By Alberto Osa García
Thomas M. Philips is a stroke survivor with a language impairment called aphasia. He experienced difficulties expressing and understanding verbal speech after the stroke. During his recovery, he claimed that aphasia became “a contagious disease” around him: since he first tried speaking with those around him, everyone gradually stopped talking to him, regardless of how hard he tried to communicate (1).
Aphasia is one of the most devastating consequences of stroke, affecting comprehension and production of language (2). Although other types of neurological conditions can cause aphasia (e.g., tumours), stroke remains the leading cause (3). An estimated two thirds of people with an initial aphasia continue to have some degree of impairment one year after stroke (4). Even simple daily life interactions, such as calling a friend or asking for help in a shop, can become burdensome.
Therapists usually encourage people with aphasia to join community activities so they can improve their speech in a safe space (5). Since there is greater risk for depression in this population, community involvement can also prevent feelings of isolation (6). However, engaging in social activities can be challenging for individuals who have had a stroke, as they may perceive that they cannot keep up with others and become less motivated to engage socially. Could a creative outlet, one which encourages people with aphasia to step outside of their social comfort zone, lead to a more supportive therapeutic environment and better outcomes?
The origins of Le Théâtre Aphasique
This type of creative outlet is what Anne-Marie Théroux had in mind when she founded Le Théâtre Aphasique, a drama group for people with aphasia. In 1992, she worked as a speech pathologist at a rehabilitation hospital in Montreal. With her background in theatre, Théroux wanted to offer drama lessons at the hospital to accomplish group communication therapy more creatively and engagingly. What began as a weekly, one-hour drama workshop became a serious enterprise when Le Théâtre performed at the Second Congress for People with Aphasia, held in Quebec in the following year.
After Théroux left the organization in 1996, Isabelle Côté, the regular assistant in the Troupe’s performances, took over administration of Le Théâtre. “When we continued Anne-Marie’s work, there were no more than 20 participants in the workshop. Now there are at least 160 participants and we host workshops in towns all around Quebec. Some groups completely fill up every session!”
Any person with a language disorder (including articulatory impairments or dementia) is welcome. Le Théâtre is led by theatre trainers who work alongside speech therapists and volunteers. Moreover, participants only pay a symbolic fee since most of the project is funded through grants from the province of Quebec and the city of Montreal.
How does a drama workshop work for people with aphasia?
The workshops are divided into two categories: general courses on theatrical skills, and the Troupe. In the general workshops, participants learn improvisation techniques through memory, gesture, and attention games, or through dramatic readings recorded on video. In the Troupe, participants prepare real plays, often in the form of scenes or sketches, and participate in the show production.
Being the first official organization in the world using drama as a means of rehabilitation and social reintegration for people with aphasia, Le Théâtre has received special attention wherever they showcase their work.
“The best is traveling with a troupe of aphasic actors,” says Côté, smiling. “They really feel they are doing something with an impact. Moreover, they have the chance to discover new places, people, and travel outside their home city. It is the moment when they realize they can live life just like anyone else.”
So far, Le Théâtre has been to France, Belgium, Portugal, and the United States to perform at congresses and international meetings on rehabilitation. The performance is like the final step of a long journey: like any actor, participants must have attended rehearsals, learned their lines by heart (or with the help of a lectern on stage), and recognized their cues.
“We still want to spread the word that this activity is open for any person with aphasia, no matter how severe their condition,” says Côté. “Therapists come to our performances and often say, ‘Oh, my client cannot do that, it is too difficult.’ However, there is much more than what you see in a show. Even people with mutism participate very actively in the workshops once they feel included.”
Pénélope is one of the Troupe’s most recent members. She had two strokes in 2012 and 2014 and learned about Le Théâtre in 2017 from her therapist.
“In the beginning it was a little strange. Most of the people in the workshops are much older than me, so I was not sure if this would help me. But I came back, and something clicked for me.” – Pénélope
Pénélope now participates in workshops held in schools to raise awareness of communication disorders and has travelled with the Troupe to other cities. “When you are in the rehearsals, it feels good because nobody will judge you, no uncomfortable questions… A new space for us appears when we play.”
