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All The Things We Love About Speech Therapy With Adults

This blog is about all the things we at Sanapsis Love about Speech Therapy with Adults. 

This one is for the caregivers

Nana Lehtinen

Today was day 1 of a great conference, the 15th annual PSA Regional Stroke Conference. First of all, the conference took place at The Magnolia of Millbrae which I thought was an awesome venue for this crowd. A stroke conference in a retirement home, very cool! (I feel bad I did not have time to get a better look at the premises - I might have to go back soon to check the place out in detail.. I just loved their attitude!) 

Secondly and more importantly, I was lucky to hear three great speakers, Dr. Jeremy Bornstein, Dr. Sheila Chan and Dr. Stephanie Linn. Amazing presentations, all of them! The one that stuck to me most today was “Patterns of Psychological Adjustment of Stroke Patients and Families” by Dr. Jeremy Bornstein. He did a great job reminding us all of the huge and overwhelming impact stroke has not only on the patient, but also to those around him or her.  

When working in outpatient rehab, we get to see our patients after they return home from the hospital. This time is usually filled with hope and high expectations, but the new days, weeks and months in familiar surroundings can also be full of new and surprising obstacles. Figuring out how to overcome these obstacles and rebuilding ways of doing things (like communicating needs, wants and feelings or socializing) can be scary and hard.

Also, rebuilding a way of functioning as a spouse, daughter, son or parent is a complicated process. Dr. Bornstein reminded us today that there are many, many paths people take to rebuild their relationships after a stroke and sometimes that path can be a winding one.

I have been lucky to meet many amazing people who work tirelessly to provide the best possible care for their loved ones - sometimes at the cost of their own well being. We all know that recovering from a stroke involves the risk of depression. The one thing I was reminded today was that in regard to this it is not only the patient we need to be looking at - we need to turn our attention to the caregivers too. Also they have had dramatic changes in their lives and have great demands in their new role.

As professionals working with stroke patients our holistic view of the recovery process needs to include the people close to the patient. One thing we should include in our routine when working with caregivers is encouraging them to take care of themselves as well as their loved ones. In speech therapy this can be done by simply acknowledging the great job the caregivers are doing. Positive reinforcement works! I also like to talk about what the caregiver has done that they themselves enjoy. Sometimes a gentle reminder that it is ok to take care of yourself too works amazingly well.

When the caregiver is well rested, happy and balanced, they are able to maintain better care for the patient too. Also, caregivers need time and space to adjust to the new circumstances to be able to rebuild a balanced relationship with their loved ones. Kind of simple, right? 

So everybody, lets give it up for all the caregivers out there doing a great job! You guys are true heroes of our time. 

P.S. Today was day 1 of the 15th annual Stroke Conference. Day 2 is coming up on May 15 and to my understanding you can still register for that one. Hope to see you there!


Nana Lehtinen

So, you work with adult patients who have aphasia. Do you ever give your patients homework? You know, those sheets of paper full of writing, matching or naming exercises? You ask them to bring it back completed for the next session, and then together you go through the tasks and give praise on how well they did. I used to do that, too! 

Having done that for a number of years (!) I started to get tired of it. Why? Not because of me, but because I felt it was not getting us anywhere. Sure, the patients felt the joy of achievement while completing the tasks at home. Sure, I got some info on what they were doing at home or whether were they doing anything at all. Sure, it gave us continuity between sessions. 

However, what I did not feel good about was feeling like a teacher. When the patients lost interest in homework, forgot about homework or I could not convince the caretaker to get involved or in general the circumstances were just against us, I hated it when I saw how my patients felt. Some felt like they had to make excuses on why their work was not completed or they felt embarrassed because they had forgotten. And even when they did complete their homework on time and perfectly, I did not like the student/teacher relationship this got us in (I’m not even going to mention the number of times the homework was completed by the spouse. Aargh!) Again, I wanted more. 

So, I took a different approach. Typically, I never give anyone anything to take home. Instead I ask them to bring stuff from home to me. 

 I ask my patients to do things like: 

·       When reading the newspaper on the morning of speech, circle an article/headline/picture you find interesting and bring that newspaper with you! 

·       Mark the shows you watched on TV during the week on your TV guide and bring that! 

·       Take pictures of your garden and write down the names of the plants! 

And then we actually USE that material in therapy. I always alter the tasks to be relevant to the patients’ everyday life. When suitable, I include loved-ones in these tasks, and give specific instructions on what the patient is supposed to do and how the loved-one is supposed to work with him/her.  

