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Aphasiology
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PACE revisited

Albyn G. Davis a a University of Massachusetts at Amherst. USA To cite this Article: Davis, Albyn G. , 'PACE revisited', Aphasiology, 19:1, 21 - 38 To link to this article: DOI: 10.1080/02687030444000598 URL: [Link]

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APHASIOLOGY, 2005, 19 (1), 2138

PACE revisited
G. Albyn Davis
University of Massachusetts at Amherst, USA
Background: PACE therapy is a widely referenced treatment procedure that was developed nearly 30 years ago. Since then, several critiques and studies of the procedure have been published, and the climate for rehabilitation in the United States has changed dramatically. Aims: The main goals of this retrospective essay are to introduce new clinicians to PACE therapy and analyse what has been published about the procedure for experienced aphasiologists. Main Contribution: The article provides a description and history of the procedure and then proceeds with discussions of conceptualisation, modifications, and efficacy. Responses to several concerns about PACE should clarify many aspects of the procedure. These concerns include the procedure's naturalness, applicability to a variety of patients, and absence of corrective feedback. Conclusions: PACE has an uncertain place in the healthcare environment of the United States. Because of its mixed reviews and unsettled efficacy, it may still be considered to be an experimental treatment.

While she was a doctoral student, Jeanne Wilcox entered my office one day and announced that we were doing aphasia therapy all wrong. Instinctively I thought, ``I'm the professor and you're not'' and then listened intently to what she had to say. Based on her work with children, she believed that our treatment of aphasia should be more interactive and natural than the object naming and picture pointing that I was used to. That was nearly 30 years ago. We devised a procedure called Promoting Aphasics' Communicative Effectiveness (PACE). The treatment consisted of a few modifications of the traditional picture-naming task in order to create a clinical activity that contains essential ingredients of face-to-face conversation. Now, PACE is one functional approach to helping aphasic individuals improve their communicative skills. The main goals of this retrospective essay are to introduce new clinicians to this technique and review what has been published about the procedure for experienced aphasiologists. It begins with a description and history of the procedure, and then proceeds with discussions of conceptualisation, modifications, and efficacy. Hopefully my responses to concerns about PACE will clarify most aspects of the procedure.

Address correspondence to: G. Albyn Davis PhD, Communication Disorders, Arnold House, University of Massachusetts, Box 30410, Amherst, MA 01003-0410, USA. Email: albyn@[Link] # 2005 Psychology Press Ltd [Link] DOI:10.1080/02687030444000598

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INTRODUCTION TO THE PROCEDURE

PACE was developed on two assumptions, namely that most aphasic individuals have an ability to communicate and that natural conversation presents these individuals with communicative difficulties to overcome. Four features of face-to-face conversation contributed to the four principles, which follow:
. Equal participation: The clinician and client participate equally by taking turns sending messages. . New information: The message-sender keeps picture stimuli from the view of the other participant so that the clinician and client exchange new information. . Modality choice: The client has a free choice as to the communicative modes used to convey a message. . Natural feedback: The receiver's feedback is directed towards figuring out the sender's message.

The confluence of equal participation, new information, and the other principles creates certain communicative circumstances that do not exist in confrontation naming tasks. Equal participation through turn taking is probably the most significant procedural difference from the naming task. The patient and clinician alternate in conveying what is pictured on a stimulus card. Because messages can be conveyed by any means, conversational roles are identified broadly as sender and receiver instead of the more specific speaker and listener. To create the ``new information condition'', the picture cards are turned over. Participants take turns drawing a card from the stack. The message sender keeps the picture from view of the receiver so that the sender has to convey information unknown to the receiver. Each turn is an exercise in communicative problem solving. The new information principle should influence the nature of the clinician's feedback when receiving a message. In the naming task, the pictured stimulus is viewed by both participants at the same time. This common knowledge of a message minimises the communicative usefulness of a patient's verbal or gestural attempt. The clinician's knowledge permits him or her to modify or correct a patient's attempt. However, without prior knowledge of the message in PACE, the clinician would be unable to refine linguistic form by cueing or correcting. Feedback is aimed at working out the patient's message. The patient acknowledges that the clinician has either understood or not understood. The patient's turn ends when the message is conveyed, not when a predetermined linguistic form is produced. Thus, the patient practises skills that are unique to conversation, such as responsiveness to a listener's attempts to interpret what the patient is trying to say. Equal participation means that the clinician and aphasic participant take turns performing the same communicative acts. Just as the patient does not direct the clinician to do anything in particular, so the clinician does not direct the patient to do anything in particular. So, what does the clinician do? The clinician's turn as sender becomes an opportunity to model communicative behaviours that are within a patient's capability. This mere modelling function has been controversial, because it does not seem to be therapeutic enough. Our intent was to use modelling as a suggestive device that reduces pressure on the patient to perform. Holland and Hinckley (2002, p. 422) regarded modelling in PACE as ``a powerful tool for training strategies''. The clinician demonstrates that a modality can be communicative and socially acceptable, and the patient makes his or her own decision to use

