Speaking Up and Being Heard: The Importance of Functional Communication and Discourse Principles in Aphasia Intervention

Abstract

This article acknowledges Audrey Holland's influence on aphasiology as it specifically relates to the emergence of a strengths-based perspective on the everyday communication of people with aphasia. We explore a historical perspective, as well as current ways in which everyday communicative events are approached in both clinical and research practice. The term “functional communication” is synonymous with Audrey's work, with linguistically-based discourse analysis and therapy both viewed as natural companions and extensions of the concept within aphasiology. Audrey's focus on the interactional side of communication and psychosocial impacts of aphasia, as well as her expertise in analysis and measurement, contributed to the coalescing of impairment-based and social communication approaches, encompassing a true sense of humanity and connectedness. Her application of these in international contexts was also noteworthy. In this article, we hope to capture principles of aphasia management that underpin current clinical practice, and also move beyond the traditional clinic context to consider aphasia groups that have had such a key role in promoting successful social communication by and with people with aphasia. We suggest future directions to further promote the principles advocated by Audrey Holland in assisting people with aphasia to move forward with confidence with their conversation partners, friends, and communities.

Keywords

aphasia - functional communication - discourse - conversation - group therapy

Learning Outcomes: As a result of this activity, the reader will be able to:

• Explain the significance of everyday communication as a focus of treatment in aphasiology.

• Describe the role of conversation and discourse analyses in the measurement of aphasia.

• Identify gaps in current knowledge regarding the efficacy of conversational and discourse-oriented therapies.

• Define what a strengths-based approach is in aphasiology.

In the year 2000, Professor Audrey Holland visited Adelaide, South Australia, as a guest of the Talkback Association for Aphasia, renamed Aphasia SA over 20 years later. She gave a talk to an audience of local people with aphasia and their families about living well with aphasia. This talk was a classic example of the way Audrey worked: down-to-earth, accessible to her audience, well-judged, and relevant. Each person there knew she was talking directly to them. I (Deborah) remember that at the end of her talk, many people in the audience came up to speak with her about their experiences. One of them was Carol Fuller, the spouse of a man with aphasia, Clive, who attended one of our Talkback Groups. Carol had a lot of questions and Audrey gave her time, and her absolute attention. Over her career, Audrey would have spoken to thousands of people affected by aphasia, but Carol came away knowing that this visiting professor valued and appreciated their personal aphasia story. Many years later, Carol published a book “Echoes of a Closed Door” (Fuller, 2016) about how the couple achieved a life of quality and meaning. She wrote of Audrey's visit: “This seminar gave Clive and me a chance to speak about the effects of his language impairment, and of our efforts to overcome his impairment in an endeavour to move forward in our lives” (p. 98). Clive's aphasia was severe, and he was unable to speak up, but he and Carol both felt they were being heard that afternoon. This situation typified Audrey's influence in the aphasia world: she encouraged people with aphasia and their families to speak up and be heard, to self-advocate, and to live positive and meaningful lives. She recognized the primacy of relationships, and the expression of identity through relationships themselves built and sustained through interaction and communication. Her wisdom, intellect, straightforwardness, practicality, and caring and nurturing of other people were her dominant characteristics along with a wicked sense of humor and generosity of spirit.

It seems as if we are stating the obvious when we note that conversation and everyday communication are absolutely at the forefront of what should be done in aphasia intervention, using whatever modalities and strategies make this possible, enabling the establishment and maintenance of friendships, “and occasions to laugh together with people who understand their problems” (Beeson & Holland, 2007, p. 145). Nevertheless, Audrey was a pioneer in her time by emphasizing this message. She also especially argued that being able to converse with people with aphasia was important for all health professionals (Holland & Halpery, 1996), a point that still needs to be made today (Carragher et al., 2021; Kagan et al., 2024) and Audrey often challenged clinicians to do better:

