The aphasia therapeutic process: implications of enunciative-discursive neurolinguistics

ABSTRACT

Enunciative-Discursive Neurolinguistics aims to investigate the relationship between language and brain considering the sociohistorical and cultural context in which the subject is immersed. In this perspective, speech and language therapy for aphasias proposes situations where aphasic patients can experience the reversibility of the discursive role inherent to the social use of language. The aim of this paper is to present linguistic strategies used by an aphasic subject (case study) during the therapeutic process in a Speech and Language Clinic of a private Brazilian university, illustrating practical examples of the Enunciative-Discursive Neurolinguistics assumptions. Therapy sessions were recorded and analyzed under an enunciative-discursive aspect and underpinned by the Literacy theory. Thus, clinical episodes were based on interactive situations related to the subject's historical context. Analysis showed that, during the dialogical interaction, the subject used not only the verbal modality to achieve an effective communication, but he also used gestures and other semiotic resources. In addition, it was observed that not only the subject's position in the interaction was important to the construction of his enunciation, but also the listener/therapist's stance (attention and responsive attitude) interferes collaboratively on subject/patient's enunciation chain. The conclusion is that the use of intersubjective activities as well as the consideration of verbal and nonverbal strategies during the interaction may expand aphasic patients' discursive linguistics possibilities since they are placed, in the interaction, as a discourse subject, therefore, able to act upon language.

Keywords: Aphasia; Speech, Language and Hearing Sciences; Therapy; Reading; Interpersonal Relations

RESUMO

Na perspectiva da Neurolinguística Enunciativo-Discursiva busca investigar as relações entre a linguagem e o cérebro a partir do contexto sócio-histórica e cultural em que o sujeito se insere. Nesta perspectiva, a terapia fonoaudiológica das afasias propõe situações em que o sujeito afásico pode experienciar a reversibilidade de papéis discursivos inerentes ao uso social da língua. O objetivo deste artigo é apresentar as estratégias utilizadas por um sujeito afásico (estudo de caso), durante o processo terapêutico em uma Clínica de Fonoaudiologia de uma universidade particular do Brasil, ilustrando exemplos de aplicação dos pressupostos da Neurolinguistica Enunciativo-Discursiva. As sessões foram gravadas e analisadas sob a vertente enunciativo-discursiva, com aporte teórico do Letramento. Assim, os episódios clínicos pautaram-se em situações interativas, relacionadas ao contexto histórico do sujeito. A análise mostrou que, durante a construção dialógica, o sujeito fez uso não apenas das modalidades verbais para alcançar o efeito discursivo esperado, como também gestos e outros recursos semióticos. Além disto, foi possível perceber que não apenas a posição do sujeito na interação é relevante na (re)construção dos seus enunciados, mas que o posicionamento (atenção e atitude responsiva) do interlocutor/terapeuta também interfere colaborativamente no encadeamento enunciativo do sujeito/paciente. O que se conclui é que as atividades intersubjetivas e a consideração das estratégias verbais e não verbais utilizadas na interação podem ampliar as possibilidades linguístico-discursiva do sujeito afásico a partir do momento em que ele é colocado, na interação, como sujeito do discurso e, portanto, capaz de realizar ações sobre a linguagem.

Descritores: Afasia; Fonoaudiologia; Terapia; Leitura; Relações Interpessoais

Introduction

Research expansion in Aphasiology contributes to the development of different approaches in treating aphasic subjects^1),(2. That is because the diversity of theoretical perspectives resulting from linguistics and cognition studies imply different clinical approaches³. Among the best-used approaches, roughly we have a more cognitive and a more social branch. Such perspectives do not exclude each other; however, they start from investigative focuses which underlie different views on language, subject and aphasia.

The behavior of the cognitive branch in the therapeutic process aims to help patients use their remaining skills in order to understand and express themselves in the best possible way in spoken as well as in written language⁴. Cognitive branches, such as connectionism, have been interested in aphasia studies from the perspective of paralleling processing. Assumptions on language processing have been changing since new studies of neuroimaging have demonstrated that there is not straight relationship between brain injury and aphasia linguistic symptom, that is, the same linguistic symptom may be present in patients presenting different injury loci. Thus, difficulties in lexical search and access may be related to more anterior, more posterior injuries, and even in cortical zones including thalamus. This points to the assumption that aphasia manifestations are not limited to the external language expression, but to joint mental operations carried out by a wide neuronal network⁵.

Apart from cognitive explanations, therapeutic practices focusing on the language social practice are mainly concerned with the recovery of conversational skills, possibly lost in aphasias⁶. Such studies consider that the verbal interaction plays leading role in building social identities and personal interrelationships, besides involving speakers' huge linguistic skill. Thus, in these studies, there is a detailed analysis on how language is structured in order to favor conversation: discursive item, turn taking, among other issues⁷. In Brazil, one of the outstanding branches in this area has been the enunciative-discursive Neurolinguistics, which considers language a constitutive activity of the subject and the world⁸, according to a vygotskian conception. In this perspective, the therapeutic follow-up views oral communication and writing as social practices, an ongoing process which introduces each subject in the social plotting of his/her community⁹. Therefore, such follow-up breaks the stigmas related to a view which disregards the subject, his/her linguistic actions and social practices^1),(8),(10) .