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them. This decision making is regarded as an acknowledgement that most aphasic individuals are thinking adults. Some do not care for being ``bossed around'', especially when a stroke is in the right hemisphere (Johnson, 1990). Holland and Hinckley added that ``when the clinician uses the very strategies that her clients could benefit from using, the effectiveness of the training typically becomes apparent to clients, who in turn are more likely to adopt the strategies'' (p. 422). Nevertheless, aphasic patients also look for guidance, and we suggest that direct instruction be used in another task to train a communicative modality such as gesture or drawing. Then we can see if the patient decides to use the trained behaviour during PACE. In general, PACE is supposed to provide an aphasic individual with the experience of communicating successfully. This experience is provided by the stipulation that the message is new information, and it is sustained by participants working together to make sure that new information is conveyed. The clinician takes a hint from the client's imperfect linguistic form and figures out the message. For example, let us suppose a patient is talking about a bargain purchase and says, ``I'm a cheap steak.'' The PACEoriented clinician silently realises he means cheapskate (slang for miserly) and does not bother to correct. In time, the patient may recognise that a failure of linguistic precision can still lead to communication. We hope that the patient gains some added confidence in communicating and some added comfort in realising that conveying messages is not solely his or her responsibility. PACE has been used for additional purposes besides stimulating patients in a relaxed communicative interaction. It has been a late generalisation stage in a language-specific treatment programme (Bandur & Shewan, 2001; Byng, Nickels, & Black, 1994). The principles have contributed to shaping group treatments (Holland & Beeson, 1999; Kearns & Elman, 2001; Springer, 1991). We discovered that a spouse could slip easily into the clinician's position without special training to work out communicative strategies (Newhoff, Bugbee, & Ferreira, 1981; Visch-Brink, van Harskamp, van Amerongen, Wielaert, & van de Sandt-Koendermen, 1993). In one case study, PACE provided a condition for measuring generalisation of treatment effects (Murray, 1998).

DEVELOPMENT OF PACE
In the mid-1970s most treatment of aphasia in the United States was aimed at repairing language functions, mainly with the stimulation approach advocated by Hildred Schuell (Schuell, Jenkins, & Jimenez-Pabon, 1964; see also Duffy, 1981). Tasks were oriented towards fundamental skills, applicable to a wide variety of communicative situations. A clinician planned specific stimuli, and a patient attempted expected responses. There was no managed care. Then, Audrey Holland (1975) told us at a convention that aphasic individuals communicate better than they talk. At the University of Memphis, a Veterans Administration Education and Training Grant gave us time to ``experiment'' with treatments in individual and group settings. With respect to PACE, I felt that we should remain structured while recognising what is unique about conversation. We started with a list of seven principles, eliminated redundancy, and then pared the list down to the aforementioned four. We tried the procedure with several aphasic individuals and then reported on the four principles at the annual ASHA Convention in San Francisco in 1978 (see Davis, 1980). Clinicians began inquiring about where they could obtain the ``kit'' or ``programme''. These early inquiries indicated just how different PACE was turning out to be. It required a different way of thinking about therapeutic interaction. This treatment would not

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consist of small steps, and clinicians would not be engaged in explicit instruction or correction. Its four principles could be explained on one page, and the principles would have to be applied flexibly and imaginatively to each client. In fact, as will be discussed later, PACE has been criticised simply because it lacks some of the more familiar features of aphasia treatment. In the ensuing years in Memphis, we devoted our energies to learning about how PACE would work with a variety of types and degrees of aphasia. We discovered the nuances of the procedure. The first major publication of the principles was in Chapey's text (Davis & Wilcox, 1981; see also Davis, 1986). We made a crude instructional video, which was distributed to about 40 clinical training sites. Our most complete report was a book on pragmatic rehabilitation for aphasia, and most of the literature reviewed here followed this publication (Davis & Wilcox, 1985). More recent writing has appeared only as short summaries in my texts (Davis, 1993, 2000). Although we worked on measuring PACE-related behaviour, we did not pursue efficacy studies. Our strategy was to share the idea freely and encourage others to do that research. Clinical specialists outside the United States have been particularly attentive to PACE. In Italy, Carlomagno (1994) authored a book devoted primarily to this method and included transcripts of several interactions. In Germany, Johannsen-Horbach, Wenz, Funfgeld, Herrmann, and Wallesch (1993, p. 323) reported that aphasic individuals were likely to receive the ``neurolinguistic therapy'' practised in Aachen or ``communication oriented treatment such as PACE'' (see also Glindemann & Springer, 1995). PACE has been employed in Australia (Worrall, 1995), Belgium (Seron & de Partz, 1993), Japan (Sasanuma, 1993), the Netherlands (Visch-Brink et al., 1993), and Poland (Pachalska, 1993). In England, Edelman (1987) published a kit. It contained a manual and a set of photographs for message stimuli. These stimuli depicted variations of everyday actions to encourage the communication of distinctions such as ``hanging a picture'' versus ``hanging laundry''. Later, this kit was translated into Italian (La Favelliana, 2004). In Canada, Kagan and Gailey (1993) ``found PACE to be an extremely useful and flexible clinical tool: It is easily adapted for different levels of severity, works well in a group, and can be presented in formats diverse enough to maintain interest and motivation'' (p. 215). In the United States, PACE has been taught in books about aphasia rehabilitation (Brookshire, 1997; LaPointe, 1997; Rosenbek, LaPointe, & Wertz, 1989). Aphasiologists started to recommend the procedure for different syndromes in later editions of Chapey's text (e.g., Marshall, 2001; Peach, 2001; Thompson, 1994). It was one of five intervention methods for aphasia summarised in a resource manual for speech-language pathology (Roth & Worthington, 2001), and it has been mentioned occasionally in general introductory texts about communication disorders (e.g., Boone, 1987; Swindell, Holland, & Reinmuth, 1990). Despite these acknowledgments, my impression is that PACE has served limited duty in the managed care environment. Relative to other methods, it was regarded lightly in the section on therapies in Worrall and Frattali's (2000) important book on the functional approach.

