A Combined Speech-Language and Counseling Intervention for Primary Progressive Aphasia: Acceptability, Feasibility, and Preliminary Outcomes

Abstract

Purpose:

Individuals with primary progressive aphasia (PPA) face negative psychosocial repercussions, yet few studies have investigated counseling for this population. In a prior study, a novel intervention encompassing script training and aphasia-modified cognitive behavioral therapy was piloted with an individual with PPA, yielding promising results. The purpose of this study is to determine the acceptability and feasibility of this intervention for individuals with different PPA subtypes, with secondary aims of understanding preliminary treatment outcomes and evaluating the sensitivity of selected psychosocial measures.

Method:

Nine participants with PPA were recruited (three with nonfluent/agrammatic variant, three with logopenic variant, and three with semantic variant). Acceptability was measured using a posttreatment questionnaire. Feasibility was examined via intervention adherence, independent practice engagement, retention, assessment completion, interrater reliability, and fidelity ratings. Speech-language outcomes were evaluated via hypothesis testing using simulation analysis from pre- to posttreatment for all participants and from pretreatment to follow-up time points for six participants. Counseling outcomes at posttreatment were measured via psychosocial scales and analyzed using Wilcoxon signed-ranks tests.

Results:

Findings indicate that this treatment is acceptable and feasible. All participants demonstrated significant improvement in speech-language performance following treatment, with five participants demonstrating significant improvement up to 1 year posttreatment. Despite promising qualitative evidence regarding counseling outcomes, a sensitive quantitative measure of psychosocial functioning was not identified.

Conclusions:

Pairing tailored speech-language interventions with counseling for individuals with heterogeneous PPA phenotypes is acceptable and feasible. Preliminary outcomes indicate positive communication findings and that alternative psychosocial measures may be beneficial in a future efficacy trial.

Supplemental Material:

https://doi.org/10.23641/asha.31836103

When a person is diagnosed with primary progressive aphasia (PPA), a language-prominent dementia, they often grapple with multilayered psychosocial impacts, ranging from processing grief to experiencing depression (Lo et al., 2022; Medina & Weintraub, 2007). In the realm of speech-language pathology services and in alignment with the World Health Organization International Classification of Functioning, Disability and Health and Living with Aphasia: Framework for Outcome Measurement models (Kagan et al., 2008; World Health Organization, 2001), clinicians can thus seize opportunities to provide holistic treatment that focuses on not only the communication impairment itself but also the whole person, inclusive of their psychosocial well-being.

PPA Clinical Presentation

Individuals with PPA initially present with relatively isolated and slowly progressing language and/or speech difficulties (Gorno-Tempini et al., 2011; Mesulam, 1982). With time, additional symptoms manifest, which may include more generalized cognitive deficits, nonspeech motoric involvement, and personality/social behavior changes (Harciarek et al., 2014). Per established consensus criteria, there are three PPA variants (Gorno-Tempini et al., 2011). People with the nonfluent/agrammatic variant (nfvPPA) demonstrate core deficits in grammar and/or motor speech production. Individuals with the semantic variant (svPPA) present with naming and word comprehension impairment caused by the underlying deterioration of semantic knowledge. For people with the logopenic variant (lvPPA), core deficits include impaired naming and phrase/sentence repetition abilities resulting from phonological processing difficulty.

Neuropsychiatric and Psychosocial Sequalae of PPA

In the context of living with a neurodegenerative disorder, people with PPA face negative impacts on their psychosocial well-being. Individuals with PPA have cited low self-esteem, reduced confidence, and social withdrawal while processing ongoing grief and loss (Lo et al., 2022; Volkmer, 2013). Moreover, as symptoms evolve over time, people with PPA may also demonstrate neuropsychiatric and behavioral features such as agitation, apathy, depression, and anxiety (Medina & Weintraub, 2007; Singh et al., 2015). These symptoms may have a compounded negative impact on communication functioning, life participation, and quality of life.