At the end of the 1980s, the first studies related to the discursive processes in aphasia cases began in Brazil¹⁰. Such studies are concerned with the subjects and their discursive strategies facing aphasia, not with the investigation of aphasia itself. In this field of study, Coudry's pioneering work¹⁰ stands out, criticizing the practice of psychometric assessments in the language under the domain of normative writing tradition, thus apart from the intersubjective, social exercise of the language.

Unlike that, by viewing language as subjects' constituting job in the speech language therapeutic clinic, it tries to (re)insert the currently aphasic subject into his meaningful routines to him, close to the former daily routine prior to the brain lesion. In this perspective, the therapist must be a privileged speaker who knows aphasic patients' linguistic processes, able to propose therapeutic strategies to (re) insert the patient into the language¹. This re(insertion) is carried out by means of proposed practices of oral communication, reading and writing related to the subject's social practices.

To the Enunciatve-Discursive Neurolinguistics, speech is multimodal, in such a way that non-verbal contributions providing linguistic interaction are also considered in the therapeutic process. Such contributions expand aphasic subjects' meaning possibilities and facilitate patients' (re)insertion into the managing, ideological speech position. Thus, oral communication and writing are viewed as interdependent social practices, gestures (facial and body gestures, pantomime and symbols) as components from the same speech matrix¹¹, and drawing assumes a symbolic function, representative from verbal, social and ideological content⁶.

In this perspective, working with the language under a sociohistoric approach considers the social milieu as a factor which, in spite of being exterior to the brain, participates in the cognitive functioning, interfering in the brain functioning¹², because language

(...) integrates its functioning, in the contextual, social dimension so that through it, men act upon others, in the subjective dimension so that through it, men constitute themselves as subjects, in the cognitive dimension so that through it, men act upon the world, structuring reality¹⁰.

Under this focus, authors¹³ point to the importance of considering literacy practices that the subject is inserted before the aphasia. Literacy¹⁴⁾ is defined as a set of daily practices using writing as a symbolic, technological system, in specific contexts (literacy events), corresponding to linguistic genres marked by socially-determined goals. It is assumed that the involvement in different literacy practices may put forward an individual's awareness on the linguistic processes involved in several social situations. However, it must be observed that the process of literacy is not held only through writing, but also by means of multi-semiotic language practices, entailing graphs, illustrations, images, colors, sounds, among others¹⁵.

At this point, it deems to clarify that the term literacy evolves to explain writing impact on all spheres of human activities in the current graphocentric society. That is, literacy is not only related to school activities, but it is a concept referring to the use of written language in all social settings. Thus, in relation to writing, the literacy perspective goes beyond the act of reading and writing graphic symbols, code and decode, it refers to the social use that each subject makes from reading and writing¹⁶. Working on aphasic patients' written language from the literacy perspective enables the therapist to view writing not as an individual task ¹⁷, but analyze it as a social activity, which concomitantly evidences subjects' uniqueness.

Therefore, therapeutic work with writing needs to include diverse discursive genres, which depend on different production contexts¹⁷, such as: letters, journalistic articles, crossword puzzles, appointments, shopping lists, social network messages, e-mails, among others. In Jakobson's words ¹⁸, language must be elaborated "at work", since it is through the discourse, the subject's stance as the enunciator of a given text that language can be reorganized in all its levels. Thus, the therapeutic practice, through the production of different discursive genres is utmost for individuals' (re)insertion in reading and writing activities¹³.

Regarding gestures, it is deemed to point out that they are considered a language-related, cognitive activity since acquisition phase. There are several kinds of gestures, which are different according to their speech relationship. Therefore, there are gestures configuring movements following the speech flow, and necessarily occurring along with that (gesticulation); gestures representing things or action sequences, occurring in the absence of speech (pantomime), and socially determined gestures, varying according to each culture, occurring with or without speech (symbolic). Except gestures from the sign language, an independent linguistic system, and out of this discussion, gestures feature social, cognitive and individual blueprints, co-acting with the speech, expanding and making interaction feasible. This way, for a broader analysis of the linguistic reorganization, it is deemed necessary the observation and consideration of gestures in the scope of aphasic subjects' dialogical, discursive strategies in the therapeutic process¹⁹.

Thus, keeping in mind those considerations, this article aims to analyze and discuss the linguistic strategies used by an aphasic subject during speech language therapy sessions, underpinned by the theoretical assumptions of the Enunciative-Discursive Neurolinguistics.

Case Presentation

This research is guided by the assumptions of the Enunciative-Discursive Neurolinguistics, and is configured as a longitudinal case study (1 year and 4 months) of an aphasic subject (M, 45 years old). The research study was authorized by the Ethics Board of the Universidade Tuiuti do Paraná (Tuiuti University of Paraná) under protocol number 22/2004. Permission for recording the sessions was discussed with this research subject who agreed with and allowed, by means of the Free Consent Form, the publication and scientific presentation of the data material.