With this change I really feel like we are getting somewhere! Patients and caregivers are more alert on how to use their environment for speech-related tasks (and communication, bonus!), they have a say in what topics we cover in speech therapy and in general I feel that our sessions are actually based on the everyday life of my patients. Instead of going to school and completing tasks, patients come to speech therapy to tell me about their everyday lives and the obstacles they face - often resulting in good conversations on how to make that environment more supportive and accessible! 

 This approach has proven to be more fruitful in the long run, too. The reality of Speech Therapy services is that they are not endless. Embedding the homework in real life tends to stick more than completing sheets of paper or using random tasks as homework. Quite often patients and loved-ones find new ways of doing or talking about things together and that is what we all like to see. 

What have you been up to?

Nana Lehtinen

Many discussions start with the question "What have you been up to?" Quite often we get the "Nothing much" or "You know, the usual" as the first reply. But then, the magic happens. The question triggers stories about meeting old friends at the grocery store, finally fixing the broken lawnmower, relatives who visited on Sunday or a good movie on TV the other night.

However, in speech therapy, even with our high functioning, fluent patients the “nothing much” is often the end of the story. The question does not trigger the spontaneous ideas behind the stories that could be. The overlearned phrases are enough to get us through the exchange and that is where the exchange ends. 

However, sometimes this can be a great achievement for a person who has difficulties with speech! Being able to react, respond and engage. The overlearned, automatic responses are there to establish a connection between individuals, and as such, they are great. I encourage my patients to use these automatic phrases as much as the next guy! 

But being an SLP, I want more. I want these phrases to be a starting point, not the whole deal. I want the phrases to buy time for making that connection between the time since I last saw the person I’m talking to and what I could tell them. This is why I generally begin our session like this: 

 Me:      Hi, how are you? (Pause)

P:         Good. 

Me:      Good to hear. What have you been up to? (Pause) 

P:         Nothing much.

Me:      Really? Now, I don’t believe you. It’s been a week since I last saw you. What have you been doing? (Pause) 

P:         The same.

Me:      Ok, tell me about your “the same.” What does that include? (Pause) 

If you want, I can help you think about things you might have done during the week. Would that be good?

I offer ideas that might relate to that person (for example, have you talked to your neighbor?). Write down different options—everyday things and unusual activities (remember to include crazy ones like “went bungee-jumping” to prompt reactions) and so forth. 

I tell my patients that we will be doing this every time we meet, so “come prepared”. And usually about the third time I meet with them, they get the idea and the discussions go something like this: 

T:         Hi, how are you? (Pause)

P:         Good. 

T:         Good to hear. What have you been up to? (Pause) 

P:         Nothing much. (Long pause) But in physio, it was not the same girl.

T:         Really? You have a new physiotherapist?  

P:         Yes.

T:         Tell me about her. (Pause) 

 And Voilà - we have a story. Something the patient came up with by themselves, something important to them. And they know I’m there to hear that story, I have time to wait for it to unfold. A step closer to a real conversation which I always see as “The Ultimate Goal in Speech Therapy.” 


Nana Lehtinen

The possibilities of a computer in speech therapy have been explored since the very early computers became available. Tablet computers are a new, fascinating platform that has created a great opportunity to explore the possibilities of technology within rehabilitation. We are very lucky to have witnessed a huge outbreak of different kinds of apps for different platforms since Apple launched the iPad in 2010. It is amazing how much creativity, talent and knowledge has been poured into apps that are targeted for speech therapy in a few short years.

 As with everything new, time and experience tend to give a clearer perspective on what the pros and cons actually are. Exploring with different types of apps tends to result in a crystallized view on the benefits you actually get from using new technology in your day to day practice.

 But one thing technology is not good at is flexibility. And boy Oh Boy do we need to bend and twist and turn with our patients. In my experience the most desirable quality of an SLP is the gift of being able to adjust to current circumstances by holding on to your goals, but finding new ways to get there when your first plan fails. As with almost anything, the simple, well designed things tend to pass the test and prevail to help you work better.

We created Sanapsis to be as flexible as you are. Sanapsis is designed to give you an open platform for working with your patient. Yes, Sanapsis has specific tasks to complete, and yes, it will provide you the stimuli. But Sanapsis does not determinate the goal of the task or force you to do one thing with an exercise. It gives you ideas. It allows you to be flexible and work with your patient. With Sanapsis it is always you two working with the provided stimuli, not the patient working with the device while you observe. 