We need to develop strategies that optimize conversation and communication. As a first step, I believe we need to understand what makes it so difficult for us clinicians to converse with our patients. That is, what relegates conversation to some sort of sleazy, shady, unreimbursable Neverland that must perforce either precede or follow the real goods - the therapy? (Holland, 1998)

Arguably, Audrey's question remains relevant today even though aphasiology has moved forward with many examples of how conversation and communication have been researched and addressed in clinical practice (Beeke & Bloch, 2023; Simmons-Mackie et al., 2016). In this article, we highlight some of the contributions Audrey made during her career to influence perspectives in the field of aphasiology on communicative function, the social and communication implications of having aphasia, and the need for assessment and treatment methods that focus on facilitating the person with aphasia's voice in a variety of contexts using a strength-based approach.

Audrey's work had an international influence that led to a range of developments across different fields in aphasiology. These included a focus on detailed collection of data around language characteristics of people with aphasia (AphasiaBank), as well as thorough examination and facilitation of the communication between the person with aphasia and their family and friends (e.g., Hopper et al., 2002). In addition, her influence extended to a greater interest in the experiences of people with aphasia in non–English-speaking environments, minority, and ethnically diverse populations (e.g., Centeno & Laures-Gore, 2024).

Audrey strongly advocated for people with aphasia, enabling them and their families to speak up and be heard, to be supported to engage in conversation, to be respected as experts, to reconnect with others, and to enjoy interactions. Readers are encouraged to refer to an article by Audrey entitled “Lessons From a Clinical Life in Aphasia” (Holland, 2010) that captured her philosophy. For Audrey, language use was always positioned in a social context, with interpersonal relationships always being at the fore (Holland & Nelson, 2020).

Here, we focus on two of the ways in which she enacted the above philosophy—first, through shifting thinking to bring an appreciation of functional communication in everyday contexts into mainstream practice, and second, her influence on the inclusion of discourse principles to help guide aphasia intervention. We describe how these concepts continue to be applied and developed into innovative assessment and treatment practices, and we provide a particular focus on the role of aphasia groups as a central facilitating context.

Functional Communication: From the Wings to Center Stage

Aphasia clinicians now take for granted that their assessments and therapy should be relevant to the real contexts in which people with aphasia live and the authentic demands that they need to manage (Doedens & Meteyard, 2022). They make sure that their clients participate in setting goals that are relevant and tailored (Hersh et al., 2012); they choose stimuli for naming tasks that are useful for their clients to practice (Devane et al., 2024); they involve family members in communication partner training (CPT) so that conversations can happen at home (Simmons-Mackie et al., 2016); and they practice with scripts and scenarios that have genuine value (Holland et al., 2010; Hubbard et al., 2020). However, as Hallowell (2017) notes, this approach started only in the 1980s and 1990s and she describes Audrey Holland as a “magnificent catalyst” (p. 410) behind this shift in practice.

All of the aforementioned were embodied in Audrey's approaches to aphasiology. She was an expert at diagnosing linguistic impairments but was even more expert at promoting the strengths of people with aphasia and finding ways to “reveal their competence” as Duchan, Maxwell, and Kovarsky (1999) framed this approach. Her famous insight that people with aphasia “communicate better than they talk” (Holland 1977, p. 173) highlighted the numerous resources that people who have aphasia use to communicate apart from words. Audrey's emphasis on strengths rather than deficits (exemplified particularly in Holland, 2006) introduced a way of looking at aphasia that focused on communicative skills in the context of someone's life, prestroke identity, and current aspirations, rather than impairments. Her approach was one of the first to systematically explore communication in everyday contexts rather than focusing speakers' performance on decontextualized language and clinic-based assessments. Her contribution to the establishment of AphasiaBank (Macwhinney et al., 2011)—the first international database of aphasic discourse—underlined her ongoing commitment to having clinicians and researchers explore the connected speech of people with aphasia for research purposes.