The choice for the methodology is due to the language conception that the current study is grounded (constituent and integrating of the social, subjective and cognitive dimensions), as well as the possibility of the emerging relations compression (verbal and non-verbal) of the subject's epilinguistic job, which evidence the interaction process.

Data generation occurred in a context of interactive situations of conversation, reading and written production, involving therapist and aphasic patient, proposed during the video-recorded speech language therapy sessions. The period for data collection extended from March, 2008 to the end of July, 2009. Recording was held in the speech language therapy room, lasting an average of 45 minutes.

The following strategies were used during the therapeutic process: daily personal account, photo description and comments, map of Brazil, reading of traffic laws, truck bumper stickers and broadsheet reports from the State where the aphasic subject lives in. According to the adopted theoretical perspective, historic-cultural issues were considered, which portrayed subject/language relation in a steady and continuous way that a longitudinal study case enables to apprehend. Thus, the proposed therapeutic strategies were not previously established, but along the sessions, the subject's history and interest.

From the procedures mentioned above, 6 episodes are presented. Episode 1: personal account through oral and written communication; Episode 2: subject's account on the renewal of his driver's license; Episode 3: personal account on the cities that the subject had visited; Epidode 4: information text reading - Traffic laws; Episode 5: reading and discussions on truck bumper stickers; Episode 6: reading of a journalistic text. The established convention to identify the speakers in the data transcription was: Ig for the therapist and Ma for the aphasic subject. It is worth pointing out that there were not any other speakers during the recorded sessions at any moment but the ones already mentioned here.

Participant Subject

Ma is a 45-year-old man, divorced, father of two daughters (27 and 23 years old), and grandfather of two girls (6 and 3 years old). With 11 years of schooling, Ma worked as a truck driver, having already traveled to many places in Brazil.

In June of 2006, Ma was robbed at the traffic lights while he was giving a ride to a friend. According to medical records and tomographic exams, Ma was beaten in the skull, resulting in temporo-parietal traumatic brain injury in the left side as well as underlying parenchymal hemorrhage. In March of 2007, Ma was referred by his neurologist to speech language therapy follow-up, thus starting treatment at the Speech Language Therapeutic Clinic of a private university only in April 2008 (a year after the neurological event). In a speech language therapeutic assessment, impairment of oral and written language was observed, current manifestations being described in the results of this study. It should be pointed out that Ma did not feature any associated physical disabilities, being independent, living alone, carrying out household tasks and driving. He was independent in the activities of the daily living.

In the first interview, the patient reported that he could not speak soon after the accident, and later he recovered speech; however, he had great difficulty n speaking. Ma said he felt better, he could count money and drive to other states, however, the language impairment bothered him a lot. According to the report, his difficulty was noticeable to the point of being mixed up with a foreigner.

Since the beginning of the therapeutic sessions, Ma concomitantly used oral and written communication as complementary forms in the dialogical interactions. In spite of making use of the written language, at the beginning of the therapy, Ma's main complaint was related to resume reading and writing as he intended to renew his driver's license.

Besides the speech language therapeutic sessions, Ma attended the aphasic group at the same Speech Language Therapeutic Clinic. During the sessions, Ma enjoyed telling stories about his life, especially situations from the time he worked as a truck driver. As he often traveled, he reported curious situations, such as participating in birth deliveries and fires, which would catch other speakers' attention. Ma's language assessment will be discussed in the data as follows.

Results and Discussion

Episode 1 (04/09/2008)

Aiming to assess Ma's language through meaningful linguistic tasks, he was requested to describe his daily routine. For this activity, the therapist (Ig) took to the session: a map of Curitiba, cards with the letters of the alphabet and a calendar.

Figure 1:
Data 1 - Written on 04/09/08, as a way to put meaning in his discourse

[1] Ig: How was your day?

[2] Ma: ((making a gesture of 5))

[3] L3 Ig: Did you wake up at 5:00 a.m.?

[4] Ma: No (...)

[5] Ig: 7:00 a.m.? And what did you do?

[6] Ma: ((wrote down 6:30 in the paper))

[7] Ig: You woke up at 6:30, and what did you do?

[8] Ma: Er... don't know ... I knew it before ... ((cgesture of running))

[9] Ig: RU... RU.

[10] Ma: RUN ... There ... near ... every day ((takes the map of Curitiba that the therapist had brought))

[11] ((shows the Botanical Garden)).

[12] Ig: Then you live near the Botanical Garden! ... And runs in the morning ... nice, isn't it !? Then what?

[13] Ma: ((gesture of taking a shower, and uses the alphabet to spell the word shower with the therapist's help))

[14] Ig: You take a shower, and then?

[15] Ma: That ... like this ... ((draws a gourd of mate)) I knew everything, don't know ... ((tries to write mate))

[16] Ig: You took a shower and had mate ... "Gaúcho" - from Rio Grande do Sul State ...!? (...)