Entertaining and engaging, but effective?
Although there is a lack of scientific research addressing the efficacy of theatre in rehabilitation, Côté highlights the benefits she has witnessed. “Many of our participants do not improve their linguistic skills, but they feel taken care of in an occupational way.”
Pénélope explains that she now better handles communicative situations, such as deciding when to start talking or how to maintain her conversational rhythm. “There are these rules in language that you lose when aphasia appears.” However, in Le Théâtre, there are new rules about how to interact in every exercise, so everyone is at the same level when on the stage.
Long-term rehabilitation remains one of the greatest challenges in aphasia research. The diverse profiles of aphasia and other stroke comorbidities make it difficult to carry out balanced and controlled clinical trials. Other types of research studies have shown that people with aphasia, after participating in drama workshops, have improved mood and confidence scores during communication (7,8). Similar activities, such as public speaking workshops, have also shown improvements in quality of communication life (9).
Therefore, the question is whether these effects result from participating in a social activity or in a creative activity. The literature has numerous examples of the use of art in stroke rehabilitation (10-13), with music engagement (listening and performing) being one of the most effective therapies used in the aphasic population (14,15). As a natural link between musical performance and social activity, choral singing has also been studied and recommended as a helpful activity for people with aphasia (16,17). So, are choral singing and theatre much different from each other? A recent study found that drama workshops, as given by Le Théâtre, were as effective as choir workshops for improving functional communication (18). Given this evidence, is there anything that makes theatre special?
Drama therapy has shown to be useful for enhancing social and cognitive skills, for example, in adolescents with Autism Spectrum Disorder (19,20). People with aphasia may similarly encounter confusion and derision from others about their daily life communication, augmenting their shyness, fear, and even shame. They realize they cannot maintain the social rhythm they used to have. But when acting, the whole scenario is different. People with aphasia are given a situation that they must solve, sometimes very imaginatively, sometimes more constrained by rules, but always in a supportive context. This trains their spontaneity – a vital skill in real-life social interactions. Choir singing, conversely, does not seem to train spontaneity in performance the same way theatre does (e.g., through improvisation).
The brain can find ways to return to the pre-stroke functioning level (21), but much is still unknown about what really drives long-term recovery. Le Théâtre Aphasique helps people with aphasia to think of life as just another stage where they can use what they learn in the workshops. Gestures, faces, words, and even silences can be mastered. Susan Yankowitz, award-winning playwright, wrote Night Sky, a play inspired by her mentor Joseph Chaikin who lived with post-stroke aphasia. Here we conclude with a thoughtful monologue of a character with aphasia (22) which poetically shows that aphasia can inspire theatre as much as theatre can inspire people with aphasia:
“Look at the cosmos and you see: Great spaces between stars.
Now for me, spaces between words, holes listening, holes talking.
I search many truths I feel I cannot express.
Ideas in head but pure ― poor words.
I am aphasia.”
Featured illustration by Daniela Casas for rehabINK.
To refer to this article, it can be cited as:
Osa García A. When aphasia comes on the scene: The journey and achievements of Le Théâtre Aphasique. rehabINK. 2019;7. Available from: https://rehabinkmag.com
- Phillips TM. Aphasia is contagious! [Internet] National Aphasia Association website. [Cited 2019 Feb 2] Available from: https://www.aphasia.org/stories/aphasia-is-contagious/
- Brady MC, Kelly H, Godwin J, Enderby P. Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews. 2012; 5, CD000425
- Ardila, A. Aphasia Handbook. 2014. Florida International University, Miami.
- Pedersen PM, Stig Jørgensen H, Nakayama H, Raaschou HO, Olsen TS, Jorgensen HS, et al. Aphasia in acute stroke: Incidence, determinants, and recovery. Annals of Neurology. 1995; 38: 659–666.