Now that functional communication is so much a part of everyday practice, it has come to mean different things to different people. Doedens and Meteyard (2022) argue that a lack of common understanding of the term functional communication has a negative effect on assessment and intervention and that this now means it requires redefinition. They suggest it should be seen as situated language use and should include certain elements: that it is interactive, multimodal, and contextual.

One of the most authentic ways to enact situated language use, with these three elements, is by offering people with aphasia the opportunity to meet others through aphasia groups. These provide an ideal context for promoting communication in people struggling with the challenges of aphasia, particularly if they are run in such a way that members can actively contribute and feel that they are accepted and regarded as competent (Lanyon et al., 2018). Aphasia groups are conducted now in many countries, and encompass numerous different models (Elman, 2007), ranging from those focusing on impairment-based activity to others emphasizing psychosocial support or conversational skills (Lanyon et al., 2013). They may be led by clinicians, volunteers, and/or peers depending on the model(s) employed (Pettigrove et al., 2022) and can vary in size and formality of structure.

Aphasia groups have been important to both authors in this article. The first Talkback Group for Aphasia ran in Adelaide, Australia, in 1995 (Hersh, 2007), an initiative greatly influenced by a visit (by Deborah), the year before, to the Aphasia Institute in Toronto, and several aphasia groups, including the ones run by Pelagie Beeson and Audrey Holland at the University of Arizona (Beeson & Holland, 2007). Audrey's influence on the Arizona groups was clear. They were full of laughter and humor; they were relaxed and social and emphasized the members with aphasia as the “experts,” with students learning from them about how to communicate effectively. Aphasia groups run in the spirit of these early models have become a key vehicle for the enactment of functional communication or situated language use: they are highly interactive, all forms of communication are used as suits each individual, and the context is authentic and social. Groups are no longer an addition offered at the end of individual therapy but are important in their own right. They are one option in the array of therapies and opportunities for people with aphasia to practice their communication skills in a supportive environment and feel a sense of belonging and connection.

The cross-cultural relevance of group therapy for individuals with brain damage, including those with aphasia, has recently been described in an Aboriginal context in Australia (Armstrong et al., 2024). “Yarning circles” based in metropolitan and rural areas for Aboriginal people with brain injury, conducted by Aboriginal facilitators in Aboriginal community settings, have been well-attended and have received positive feedback from participants and their families/carers. In Australian Aboriginal culture “yarning” (which Audrey too often confused with “yawning” during my Australian accented explanations—EA) is a form of discourse that often involves storytelling but which is “reciprocal and mutual” (Bessarab & Ng'andu, 2010, p. 38). Bessarab and Ng'andu refer to Nyoongah author Terszack's definition to further elaborate on the cultural significance of yarning—“a process of making meaning, communicating and passing on history and knowledge … a special way of relating and connecting with the Nyoongah culture” (2008, p. 90). In the yarning circles reported on by Armstrong et al. (2024), yarning about a range of topics was central to all groups. However, the authors noted that a safe cultural space is essential for truly reciprocal yarning and for group participants to be able to actively engage and explore their new identities after brain damage. In a context in which therapists are typically white middle-class females and access to services has been historically restricted due to ongoing colonization practices, the group activities in the yarning circles were meaningful, educational, and fun, and provided dignity, mutual support, and connection not always offered in a non-Aboriginal space. The circles facilitated “a strong relational ethic of sociability of Aboriginal people and the community and service-based setting frequently allows for reconnection to kin and countrymen” (p. 9). This was made possible as they operated in familiar community settings where extended Aboriginal families met regularly for broad social and cultural purposes.

