Today, I’m sharing a success story in which my patient “James” went from rarely speaking to cracking jokes in five sessions. Five! Read on to learn about James, ECoLoGiC-Tx for aphasia, and why I think it was so successful. (And so easy to do!)
Free DIRECT download: ECoLoGiC-Tx for aphasia – cheat sheet. (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- Meet James, a stroke survivor with aphasia.
- At baseline, James rarely spoke.
- We failed to develop a home exercise program.
- My original (unsuccessful) therapy approach.
- Trying a new approach with ECoLoGiC-Tx.
- What are the benefits of ECoLoGiC-Tx?
- How to do ECoLoGiC-Tx.
- Dramatic improvement.
- Why I think ECoLoGiC-Tx helped James.
- Learn more about ECoLoGiC-Tx.
- Related Eat, Speak, & Think posts.
- References.
Meet James, a stroke survivor with aphasia
My patient “James” is an 82 year old man, living with severe expressive aphasia from a stroke two years ago. He lives in a secure memory care unit due to mild Alzheimer’s dementia and being dependent for ADLS. He moved into the facility less than a year ago.
James is widowed, with a son and daughter who live far enough away that they only visit a couple of times a month. He watches TV, naps, and participates in the group activities with support from the facility staff.
At baseline, James rarely spoke
When I met James, he rarely initiated conversation with anyone although he was clearly interested in what the people around him were doing.
His responses to conversational overtures or questions were limited to 1-2 words. When he tried to say more, he consistently had difficulty retrieving his intended words.
James had low tolerance for word retrieval failures. The moment he had trouble, he showed signs of frustration – frowning, shaking his head, making sounds of frustration, and waving his hand dismissively. He then would sit quietly and stare at the floor.
When confronted with a communication breakdown, James sometimes used pointing, but he didn’t use other compensatory strategies such as gesturing, writing, substitution, or description.
James understood spoken language well enough for every day interactions. Assessment revealed mild deficits at the paragraph level, but this may have been related to memory deficits.
I didn’t detect any sign of dysarthria or apraxia of speech.
He was able to write single words, laboriously and not very legibly. (OT addressed this; by the time I discharged, James was able to write single words legibly although still slowly.)
I informally assessed reading skills and determined that reading was not compromised at the sentence level.
We failed to develop a home exercise program
Since I saw James 1-2 times a week, I wanted to set him up with a daily home exercise program as early as possible. Here are the things that I tried over the course of the first six sessions:
- A free 2-week trial to Constant Therapy on his iPad.
- Repeated oral reading of personally-relevant words which I wrote in his speech notebook.
- Write a single sentence for a journal entry every day.
- Read aloud from a simple personalized script.
- Complete a simple, multiple-choice vocabulary worksheet.
- Practice recalling the name of his first cat with a flashcard.
James did not perform any home exercise program over those three weeks. I think there were a number of barriers, including:
- Forgetfulness. (I did place a reminder in a visible location.)
- Most of his time spent in communal living spaces.
- Requires assistance to return to his room.
- Family was unable to offer support.
- Staff willing to remind patient and help with set-up, but unable to sit with James to cue or assist him.
- James was only independent with the reading tasks (from the notebook or the flashcard).
My original (unsuccessful) therapy approach
During speech therapy sessions, I always begin by asking my patients if there is anything in particular they want to work on, such as difficult topics of conversation, difficult situations, or difficult people to communicate with.
James generally said ‘no’. The one exception was that he wanted to be able to ask for ketchup in the dining room. We devised a simple script and practiced it with and without the written support (using spaced retrieval).
That worked brilliantly! From that day forward, James has been able to request ketchup.
However, he was unable to identify any other particular communication challenge that he wanted to focus on.
I spoke to his son and made a list of topics, facts, and vocabulary that James would likely find useful to be able to say. Despite the success with the ketchup, he wasn’t motivated to create a script based on these ideas.
In therapy, I tried Response Elaboration Treatment and Semantic Feature Analysis. He really liked Tactus Therapy’s Naming Therapy app, but required significant support. James liked the concept of the Conversation Therapy app, but he experienced frequent frustration.
I taught him repair strategies (and provided them in writing), but he didn’t really show an improvement in using them over those initial three weeks of therapy.
Trying a new approach with ECoLoGiC-Tx
At my 30-day functional reassessment, the primary improvement was that he was now able to request ketchup in the dining room. He hadn’t improved on reassessment measures, and he didn’t have a home exercise program that he was able to perform.
That’s a positive improvement, but I felt that James had the potential to achieve more. He certainly wanted this as well! But nothing I was trying was gaining traction.
It was around this time that I heard about a relatively new conversation-based aphasia intervention that sounded easy to implement and potentially quite effective.
The intervention is called “Expanding Communication and Language Opportunities Generated in Conversation Treatment” (ECoLoGiC-Tx; Leaman et al., 2026).
What are the benefits of ECoLoGiC-Tx?
ECoLoGiC-Tx improves recovery of language skills, including verbal expression, auditory comprehension, reading, and writing in people with moderate to severe aphasia, in group or individual therapy (Leaman et al., 2026).
Leaman et al. (2026) reported on the outcomes of 10 individuals with moderate to severe aphasia after 10 weeks of therapy and again at six weeks for maintenance. I won’t go into the nitty-gritty details, except for a few points:
- Excellent improvement noted for 9/10 participants.