- Elman RJ, Bernstein-Ellis E. The Efficacy of Group Communication Treatment in Adults With Chronic Aphasia. Journal of Speech, Language, and Hearing Research.1999;42: 411-419.
- Nyström M. Aphasia – an existential loneliness: A study on the loss of the world of symbols, International Journal of Qualitative Studies on Health and Well-being. 2006;1;(1): 38-49.
- Cherney L, Oehring A, Whipple K, Rubenstein T. “Waiting on the Words”: Procedures and Outcomes of a Drama Class for Individuals with Aphasia. Seminars in Speech and Language. 2011;32(03): 229-242.
- Joly A. La fonction pragmatique du langage est-elle améliorée chez la personne aphasique par une pratique en groupe du jeu de rôle en orthophonie? Non-published master thesis [Internet]. 2003 [Cited 2019 Feb 2]. Available from: http://docnum.univ-lorraine.fr/public/BUMED_MORT_2013_JOLY_ALINE.pdf
- Plourde JMH, Purdy SC, Moore C, Friary P, Brown R, McCann CM. Gavel Club for people with aphasia: communication confidence and quality of communication life. Aphasiology. 2019; 33(1): 73-93.
- Lo TLT, Lee JLC, Ho RTH. Creative Arts-Based Therapies for Stroke Survivors: A Qualitative Systematic Review. Frontiers in Psychology. 2018; 9:1646.
- Morris J, Toma M, Kelly C, Joice S, Kroll T, Mead G. Social context, art making processes and creative output: a qualitative study exploring how psychosocial benefits of art participation during stroke rehabilitation occur. Disability and Rehabilitation. 2016; 38(7): 661-672.
- Beesley K, White JH, Alston MK, Sweetapple AL, Pollack M. Art after stroke: the qualitative experience of community dwelling stroke survivors in a group art programme. Disability and Rehabilitation. 2011; 33 (22-23): 2346-2355.
- Patterson KK, Wong JS, Nguyen TU, Brooks D. A dance program to improve gait and balance in individuals with chronic stroke: a feasibility study. Topics in Stroke Rehabilitation. 2018; 25(6): 410-416
- Zumbansen, A, Peretz, I, Hébert, S. Melodic intonation therapy: Back to basics for future research. Frontiers in Neurology. 2014B; 5.
- Altenmüller E, Schlaug G. Apollo’s gift: new aspects of neurologic music therapy. Progress in Brain Research. 2015; 217:237-252
- Unwin MM, Kenny DT, Davis PJ. The effects of group singing on mood. Psychology of Music. 2002; 30:175–185.
- Fogg-Rogers L, Buetow S, Talmage A, McCann CM, Leão SHS, Tippett L. Choral singing therapy following stroke or Parkinson’s disease: an exploration of participants’ experiences. Disability and Rehabilitation. 2016; 38(10): 952-962.
- Zumbansen A, Peretz I, Anglade C, Bilodeau J, Généreux S, Hubert M et al. Effect of choir activity in the rehabilitation of aphasia: a blind, randomised, controlled pilot study, Aphasiology. 2016; 31(8):879-900.
- Corbett, BA, Key, AP, Qualls, L, Fecteau, S, Newsom, C., Coke, C., & Yoder, P. Improvement in Social Competence Using a Randomized Trial of a Theatre Intervention for Children with Autism Spectrum Disorder. Journal of autism and developmental disorders. 2016; 46(2):658-672.
- Reading S, Reading J, Padgett RJ, Reading S, Pryor P. The Use of Theatre to Develop Social and Communication Behaviors for Students with Autism Spectrum Disorders: A Preliminary Investigation. Journal of Speech Pathology and Therapy. 2016; 1:102.
- Saur D, Lange R, Baumgaertner A, Schraknepper V, Willmes K, Rijntjes M, et al. Dynamics of language reorganization after stroke. Brain. 2006; 129:1371–1384.
- Ganzfried E, Greenfield M. The Word Escapes Me: Voices From Aphasia. Bloomington, Balboa Press, 2016.