe why behavioral activation's reduced linguistic demands and focus on functional life areas make it particularly well suited to use with people with aphasia.

Locate behavioral activation as psychosocial intervention within ASHA's counseling domain of service delivery and SLPs' scope of practice.

Connect behavioral activation principles to the Life Participation Approach to Aphasia and the Aphasia Framework for Outcome Measurement (AFROM).

Transcript:

Lyssa Rome

Welcome to the Aphasia Access Aphasia Conversations Podcast. I'm Lyssa Rome. I'm a speech language pathologist on staff at the Aphasia Center of California, and I see clients with aphasia and other neurogenic communication disorders in my LPAA-focused private practice. I'm also a member of the Aphasia Access Podcast Working Group. Aphasia Access strives to provide members with information, inspiration, and ideas that support their aphasia care through a variety of educational materials and resources.

I'm today's host for an episode that will feature Dr. Deena Schwen Blackett, an assistant professor in the School of Communication Sciences and Disorders at the University of Central Florida, and director of the Communication, Aphasia Recovery, and Emotion (CARE) Lab. Dr. Schwen Blackett's research focuses on understanding the relationship between emotion and language in aphasia, developing methods for improving psychosocial well being in aphasia, and improving aphasia rehabilitation outcomes. Deena Schwen Blackett, thank you so much for being here. I'm really glad to be talking with you today.

Deena Shwen Blackett

Thank you so much for having me. I'm very honored to be here as a longtime fan of Aphasia Access.

Lyssa Rome

Often on this podcast, we get started by asking people about whether they've had an aha moment, or if there's another anecdote that they want to share. What made you want to study emotions and psychosocial interventions and aphasia?

Deena Shwen Blackett

Yeah. So as an undergraduate at Purdue University, I started out in chemical engineering, which is quite different. But about midway in my sophomore year, I decided that's not the career for me, and I was exploring other options. I was really drawn to psychology, actually, and I decided to switch my major to psychology. I was really considering a career in psychiatry or clinical psychology, but I wanted to double major in something, to kind of set myself a little bit apart from the massive amounts of psych majors.

I hadn't actually heard about speech language pathology until my aunt brought it up to me and the you know, I decided, oh, this could be a great compliment to psychology, and I decided to double major. And the more I learned about our field, and especially aphasia, I became just so hooked. And I reflected quite a bit on how impactful it could be to help somebody with communication, given how essential it is to our daily lives and our relationships and our overall well being.

When I went to graduate school at The Ohio State University to really study aphasia more and learn how to do research, I worked with Dr. Stacy Harnish there. In our early discussions about research and projects, she told me about a patient she had with pretty severe aphasia, who, whenever they would do a picture naming task, whenever the word "gun" would come up, she was able to say it very quickly and fast. And that was intriguing. It was something about the emotionality of that that helped her say the word, because otherwise it was very difficult for her. That drew me in immediately. I really wanted to understand how emotional language was different from non-emotional language. And this phenomenon of, you know, people cursing pretty fluently, even though they have very severe aphasia, or saying just very emotional words.

It dates back to the 19th century, but we didn't really know much about it. It hasn't really been empirically studied very much. So I was really curious about whether we could harness that ability of more preserved emotional language in therapy to maybe enhance communication ability. So reflecting back, I've always had this strong interest in emotion and psychology and how that kind of ties into our field of communication.

Lyssa Rome

It is so interesting to observe, and I have had similar observations in my clinical practice. I'm wondering if you could tell us a little bit about the work that stemmed from that early interest, and you've studied in terms of emotional stimuli.

Deena Shwen Blackett

So this was really the bulk of my work as a PhD student, and I was really interested in, again, empirically, studying how emotionality of stimuli could impact language processing, but especially word retrieval, given how much that is affected in aphasia. I designed a series of word retrieval tasks, including object picture naming, action picture naming, verb generation, where participants saw a noun and they had to name a verb associated with it, and category member generation, where they saw a category and had to name one thing in that category. So each of these four tasks had a set of positively valence stimuli. So in the case of object picture naming, like a picture of puppies. They also had a set of negatively valence stimuli, like a picture of cockroaches. And then another set of neutral stimuli, so something like a picture of cows, where in our culture, like that's pretty neutral. And so I had people name in each of these tasks, and we looked at how quickly they named and how accurately they named.

