Episode 132: Group Treatment with Dr. Liz Hoover

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 Liz Hoover about group treatment for aphasia.

 

Guest info

Dr. Liz Hoover is a clinical professor of speech language and hearing sciences and the clinical director of the Aphasia Resource Center at Boston University. She holds board certification from the Academy of Neurologic Communication Disorders and Sciences, or ANCDS, and is an ASHA fellow. She was selected as a 2024 Tavistock Trust for Aphasia Distinguished Scholar, USA and Canada. Liz was a founding member of Aphasia Access and served on the board for several years. She has 30 years of experience working with people with aphasia and other communication disorders across the continuum of care. She's contributed to numerous presentations and publications, and most of her work focuses on the effectiveness of group treatment for individuals with aphasia.

 

Listener Take-aways

In today’s episode you will:

• Describe the evidence supporting aphasia conversation groups as an effective interventions for linguistic and psychosocial outcomes.
• Differentiate the potential benefits of dyads versus larger groups in relation to client goals.
• Identify how aphasia severity and group composition can influence treatment outcomes.

 

Edited 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. Elizabeth Hoover, who was selected as a 2024 Tavistock Trust for Aphasia Distinguished Scholar, USA and Canada.

 

Liz Hoover is a clinical professor of speech language and hearing sciences and the clinical director of the Aphasia Resource Center at Boston University. She holds board certification from the Academy of Neurologic Communication Disorders and Sciences, or ANCDS, and is an ASHA fellow. Liz was a founding member of Aphasia Access and served on the board for several years. She has 30 years of experience working with people with aphasia and other communication disorders across the continuum of care. She's contributed to numerous presentations and publications, and most of her work focuses on the effectiveness of group treatment for individuals with aphasia. Liz, welcome back to the podcast.

 

So in 2017 you spoke with Ellen Bernstein Ellis about intensive comprehensive aphasia programs or ICAPs and inter professional practice at the Aphasia Resource Center at BU and treatment for verb production using VNest, among other topics. So this time, I thought we could focus on some of your recent research with Gayle DeDe and others on conversation group treatment.

 

Liz Hoover

Sounds good.

 

Lyssa Rome

All right, so my first question is how you became interested in studying group treatment?

 

Liz Hoover

Yeah, I actually have Dr. Jan Avent to thank for my interest in groups. She was my aphasia professor when I was a graduate student doing my masters at Cal State East Bay. As you know, Cal State East Bay is home to the Aphasia Treatment Program. When I was there, it preceded ATP. But I was involved in her cooperative group treatment study, and as a graduate student, I was allowed to facilitate some of her groups in this study, and I was involved in the moderate-to-severe group. She was also incredibly generous at sharing that very early body of work for socially oriented group treatments and exposing us to the work of John Lyons and Audrey Holland. Jan also invited us to go to a conference on group treatment that was run by the Life Link group. It's out of Texas Woman's University, Delaina Walker-Batson and Jean Ford. And it just was a life changing and pivotal experience for me in recognizing how group treatment could not be just an adjunct to individual goals, but actually be the type of treatment that is beneficial for folks with aphasia. So it's been a love my entire career.

 

Lyssa Rome

And now I know you've been studying group treatment in this randomized control trial. This was a collaborative research project, so I'm hoping you can tell us a little bit more about that project. What were your research questions? Tell us a little bit more.

 

Liz Hoover

Yeah, so thank you. I'll just start by acknowledging that the work is funded by two NIDCD grants, and to acknowledge their generosity, and then also acknowledge Dr. Gayle DeDe, who is currently at Temple University. She is a co- main PI in this work, and of course it wouldn't have happened without her. So you know, Gayle and I have known each other for many, many years. She's a former student, doctoral student at Boston University, and by way of background, she and I were interested in working together and interested in trying to build on some evidence for group treatment. I think we drank the Kool Aid early on, as you might say.