Unfortunately, people with aphasia, regardless of etiology, may struggle to find appropriate counseling resources. This is likely due to several factors, including underreferral of individuals with aphasia for counseling, prohibitive costs associated with mental health services, perceptions of stigma surrounding mental health, and licensed mental health providers lacking training and confidence in treating individuals with aphasia/PPA (Morrow-Odom & Barnes, 2019; Schaffer Mendez & Gallée, 2024). This creates an important opportunity for speech-language pathologists, whose scope of practice includes counseling, to incorporate counseling into their treatment of patients with otherwise unmet mental health needs.

PPA Treatment

Over the past several decades, restitutive interventions for PPA have proliferated (Wauters et al., 2024). By comparison, limited research exists regarding PPA interventions that contain a counseling component (Schaffer & Henry, 2021). Counseling approaches in the literature have included support groups for people with PPA and/or care partners, led by psychologists, social workers, or speech-language pathologists (Jokel et al., 2017; Morhardt et al., 2019; Schaffer & Henry, 2023), and holistic interventions that provide counseling as a complement to speech-language treatment. One holistic intervention, Communication Bridge, offers restorative and communication participation–based treatment, care partner training, and informational counseling focused on disease-related education (Rogalski et al., 2016, 2025). Another holistic treatment features script training paired with aphasia-modified cognitive-behavioral therapy (CBT; Schaffer et al., 2021). Preliminary evidence across these studies indicates that, regardless of whether the counseling is provided on an individual or group basis, for people with PPA or their care partners, these treatments are feasible to administer, and participants demonstrate quantitative and/or qualitative gains in the areas of communication and/or psychosocial well-being.

Current Study

CBT is a popular counseling approach that is efficacious across a variety of diagnoses and is amenable to modification (A. T. Beck, 1964; Cully & Teten, 2008; Fordham et al., 2021; Gallagher et al., 2019). This goal-driven, present-focused, and person-centered counseling approach is rooted in the theory that one's thoughts, feelings, and behaviors are connected. Consequently, negative/maladaptive thoughts can enact a cycle of negative feelings or behaviors. Through CBT, the goal is to identify, examine, and modify maladaptive thoughts to facilitate improved mood and affect behaviors more broadly (J. S. Beck, 2011).

Given the theoretical underpinnings, empirical support, and adaptability of CBT, we sought to investigate this counseling approach in PPA. Our first research endeavor was an initial pilot study (Stage 1A study per the National Institutes of Health [NIH] Stage Model; Onken et al., 2014) in which the novel speech-language and aphasia-modified CBT treatment manual was created, initial feasibility was assessed, and preliminary outcomes with a single participant with nfvPPA were obtained (Schaffer et al., 2021). This treatment was found to be feasible and showed potential for improving psychosocial and communication outcomes at the single-case level.

The current study is positioned as an NIH Stage 1B study (Onken et al., 2014), with the purpose of investigating acceptability and feasibility of this novel intervention with a group of individuals representing each PPA variant (i.e., nfvPPA, svPPA, lvPPA). Additionally, in this study, different tailored speech-language interventions (i.e., script training and naming treatment) were paired with aphasia-modified CBT. A secondary purpose was to investigate preliminary evidence of treatment response.

In this study, we pose four research questions and associated hypotheses: Research Question 1: Is this combined speech-language and counseling intervention acceptable to participants? We predicted that the treatment would be acceptable, as evidenced by posttreatment outcomes on the Client Satisfaction Questionnarie–8 (CSQ-8; Larsen et al., 1979). Research Question 2: Is this intervention feasible? We predicted that this treatment would be feasible, as measured by adherence to intervention, engagement in independent practice, retention rates, assessment completion, interrater reliability, and fidelity ratings. Research Question 3: Does participating in this intervention yield positive speech-language outcomes? We predicted that the participants in this study would demonstrate positive speech-language outcomes following treatment, supported by hypothesis testing via simulation. Research Question 4: Is there preliminary evidence of positive psychosocial outcomes in this pilot sample? Quantitatively, we predicted that the participants would demonstrate improved patient-reported psychosocial outcomes. Qualitatively, we predicted that the participants' responses on semistructured interviews would reveal an increase in positive/adaptive themes in managing life with PPA at posttreatment relative to pretreatment. For detailed information regarding qualitative outcomes, see Schaffer Mendez et al. (2026b). We also evaluated psychosocial response on a variety of standardized measures. As there are no established, psychometrically validated measures for assessing psychosocial and communication functioning in PPA, we evaluated several candidate outcome measures for sensitivity to inform future efficacy studies. We predicted that participants would demonstrate an improvement in psychosocial and/or communicative functioning from pre- to posttreatment on one or more measures; however, we predicted that some measures may lack sensitivity for detecting change over time in this population.