We looked at both neurotypical aging adults and people with aphasia, because we actually didn't really know much about how emotional stimuli affects word retrieval in neurotypical, normal aging. I really expected that people would respond faster and act more accurately to the emotional items because of that emotional language phenomenon that we were just talking about. But I found the opposite. So people named emotional images and words less accurately and more slowly than neutral, non-emotional items. The more I thought about this, you know, the more it kind of made sense to me, and is consistent with anecdotal reports from people with aphasia about when they are frustrated or angry or excited even, it's really much harder for them to think of the words they want to use and express themselves, so it really mimics those reports and is a nice foundation that led me to continue this work in emotion and language.

Lyssa Rome

So I'm curious then about how that where you're really doing your the focus was on naming right and answering this question about emotion, like the emotional valence of naming. How did that lead into the work that you have done more recently on behavioral activation for people with aphasia?

Deena Shwen Blackett

Yeah, great question. So after I graduated with my PhD, I did a postdoc at the Medical University of South Carolina. When I was there, based on my clinical work, when I was finishing up my practice, and you know, the interactions I had in research with people with aphasia, I just really felt this strong urgency to do more to support emotional well being of patients with aphasia. I could see a clear path of clinical need and translation that I wanted to explore more because there. Myself as an SLP, I just knew there was more that we could be doing as clinicians, and I wanted to explore that. So I initiated a collaboration with a clinical psychologist during my postdoc, we wrote a pilot grant, and it was funded, and so we had the opportunity to c- develop a protocol for a psychosocial-focused intervention for people with aphasia that was really mostly focused on using a technique called behavioral activation. And so that was where my most recent work has been focused, truly, because of how urgent I feel like the need is, and I see a clear path toward how it could be implemented clinically.

Lyssa Rome

Yeah, yeah. I mean, I think that everyone who works with people with aphasia would probably agree about that urgency. So let's take a step back, and I'm wondering if you could define for us, what is cognitive behavioral therapy, what is CBT? What's behavioral activation?

Deena Shwen Blackett

Great question. So cognitive behavioral therapy, or CBT for short, is really an umbrella term nowadays that refers to mental health interventions that are centered on the idea that our thoughts, our behaviors, and our feelings are all interconnected, and they all relate to each other, and so we can regulate or improve our mood or our feelings through a change in behavior or a change in our thinking.

Behavioral activation is just a very specific CBT technique or skill that can be delivered on its own. That's really focused on changing our behaviors to improve our mood and our feelings. It shows really great evidence. There's great data behind it to show that it's got moderate to large effect sizes for improving psychological symptoms, particularly depression symptoms, is where most of the research on behavioral activation and CBT has been done, but there is growing research looking at its effects on anxiety.

The main premise of behavioral activation is that when somebody is depressed or anxious, they get into this cycle of avoidance. So, "I don't feel like going out with my friends or I… you know, I don't feel like going out to a restaurant." And so people don't do those things that will actually make them feel good, and then they get into the cycle in which they feel worse and worse because they're not having these reinforcing activities in their daily life. And so the idea is that behavior, we change the behavior first, and over time, we see that positive effect on well being and emotion. So we're really disrupting that cycle of avoidance. And there's a series of steps that you take to you know do deliver behavioral activation, but a lot of it is about understanding what that person finds enjoyable and finds important in varying areas of their life, and trying to increase those number of activities

Lyssa Rome

That totally makes sense and it really reminds me so much of conversations that I have with clients all the time about how the best way to get better at talking is to talk. The best way to get better at conversations with friends is to have conversations with friends. And I feel like it overlaps so much with some of those principles of neuroplasticity from Kleim and Jones and certainly with LPAA. So I am really looking forward to talking with you more about it and learning more about behavioral activation. Why did you think that this might be a promising intervention for people with aphasia?

Deena Shwen Blackett

Well, first, like you said, it's so well aligned with the Life Participation Approach to Aphasia and these other models of holistic, patient-centered care, and it addresses such a very common response to having aphasia—that avoidance. SLPs also can learn this technique. It's something that has been shown to be effective even when administered by non-mental-health professionals. So speech language pathologists can learn this without extensive training in psychology. I also think it can be just so well integrated in our language or communication goals. A lot of the activities that people do that they find enjoyable or important to them involve language and involve communication. So there's a clear need to support communication in those activities.

The other piece that I want to mention is that behavioral activation, in comparison to something like cognitive restructuring or cognitive reframing, is a bit less demanding in terms of language. So it's a bit less linguistically demanding. Because we're not having to help our patients really articulate their cognitive distortions or their unhelpful thoughts, and really put those into different words for people to rehearse. For some of our patients, I think that can work really well and be very impactful, but for people with more severe aphasia, that might be a barrier to really getting the most out of the intervention.

