It is interesting to write an introductory foreword to an issue devoted to exploring the Life Participation Approach to Aphasia (LPAA) philosophy and model of service delivery to persons with aphasia. As I reflect back on my 30 years as a speech-language pathologist working with individuals with aphasia, I recall that my clinical preparation was firmly based in the medical model of impairment. I remember supervised clinical practicum experiences in which I was instructed to write specific goals designed to help my moderately impaired client with nonfluent aphasia to consistently produce S-V-O sentences. Success was measured not in how well the client conveyed information but in how precisely the client created a grammatical sentence.

I recall as well the clear expectation that was conveyed to me that the responsibility for establishing treatment goals rested firmly on my shoulders as the clinician. My meetings with my supervisors to review my semester goals and objectives never included my clients or their families. We would meet with the clients and their family member(s) separately and share with them our "expert" analysis of what was wrong and how we would "fix" it.

It is gratifying to be in a profession long enough to see great change and shifts in paradigms that (from my personal perspective) have significantly altered and improved the way we provide services to persons with aphasia. It would be beyond the scope of this piece (and issue) to try to capture all the key shifts and points in time of these changes. This issue is devoted to a focused presentation on one of these key shifts, which is known as the LPAA.

In the six years since the initial publication of a set of guiding principles (LPAA Project Group, 2000), the model has evolved to a point where it could support the development of an issue of Topics in Language Disorders devoted to the model and its implementation. The collection of articles in this issue provides a valuable resource for clinicians, supervisors, and instructors interested in incorporating and promoting a LPAA treatment paradigm in theory and practice.

Elman starts the issue with an excellent historical review of the evolution of aphasia treatment from a medically based intervention model to a socially oriented model in which the clinician and the person with aphasia are partners in working toward achievement of communication goals. She describes the history of the creating of aphasia centers as an alternative treatment milieu to medical and more traditional clinical setting. Elman identifies the power of incorporating a group therapy model to achieve a host of communication and social benefits for the person with aphasia. In the best tradition of evidence-based practice, Elman offers a compelling review of the research supporting the positive benefits of group treatment.

It is reasonable to suggest that most clinicians working with persons with aphasia would support the philosophical core of the LPAA model. The challenge for advocates of the LPAA treatment is to convince clinicians that utilizing this approach will lead to robust clinical outcomes consistent with third-party payor expectations and, where required, those of external accrediting agencies. Kagan and Simmons-Mackie provide a conceptual model called A-FROM for identifying intended end of intervention functional life participation outcomes before assessing and treating the person with aphasia. They posit that this a priori top-down approach will lead to improved clinical success when working with persons with aphasia. The authors demonstrate how to apply this model throughout the continuum of care from acute hospitalization to return to home and community.

LPAA treatment models recognize that at the heart of the clinical enterprise are adults, who, despite their aphasia, are capable and responsible for establishing their life participation goals and objectives. Intuitively, it makes sense that the person with aphasia would be highly motivated to work toward achieving self-directed goals that will lead to personally relevant life participation outcomes. Kimbarow introduces the reader to the theoretical bridge that links LPAA treatment to adult learning theory. He reviews some of the core principles of androgogy and demonstrates the synergy between these principles and the LPAA approach. Kimbarow suggests that exploration of adult learning theory is useful to understand how the aphasic person's life experiences before the onset of aphasia are retained at the core of the person's life experiences after onset of aphasia. These personal experiences inform many of the choices the person with aphasia may make in dealing with the life consequences of this communicative disorder.

The importance of life experiences for the person with aphasia is found in the expression of personal narratives. Shadden and Hagstrom describe the role that story-telling can play in creating a sense of balance and connection between a person's life before aphasia and a person's life after onset of aphasia. They offer a rich review of the literature on the importance of personal narrative in defining one's personal identity. Shadden and Hagstrom discuss the importance of personal narrative in assisting the person with aphasia to address the life changes that result after the stroke. They offer the reader excellent recommendations for how to incorporate personal narrative within the clinical enterprise and the central role narrative can play in the LPAA treatment model.

The theme of life experiences and helping persons with aphasia achieve a sense of purpose and return to a desired level of social and emotional well-being is carried through in Holland's article on incorporating counseling/coaching to effect positive life changes. Once again, as she has done so often throughout her rich career, Holland breaks new ground, this time in educating professionals about the relatively young field of life coaching. She explains the difference between counseling and life-coaching and discusses the theoretical connection between life-coaching and positive psychology. In our current evidence-based practice world, this approach may be challenging for some readers to accept. However, one may argue that as a profession we are still underprepared in the counseling arts. Consequently, the reader will be well served to consider Holland's numerous examples of how to use life coaching to help persons with aphasia and their families adjust to and come to terms with the changes wrought by the aphasia. She identifies the clinical applications of life coaching for establishing communication strategies for the person with aphasia and his or her communicative partners.

The theme of educating clinicians is carried through the issue-ending article by Glista and Pollens. They offer a well-conceptualized approach for educating graduate student clinicians on how to create a clinical service delivery program based on the LPAA model.

Glista and Pollens explicitly and implicitly acknowledge that traditional models of clinical education may not adequately prepare future professionals to implement a patient-choice-based treatment program. They provide recommendations for how to connect curriculum and practice as well as recommendations for preparing students to successfully implement a group treatment model to achieve person- centered life participation outcomes for clients with aphasia. Many readers may find their discussion of student outcomes particularly helpful in considering how to set up LPAA clinical training experiences in their own university programs.

In summary, the articles in this issue demonstrate that the LPAA treatment model and philosophy have moved beyond its initial declaration of principles in 2000 to a more advanced stage in which the principles have been operationalized and implemented in practice. LPAA treatment aligns well with a number of different theoretical and applied models from outside the discipline of communication disorders. I predict the LPAA treatment model will continue to exert influence on the field for years to come.

Michael L. Kimbarow, PhD

Issue Editor, San Jose State University, San Jose, CA

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