In these data, it is possible to observe that Ma's difficulties are not related to phonetic-phonological issues, but they are due to syntactic and semantic aspects. Difficulties in the lexical access evidencing a deficit in the paradigmatic axis also hinder the syntagmatic axis¹⁸, in this case, marked by the absence of functional words, necessary to the articulation of the semantic content. In Ma's speech, it is evidenced an interdependence between the syntactic and semantic levels, causing an effect of telegraphy and crystallization, hindering the effective construction of enunciates.

However, in spite of the featured disabilities, Ma can put himself in a discourse situation during the dialogue. It is observed in dialogue 1 that Ma participates actively in the dialogue, using several meaningful mechanisms: gestures, speech, drawing and writing. By means of this set of semiosis, Ma effectively describes his daily routine, in spite of his difficulties in the lexical access justify a "don't know" many times, like in line 8 where he states: "don't know...I knew it before" , disclosing the conflict between the changes provoked by the aphasia in the subjectivity.

Gestures, in this case pantomime gestures, are driven by the temporary absence of speech. However, just like the oral language, gestures are changed, and can be "selected" in a wrong way. The difficulties in selecting gestures evidence an interrelationship between the verbal and non-verbal semiotic systems. Thus, in line 5, Ma makes a gesture of number 5, meaning the time he had woken up, but he writes 6:30. In line 8, he makes another pantomime gesture, indicating the action of "running" correctly. The speech as well as the gesture seem to be dtheisturbed, in suspension, in the aphasic speech, however, they may present moments of normalcy. It's because the normal subject does not feature an ideal speech, and in turn, the aphasic subject is not always aphasic: there are longer difficult moments in the aphasic subject's speech, but there are also moments when speech goes through without difficulties.

It is still observed that Ma reports his activities by means of writing and drawing: "6:30 - 7:30 - 8:20." Not being understood by his listener, he resumes his report through gestures. The pronunciation of the corresponding word is effected by means of his therapist's phonological clue ("Ru ... Ru"), evidencing that Ma's difficulty lies more in the lexical search and access than in the semantic integrity, which seems to be preserved. Thus, Ma, structuring his time schedule, writes "RUN" between 7:30 - 8:20. From this structure, Ma makes use of the map of Curitiba to show the Botanical Garden, the neighborhood he walks around and lives in.

Subsequently, the therapist investigates what happens in the time sequence after running. Ma uses gestures to describe (line 13 and 14), besides relying on the letters of the alphabet and its memorized sequence (a-b) to spell the target word "banho" (shower). Thus, he stops in the second letter, "b", and spells "bunho." When he finishes it, he searches for the therapist's assertiveness, showing his spelling and making a symbolic gesture of positive. Here, enunciation and interrogative intonation are substituted by a culturally established gesture within a context of verbal production, which allows the adequate understanding of Ma's intention. This way, Ig spelled the word "banho" with the alphabet cards. Ma looked at it, crossed what he had written, and wrote the letter "a" on the letter "u".

The therapist goes on with the narrative, articulating the sequence of the patient's enunciates. She asks what Ma did after taking a shower (line 15). Ma unsuccessfully makes use of gestures. He modifies his strategy and draws a gourd (line 16) instead, still a scarce resource to establish the understanding between the subjects of the interaction. That is because the context related to this information had not yet been shared by the subjects. Finally, Ma writes "chimão" (he meant, "chimarrão", mate), adding it to the drawing and the gesture, the necessary clue so that his therapist could understand the information by associating writing processes.

Again, he pointed to the word, making the symbolic gesture of positive. Nevertheless, different from the first use, when Ma searched for his therapist's assertiveness, at this moment of the interaction, the same act is re-meant in the context, getting another meaning. Ma carries out the same strategy to make sure of the effectiveness of the understanding. This gesticulation resource, in the established dialogical construction, can be interpreted as a conversational marker, the same kind as "isn't it?", "right?", thus, working discursively as an interaction feedback. In reply, Ig reassures the understanding and writes "chimarrão", showing Ma that she understood the word he meant. The patient compares the words and re-writes it ("chimarrão"), evidencing the traits of the aphasic pattern which hinder code copying.

Thus, by means of multiple semioses: writing, drawing, gestures, speech, visual support on the map, in the letters, Ig put Ma in the condition of the narrator of his own story. In addition, under this condition, Ma writes what he cannot speak and makes use of gestures. It can be noticed in this episode, a continuum between verbal and non-verbal language. This continuum, along with the indispensable role of the therapist for the organization of the patient's turns, makes him play his role of speaker in the conversation¹³.

It is worth observing that Ma's personal account was only possible because his therapist carried out a shared work of meaning construction in Ma's speech. Therefore, she focuses on Ma's work over his speech, in spite of his deficits, to keep the narrative flow. It is possible to detect in the linguistic task the subject carries out, his traits of subjectivity, of a subject acting upon, managing, working over the language, even if he is not aware of his linguistic activities, and even if his linguistic task does not bring on the intended effect²⁰.

It is highlighted that rehabilitation in a specific language process during speech production is a complex task²¹. Therefore, the therapeutic work, in the perspective of the Enunciative-Discursive Neurolinguistics stresses not only the word analysis (its place in the enunciate, its grammatical function), but the analysis of a language damaged by the aphasia. Thus, it takes into consideration the discursive context so that underlying processes to the occurrence of phenomena can be understood.