 But what about collecting data? Or documenting progress? We have not found a way that would be simple to use in clinical settings and yet be flexible enough to gather relevant information about the process. We feel that the observations and analysis of the situation need to be completed and documented through professional eyes. A score of correct answers, automatic data collection on how fast a patient performs can turn speech therapy into an arcade game, and we do not want that, do we? 

 We need flexibility to adjust our methods and help the patient understand their symptoms--a way to help our patients cope with their everyday challenges. Sanapsis will be there to help you plan and deliver highly productive therapy sessions, and you need to be there to deliver and document the functional progress.   

Student? New to aphasia?

Nana Lehtinen

As you may have noticed, I am quite passionate about speech therapy with adults. To be honest, every now and then people around me actually ask me to stop and talk about something else. Some of them seem to think it would  be a good idea not to look at the world through "How I Can Use This in Therapy?" glasses all the time. Weird, huh?

Anyways, our love for sharing ideas seems to be quite popular with students and SLP:s who are new to aphasia. And we love it! We have students visit our clinic for demos, we supervise students and of course, we love to talk about things they observe in patients. This has led to quite a few people contacting us with questions when they get to the Hands on- phase of therapy with patients of their own.

The hard part comes when colleagues ask "What should I do, can you give me some exercises or examples of what to actually do with him/her next time we meet?". Now this might seem easy enough. But "Sure, here is a list of sentences I like to use when I target various things with my patients" just seems blunt. We like to explain Why, How and When we use certain materials and also encourage our colleagues to think about these things during therapy.  So it's usually a loooong phone call..

A part of why we decided to start developing Sanapsis was that we wanted to reach out to colleagues and colleagues to be. We  wanted to be able to have these discussions all the time! In the Instructions of each exercise in Sanapsis you will find our guidelines on Why, How and When about the exercise and also ideas on how to expand the task outside the iPad. Sometimes we encourage the clinician to use other materials then the iPad all together!

We also also provide ideas in Sanapsis where to go next and what to try when one particular idea does not work well with your patient. We like to think of our instructions as bouncing ideas between colleagues, as many times that is the best way to learn to understand your patient better.

You can have a quick look at the instructions in our video about the Key Features of Sanapsis. Have fun and contact me with any questions. Let's talk! 

No feedback?

Nana Lehtinen


We have had a lot of questions about why Sanapsis gives no feedback to patients, such as a reward sound or green color when you get the task right and a horn or red color when you make a mistake. We are so happy when people ask that question because this is actually one of the key features in Sanapsis! 

Sanapsis only records the answers that the patient gives. For example: 

Listen to a story

The therapist reads the story displayed to the patient using a normal speech rate. After listening to the story, the patient is asked to determine what the topic of the text was. Each question has three choices, and the patient taps one of the answers to select it.

 When tapping the text, the answer changes its color to orange. It does not matter if the answer is right or wrong. Why? Because now you, as the skilled professional, can use this task to target many different goals instead of just what the developers had in mind! 

 Usually I like to do 3 or 4 stories and then go back and confirm if the answers were right or wrong. While the app does not tell the patient if the answer they chose the first time was right or wrong, I get to have them evaluate their own performance with me. I often ask the patient to verify the answers while helping them find the keywords on which to base their evaluation. It’s a great way to increase self-awareness and self-assessment in patients! 

 For those patients who need lower level tasks I especially enjoy this “no feedback” feature in: 

Word and picture. 

Sanapsis shows you one word and 2-4 pictures to which you match the word. Tapping a picture frames it with orange. 

 Again, Sanapsis accepts all answers that the patient gives whether correct or not. Now you, as a therapist, get to work with your patient to determine if the answer is correct! You can use this as a word-level reading task and have the patient work by themselves for a while. Then go through the tasks together after completion (yes, you can move back and forward between the completed tasks without losing data). Or, you can use this as a word-level comprehension task, where you read the word to your patient in your own voice and at your own pace, give feedback and learn from them. All without the anxiety of a buzzer going off if you touch the wrong picture and never actually knowing why it went off. 

 With Sanapsis you, as the therapist, determinate the pace and manner in which to work with your patient. As we know, some patients are faster, some need more time and repetition and this is all possible with an app that gives you the power of control.