So this focus on behaviors, I think, is a bit more well suited for people with aphasia. We have some early evidence that this can be effective with people with aphasia. Dr. Shirley Thomas in the UK has done some studies on behavioral activation and people with aphasia, and shown good evidence, early evidence for it. But in her studies, I believe, it was delivered by psychology assistants instead of speech language pathologists. So that's the piece that I really want to dive into: How can we train SLPs to do this and use it in their clinical practice.

Lyssa Rome

You mentioned that there was some research into delivering behavioral activation intervention in the UK, but it was delivered, or in the study, it was delivered by psych assistants. And so I want to sort of contextualize your study and this potential intervention for speech language pathologists within the context of our scope and the kinds of counseling that we can do with people with aphasia.

Deena Shwen Blackett

Yeah, great question. I get this question a lot. Counseling, of course, is one of our eight domains of service delivery as SLPs, right? And I think people get caught up in what do we mean by counseling, or how do we define that, and what can we do in that definition? ASHA defines counseling pretty broadly, and I actually went back and looked up part of the definition, and it's providing support around the emotions, thoughts, feelings and behaviors that result from living with the communication disorder. That is very vague, and I think that partially it's intentional. But SLPs know this is important, and they see that it, you know, emotional dysfunction, depression, anxiety, can interfere, or be a barrier to rehabilitation. So SLPs, I think, are really eager for more tools and methods that are evidence-based, that can be used in their sessions. And I do think that behavioral activation and CBT techniques fall within the definition of our counseling domain.

In graduate school, we're often taught common factors of counseling, things like developing a therapeutic alliance, and active listening, and unconditional positive regard, and having empathy for our patients, which, of course, are all very, very important. And we're taught about, you know, giving education to clients as part of our counseling, educating about the disorder and connecting patients with resources. But there's a little bit more that we can do beyond that, right? Like we can use evidence based methods that are meant to target mood and improve psychological well being beyond those common factors.

And we see this in other parts of our field, I think a little bit more so in fluency disorders, for example. You know, CBT is more frequently used by SLPs to target the anxiety and fear around stuttering. And we see, you know, I teach cognitive communication disorders to graduate students, and we use a book by McKay Sohlberg and her colleagues, Transforming Cognitive Rehabilitation is the title. She has a whole chapter on psychological mindedness and CBT is, you know, one of the tools that she mentions as a possible technique that we can integrate in our care.

So I think that the hesitancy is really just coming from a lack of confidence or a lack of knowledge or training to really understand what we can do and what the line is between what we can and can't do. But my perspective is that we can do quite a bit more. We just need more data, more you know, clear adaptations of existing interventions for our populations and more training.

Lyssa Rome

It makes me also think about Ian Kneebone's stepped model of support for psychological well being for people with aphasia. And it seems like this clearly, kind of falls within those early steps where we don't need to refer out necessarily, we may be able to offer, we as speech language pathologists, may be able to offer the support that people need. And that said many of us might not have the confidence to use specific techniques, and I think that that may be what you're getting at. Is that right?

Deena Shwen Blackett

Yes, I'm so glad you brought up that model because I think it could be such a great framework for our care in terms of having a stepped care model to intervene at different stages, right? I think, from my recollection, there's four levels of the model, levels one and two are patients with mild to mild to moderate symptoms of depression, for example, or anxiety. And at those levels, you know, SLPs, according to the model, can intervene in certain ways. So at level one, they might recommend support groups, or, you know, do just general psychoeducation. Level two, they might provide more of those formalized techniques, like using CBT techniques or behavioral activation to support emotional well being. And then levels three and four, certainly, we would need to enlist the help of mental health professionals and refer out for more support. But that doesn't mean we can't also be doing what we can as SLPs when we're with the patients to support them.

Lyssa Rome

Yeah. So let's get to your study and the intervention that you were looking at. Tell us about it.

Deena Shwen Blackett

Yeah, so we've done one pilot study, and we're in the process of another, actually. And in the first pilot that we did, we recruited 11 people with aphasia, and we delivered a psychosocial intervention that comprised psychoeducation, so really just helping people with aphasia understand what could be the emotional impacts of aphasia, what are the risks of depression, anxiety, and having a conversation about their emotional experience. And then the other component was relaxation training, or relaxation exercises, where we, you know, really try to address some of those symptoms of anxiety that people with aphasia have. And we did some deep breathing, visualization, some progressive muscle relaxation. We did some sleep hygiene education, and my learning from Dr. McTeague, the clinical psychologist who I was working with. She knows how important sleep is for psychological well being. So we included that. And then the main thread, the main component, was the behavioral activation.