In this sense, in the dialogical practices between Ma and Ig, the use of the language was not in decontextualized situations, but in a process of communication, taking into consideration the stories and uniqueness of the participant subjects in the clinical practice^1),(22. This way, the "linguistic idiosyncrasies", in terms of the Enunciative-Discursive Neurolinguistics, emerged from the interactions between the subject and the therapist-investigator, without pre-determination of general laws or functioning patterns. . In episode 1, references are observed to language and cognition changes and, therefore "in being in life" after having suffered aphasia. Much of what should traditionally be considered failure or absence, it was interpreted here as the "subject's presence," of a subject searching for the other in his intent to carry on the language, and carry on (life) by the language²³.

Episode 2 (09/17/08)

In the episode below, already in the therapeutic process, Ma talks to Ig about his concern of renewing his driver's license:

[1] Ma: It's hard for me to speak.

[2] Ig: To speak what? Do you want paper to write down? It's a book...

[3] Ma: Yes, it's hard to speak.

[4] Ig: What do you want to do?

[5] Ma: I was going there to see, I don't know!

[6] Ig: Take the Li... Li...

[7] Ma: ((takes his former driver's license)) I used to say, I can't say, I know everything so...so,

[8] but I can't speak. I know everything that's in here, but I can't speak.

[9] Ig: This book here, it's a traffic manual, and let's start working here, during the sessions.

In this episode, it can be noticed a subject marked by the changes occurred after his neurological episode as well as the conflict, evidenced by his discourse: between who Ma used to be ("I used to say"), and who he is ("but I can't say"). Ma's discourse reveals traces of a subject marked by the modifications that aphasia brought about, his inadequacy to a language (more) adrifted, but it also evidences potentiality, possibilities and functioning in this language ("I know everything, so...so, I know everything that's here"). The ways Ma refers to himself in relation to his "new position in the world," is configured by "the loss of himself," which emerges from the language loss-impairment²³.

The subject emerges from an incompleteness in relation to the language, the discourse and his sociohistorical trajectory. His subjectivity is built from the relations to the other and, in this sense, language is viewed not as a tool, but an inherent activity to human beings, therefore a humanizing one²⁴. From this conception, speech language therapy must act upon aphasia implications on the speaker's role in society. This implies that the therapist must re-mean his/her role, showing aphasic patients what they can produce and interpret, how they can effectively place themselves in interactions, in spite of their deficits. Re-meaning impaired subjects' role implies that therapists professionally aim to rebuild a meaningful relationship of the subject to his/her language. That is, the re-meaning of the symptoms must be built with the subjects strongly marked by the impairment blueprint, thus contributing to their autonomy and position as speaking subjects²⁵.

Episode 3 (10/22/08)

In this session, Ig takes many resources to the therapy, such as: maps, cards with the letters of the alphabet and pictures of traffic signs. Ma reports, helped by the map, the cities he has already traveled to (Irati, Laranjeiras do Sul, São Paulo, Lapa, Chapecó). These words are written because Ma could not name them from the map of Brazil, according to what is presented in Figures 2 and 3.

Figure 2:
Data 2 - Drawing related to the episode on 10/22/08

Figure 3:
Writing related to the episode on 10/22/08

In this episode, Ma narrated a moment of his life, using for that the oral language, writing, drawing, besides resources offered by the therapist. It can be observed that the drawing is better structured than the written word, showing that, in spite of drawing and writing being semiotic elements, they do not configure the same way. In this case, writing and drawing are affected in a distinctive way, being oral language more damaged than the non-verbal one.

Supported by truck drawings, Ma reports his trips, the different vehicles he used to drive, and the relation between his profession and his personal life. According to his account, when Ma began his trips, before getting married, he used to drive small trucks as well as short routes. Along the time, and getting to know the highways, he started travelling to farther places, such as: the whole Southern Brazil, from São Paulo to Amapá - reason of arguments with his wife. In order to indicate the moment of his divorce, Ma writes his wife's name and crosses it off. Thus, he metaforically marks down that his wife was present,but she was crossed off his life. The scribble in the paper stands out a trace, the indelible presence of his wife in his life history.

Here, there is effective linguistic work, which puts Ma as the speaker, the manager of his discourse, away from the mechanic use of the code, he expresses himself in a creative way, exploring the possibilities of a language at work. Ma uses writing as a communicative resource. However, these written resources do not mean anything if individually analyzed. That is, apart from the interaction they were produced, they would feature a bunch of papers, only viewed as fragments of Ma's writing, without constituting a semantic unit. It is in the verbal context that speakers understand each other and interpret their enunciates¹⁷. Thus, Ma's writing loses its fragmented trait as soon as it is revealed in the oral communicative context. That is to say, subject Ma's written data unveil a meaning when analyzed in the context of discursive production.

To the city of Laranjeiras do Sul, Ma writes "Lan" and says the end of the word, giving up writing it in full. In spite of not completing the words, the clues Ma puts in writing are valued by the therapist, that is, she considers what the subject produces, instead of focusing this attention on what he does not.