Nana Lehtinen

So, we were at Long Beach 5-8 March. What an event, guys, what an event. We met many great colleagues (and colleagues to be) and will be busy for weeks going through leaflets and brochures from the expo! What a information and fun filled hall that was. 

In addition to learning about things we were lucky to have swarms of colleagues at our booth to check out Sanapsis. And the feedback had us blushing! Thank you so much for your "Oh, really, that is cool" "OMG, I need this" and "Yes, that is something I really like, I like that" -comments! Also an extra sweet thank you for all of you who came back a couple of times and brought friends! "Here is the cool app I wanted to show you"-moments were the best! 

We were able to attend some of the sessions too. The selection was versatile and the ones we attended were inspirational and packed with information. Luckily we had a lot of pens, pencils and sticky notes from the expo to make notes with!  

And for all of you students out there - As promised at CSHA, I will soon write a post about why Sanapsis is the perfect tool for someone with little experience with adults. 


Everyday noise, noise everywhere.

Nana Lehtinen

Are you at home reading this? Stop for a minute and listen. What do you hear? Is it quiet and peaceful? Just the TV from the other room and maybe the dishwasher doing its stuff? Or just the AC blasting? These are background noises that we tend to get accustomed to and hardly notice them after a while. It’s easy to focus on reading a newspaper, or writing down a list for the grocery shop.

 For many of our patients with TBI or stroke, things are not as simple. Background noise, however slight in our ears, may be utterly disturbing or just distracting. For many of our patients, background noise may be distracting enough to restrain them from being able to finish a task, understand long passages of speech or gather their thoughts for a shopping list for the grocery store.  

 I have come across many patients who are able to perform quite well in a quiet therapy room, but performing the same task after I turn on the radio becomes almost impossible. Having done this with a patient, I often get mixed responses, and questions about what just happened and why.

 One of my favorite tricks to demonstrate my point is this. I give the patient two short, simple stories to read in a seemingly quiet room. After reading the first story, I give them noise cancelling headphones (good ones!) and ask them to turn them on and read the next story. Oh the difference! One of my patients described this experience “as a cool drink on a hot afternoon”. One patient could not function during the daytime at her home because the noise from the street - after trying on noise cancelling headphones she has been able to read school books during the day! No more need to stay up until the traffic has slowed down!

Now, background noise is not all bad. Erik X. Raj has written an excellent piece on the good about background noise, and I could not agree more. It is definitely something we should be working on with these patients when they are able to handle it.

To help patients understand the quality of their symptoms and find help my choice of weapon is Bose Quiet Comfort 15 headphones. Yes, they are expensive. But boy, are they good…

I use mine when working on an airplane and in a coffee shop, or just at home with all my appliances blaring. For me, it’s nice. For my patients, it can make a crucial difference in being able to fill in a form on their own and understand what they are reading or not being able to function without help.

Interaction between you and your patient

Nana Lehtinen

Interest. Support. Presence. Experience. Reward. Professionalism. Contact. Kindness. All the tools and things and gadgets we have in our therapy room can never override interaction between a patient and a therapist. It might surprise you, but this is exactly why we developed Sanapsis.

Sanapsis is designed especially to promote interaction between you and your patient. The app is filled with ideas about what to do with your patient and the it has means for you to execute them in therapy (picture and text material). The key is that while using Sanapsis it is YOU who is working with your patient - not the app! In other words, the app does not guide your patient, give feedback and move forward in it’s pace. It lets you do the guidance, adjust and use the app for your needs. It even lets your patient make mistakes! 

While using Sanapsis in therapy you get to have all the time and space you need for talking with your patient about the task at hand, making observations, going through the completed tasks, correcting and learning about mistakes.  All the good stuff we get when using more traditional tools like picture cards or paper and pen. And yes, it’s an app. It’s all there, at your fingertips when you launch the app.

Photos in Therapy

Nana Lehtinen

So, I’m sitting in a cafe, having a latte and leafing through an issue of Wired. Getting to page 036 made the people around me give me funny looks. Thats how hard I was nodding and making little noises of agreement. Clive Thompson just nailed the thing about stock photos that has irritated me all these years using picture cards in therapy!


According to Clive, most of the stock photos represent a cliche, the imaginary is hackneyed and in fact these photos do not represent the real life as we (and our patients) know and experience it. This is one of the reasons we do not use any stock photos in Sanapsis and always encourage our patients to take pictures from their everyday environment and use those pictures in therapy.  Please read what Clive had to say in a broader context and let us know what you think. Have a great day!