 

And you know, just looking at the literature, there have been two trials on the evidence for this kind of work. And so those of us who are involved in groups, know that it's helpful for people with aphasia, our clients tell us how much they enjoy it, and they vote with their feet, right? In that they come back for more treatments. And aphasia centers have grown dramatically in the last couple of decades in the United States.

 

So clearly we know they work, but what we don't know is why they work. What are those essential ingredients, and how is that driving the change that we think we see? And from a personal perspective, that's important for me to understand and for us to have explained in the literature, because until we can justify it in the scientific terms, I worry it will forever be a private-pay adjunct that is only accessible to people who can pay for it, or who are lucky enough to be close enough to a center that can get them access—virtual groups aside, and the advent of that—but it's important that I think this intervention is validated to the scientific community in our field.

 

So we designed this trial. It's a randomized control trial to help build the research evidence for conversation, group treatment, and to also look at the critical components. This was inspired by a paper actually from Nina Simmons Mackie in 2014 and Linda Worrell. They looked at group treatment and showed that there were at least eight first-tier elements that changed the variability or on which we might modify group conversation treatment. And so, you know, if we're all doing things differently, how can we predict the change, and how can we expect outcomes?

 

Lyssa Rome

So I was hoping you could describe this randomized, controlled trial. You know, it was collaborative,

and I'm curious about what you and your collaborators had as your research questions.

 

Liz Hoover

So our primary aims of the study were to understand if communication or conversation treatment is associated with changes in measures of communicative ability and psychosocial measures. So that's a general effectiveness question. And then to look in more deeply to see if the group size or the group composition or even the individual profile of the client with aphasia influences the expected outcome.

 

Because if you think about group treatment, the size of the group is not an insignificant issue, right? So a small group environment of two people has much more… it still gives you some peer support from the other individual with aphasia, but you have many opportunities for conversational turns and linguistic and communication practice and to drive the saliency of the conversation in a direction that's meaningful and useful and informative.

 

Whereas in a large group environment of say, six to eight people with aphasia and two clinicians, you might see much more influence in the needed social support and vicarious learning and shared lived experience and so forth, and still have some opportunity for communication and linguistic practice. So there's conflicting hypotheses there about which group environment might be better for one individual over another.

 

And then there's the question of, well, who's in that group with you? Does that matter? Some of the literature says that if you have somebody with a different profile of aphasia, it can set up a therapeutic benefit of the helper experience, where you can gain purpose by enabling and supporting and being a facilitator of somebody else with aphasia.

 

But if you're in a group environment where your peers have similar conversation goals as you, maybe your practice turns, and your ability to learn vicariously from their conversation turns is greater. So again, two conflicting theories here about what might be best. So we decided to try and manipulate these group environments and measure outcomes on several different communication measures. We selected measures that were linguistic, functional, and psychosocial.

 

We collected data over four years. The first two years, we enrolled people with all different kinds of profiles of aphasia. The only inclusion criteria from a communication perspective, as you needed some ability to comprehend at a sentence level, so that you could process what was being said by the other people in the group. And in year one, the treatment was at Boston University and Temple University, which is where Gayle's aphasia center is housed. In year two, we added a community site at the Adler Aphasia Center and Maywood, New Jersey, so we had three sites going.

 

The treatment conditions were dyad, large group, and then a no treatment group. So this group was tested at the same time, didn't get any other intervention, and then we gave them group treatment once the testing cycle was over. So we call that a historical control or a delayed-treatment control group. And then in years three and four, we aim to enroll people who had homogeneous profiles.

 

So the first through the third cycle was people with moderate to severe profiles. And then in the final, fourth cycle, it was people with mild profiles with aphasia. This allowed us to collect enough data in enough size to be able to look at overall effectiveness and then effects of heterogeneity or homogeneity in the group, and the influence of the profile of aphasia, as well as the group size.