Thus, by (re)building his writing, as well as drawing, Ma also rebuilds his oral language, re-meaning the written form: a way out of the difficulties faced in the oral communication, a vector that guides the reconstitution of oral communication and subjectivity^1),(25. Therefore, writing analysis is grounded in the use of the language, in what Ma can do in spite of his disabilities, in the different contexts of production. The speech language therapeutic process interpreted this way aims to focus on the potentialities of aphasic subjects, considering their uniqueness and helping them expand their communicative possibilities as language is not static and the brain is not plastic^6),(12),(13.

Episode 4 (05/13/09)

In the episode below, Ma, concerned with the renewal of his driver's license, reads traffic signs, car manuals, maps and other texts favoring his approval in Detran (Traffic department) exam with his therapist. Ma points to the signs, writes words and speaks, showing his possibilities to use verbal as well as non-verbal resources to discuss the theme. On this day, Ma also states his intention to trade in his car, and then Ig suggests that they read a text about a car. This theme is important to Ma, which makes the proposed therapeutic activity meaningful to him. Thus, during the discussion about the text, Ma finds it difficult to name the car brand orally, that is why he turns to writing and the symbol (the brand logotype), ractifying the use of writing to help his oral production.

Figure 4:
Traffic signs used during therapy on 05/13/08

Figure 5:
Ma's writings related to the traffic signs during therapy on 05/13/08

[1] Ig: First, let's read this text about a car, you're used to.

[2] Ig: Let me find it here.

[3] Ma: Here ... er... hard to speak ... it's, it's, it's, it's ... this one ... it's hard to speak. Here you can't, here you can't go.

[4]. I go everywhere, but I can't speak. I know everything! ((pointing to the traffic signs))

[5] Ig: Then let's do like this, I'll read for you, OK?!?

[6] Ma: This one er...er...er...

[7] Ig: What is it?

[8] Ma: I can't speak ... I know...

[9] Ig: What does a car need? Look at this one.

[10] Ma: mo ....

[11] Ig: Tor e ener ...

((takes the paper and writes motor))

[12] Ig: Exactly.

[13] Ma: Like this, I know, See... I know everything... but it's hard to speak.

[14] Ig: I got it, you're telling me that when you see it, it's easier, speaking is something else.

[15] Hard. Then let's try to do like this ... Let's talk about what is

[16] written.

((takes the text and reads through))

[17] Ma: car ... this ... like this oh ((writes the brand and model of his car))

[18] Ig: Your car is a Gol, mine is too! And let's spell here what it needs

[19] to move, according to the text.

((Ig and Ma uses the letters of the alphabet to spell the words, and then he copies them))

Figure 6:
Text used as support for the therapy on 05/13/09

After reading the text (Figure 6), Ig asks Ma what is necessary for a car to work well. It is not possible to state that Ma has understood the whole text, but it is not also possible to state that his difficulties with the text are mainly the result of the aphasia or general difficulties of the text. It has to be considered that literacy events determine the social practices and uses of the written reading. This means that the familiarity with the genre interferes in the quality of its use.

The notion of discursive genre has become more and more fruitiful in the analyses of aphasiological phenomena, once depending on the kind of aphasia and its severity, more complex genres greatly impact. There are subjects who practically reduce their verbal productions to genres considered by Bakhtin as primary (less complex), among them we find the daily conversation⁶.

Bakhtin claims that lexical composition and grammatical structure of the mother tongue is not learned in dictionaries and grammars, but by means of concrete enunciates that we hear and reproduce at the moment of active verbal communication with the individuals around us. Discourse genres are concomitantly inserted in our experience and in our conscience. He postulates that "learning to speak is learning to structure enunciates"²⁴, as we speak by means of enunciates, not by words or isolated sentences. Our speech is organized by the discursive genres as well as by the language modes (grammatical - semantic/lexical and syntactic)⁶.

Thus, we must understand that Ma's reading difficulties are also related to the discursive genre. Discourse genres entail a short reply in a daily conversation, a family account, a letter, up to varied ways of scientific exposition and literary modes. Primary discourse genres encompass daily verbal communication, secondary discourse genres emerge in those circumnstances of more complex cultural communication, mainly written ones¹⁴.

Therefore, discourse genres are produced according to the different spheres of human activities. This means that subjects take different positions facing the genre to be used²⁴. However, in aphasia cases, although secondary genres are generally harder than primary ones, there are cases, like Ma's, that such difficulties emerge in varied genres. Informative articles, maps, news, proverbs, for example, are difficult for Ma to understand, his reading is preserved for isolated and more frequent words, as revealed in the episodes that follow.

Episode 5 (08/19/09)

Figure 7:
Proverbs used in therapy on 08/19/09, and Ma's written explanation

[1] Ig: Let's try and read this sentence? Try to understand...

[2] Ma: ((looks at the sentence and reads it silently)) And... and... I... if... And ... I look... I know...

[3] ma... ma ... num...Here, I look and think ((gets emotional)).

[4] Ig : So, let's go!