CRITICISM AND MISCONCEPTION

There has been some disagreement about how PACE fits into the rehabilitation of aphasic individuals. Perkins and Lesser (1993) put it in their ``direct therapy'' category, but Herbert, Best, Hicklin, Howard, and Osborne (2003) considered it to be an indirect

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approach. Comprehensive rehabilitation has been constructed to deal with the three dimensions suggested by the World Health OrganiSation (e.g., Worrall, 2000). Following the original terminology of impairment, disability, and handicap, PACE is usually related to working at the level of communicative disability caused by language impairment (or a person's ``activity limitation'', according to the recent revision). Davis (2000) classified it within ``interactive therapies'' along with Kagan's (1998) supported conversation and Holland's conversational coaching (Holland & Hinckley, 2002; Hopper, Holland, & Rewega, 2002). On the other hand, Peach (2001) put it in the category of ``Gestural-assisted programs''. Partly in an effort to figure out where PACE belongs, it has been the target of a few critical commentaries. Some criticism points out its limitations, whereas other criticism is suggestive of misunderstanding of the point of the procedure.

Conceptual concerns
Howard and Hatfield (1987) concluded that we confused the means and ends of treatment, with PACE representing the ends. They suggested that direct language instruction is a means to achieving the goal of improving communicative ability. Glindemann and Springer (1995) agreed, and noted that ``because of this identification of aims with methods, stepwise procedures are missing in the conventional PACE approach'' (p. 100). Why this should be a problem is not entirely clear. Is there an assumption that a therapeutic procedure must consist of direct instruction and have stepwise procedures? Does the goal of improving functional communication not have associated procedures? Let us think of it this way. So-called authentic therapies in the United States consist of common real life scenarios in which functional goals are explicitly realised (e.g., Hopper & Holland, 1998; Lyon, 2000, 2004; Simmons-Mackie, 2001). That is, having an aphasic individual practise ordering food in a cafeteria is a means to a functional end. PACE is likewise a means to an end. Byng (1995) inserted PACE briefly into an essay on the nature of aphasia therapy and its approaches. She was making fine distinctions among aims, rationales, strategies, tasks, and interactions. She seemed to be arguing that the tasks and materials of a therapy should be separated conceptually from the goals of a therapy. In addressing assumptions underlying approaches, she considered PACE to be a good example of when ``the therapy is synonymous with the task''. It is not an approach to therapy, she added, but instead is ``a useful medium through which therapy can take place'' (p. 9). Furthermore, ``it does not describe the therapy itself ,'' and Byng added that reports do not specify the procedures used to facilitate gesturing and so on. I am not sure if this is a limitation of PACE per se or of its descriptions in the literature. In general, Byng appears to have been saying that PACE is an activity without an overarching set of assumptions about the therapeutic process engaged by the procedure. This may be true. Byng's challenging commentary made me think about the atheoretical underpinnings of PACE. It is an empirically driven procedure, based primarily on observations of natural conversational interaction. Our claims have been mainly what we think a patient can do when engaged in this particular form of interaction. Although we make some rather broad assumptions about the minds of participants in the procedure, it was not explicitly derived from a cognitive construct. It was not built to test a theory of the hidden mechanisms of communication nor a theory of mechanisms by which its procedures would cause certain effects.