We weaved these techniques together into a five session intervention where we saw people once a week for one hour per week, and we tested depression and anxiety symptoms before the intervention and then after the intervention, and then again a one month follow up. We also tested some other psychosocial variables, but our main outcome was depression and anxiety symptoms. We actually saw a significant reduction in depression symptoms from pre- to post-, which was pretty surprising to us with such a small sample and such a short intervention. We were more interested in feasibility and acceptability of the intervention, but we did see some preliminary benefit of it, and we did see at the one month follow up, those levels returned closer to baseline again. So we do need to investigate more about the maintenance of these sorts of benefits. But it's really promising to see.

In terms of what we did, specifically when it came to behavioral activation, that entailed a series of steps. So the first step is daily activity tracking, where people with aphasia keep track of what they're doing all day and they talk. They rate how enjoyable each activity they do is and how important it is to them, and they track their mood. So it's really meant to build this understanding of the connection between the activities they do and their behaviors and how they're feeling.

Another step of behavioral activation is discussing their values in each of five life areas. And those life areas are personal relationships; education, career, and learning; mind, body and spirit; daily responsibilities; and recreation or interests. And so in each of those five areas, we talk about what's important to you. We think about under each value, what are the activities that you do or want to do that are in line with that value. So for example, in the category of personal relationships, if it's really important to them to be a loving and caring spouse, we will talk about, what are the activities or things you could be doing or are doing that are in line with that value, whether it's, you know, making their coffee in the morning, saying "I love you" once a day, saying "Thank you" once a day, or every time they want to. So we get really specific. And then, you know, we talk about, how can we get more of these activities into your schedule? And we will schedule specific activities throughout the week just to increase that activity level. Specifically, not just activity level, but activity level and things that they really enjoy and find important.

There are definitely ways that I learned from this first pilot that we can improve the intervention and make it a bit more accessible and work a little bit smoother with people with aphasia, so we're working on refining it and continuing to make it better and better, but we're kind of on the next iteration of that right now.

Lyssa Rome

So it sounds like you found a significant reduction in depression, at least at first and so and that you're still refining to see sort of what needs to happen next. And I'm curious too, though about the feasibility and acceptability. What did the people with aphasia who participated in this research have to say about that?

Deena Shwen Blackett

Great question. So they had very favorable things to say for the most part. One hundred percent of them completed the intervention, right? So that told us that it was feasible to them. They seem to like the once a week timing and frequency. They liked the hour-long sessions. So they seemed to logistically think it worked well. And many of them—the majority of them—reported that they felt a positive impact on their quality of life or mood. And so we did see a lot of people saying, you know, we think that this should be a more regular, traditional part of our speech therapy, right, that we are getting language support, but also emotional support included in our sessions. And so that was a really nice take home.

People did have some varying views about when they thought it would be most helpful to get this sort of support or intervention. With some people saying right away after their stroke. Others saying, "I think if I had more time to get settled and understand what my, you know, equilibrium is after such a shocking event, then I think I would be ready to explore some of these coping strategies and explore my emotions more so." So I think there will be some individual preferences for when this might be most beneficial, but we just need more data.

Lyssa Rome

I want to come back to the Life Participation Approach to Aphasia, because it seems like the behavioral activation intervention is so closely aligned with the kinds of goal setting that we do from an LPAA approach, like, "What is it that you want to be doing, and how can we support you to make that happen?" I'm wondering if you could say a little bit more about that, and about whether and how that factored into your thinking, as you are kind of starting to explore this.

Deena Shwen Blackett

Yeah, it's 100% aligned, right? I think the whole idea behind the Life Participation Approach is to, like you said, help people with aphasia participate in life fully and re-engage in the activities that are important to them, and that is exactly what we're doing with behavioral activation. And if we look at the AFROM or the Aphasia Framework for Outcome Measurement, the personal factors, the identity, attitudes, and feelings, they can be intervention targets under the LPAA model. And so that's exactly what we're hoping to achieve, is targeting that aspect of functioning and helping improve overall outcomes and overall living with aphasia by addressing those personal factors and the emotional impact.

And the next step that I'm really interested in exploring is not just how that improves overall living with aphasia, but how that, in turn, affects benefit from language rehabilitation, or language rehabilitation itself. So if people are feeling better, are they engaging in speech therapy more effectively? Are they cognitively, neurophysiologically, better able to benefit from relearning and language rehabilitation. So I think it's twofold, right, like it helps somebody's overall quality of life, but it could potentially also help the language recovery itself.

Lyssa Rome

Those are such interesting questions. So you've already started to answer this question, but I'm curious about what comes next.