[5] Ma: Be... Because, look, it's hard to speak. I ... I ...num...

((gestures with his hand to go ahead))

[6] Ig: Let's see it here ... VI...

[7] Ma: Vi...DA ("LIFE")

[8] Ig : Now, let's try another! A...Pe...NAS ("ONLY")

[9] Ma: ((repeats together)) NAS

[10] Ig: APE... APE ... NAS

[11] Ma: APENAS ... Apenas uma de ("Only one of") ... What is it?

[12] Ig : DA ...

[13] Ma: What?

[14] Ig : Look at me DA .. DA ... Oh! D and A .. DA ... now the first letter of your

[15] name? What is it?

[16] Ma: Mateus!

[17] Ig: Then, look! Apenas uma DA ...?

[18] Ma: Dama (Queen)! Mã... mã... and what is this one? How do you spell this one?

[19] Ig : N and O .. look .. NO... ((Ma looks at the therapist and keeps quiet)) NO... then

[20] come on? No..

[21] Ma: BA... RA... LHO ("DECK OF CARDS")

[22] Ig : BARALHO

[23] Ma: Dão... no ...

[24] Ig : Vi... iii

[25] Ma: VIDA ... EN... CON... TREI ("I FOUND")

[26] Ig: Encontre::i....

[27] Ma: A mulher ... ("The woman")

[28] Ig : Apenas...

[29] Ma: ((Repeats altoghether)) Apenas uma da ... gama...

[30] Ig : Da...

[31] Ma: Dama ... Yeah .. this one, or like this ((Makes the symbol Q and K from the deck of

[32] cards))

[33] Ig : That's it, from the deck of cards ...

[34] Ma: Yeah, I said .. like this, look!?

(...)

During the session, first, there was the text reading (Figure 7) due to Ma's difficulty in communicating the words when he cannot recognize them. As he reports in other passages, when he knows the word, reading aloud is carried on more fluently. In the interaction, between lines 1 and 5, Ma refers to his own difficulty in reading the sentence in a loud voice. In order to read in a loud voice, it is necessary not only communicate, but also to carry on some work with the sound production of the speech keeping in mind the listener's consideration²⁶.

Ma and Ig started a joint reading: the therapist would read some words and Ma would complete and continued the sentence construction. In the end, a second reading was held. It is possible to observe in this episode that, in some moments, the implied meaning in the sentences was understood with the therapist (lines 21 and 26). Thus, it can be perceived that the interpretation of the written enunciate demands the understanding of the relations among the syntagmas, which are only possible from the dialogical relation between the therapist and the patient. That is, the other is a co-constructor of the aphasic language. In this sense, current research studies^12),(27),(28 legitimate Vygotsky and Luria's concepts to underpin aphasia therapy. Therefore, concepts such as mediation, social practice, internalization and the role of language as the main symbolic function and organizer of the other cognitive processes, ground clinical practice.

Episode 6 (09/02/09)

Ma arrives for the speech language therapy session with a newspaper distributed at the University. He points to it and Ig asks him if he wants to read it. The subject points to a word. The therapist reads it, analyzes the report and both (Ig and Ma) read it together, as reported in the episode below.

Figure 8:
Text used during the therapy on 09/02/09, and Ma's writing of the most significant words in his opinion.

[1] Ma: What is this here? ((points to the word))

[2] Ig: Young!

[3] Ma: Young ... And this one? There are a lot I know everything ...this, this one here ... I didn't

[4] know anything, did I? I look, but it's hard to speak!

[5] Ig: Now, this report we've already read, and these words you've already known,

[6] you're going to try to write down here! Only the ones you've underlined ...

[7] Ma: Can be...

[8] Ig: Let's try to read!? Do you want to read?

[9] Ma: You first!

[10] Ig: Número ... ("Number")

[11] Ma: What?

[12] Ig: Número ...

[13] Ma: O número ... ("The number")

[14] Ig: Crescente ("Increasing")

[15] Ma: Crescente de ... Bo .. bordage ... ("Increasing approaching")

[16] Ig: Erros ("Mistakes")

[17] Ma: Erros em bo ... ...

[18] Ig: Abordagens ... ("Approaches")

[19] Ma: Bordagem policial ("Police approach")

[20] Ig: Policial ("Police")

[21] Ma: Esse aqui? ("This one"?)

[22] Ig: A ... afeta ... ((tries to repeat, but he can't) Afeta ... ("Affects")

[23] Ma: AFETA faze... fa... família (affects Family)

[24] Ig: E gera i.. ("And generates i...")

[25] Ma: Insegurança na pó ... pó ... ("Insecurity in the po...")

[26] Ig: População ("Population")

[27] Ma: População ban ... BA... BA...

[28] Ig: brasileira ("Brazilian")

[29] Ma: brasileira

[30] Ig: especialista ... cara ... ("specialist...chara...")

[31] Ma: caracterizando o a... What?

[32] Ig: aumento nas .... ("increase in the...")

[33] Ma: abordagens ("approaches")

[34] Ig: e.... e..... ("and...and...")