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PACE is unnatural
A common critique is that PACE is not real conversation, or, as Howard and Hatfield (1987) stated, it is ``as far from true communication as one can imagine'' (p. 85). Later, Glindemann and Springer (1995) worried that PACE is ``highly artificial'' and pointed out several departures from naturalness. One of these departures is that a clinician is not really an equal partner, because he or she possesses ``a high standard of therapeutic competence''. However, equality in PACE has nothing to do with a participant's status or experience. The principle of equal participation pertains to performing the same conversational move, namely, taking a turn as sender or receiver of messages. Moreover, a clinician can be easily replaced with a family member, inexperienced student, or stranger (Newhoff et al., 1981). This interchangeability introduces variation in mutual knowledge of topics that is likely to be absent if we were to assume that PACE always involves a client and a clinician. Aphasic patients should practise more than a symmetrical interaction, according to Pulvermu ller and Roth (1991). ``If you stick to the PACE norm of symmetry too rigidly you will miss out on some communicative skills worth developing'' (p. 42). They indicated that what is lost in this singular style is a variety of interaction types which they identified in terms of speech acts. They stated that PACE consists mainly of ``Informing'', whereas it does not permit `` other forms of communicative interactions such as Requesting, Questioning and Answering, Thanking, Advising, Warning, Bargaining, Arguing, or Story-telling'' (p. 42). This concern can be dealt with by distinguishing types of interaction from speech acts. PACE is truly not compatible with storytelling, psychotherapy, meetings, and other interaction types. A freewheeling conversational scenario would provide the opportunity for a wider variety of speech acts to occur. Although PACE is a singular type of interaction, a variety of speech acts do occur. A closer study of conventional PACE should reveal the possibility of requesting (e.g., please tell me more), questioning (e.g., Did you mean cheap steak?), warning (e.g., You talk too fast), disagreeing (e.g., That's not what I meant), and more. Of course, use of PACE does not eliminate a wide variety of interactions from being employed in rehabilitation. PACE's structure also appears to have limited its value for those advocating authentic treatment activities. A Life Participation Approach to Aphasia was featured in Chapey's (2001) latest edition where the ``LPAA Project Group'' recommended ``a general philosophy and model of service delivery, rather than a specific clinical approach'' (p. 235). As part of this group, Simmons-Mackie (2001) stated that the ``social approach'' to treatment has two primary goals, namely ``the exchange of information (transaction) and the fulfillment of social needs (interaction)'' (p. 248). She concluded that Davis and Wilcox (1985) represent the first goal with respect to getting ideas across by any means. PACE was considered to be a ``traditional aphasia therapy'' that ignores social objectives of communication. The social approach, on the other hand, attends to conversational repair behaviour and the involvement of communication partners (see also SimmonsMackie, 2000). This view of PACE emphasises the principles of sending new information and choosing modalities. Yet, the turn-taking feature of this procedure fits well with the interactional component of the social approach. Repair behaviour is common in the hintand-guess sequences occurring with PACE. Substitution of a family member as a patient's communicative partner is also consistent with the social approach. We have claimed that PACE models elements of conversation, not that it is conversation. It contains elements of conversation that are missing in traditional direct stimulation or instruction. The structure of PACE may have some advantages over

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authentic conversation as a clinical method. Certain variables of natural conversation can be more readily identified, evaluated, and manipulated with PACE. These variables include conversational roles, shared knowledge of message stimulus themes, and relative status of participants.

PACE is a nonverbal approach

Simmons-Mackie seemed to focus on ``getting ideas across by any means'' as the main feature of PACE. One misconception has been to position this procedure in the category of options for training nonverbal communicative modalities (Lyon & Shadden, 2001; Peach, 2001). These options include communication boards, Blissymbols, drawing, and computer-aided communicative devices. This emphasis is understandable considering that PACE has been used as a means of training nonverbal modalities (e.g., Cubelli, Trentini, & Montagna, 1991; Lyon & Sims, 1989; Rao, 2001). Herbert et al. (2003) claimed that PACE is an example of indirect approaches that ``bypass'' the language impairment and ``supplement speech with the use of additional modalities''. This view is understandable because of the implied acceptance of linguistic deficits in favour of their communicative value. However, Peach (2001) recognised that PACE can be ``a framework for incorporating traditional language stimulation techniques into a communicatively dynamic context'' (p. 506). Focusing on one modality seems to diminish consideration of the broader motivations for the use of PACE. The main goal is to improve communication. Gesturing is part of it, but a quiet session is not a good PACE session. The conceptual error in classifying PACE this way is to identify one feature or principle, such as free choice of modalities, as representing the whole. Also, supplementing language is not the same as bypassing it. Supplementing language implies an inclusion of language as part of the whole package of methods for communicating messages. PACE is intended to combine modalities into an interactive communicative situation.

PACE is not for all patients

Glindemann and Springer (1995) concluded that ``the PACE approach is not applicable for all patients or severities of aphasia'' (p. 99), especially Wernicke's and other severely aphasic individuals (see also Carlomagno, 1994). One of the reasons for this view was a claim that indirect approaches to the training of compensatory strategies are often not effective for the severely impaired. My response is that direct instruction might be required initially for the severely impaired to demonstrate capacity and that PACE can be instituted quickly once communicative attempts are recognised. PACE is still an opportunity to determine whether direct approaches generalise to relatively indirectly managed interactions. The claim that an indirect approach does not help patients with severe aphasia appears to me to be without evidence. Glindemann and Springer also contended that severe impairment includes a lack of nonverbal abilities necessary to perform in the PACE interaction. I do not believe that this contention can be supported for all globally or severely impaired patients. It is well established that even the most severely impaired aphasic individuals display a desire to communicate. This display consists of a communicative resource of some kind, namely, by sound making, gross pointing, facial gesture, and so on. I recall a student feeling panic in planning a PACE session for a client ``who has no communicative strategies''. This speechless patient's right hand was stilled by paralysis, and his left hand was restricted by trauma. My response to this student was that he was just not looking hard enough. The