Deena Shwen Blackett

Yeah, so like I said earlier, we want to continue refining this intervention, but also exploring how it will be integrated into a clinical speech therapy session. Right now, the next iteration of pilot testing is looking that at the behavioral activation in the context of an intensive, comprehensive aphasia program that we have here at UCF at the Aphasia House, and we're kind of exploring the feasibility of testing this intervention in the context of a clinical setting and clinical program, but I think it will also help us refine it and also to develop a training protocol for other SLPs and graduate students to learn how to deliver modified behavioral activation. So far, I've been the only SLP to deliver it in my work. And so my next step is to really figure out what's the best, most feasible way to train active clinicians and graduate students to use this technique.

Like I said, I want to also examine how this intervention could also affect language outcomes in addition to psychosocial outcomes. Another study that I'm involved with right now is a collaboration with Dr. Michelle Woodbury and again, Dr. Lisa McTeague at the Medical University of South Carolina. Dr. Woodbury is an occupational therapist, and we've been working together on a tele-rehab study. So we've been seeing stroke survivors who need occupational therapy or speech therapy, and we're looking at the effect of integrating cognitive behavioral therapy strategies to promote emotional well being, and seeing if integrating that with our therapy really does improve emotional well being. And so that opens up a whole nother world of this in terms of virtual delivery and tele-rehab, and then our next step for that is to also look at the feasibility of doing a maintenance program in terms of a virtual group where we continue carryover and maintenance of these CBT strategies, because we've seen in my one pilot right that people kind of go back to their their baseline of functioning after a while. So it'll be really important for us to think about, how can we maintain those benefits?

Lyssa Rome

Yeah, that is so exciting. I'm wondering what you want clinicians to take away from your work on this.

Deena Shwen Blackett

So I think one of the biggest takeaways is for people, for SLPs, to really believe that we can be doing more, right? There is more within our scope that we can do to support emotional well being. We just need to develop the tools and the evidence to use that and help train our clinicians to do those things.

But one thing I haven't really talked about that I want clinicians to take away is: it's important for us to screen for depression, anxiety, and one other area is suicide that we really noticed is important for us to be screening for. It's a scary topic for a lot of clinicians. We don't really talk much about it. I certainly didn't get any exposure to suicide risk assessment as a graduate student or even as a working clinician. And I think the biggest fear comes from clinicians being scared that if they bring it up, they'll put the idea of suicide in our patient's head. But we know there's a lot of research to show that's just not the case. That you're not going to give them the idea. But on the contrary, you can really decrease their risk by asking them about it. And there are tools out there that can be adapted for people with aphasia and are currently validated for people with aphasia. Not enough. We need a lot more research to build up those tools. And that's another part of my work and research interest is, you know, finding more tools that we can use to assess these things. But I want clinicians to really think about, how could I be screening for this?

Then, you know, the other thing that I found really important, but hard to do is developing relationships with mental health professionals in your area. There are clearly not enough mental health professionals, period, especially ones that know about aphasia, right? And that is one of the sources of this issue for people with aphasia—not being able to get the support they need. But I think that SLPs can really have a role in developing those relationships and reaching out to mental health professionals, because they just don't know that this is a need, and they don't know where to begin. And so if we reach out and we say, "Hey, you know, I have this population who really needs support, but we're having trouble finding people who can help. Would you be willing to take some of these patients on and be willing to learn about how to communicate with people with aphasia." It's no small task, for sure, but I think we can start building that network of people if… it's a lot on our plate already, but anything we can do to just build that network, step by step, will be really important.

Lyssa Rome

Yeah, I totally agree. Dr. Deena Schwen Blackett, thank you so much for telling us about your work. I'm really excited about your research and about everything that you have been developing to help speech pathologists support people with aphasia with their mental health. So thanks.

Deena Shwen Blackett

Oh, thank you so much. It was my pleasure. I'm very flattered to be asked to be on this podcast, and I'm so so in belief of the mission of Aphasia Access. So it's an honor to be here. Thank you for the conversation,

Thanks also to our listeners. For the references and resources mentioned in today's show, please see our show notes. They're available on our website, www.aphasiaaccess.org. There, you can also become a member of our organization, browse our growing library of materials and find out about the Aphasia access Academy. If you have an idea for a future podcast episode, email us at info@aphasiaaccess.org. Thanks again for your ongoing support of Aphasia Access. For Aphasia Access Conversations, I'm Lyssa Rome.

Resources

Suicide and Crisis Lifeline (call or text): 988

Communication, Aphasia, Recovery, and Emotion (CARE) Lab

Google Drive folder with possible screening tools for depression, anxiety, quality of life, and suicide

Dynamic Visual Analogue Mood Scales

Organizations that have a focus on emotional wellbeing and mental health with aphasia or post-stroke

Stroke Onward

National Aphasia Association

Love Your Brain

Aphasia Recovery Connection