 

And across the four years, we aim to enroll 216 participants, and 193 completed the study. So it's the largest of its kind for this particular kind of group treatment that we know of anyway. So this data set has allowed us to look at overall efficacy of conversation group treatment, and then also take a look at a couple of those critical ingredients. Does the size of the group make a difference? And does the composition of your group make a difference?

 

Lyssa Rome

And what did you find?

 

Liz Hoover

Well, we're not quite done with all of our analysis yet, but we found overall that there's a significant treatment effect for just the treatment conditions, not the control group. So whether you were in the dyad or whether you were in a large treatment group, you got better on some of the outcome measures we selected. And the control group not only didn't but on a couple of those measures, their performance actually declined. And so showing significantly that there's a treatment effect. Did you have a question?

 

Lyssa Rome

Yeah, I wanted to interrupt and ask, what were the outcome measures? What outcome measures were you looking at?

 

Liz Hoover

Yeah. So we had about 14 measures in total that aligned with the core outcome set that was established by the ROMA group. So we had as our linguistic measure the Comprehensive Aphasia Test. We had a primary outcome measure, which was a patient reported measure of functional communication, which is the ACOM by Will Hula and colleagues, the Aphasia Communication Outcome measure, we had Audrey Holland and colleagues’ objective functional measure, the CADL, and then a series of other psychosocial and patient reported outcome measures, so the wall question from the ALA, the Moss Social Scale, the Communication Confidence Rating Scale in Aphasia by Leora Cherney and Edie Babbitt.

 

Lyssa Rome

Thank you. When I interrupted you to ask about outcome measures. You were telling us about some of the findings so far.

 

Liz Hoover

Yeah, so our primary outcome measures showed significant changes in language for both the treatment conditions and a slightly larger effect for the large group. And then we saw, at a more micro level, the results pointing to a complex interaction, actually, between the group size and the treatment outcome. So we saw changes on more linguistic measures. like the repetition sub scores of the CAT and verb naming from another naming subtest for the dyad group, whereas bigger, more robust changes on the ACOM the CADL and the discourse measure from the CAT for the large group.

 

And then diving in a little bit more deeply for the composition, these data are actually quite interesting. The papers are in review and preparation at the moment, but it looks like we are seeing significant changes for the moderate-to-severe group on objective functional measures and patient reported functional measures of communication, which is so exciting to see for this particular cohort, whose naming scores were zero, in some cases, on entrance, and we're seeing for the mild group, some changes on auditory comprehension, naming, not surprisingly, and also the ACOM and the CADL. So they're showing the same changes, just with different effect sizes or slightly different ranges. And once again, no change in the control group, and in some cases, on some measures, we're seeing a decline in performance over time.

 

So it's validating that the intervention is helpful in general. What we found with the homogeneous groups is that in a homogeneous large group environment, those groups seem to do a little better. There's a significant effect over time between the homogeneous and the heterogeneous groups. So thinking about why that might have taken place, we wonder if the shared lived experience of your profile of aphasia, your focus on similar kinds of communication, or linguistic targets within the conversation environment might be helping to offset the limited number of practice trials you get in that larger group environment.

 

So that's an interesting finding to see these differences in who's in the group with you. Because I think clinically, we tend to assign groups, or sort of schedule groups according to what's convenient for the client, what might be pragmatic for the setting, without really wondering why one group could be important or one group might be preferential. If we think about it, there are conflicting hypotheses as to why a group of your like aphasia severity might have a different outcome, right? That idea that you can help people who have a different profile than you, that you're sharing different kinds of models of communication, versus that perhaps more intense practice effect when you share more specific goals and targets and lived experiences. So it's interesting to think about the group environment from that perspective, I think,

 

Lyssa Rome

And to have also some evidence that clinicians and people at aphasia centers can look to help make decisions about group compositions, I think is incredibly helpful.

 

Earlier, you mentioned that one of the goals of this research project has been to identify the active ingredients of group therapy. And I know that you've been part of a working group for the Rehabilitation Treatment Specification System, or RTSS. Applying that, how have you tried to identify the active ingredients and what? What do you think it is about these treatments that actually drives change?