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patient was still capable of rudimentary pointing to pictures for conveying messages. A few clinicians have considered PACE to be useful for globally impaired aphasic patients (Collins, 1986; Lyon & Sims, 1989; Peach, 2001). Others have recommended it for Wernicke's aphasia (Graham-Keegan & Caspari, 1997; Horner & Fedor, 1983; Marshall, 2001). Pulvermu ller and Roth (1991) argued that PACE should not be used for severely impaired patients, because a clinician is too often uncertain about the patient's comprehension of a clinician's sending behaviour. Yet this uncertainty about comprehension occurs in real-life conversation. It is something that has to be dealt with. The clinician (as well as family members) must live with the uncertainty of whether the patient has comprehended. In real conversation, we may change the topic when participants are not following the point. In PACE, we move on to another message and a better chance for comprehension. Direct language stimulation is a better method for determining a patient's level of comprehension, and the results should dictate the level of a clinician's sending behaviour in PACE. Pulvermu ller was not satisfied with the option of providing pictures for the patient to identify the clinician's message. However, pointing to pictures is a preparatory stage for becoming comfortable with compensatory communication boards or notebooks.

Corrective feedback is absent

Finally, Glindemann and Springer (1995) stated that ``the principle of free choice of communicative strategies and modalities . . . will not allow the correction of deficit utterances of a patient'' (p. 100). Clinicians have been uncomfortable with the elimination of directive behaviour (see also Pulvermu ller & Roth, 1991). I assume that ``correction'' refers to pointing out someone's grammatical error and stating the correct version. Perhaps because we labelled the fourth principle as ``natural feedback'', Glindemann and Springer argued that the absence of correction is unnatural. They claimed that people correct each other all the time in conversation. I am not so certain about the pervasiveness of corrective behaviour in everyday interaction, especially in polite conversation. I know that I very seldom correct my father. Let us again consider the rationale behind the removal of correction (and instruction) from this activity. When a clinician does not initially know the message being conveyed, the clinician would be unable to correct or cue the patient for the best communicative attempt. The clinician does not know the target and is busy trying to figure out the patient's message. Thus, if PACE is conducted correctly, correcting a patient is not possible until the patient has confirmed the clinician's comprehension. Also, there should be no ``correct'' form of message sending as long as the message is conveyed, often by hint-and-guess sequences. The idea is to convey a message successfully. Once this is accomplished, a turn ends, and another turn begins. PACE provides a patient with a few minutes of communicating while not being directed or corrected. Focusing on one modality or linguistic virtuosity are desirable aims for other treatments. The apparent need to correct patients differs from the prevailing approach to direct language treatment in the United States, which was motivated mainly by Schuell and Brookshire at the VA Medical Center in Minneapolis (Brookshire, 1978; Schuell et al., 1964). This stimulation approach is grounded in the fundamental theory that aphasia is a disorder of processing, not a loss of knowledge requiring new learning. Stimulation tasks are constructed to be easy enough so that an aphasic patient is ``correct'' most of the time. Thus, the aphasic individual is exercising normal cognitive events, not faulty ones.

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Response to the occasional error is mainly a ``restimulation'' in order to improve the response. Clinicians are supposed to spend little time correcting good efforts (Davis, 2000).

PACE-LITE
Because of the discomfort with conventional PACE, clinicians and researchers employ what is often identified as a ``PACE-like'' procedure (e.g., Katz, 1995; Lawson & Fawcus, 1999). Usually one principle is discarded. For example, Visch-Brink (personal communication, March, 2004) reports that clinicians in the Netherlands tend to ignore turn taking and, therefore, eliminate a clinician's modelling (see also Cubelli et al., 1991). Instead of modelling, the clinician makes suggestions about the use of communicative modalities or strategies. In the preservation of the other principles, messages are still hidden from the clinician while the client has a choice of communicative modalities, and feedback is oriented to resolving miscommunication. This ``PACE-lite'' becomes a referential communication activity that emphasises the practice of conveying information not specifically known to the clinician. Cle re baut, Coyette, Feyereisen, and Seron (1984) originated a strain of PACE-motivated referential tasks which I have called the ``Brussels modification''. They placed a screen about eight inches (or 20 centimetres) high between participants in the interaction. A barrier was also employed by Carlomagno (1994), Pulvermu ller and Roth (1991), and Springer, Glindemann, Huber, and Willmes (1991). Instead of drawing from one stack of message cards, potential message stimuli (or referents) are usually duplicated on both sides of the barrier. The barrier keeps a receiver from knowing which message the sender is trying to convey. A sender's communicative effectiveness is often measured by the receiver's accuracy in identifying the message from the duplicated choices. The method has the advantage of being easier to score than relying on a receiver's guesses about a sender's message. Referential tasks may have originated with Glucksberg and Krauss's (1967) study of children, and they have become more sophisticated theoretically with the use of eye tracking to follow a listener's search of possible referents (e.g., Barr & Keysar, 2002; Hanna, Tanenhaus, & Trueswell, 2003). One advantage of the referential task is that the aphasic individual has more ``turns'' as a message sender in the same amount of time. However, the omission of turn taking makes the procedure much less like conversation and, consequently, some communicative opportunities for the client are reduced. The client's turn as message receiver is also eliminated. With conventional turn taking, on the other hand, the client can practise providing a sender with feedback and evaluating a receiver's comprehension. In addition, it may be contradictory to claim that the new information condition is maintained with the barrier while the clinician provides corrective feedback. As I explained previously, a strong new information condition should eliminate the ability to supply corrective feedback. My guess is that the new information condition is diluted across trials in many referential tasks. In another procedure ``very similar to PACE'', Le Dorze, Croteau, and Joanette (1993, p. 101) stated explicitly which principles were being preserved. They discarded the free choice of modalities, because their goal was to encourage use of compensatory verbal circumlocutions to convey messages. Choice of modality and linguistic form was predetermined by instructions to produce ``definitions'' when taking a turn. The clinician's turn consisted of modelling circumlocutions with an expectation that the patient would produce the appropriate word as receiver. If we were to preserve conventional PACE with