Descriptions and evaluations of aphasia groups have included participants' performance on standardized tests pre and post group treatments (Elman & Bernstein-Ellis, 1999), participants' assessment of their communicative confidence (Dunne et al., 2023), resultant functional communication skills as measured by instruments such as the Communication Activities of Daily Living (CADL) (Holland, 1980; Elman & Bernstein-Ellis, 1999), discourse output as measured through the analysis of the amount of content offered and efficiency of that offering (Elman & Bernstein-Ellis, 1999; Boyle et al., 2023; Dunne et al., 2023), and quality of life (Rose et al., 2022). Many evaluations have shown the benefits of a variety of different aphasia groups. However, recent studies have reported on the actual kind of talk that takes place during aphasia groups. Using conversation analysis, Simmons-Mackie and Damico (2009) explored different ways of facilitating participant engagement in groups including the use of shared humor, and particular attention to gaze, body orientation, and use of gesture to facilitate comprehension and encourage the enactment of recounts and stories. Armstrong et al. (2012) described participants with aphasia successfully conveying opinions on a variety of topics via the use of evaluative language (to be outlined below—albeit with speakers having a limited range of resources). Two recent articles (Archer et al., 2021; Azios et al., 2024) focus on the ways in which facilitators assist interaction and engagement in groups. For example, one article, which explored interactions occurring in an online aphasia group, provided particularly interesting insights into participant behaviors during the group reflecting on their navigation of voice and identity (Azios et al., 2024). However, there still remains a dearth of descriptions of interactions occurring in aphasia groups. Such information may well add further insights into what is perceived as beneficial in these groups and the types of communicative opportunities that work for some participants and potentially not others. The text below is devoted to how discourse analysis provides a framework for analyzing such social communication, its use to date in aphasiology generally, and how it might reveal more about the essence of what is now commonly termed “communication-based therapies,” and how they might impact on social communication skills of people with aphasia.

The Role of Linguistic Discourse Analysis in Unpacking Functional Communication: An Assessment Perspective

As noted earlier, it was Audrey's work (acknowledging the early innovative work of Martha Taylor Sarno in this area) as well as discourse analysts (e.g., Ulatowska et al., 1981) that introduced the notion of communicative function, that is, how a speaker communicates across different genres (narrative, procedural discourse) and in specific practical contexts such as a shopping encounter, a doctor's appointment, or using the telephone (as tapped in the CADL—Holland, 1980) rather than focusing on a speaker's decontextualized language skills.

Linguistic discourse analysis enables the unpacking of functional communication and gives us a framework for looking at it systematically. The notion of genre enables us to explore different kinds of contexts and purposes of language (Martin & Rose, 2003). Martin and Rose define “genre” as referring to “…different types of texts that enact different social contexts” (p. 7). Discourse can involve telling a story—either fictional or factual (narrative), describing how something is done or instructing someone to do something (procedural), providing details/explanations related to a particular topic (expository), trying to convince someone to take a certain opinion about an issue (persuasive) or simply having a casual conversation. With respect to discourse analysis, we can examine content (the words and phrases used to convey meanings around a particular topic or event being discussed) and form (the grammar types used to convey the meanings [e.g., statements, exclamations, questions] or modality to convey definiteness [e.g., he will do X vs. he might do X]), then examine how these change for different listeners. The words and grammar may change, for example, according to how familiar the speaker is with the listener, the degree to which they already share a certain worldview, and whether the words are spoken or written. Words and phrases convey a person's attitudes and perspective on a topic. Hence lexical choices will often change depending on context; for example, Martin and White (2005) describe “the language of evaluation” which can reflect a speaker's perspective on a particular topic or experience. The following examples illustrate this type of language conveying different meanings about one activity in relation to how a reader might have differentially focused on a piece of written work:

• I glanced over the work.

• I casually looked over the work.

• I scrutinized the work.

• I looked closely at the work.

Similarly, in displaying emotions:

• I was reluctant to leave.

• I disliked leaving.

• I hated leaving.

Hence, “word-finding” activities in aphasia therapy have a scope well beyond the traditional focus on concrete names for objects. While basic names and actions are important for conveying certain things, alternatives that convey more interpersonal and nuanced meanings are crucial to having successful conversations and asserting one's identity (Armstrong, 2005). As speakers, we convey a lot of emotions as well as mere “facts.” And even the “facts” are only one person's version/perspective on an event or entity. The language of evaluation is particularly important in this endeavor as are numerous other linguistic tools that are routinely used by speakers, for example, modality, repetition, direct speech and enactment, and cohesive devices (Armstrong, 2005; Groenewold & Armstrong, 2018; Olness & Ulatowska, 2011).