 

Liz Hoover

I'll first of all say, this is a work in process. You know, I don't think we've got all of the answers. We're just starting to think about it with the idea, again, that if we clinically decide to make some changes to our group, we're at least doing it with some information behind us, and it's a thoughtful and intentional change, as opposed to a gut reaction or a happenstance change. So Gayle and I have worked on developing this image, or this model. It's in a couple of our papers. We can share the resources for that. But it's about trying to think of the flow of communication, group treatment, and what aspects of the treatment might be influential in the outcomes we see downstream.

 

I think for group treatment, you can't separate entirely many of the ingredients. Group treatment is multifaceted, it's interconnected, and it's not possible—I would heavily debate that with anybody—I don't think it's possible to sort of truly separate some of these ingredients. But when you alter the composition or the environment in which you do the treatment, I do think we are influencing the relative weight of these ingredients.

 

So we've been thinking about there being this group dynamics component, which is the supportive environment of the peers in the group with you, that social support, the insider affiliation and shared lived experience, the opportunity to observe and see the success of some of these different communication strategies, so that vicarious learning that takes place as you see somebody else

practice. But also, I think, cope in a trajectory of your treatment process.

 

And then we've got linguistic practice so that turn taking where you're actually trying to communicate verbally using supported communication where you're expanding on your utterances or trying to communicate verbally in a specific way or process particular kinds of linguistic targets. A then communication practice in terms of that multimodal effectiveness of communication.

 

And these then are linked to these three ingredients, dynamic group dynamics, linguistic practice and communication practice. They each have their own mechanism of action or a treatment theory that explains how they might affect change. So for linguistic practice, it's the amount of practice, but also how you hear it practiced or see it practiced with the other group participant. And the same thing for the various multimodal communication acts. And in thinking about a large group versus the dyad or a small group, you know you've got this conflicting hypothesis or the setup for a competing best group, or benefit in that the large group will influence more broadly in the group dynamics, or more deeply in the group dynamics, in that there's a much bigger opportunity to see the vicarious learning and experience the support and potentially experience the communication practice, given a varied number of participants.

 

But yet in the dyad, your opportunity for linguistic practice is much, much stronger. And our work has counted this the exponential number of turns you get in a dyad versus a large group. And you know, I think that's why the results we saw with the dyad on those linguistic outcomes were unique to that group environment.

 

Lyssa Rome

It points, I think, to the complexity of decision making around group structure and what's right for which client, maybe even so it sounds like some of that work is still in progress. I'm curious about sort of thinking about what you know so far based on this work, what advice would you have for clinicians who are working in aphasia centers or or helping to sort of think about the structure of group treatments? What should clinicians in those roles keep in mind?

 

Liz Hoover

Yeah, that's a great question, and I'll add the caveat that this may change. My advice for this may change in a year's time, or it might evolve as we learn more. But I think what it means is that the decisions you make should be thoughtful. We're starting to learn more about severity in aphasia and how that influences the outcomes. So I think, what is it that your client wants to get out of the group? If they're interested in more linguistic changes, then perhaps the dyad is a better place to start. If they clearly need, or are voicing the need, for more psychosocial support, then the large, you know, traditional sized and perhaps a homogeneous group is the right place to start. But they're both more effective than no treatment. And so being, there's no wrong answer. It's just understanding your client’s needs. Is there a better fit?

 

And I think that's, that's, that's my wish, that people don't see conversation as something that you do at the beginning to build a rapport, but that it's worthy of being an intervention target. It should be most people's primary goal. I think, right, when we ask, what is it you'd like? “I want to talk more. I want to have a conversation.” Audrey Holland would say it's a moral imperative to to treat the conversation and to listen to folks’ stories. So just to think carefully about what it is your client wants to achieve, and if there's an environment in which that might be easier to help them achieve that.