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the same objective, a clinician might model compensatory circumlocution (even pretending not to think of the word) without restricting channels of communication. This might even be a ``step'' following Le Dorze's procedure. A procedure becomes PACE when all four principles are followed. Each principle is important for what we tried to achieve originally with the procedure. The four principles together make the interaction most like conversation. With turn taking and the clinician's modelling, we tried to eliminate a clinician's ``telling an aphasic person what to do''. My recommendation is that one part of a session be scheduled for providing cues or instruction. Another part of the session can be scheduled to allow the client some independence to make his or her own decisions in PACE. The latter provides an opportunity for the clinician to determine whether a positive result of cues or instruction generalises to a situation in which the client is more on his or her own.

EFFICACY
In this essay, I have referred to an apparent belief that only certain direct instructional activities can be considered to be therapeutic for aphasic language impairments. However, an activity's therapeutic power depends not on its procedural characteristics per se but rather on an outcome that can be caused by the procedure. A causal relationship can be demonstrated when progress in communicative abilities is shown to ``exceed what can be expected from spontaneous recovery'' or some other factor (Holland, Fromm, DeRuyter, & Stein, 1996, p. S27). Very few studies of PACE can be said to meet this criterion for efficacy. Some authors have confidently presented PACE as one procedure with demonstrated efficacy (e.g., Peach & Rubin, 1994, Marshall, 1994). Studies cited to support this claim include those by Davis and Wilcox (1981, 1985), Li, Ketselman, Dusatko, and Spinelli (1988), Carlomagno, Losanno, Emanuelli, and Casadio (1991), and Pulvermu ller and Roth (1991). Yet studies have varied according to how PACE was administered and what was used to measure a client's progress, as well as to control for other factors. Whereas Carlomagno (1994) reported that Cubelli et al. (1991) used PACE successfully to train gestures, the study actually consisted of the procedure without turn taking, administered among other treatments in the same session. Also, the design of a study of PACE's efficacy may depend on beliefs about what it is supposed to accomplish. Springer et al. (1991) compared PACE to a linguistically oriented modification with respect to communication measures and linguistic measures. This provided each procedure with an opportunity to demonstrate what each was supposed to do.

Conventional PACE
It is difficult to find a study in which conventional PACE was studied on its own. Usually the original procedure has been compared to another treatment approach or procedure. Comparative efficacy can be an indication of whether PACE uniquely makes a difference. Davis and Wilcox (1981, 1985) reported two studies in which the procedure was compared to traditional direct language stimulation. Eight varied aphasic patients, at least 1 year post onset, were divided into two treatment groups. One group received PACE for 4 weeks. The other group received direct stimulation for 4 weeks followed by 4 weeks of PACE. Both groups were measured before and after treatment periods with the PICA (Porch, 1967) and a role-playing battery. Small improvements were detected with the aphasia battery across the PACE periods but not across the direct stimulation period. Substantial improvements in the role-playing scores were measured for seven of the eight

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patients only across PACE sessions. In a single-case study, a globally aphasic patient was given alternating phases of PACE and direct stimulation, and progress with the roleplaying probe occurred only across the PACE phases. While this evidence was supportive of the use of PACE for both linguistic and communicative goals, these studies were not subjected to the peer review process of journal publication. An investigation may test PACE as a context for stimulating improvement of language functions. Li et al. (1988) employed an ABCBC design so that PACE could be compared with direct language stimulation for the purpose of improving naming. More progress in naming was shown during the phases of PACE. Springer et al. (1991) compared an apparently conventional PACE procedure to one that was modified so that a patient could focus on semantic classification of pictures with a barrier between the patient and clinician. The linguistically focused barrier task also included corrective feedback. The two procedures were administered to four patients and were alternated as four treatment phases. Dependent measures consisted of a traditional naming task and a communication measure. Three participants with lexical-semantic deficits improved in both measures only across the semantically focused phases. Springer and his colleagues concluded that PACE should be focused linguistically in order to produce linguistic improvements. PACE has also been studied as part of a package of procedures. Carlomagno et al. (1991) presented ``typical'' PACE along with similar tasks to eight individuals of varied type and severity of aphasia at least 8 months post onset. Like many such studies, the treatment procedure was not reported in enough detail to replicate the study or to determine whether the procedure was conventional PACE; however, more detail emerged in Carlomagno (1994) and Carlomagno, Blasi, Labruna, and Santoro (2000). The PACE procedure put the patient in a referential communication condition for conveying sentences containing an agent, action, object, and location. Length of treatment ranged from 8 to 22 weeks. Measures given before and after the treatment period showed that referential communicative abilities improved, but scores on standard language tests did not improve.