- The participants improved WAB-R score an average of 11.31 points.
- 7/10 people moved to a less-impaired severity level.
- Fidelity of protocol implementation was 97.3% across 4 SLPs, suggesting it wouldn’t be hard to implement.
How to do ECoLoGiC-Tx
The name of the therapy approach (ECoLoGiC-Tx) sounds intimidating, but it’s actually a simple intervention. Our therapy session focuses on real conversation and is divided into two phases:
- Therapeutic Conversation
- Therapeutic Repair.
Therapeutic Conversation
During the session, either the client or the SLP will initiate social conversation. We engage in a real conversation in a naturalistic way until our patient has difficulty communicating an idea.
We accept any mode of communication – if our patient uses nonverbal means to get their point across, we accept it and continue the conversation.
It’s important that we don’t interview, teach, or quiz our patient. Data for goals are taken only during this phase.
The session moves into Therapeutic Repair only when our patient is unable to communicate an idea.
Therapeutic Repair
Once our patient is unable to communicate an idea verbally or nonverbally, we move into Therapeutic Repair. The idea is to provide the least amount of support possible, while inviting our patient to take an active part in the repair.
There are seven repair steps, in order from minimal support to maximal support:
- Identify the Repair: tell our patient what we understood. Make it visual. Write it down or make a line drawing or diagram.
- General Comment: ask our patient to tell us more.
- Request specific information: “Who was there?”, “Where was this happening?”, etc.
- Request description: ask our patient to describe that’s happening.
- Request nonverbal communication: Is there another way you can tell me?
- Request specific nonverbal communication: “Can you draw it?”, “Can you point to it?”, etc.
- Give a choice: “Is it [x] or [y]?”
Always start with #1 and move from least supportive to most supportive. We can skip levels.
Once you’ve repaired the communication breakdown, you return to Therapeutic Conversation. And that’s ECoLoGiC-Tx in a nutshell!
Dramatic improvement
James showed a dramatic improvement after just five sessions of ECoLoGiC-Tx, and not just during speech therapy session.
For one thing, James was initiating conversation with the people around him. During one session, an aide entered the room and James cracked a joke with her. Turns out he has a good sense of humor!
During the second functional reassessment, James volunteered to tell me a story from his childhood. He produced full sentences, with frequent pauses for word finding delays.
Even though he was still having frequent word finding delays, he wasn’t giving up in frustration.
When he was ‘stuck’ for a word, he used repair strategies that were helpful: he described the concept or attempted a similar word, he gestured or pointed, and he used tone of voice and body language to help convey his meaning.
The best part is, James used those strategies independently and without sign of frustration. He was smiling as he anticipated telling me the punch line of his story.
When I discharged, James was very pleased with his improvement in talking. The facility staff complimented James on his progress. Even his daughter commented on his improvement when I notified her of the discharge.
Why I think ECoLoGiC-Tx helped James
Looking back, I think there were two factors that helped James.
- I gave James direct feedback about what I understood from Therapeutic Conversation when we entered Therapeutic Repair. I think he was surprised at how much he was able to communicate even when he was struggling for words. I believe this bolstered his confidence and helped him realize that communication is about more than the words we say.
- I provided feedback on how the Therapeutic Repair we made together helped me understand his intended message. I think this improved his meta-cognition surrounding communication, and (despite the Alzheimer’s), James was able to implement some of these strategies in conversation on his own.
It was truly an amazing transformation to watch!
Learn more about ECoLoGiC-Tx
You can read more about ECoLoGiC-Tx in this 2026 journal article. The appendix contains a one-page summary of the protocol, with tips.
Sarah Baar (SLP) interviewed Dr. Marion Leaman* about ECoLoGiC-Tx on Medbridge’s Speech Scope podcast. I listened to this interview as I drove around from patient to patient recently.
*As an affiliate of Medbridge, I may earn a small commission on qualifying new subscriptions. There is no extra charge to you, and it will help keep Eat, Speak, & Think sustainable.
If you’re a Medbridge subscriber, you also have access to three additional resources: a data collection sheet, a cheat sheet on the repair strategies, and a four-page summary of the podcast episode.
Related Eat, Speak, & Think posts
- Easy discourse measures to demonstrate improvement.
- How intensive home exercise helped my patient talk again.
- Improve aphasia outcomes by creating intensive home exercise programs.
References
- Baar, S. (Host). (2026, January 15). Improving conversation in aphasia: What is “ECoLoGiC-Tx” all about? (Podcast episode 23). In Speech Scope: A Medbridge Podcast. https://www.medbridge.com/educate/courses/improving-conversation-in-aphasia-what-is-ecologic-tx-all-about-marion-leaman-sarah-baar
- Leaman, M. C., Edmonds, L. A., Oleson, J. J., & Williams, K. N. (2026). Improving language in individual conversation-level therapy: Group and individual results of ECoLoGiC treatment for people with moderate and severe aphasia. American Journal of Speech-Language Pathology, 35(2), 476–499. https://pubs.asha.org/doi/10.1044/2025_AJSLP-25-00113
Free DIRECT download: ECoLoGiC-Tx for aphasia – cheat sheet. (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured image by Aflo Images on Canva.com.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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