Bryant et al. (2016) provided an overview of the numerous linguistic approaches to discourse analysis that are used in aphasiology research—primarily to describe the disorder of aphasia or to monitor change over time in treatment studies. They divided the approaches into three overall types concerned with (1) productivity, e.g., a simple word or utterance counts, ratios of different categories of words measured in relation to the total words produced by the speaker; (2) information content, e.g., cohesion, lexical analysis, schema analysis; and (3) grammatical complexity, e.g., word class, syntactic complexity. With 536 different linguistic measures used over 165 research studies, the authors highlighted the gamut of measures available to tailor to particular research or clinical questions. Studies capturing a variety of international clinical practices in the use of discourse analysis (Bryant et al., 2017; Cruice et al., 2020; Stark et al., 2021) revealed a similarly varied approach to clinical applications, with Leaman and Edmonds (2023) also highlighting the significant impact of different contexts affecting discourse measurement. However, calls have been made for a smaller, consensus-developed set of measures to be used consistently across studies so as to make comparison easier, particularly when looking at treatment efficacy. This call was formalized in an article proposing a consensus approach to a core set of discourse outcome measures in aphasiology (Dietz & Boyle, 2018). However, numerous authors have also raised the challenges involved in the determination of a core set of measures (e.g., the potential of oversimplifying the nature of discourse skills and associated contexts), with subsequent therapies not tapping essential features, dominant and often quantitatively based current frameworks stifling future research creativity in a still relatively underexplored area of aphasia (e.g., Armstrong, 2018).

The Application of Discourse Analysis to Treatment Procedures

While the aforementioned studies highlighted the range of discourse measures available to assess the discourse of people with aphasia, Dipper et al. (2021) provided an overview of treatment studies focusing specifically on activities involving discourse production. In contrast to the use of measures to monitor progress/descriptive studies, they found only 25 studies claiming to undertake such treatment, and of these, only 7 met the criteria for “quality review.” Treatment foci included “word production in discourse,” “sentence production in discourse,” “discourse macrostructure,” “discourse scripts,” and “multilevel” discourse tasks. Across the 25 studies, like Bryant et al., (2017), they found a large number of discourse outcome measures used (514). However, they noted that the outcome measures did not always relate to the specific focus of treatment; for example, discourse macrostructure was “treated” but not measured in terms of specific outcomes. Positive changes were noted in the majority of studies; however, these were primarily related to productivity. Discourse treatment frameworks include Linguistic Underpinnings of Narrative in Aphasia (LUNA; Cruice et al., 2022), Novel Approach to Real-life communication: Narrative Intervention in Aphasia (NARNIA; Whitworth et al., 2015), and a novel treatment involving a focus on the exchange of new information during storytelling between the person with aphasia and their conversation partner (Carragher et al., 2015).

There appears to be increasing interest in discourse analysis as aphasiologists continue to “unpack” everyday communication and look for tools to best capture the impairments, communicative strengths, and changes in performance they see in their clients with aphasia. Discourse and sociolinguistic theories exist that offer robust insights into communicative “performance” and social interaction. These include the work of Michael Halliday, Tuen Van Dijk, James Paul Gee, and others, with the reader referred to a recent text that provides overviews of several of these (Handford & Gee, 2023). The myriad of current discourse measures used in aphasiology often reflect less of a theoretical basis and more of a need to quantify “behaviors” easily identified in a clinical or research setting to map progress in or efficacy of particular therapies. Perhaps the consensus approach to outcome measures (e.g., as proposed by Dietz & Boyle, 2018) may be best served through a focus on which theoretical approaches to use (see overview by Linnik et al., 2016) rather than which individual “measures” to employ—something for future discussion!