Studies of PACE-lite
Several clinical researchers have evaluated a modified version of PACE, often referring to the strain of barrier games that originated in Brussels and that subtracted the turntaking component. Pulvermu ller and Roth (1991) included a PACE-like ``request game'' with other communication games in a treatment given to eight varied aphasic participants over a 3- to 4-week period. The participants were at least 6 months post onset. Improvement was evaluated with a German version of the Token Test (De Renzi & Vignolo, 1962) which Pulvermu ller characterised as being a ``valid test of aphasics' communicative abilities'' (p. 45). Five of the participants made significant progress, leading the investigators to conclude that ``communicative treatment is an effective instrument to improve language and communication deficits in many chronic aphasics'' (p. 48). This conclusion is a broad interpretation of the Token Test, which literally is indicative of auditory language comprehension ability and is questionably indicative of everyday communicative skills (e.g., Glindemann & Springer, 1995). Other investigators conducted efficacy studies of a PACE-like procedure derived from the request game. Avent, Edwards, Franco, Lucero, and Pekowsky (1995) compared a sentence stimulation technique with a derivative that emphasiSed nonspeech modes of picture description. Measures consisted of verbal picture description and nonverbal picture description. Results were mixed among three aphasic patients, with one patient

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favouring the ``nonverbal treatment'', one favouring the ``verbal treatment'', and the other showing no difference. Herbert et al. (2003) included Pulvermu ller's modification within a series of treatments that was accompanied by improved naming but hardly any progress in everyday communication.

Training gestures
A few investigators have used PACE or a modification to examine more general questions regarding the training of gestural or other nonverbal behaviours. Rao (2001) reported a study that he presented at a conference in 1982. The goal was to train a severely aphasic individual to use Amer-Ind Code, a sign language used by Native Americans. The reason for instituting a ``treatment incorporating the principles of PACE'' (p. 697) after a period of more traditional instruction was that the client was rejecting use of this gesture system as the only means of communication. During the period of PACE therapy, the proportion of Amer-Ind use increased from zero to 50% across 10 sessions, but the communication of messages did not improve. Carlomagno (1994) reported a 1988 conference presentation. The Brussels modification of PACE was administered to 15 severely aphasic patients, and the researchers studied whether the participants would progress in the ability to convey simple messages and whether improvement could be attributed to an increase in gestures. The clinician's modelling maximised use of gestures, and the clinician encouraged use of gestures during the patient's turn. The treatment averaged 50 sessions for 1315 weeks. Five of the patients demonstrated improvement in communicative efficiency, whereas seven patients showed no improvement. Similar to Rao's case, the reduction in time to convey a message was due to a shift in the pattern of modality usage, particularly in a reduction of ineffective verbal and multimodal message sending turns. We should note that it took over 3 months to achieve this change for only one-third of the aphasic participants. Lyon and Sims (1989) adapted PACE to the training of communicative drawing for severely impaired aphasic individuals described as being ``expressively restricted''. A treatment session began with direct training of drawing, and the clinician provided verbal and graphic cues for improving recognition of each attempt. Then the same messages were placed into a ``PACE-like'' interaction. Progress was measured before and after the treatment period. The patients improved in drawing ability and in the pantomime subtests of an aphasia battery (Porch, 1967).

Components of PACE
Do features of PACE do what they are supposed to do? The pervasive use of a barrier has reflected the view of Springer et al. (1991) that conveying new information is the essential feature of this therapy. However, Brenneise-Sharshad, Nicholas, and Brookshire (1991) found that manipulating listener knowledge made little difference in aphasic individuals' storytelling. The investigators felt that this result weakens the value of the new information condition in PACE. However, they quickly added that their results did not strictly contradict our enthusiasm for this condition, because their experimental method differed from the usual PACE procedure. Their aphasic individuals' messages were long, and there was no hint-and-guess problem solving between participants. In PACE, messages are usually relatively short, which should increase dependence on shared knowledge to enhance communication. Does modelling influence a patient's behaviour? Early in this essay, a quote from Holland and Hinckley (2002) argued that it does. Pulvermu ller and Roth (1991) were not

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as confident and considered modelling to be insufficient for modifying modalities for severely impaired aphasic individuals. Glindemann and Springer (1995) were unimpressed with the modelling function for severe aphasia and for training compensatory communicative behaviour. They recommended systematic stepwise training for this purpose. Research can answer the question of whether modelling produces an effect. Glindemann, Willmes, Huber, and Springer (1991) examined the influence of modelling names or descriptions. Patients with mild aphasia were more likely than others to switch between names and descriptions as a function of what the clinician did as sender. Greitemann and Wolf (1991, as cited in Carlomagno, 1994) found that modelling can have an influence across verbal and gestural modalities and that the use of speech does not necessarily disappear as gesture increases.