 

Lyssa Rome

It's interesting, as you were saying that I was thinking about what you said earlier on about sort of convincing funders about the value of group treatment, but what you're saying now makes me think that it's all your work is also valuable in convincing speech therapists that referrals to groups or dyads is valuable and and also for people with aphasia and their families that it's worth seeking out.

 

I'm curious about where in the continuum of care this started for the people who were in your trial. I mean, were these people with chronic aphasia who had had strokes years earlier? Was it a mix? And did that make a difference?

 

Liz Hoover

It was a mix. I think our earliest participant was six months post-onset. Our most chronic participant was 26 years post-onset. So a wide range. We want, obviously, from a study perspective, we needed folks to be outside of the traditional window of spontaneous recovery in stroke-induced aphasia.

 

But it was important to us to have a treatment dose that was reasonable and applicable to a United States healthcare climate, right? So twice a week for an hour is something that people would get reimbursed for. The overall dose is the minimum that's been shown to be effective in the RELEASE collaborative trial papers. And then, you know, but still, half, less than half the dose that the Elman and Bernstein Ellis study found to be effective. So there may be some wiggle room there to see if, if a larger dose is more effective.

 

But yeah, I think it's that idea of finding funding, convincing people that this is not just a reasonable treatment approach, but a good approach for many outcomes for people with chronic aphasia. I mean,

you know, one of the biggest criticisms we hear from the giants in our field is the frustration with aphasia being treated like it's a quick fix and can be done. But you know, so much of the work shows that people are only just beginning to understand their condition by the time they're discharged from traditional outpatient services. And so there's a need for ongoing treatment indefinitely, I think, as your goals change, as you age, and as your wish to participate in different things changes over a lifetime,

 

Lyssa Rome

Yeah, absolutely. And I think too, when we think about sort of the role of hope, if you know, if there is additional evidence showing that there can be change after that sort of traditional initial period, when we think that change happens the most, that can provide a lot of hope and motivation, I think, to people.

 

Liz Hoover

yeah, we're look going to be looking next at predictors of change, so looking at our study entrance scores and trying to identify which participants were the responders versus the non-responders that you know, because group effects are one thing, but it's good to see who seems to benefit the most from these individual types of environments.

 

And an early finding is that confidence, or what some people in the field, I'm learning now are referring to as actually communication self-efficacy, but that previous exposure to group potentially and that confidence in your communication is inversely correlated with benefits from treatment on other measures. So if you've got a low confidence in your ability to communicate functionally in different environments, you're predicted to be a responder to conversation treatment.

 

Lyssa Rome

Oh, that's really interesting. What else are you looking forward to working on when it comes to this data set or other projects that you have going on?

 

Liz Hoover

Yeah. So as I mentioned, there's a lot of data still for us to dig into, looking at those individual responders or which factors or variables might make an impact. There is the very next on the list, we're also going to be looking very shortly at the dialogic conversation outcomes. So, it's a conversation treatment. How has conversation changed? That's a question we need to answer. So we're looking at that currently, and might look more closely at other measures. And then I think the question of the dose is an interesting one. The question of how individual variables or the saliency of the group may impact change is another potentially interesting question. There are many different directions you can go.

 

You know, we've got 193 participants in the study, with three separate testing time points, so it's a lot of data to look at still. And I think we want to be sure we understand what we're looking at, and what those active ingredients might be, that we've got the constructs well defined before we start to recruit for another study and to expand on these findings further.

 

Lyssa Rome

When we were meeting earlier, getting ready for this talk, you mentioned to me a really valuable video resource, and I wanted to make sure we take some time to highlight that. Can you tell us a little bit about what you worked on with your colleagues at Boston University?

 

Liz Hoover

Yes, thank you. So I'll tell you a little bit. We have a video education series. Some of you may have heard about this already, but it's up on our website so bu.edu/aphasiacenter, and we'll still share that link as well. And it's a series of short, aphasia-friendly videos that are curated by our community to give advice and share lived experiences from people with aphasia and their care partners.