The increasing interest in discourse has also extended more recently to functional imaging studies, as aphasiologists and other neuroscientists continue to explore how real-life and real-time communication is produced neurologically as well as linguistically. Until recently, imaging often involved a subject undertaking single word of sentence-level linguistic processing tasks to examine brain activity and function. The inclusion of discourse-level activities now reflects the acknowledgment of the importance of “real-life” communication and a need to explore what neurological processes and functions occur to underpin this activity (e.g., Maloney et al., 2023).

Incorporating a More Interactional Focus to Discourse Analysis

Again, Audrey's focus on functional communication always acknowledged the role of two speakers in a conversation, as embedded in her writings on conversational coaching (Hopper et al., 2002), the use of scripts (Holland et al., 2010), and management of group conversations (Simmons-Mackie et al., 2007). Her work encouraged the examination and facilitation of interactions between speakers rather than focusing only on monologic discourse abilities. By the late 1990s/early 2000s, this resulted in an increasing interest generally in more naturally occurring conversations than constructed assessment scenarios, but utilized more theoretical sociolinguistic frameworks for analysis, e.g., Conversation Analysis (Beeke et al., 2007; Ferguson, 1996; Simmons-Mackie & Damico, 2009) and Systemic Functional Linguistic approaches (Armstrong & Mortensen, 2006). This approach has continued to develop to the present day (Beeke & Bloch, 2023; Groenewold & Armstrong, 2018; Hersh et al., 2018, 2024; Tuomenoksa et al., 2023; Wilkinson, 2015). While the examination of the language of a particular speaker in a monologic context tells us a lot about the speaker's language “system” and access to certain types of word and sentence processing, it is during everyday interactions that the speaker's true sociolinguistic strengths and weaknesses become apparent. Some speakers with aphasia find conversations very difficult; some find conversations give them sufficient scaffolding to assist them in conveying their meanings. Of course, much has to do with the conversational partners they encounter and the way(s) in which the partners react to and allow for any aphasic difficulties of the person with aphasia, as well as their relationships with those partners. While many early examinations of the conversational skills of people with aphasia focused primarily on the person with aphasia, more recent studies have been able to capture both speakers' contributions to conversational interactions (Beeke & Bloch, 2023; Tuomenoksa et al., 2023; Wilkinson, 2015), with a limited number of studies, as noted earlier, capturing multiparty conversations such as those found in aphasia groups.

Numerous factors can influence how a conversation unfolds, ranging from the familiarity of conversation partners, familiarity of location in which the conversation takes place, the different statuses of the conversation partners (e.g., friends vs. employer/employee, parent/child), the number of people involved, and the purpose of the conversation (e.g., transactional vs. social, narrative-based vs. persuasive/opinion based). Different ways of eliciting conversation to assess these abilities in a person with aphasia have been documented as part of some of the discourse reviews above, as well as a number of individual studies covering contexts including clinic, hospital, home, by telephone, and face-to-face aphasia groups (Boyle et al., 2023; Simmons-Mackie & Damico, 2009; Azios et al., 2024). Numerous different measures of conversation are now used clinically and these have been reported as noted earlier by Azios et al., (2022) and Simmons-Mackie et al. (2014).

In terms of therapies that focus on conversation specifically, Simmons-Mackie et al. (2014) provided an overview of both conversational therapies and conversation measures. Therapies included activities such as working on specific skills or scripts with individuals with aphasia, encouraging people with aphasia to maximally participate in aphasia groups through leading conversations about particular topics, providing information about conversation principles to the person and their communication partner, and working with dyads during conversations highlighting facilitation techniques. The ultimate recommendation in the article was for further research to seek more valid conversation measures that could be used in “natural” everyday conversational contexts and for more “one-on-one” methods for working with people with aphasia. These recommendations still hold today as aphasiologists continue to explore the complex nature of aphasic conversation.