Conclusions about efficacy

Most efficacy for aphasia treatments has been demonstrated for relatively traditional direct language stimulation. Other approaches, such as PACE, take a foothold because they make sense, not because of evidence. In addition, evidence of the efficacy of PACE has been weakened for a few reasons. Although patients were studied well beyond onset and spontaneous recovery, the common use of the pre-post treatment design reflects a widespread absence of control for other factors that could have influenced change during a period of treatment. Comparing PACE to another procedure can be misleading, because PACE was not intended to compete with or substitute for most other procedures. Many efficacy studies were conducted with a modified version instead of conventional PACE. In addition, the procedure has been frequently reported in a way that should leave us wondering how or whether the four principles were implemented. Springer et al. (1991) described a ``traditional'' version of the procedure, which maintained the new information component and a free choice of modalities. They did not mention turn taking, and the clinician ``would only tell the patient whether the message was understood or not'' (p. 391). This feedback strategy may not have included a clinician's ``guess'' for the patient to deal with. Especially brief descriptions cast doubt on whether the procedure was really PACE or simply an interesting task employing two or three of the principles. In some investigations, PACE was mixed with other methods so that its unique contribution to improvement could not be determined. In the future, PACE may be most fairly evaluated as a component of a treatment programme, because the procedure is most likely to be deployed in this way. Such studies might consist of a condition or phase that includes PACE with other treatments, and another condition or phase in which the other treatments remain and PACE has been removed. Also in future research, we may consider the appropriateness of dependent variables. For example, whether PACE causes improvement of specific linguistic functions is an interesting category of questions. An investigator could ask, ``Does PACE cause improved use of verb auxiliaries?'' A study could be done. Yet, before we do it, we should wonder whether PACE was intended for this purpose, or whether there is a theory establishing a link between this interaction and auxiliary production. PACE might be more appropriately evaluated with respect to its main objectives. For example, we believe that PACE helps to improve an individual's self-confidence as a communicator. Yet this has its own difficulties. Turning this belief into a fact requires a valid and reliable measure of communicative self-confidence as a dependent variable. PACE is mainly aimed at functional communication, and the challenges in measuring functional outcomes are well documented (Cornett, 2001; Holland & Thompson, 1998).

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FINAL REFLECTIONS AND CONCLUSIONS

Let us consider my earlier speculation that PACE has served limited duty in the era of healthcare reform. Managed care in the United States pressures clinicians ``to reduce costs, achieve results quickly, and prove that particular services and procedures `work' '' (Cornett, 2001, p. 231). ``Gone are the days when therapists could provide treatment for months at a time. In this era of cost-containment in health care, clinicians frequently are asked to provide evidence that their patients have certain communication skills that enable them to function more independently and safely after only days or weeks of therapy'' (Hopper & Holland, 1998, p. 934). The demand for quick results is illustrated by Frattali's (2000) case for whom post-acute treatment was authorised initially for two sessions. Documentation of progress led to authorisation of another four sessions. Based on continued improvement, the clinician requested four more sessions, but only two were approved. These were focused on family training. These circumstances may not be conducive to the use of PACE therapy, which follows the tradition of treatments that have general applicability to any communicative situation. Thus, PACE may not be considered to be an efficient use of the short time that is often allotted. Instead, clinicians may rely on Hopper and Holland's (1998) model of providing practice in real-life situations such as communicating over the phone in an emergency. Situation-specific training offers a shorter bridge between the clinic and a patient's world. In this context, PACE may be an appropriate activity for caregivers outside the clinic. Also, a clinician wants to document that a patient improved with respect to meaningful goals. Yet when a client is provided only six treatment sessions, clinicians are not inclined to implement treatment and measurement as separate tasks. PACE presents a problem with respect to measuring progress in a treatment activity (rather than using a goal-based generalisation probe). A clinician's turn as receiver makes it difficult to score a client's sending behaviour while having to figure out the client's message. In Memphis, we would score only from a video of a treatment session. Because the message is already known in the more traditional task, the clinician can more easily evaluate behaviour and record a score. The attention given to PACE in Europe may be a manifestation of different conditions for healthcare, where therapy for months at a time is still possible. For example, rehabilitation for every citizen in Belgium is covered by a federal social security program (European Observatory on Health Care Systems, 2000). Patients at the Brussels Neuropsychological Rehabilitation Unit sign a contract for a maximum 6-month period (Seron & de Partz, 1993). This contract specifies treatment objectives and a schedule for therapy. Initial evaluation and diagnosis may take 12 months, and this assessment often overlaps with early therapy that may include PACE (Seron, personal communication, August 2004). Therapy can be reimbursed for up to four contract periods (or 2 years). Like the VA supported programme in Memphis 30 years ago, there is time for inventive approaches to treatment such as cognitive neuropsychological techniques (e.g., Edmundson & McIntosh, 1995; Hillis, 2001). Because of its mixed reviews and unsettled efficacy, PACE may be considered to be an experimental treatment. It possesses attributes of both direct language stimulation tasks and real-life conversation. That is, it is structured and consists of turn taking. It also lacks features of each. There is no focus on a particular communicative function or process, and there is less of the spontaneity and anxiety that occur in natural interactions. These characteristics may seem advantageous to some as an intermediate ``safe harbour''

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for functional verbal and nonverbal stimulation. To others, PACE may be a procedure in limbo.
Manuscript received 29 September 2004 Manuscript accepted 6 October 2004

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