[35] Ma: equivocadas ("wrong")

[36] Ig: e sugere a ... ("and suggests")

[37] Ma: necessidade ("need")((silence))

[38] Ig: tra .... ((asks him to look at her mouth))

[39] Ma: tratamento pesicológico ... ("psychological treatment")

[40] Ig: psicológico ("psychological)

[41] Ma: this word is hard ...

[42] Ig: ((laughters))

[43] Ma: para os militares ("for the military")

[44] Ig: policiais militares ("military police officers")

[45] Ma: How do you say that?

[46] Ig: in ... ves ... investigador ("investigator")

[47] Ma: invés .... ("instead")

[48] Ig: Oh! ((speaks slowly)) investigadores

[49] Ma: investigadores ... polícia militar ("investigators...military police")

[50] Ig: investigadores civis. ("civil investigators")

(...)

First, Ig read the report headline, and Ma underlined the words he knew (Figure 8). This first reading enabled Ma to get familiarized with the text content and the words, thus facilitating reading it aloud. This dynamics was used because he reported in several sessions that when he read silently before, understanding was facilitated.

Subsequently, a discussion was held on the report as well as reading it aloud. At the beginning of the reading, Ma asked for the therapist's help, and also reported that, in the text, there were several known words for him. Thus, Ma presented more autonomy in reading, completing the words from what was being read.

Writing shown in Figure 8 is related to the words that Ma read in the report and identified as "known words." After that, Ig asked him to copy and read those words. The task accomplishment evidences a visual memory, the internalization of the word that is being preserved, allowing Ma to do a more proficient reading. There are assumptions on writing and reading that aphasic individuals are able to elaborate when they carry on their production and text comprehension. It is because the aphasic are not and cannot be treated as if they do not know the language.

At this point, it is worth commenting that it is possible to perceive a change in Ma's position on his usage of the language. In episode 6, there is a decrease in the use of gestures, production of longer enunciates, the emergence of questions in oral verbal forms "What?", more adequate reading and writing. Ma expands his oral productions, starts questioning, making inferences, organizing his personal accounts.

Therapy based on an enunciated-discursive approach values subjects' unique data, which permits to view the process on how the subject manages with a language, how he/she works on his/her resources to produce language, a heterogeneous and multifaceted activity^1),(11),(29. That is to say, the way the subject copes with his/her disabilities is unique. Therefore, we can find subjects with a lesion and different linguistic traits, thus promoting changes in all language levels of aphasic people.

Enunciated-discursive approach goes beyond the focus on the brain injury and the metalinguistic analysis to show the relevance of aphasic subjects, in therapeutic process, to be considered complete in relation to the language. Thus, stressing the relation between subject and language in use, the speech language therapist, grounded in an enunciated-discursive perspective, is able to perceive that aphasic people have conditions to acknowledge their impairment, their suffering as well as the consequence of linguistic changes in their lives. Under this perspective, the speech language therapist may prioritize therapy focused on the subject with aphasia, not only on the aphasia or brain injury that this subject presents, acknowledging as essential the interactive job that preserves the aphasic status as the enunciator of a given text.

Final Considerations

This text comprised an analysis of the strategies used in the therapy of an aphasic subject under the branch of the enunciated-discursive Neurolinguistics. It can be said that therapeutic strategies are underpinned by the social practices of the language, the dialogism, the context of senses production, the therapist's co-authorship in oral and written texts, the re-meaning of the speaker's role and the interdependent relationships between verbal and non-verbal semioses.

Therefore, when social practices of reading and writing are considered in the speech language therapeutic process, aphasic subjects may broaden their possibilities of using symbolic resources to put themselves as the authors of their own discourse. Ma's use of writing is related to his social need - to renew his driver's license - and also serves as an expressive resource within dialogical interactive situations.

In interactive situations, the subject acquired conditions to operate over the language, performing questions, inferences, personal accounts. Thus, he started to occupy his place in the discourse in a more significant way, standing as the subject. It can still be observed that his writing was a relevant strategy for the process of significance in his texts, configuring as one more therapeutic resource of language production and interpretation.

Finally, it is worth pointing out that the theoretical-methodological background of the Enunciated-Discoursive Neurolinguistics, supported by the literacy concept, are essential to guide aphasic subjects therapeutics. Like everybody who interacts through the language, aphasic subjects are able to perform creatively in order to construct their enunciates. This exercise, harder to aphasic subjects, reveals the results in the use of the language which aphasic and non-aphasic individuals are subjected to. The truth is that when a linguistic difficulty is presented by an aphasic subject, the social value attributed by the listener is negative, different from what occurs to a non-aphasic subject, because the use of a proper word in a context is considered a right in aphasia, while the "deviation" is considered a symptom.

In this sense, therapy with an enunciated-discursive neurolinguistics approach helps the therapist recognize and value what continues working - despite the aphasia - and invest in aphasic subjects' linguistic-discursive potentialities, who may re-mean their role as speakers and posit discursively in the social practices, managing their communication.

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Publication Dates

• Publication in this collection
  Jan-Feb 2016

History

• Received
  01 Oct 2014
• Accepted
  03 Nov 2015