Included in the above review was Audrey Holland's work with conversational partners that ultimately prompted many conversational therapies. This work was one of the first initiatives to formally emphasize the role of partners in interactions and ways they could be assisted in communicating with their friend/family member who had aphasia (Holland, 1991; Hopper, Holland, & Rewega, 2002). In 2010, Simmons-Mackie et al. undertook a systematic review of CPT, and this was further updated in 2016 (Simmons-Mackie et al., 2016). More recently, Shrubsole et al. (2023) documented barriers and facilitators to the implementation of such training. Shrubsole et al. highlighted the strong evidence for the benefits of CPT but also commented on the relative lack of detail regarding the implementation of such training in different contexts which often precluded duplication of particular approaches. The barriers to implementation reported included a lack of resources (both lack of published programs and staffing shortages) to deliver the training, difficulty accessing family/carers, and negative attitudes of family members toward communication partner training. It should be noted here that much of both the CPT and conversational research undertaken to date in aphasiology and documented in this article emanates from a Western cultural perspective, and hence may not apply directly to different cultural contexts in which pragmatics of communication can differ significantly. This leads to the comments below which also acknowledge Audrey Holland's insights into the importance of cross-linguistic and cross-cultural research in aphasiology.

An International Perspective

Audrey Holland's influence in cross-linguistic and cross-cultural research in aphasia was evident across her career. She was very mindful of the strong Western influence in aphasiology, and the tendency for countries to work in silos. Cultural influences on principles involved in aphasia assessment and treatment frameworks, clinical judgments, client and clinician expectations of therapy, impact of aphasia and personal/community context, and indeed the essence of communicative interactions are all important to acknowledge and explore within aphasiology. In an attempt to address this, Audrey's book “International Perspectives on Aphasia” (Holland, 1993) was one of the first to combine authors from different ethnic and geographic backgrounds to reflect a range of perspectives on aphasia, careful not to privilege one approach over another and to highlight the different contexts that people with aphasia experience across the globe. This book was only a snapshot of the people and places Audrey interacted with both socially and academically at the time and beyond that time, as she continued to lecture, mentor, and collaborate across the globe and encourage others to do so. One of her “pet” and powerful projects as noted earlier—AphasiaBank (Macwhinney et al., 2011)—is but one of her many legacies that has provided an international collaborative database of aphasic language facilitating international collaborations and insights into aphasia cross-culturally (e.g., Deng et al., 2024). Culture has emerged as being of primary importance in aphasiology—in understanding different linguistic patterns, cultural identities, and communication/pragmatic styles in different cultures to name but a few important areas to consider when undertaking both research and clinical practice in aphasia. Building on the cross-cultural work of scholars such as Bastiaanse, Penn, Centeno, Brewer, Ulatowska, and others reflected in a recent special issue of Seminars in Speech & Language (Centeno & Laures-Gore, 2024), aphasiologists are being encouraged to examine practices beyond their own worldview in order to best meet the needs of all people with aphasia and their families.

Conclusions

Audrey Holland's insights into the overall impact of aphasia on the lives of individuals, their families, and significant others have laid the foundations of a “functional” approach in aphasiology that aims to recognize and facilitate the communicative strengths of people with aphasia, focus on everyday communicative needs, and maximize social connectedness—whether in clinical or community contexts. Her influence was one that placed psychosocial well-being alongside language intervention, and promoted real, everyday language to be valued in varied clinical encounters at a national and international level.

We hope that in this article we have paid tribute to Audrey's work in the above areas and how it has contributed to developments in aphasiology up to the current time. It is no surprise that Audrey's professional background focused on psychology and speech pathology, as people and communication were two of her primary interests and activities (although animals also played an important role in her life)! Both authors have learned a great deal from Audrey, through her academic writings, her workshops, the way she worked and conversed with people with aphasia, and the many opportunities to spend time with her both professionally and personally over the years. She was a generous, dear friend who will clearly be missed by many people across the world. We trust we have done justice to at least part of her enormous legacy.

Conflict of Interest

None declared.

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Publication History

Article published online:
08 August 2024