 

This project came about right on the heels of the COVID shutdown at our university. I am involved in our diagnostic clinic, and I was seeing folks who had been in acute care through COVID being treated with people who were wearing masks, who had incredibly shortened lengths of stay because people you know rightly, were trying to get them out of a potentially vulnerable environment. And what we were seeing is a newly diagnosed cohort of people with aphasia who were so under-informed about their condition, and Nina that has a famous quote right of the public being woefully uninformed of the aphasia condition and you don't think it can get any worse until It does.

 

And I thought, gosh, wouldn't it be wonderful to be able to point them to some short education videos that are by people who have lived their same journey or a version of their same journey. So we fundraised and collaborated with a local production company to come up with these videos. And I'll share, Lyssa, we just learned last week that this video series has been awarded the ASHA 2025 Media Outreach Award. So it's an award winning series.

 

Lyssa Rome

Yeah, that's fantastic, and it's so well deserved. They're really beautifully and professionally produced. And I think I really appreciated hearing from so many different people with aphasia about their experiences as the condition is sort of explained more. So thank you for sharing those and we'll put the links in our show notes along with links to the other articles that you've mentioned in this conversation in our show notes. So thanks.

 

Liz Hoover

Yeah, and I'll just put a big shout out to my colleague, Jerry Kaplan, who's the amazing interviewer and facilitator in many of these videos, and the production company, which is Midnight Brunch. But again, the cinematography and the lighting. They're beautifully done. I think I'm very, very happy with them.

 

Lyssa Rome

Yeah, congrats again on the award too. So to wrap up, I'm wondering if there's anything else that you want listeners to take away from this conversation or from the work that you've been doing on conversation treatments.

 

Liz Hoover

I would just say that I would encourage everybody to try group treatment. It's a wonderful option for intervention for people, and to remind everyone of Barbara Shadden and Katie Strong's work, of that embedded storytelling that can come out in conversation, and of the wonderful Audrey Holland's words, of it being a moral imperative to help people tell their story and to converse. It's yeah… You'll drink the Kool Aid if you try it. Let me just put it that way. It's a wonderful intervention that seems to be meaningful for most clients I've ever had the privilege to work with.

 

Lyssa Rome

I agree with that. And meaningful too, I think for clinicians who get to do the work.

 

Liz Hoover, thank you so much for your work and for coming to talk with us again, for making your second appearance on the podcast. It's been great talking with you.

 

Liz Hoover

Thank you. It's been fun. I appreciate it.

 

Lyssa Rome

And 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@aphasia access.org.

 

Thanks again for your ongoing support of Aphasia Access. For Aphasia Access Conversations. I'm Lyssa Rome.

 

 

 

Resources

Walker-Batson, D., Curtis, S., Smith, P., & Ford, J. (1999). An alternative model for the treatment of aphasia: The Lifelink© approach. In R. Elman (Ed.), Group treatment for neurogenic communication disorders: The expert clinician’s approach (pp. 67-75). Woburn, MA: Butterworth-Heinemann

 

Hoover, E.L., DeDe, G., Maas, E. (2021). A randomized controlled trial of the effects of group conversation treatment on monologic discourse in aphasia. Journal of Speech-Language and Hearing Research doi/10.1044/2021_JSLHR-21-00023

Hoover, E., Szabo, G., Kohen, F., Vitale, S., McCloskey, N., Maas, E., Kularni, V., & DeDe., G. (2025). The benefits of conversation group treatment for individuals with chronic aphasia: Updated evidence from a multisite randomized controlled trial on measures of language and communication. American Journal of Speech Language Pathology. DOI: 10.1044/2025_AJSLP-24-00279

 

Aphasia Resource Center at BU

 

Living with Aphasia video series

Aphasia Access Podcast Episode #15: In Conversation with Liz Hoover