Method

Participants

Nine monolingual, English-speaking individuals with PPA (five females and four males), ¹ residing in either the United States or Canada, were enrolled in this study. The mean age of participants who completed the prescribed intervention was 73 (SD = 8.83; see Table 1 for further demographic and clinical information). Two individuals were diagnosed with nfvPPA, three were diagnosed with lvPPA, and three were diagnosed with svPPA. Of note, one participant was given a “PPA-unspecified” diagnosis by their neurologist. However, comprehensive neurological, neuropsychological, and speech-language testing by our research team revealed a profile consistent with the nfvPPA variant (Gorno-Tempini et al., 2011). Study procedures were approved by the institutional review board at The University of Texas at Austin (Project ID: 2020010119). All participants gave informed written consent.

Table 1.

Demographic information and clinical profiles of participants.

Participant ID	NFV1	NFV2	NFV3	LV1	LV2	LV3	SV1	SV2	SV3
Age (years)	81	79	65	61	85	80	62	72	74
Gender	F	M	M	F	M	F	F	M	F
Education (years)	16	16	17	14	25	16	16	21	18
Handedness	Right	Right	Right	Right	Right	Right	Right	Righta	Right
Race/ethnicity	White/Non-Hispanic	White/Non-Hispanic	White/Non-Hispanic	White/Non-Hispanic	White/Non-Hispanic	White/Non-Hispanic	White/Non-Hispanic	White/Non-Hispanic	White/Non-Hispanic
Time postonset of symptoms	4 years	3 years	7 years	3 years	4 years	3 years	7 years	7 years	5 years

Note. NFV = nonfluent/agrammatic variant primary progressive aphasia; LV = logopenic variant primary progressive aphasia; SV = semantic variant primary progressive aphasia; F = female; M = male.

^aParticipant SV2 is ambidextrous and writes with his right hand.

Prior to initiating the treatment phase, each participant completed comprehensive speech, language, and cognitive testing (see Table 2). Inclusion criteria for participation were as follows: confirmed diagnoses of PPA, a Mini-Mental State Examination (Folstein et al., 1975) score of ≥ 15, a Western Aphasia Battery–Revised (WAB-R; Kertesz, 2006) Aphasia Quotient of > 76 (the mild impairment cutoff), scores of > 50 on the Reading Comprehension of Sentences and Reading Commands subtests on the WAB-R, and the ability to write about at least three salient items or actions in list or sentence form during a written picture description task. Moreover, participants presented with either intact or corrected vision and hearing (corroborated by audiograms, when available, and by at least 70% accuracy on a minimal pairs discrimination test; Henry et al., 2019). Exclusionary factors included complicating medical comorbidities (e.g., traumatic brain injury, multiple concussions with loss of consciousness); an acute, severe mood disorder requiring immediate intervention by a mental health professional; placement on psychotropic medication within the past 3 months/psychotropic medication dosage that has not yet been stabilized for 3 months; not being a proficient English speaker; and/or refusing to participate in both intervention components (i.e., speech-language and counseling).

Table 2.

Speech, language, and cognitive test scores at pretreatment, posttreatment, 3-month follow-up, 6-month follow-up, and 12-month follow-up time points.

Participant	Time point	Assessment
		Mini-Mental State Exam (_/30)	Western Aphasia Battery–Revised Aphasia Quotient (_/100)	Boston Naming Test (_/30 or 60)	Pyramids and Palm Trees Test (_/25 or 52)	Motor speech evaluation: Apraxia of speecha (0–7)	Motor speech evaluation: Dysarthriaa (0–7)	Northwestern Anagram Test (% _/12 or 30)
NFV1	Pre	27	93.4	22/30	24/25	2	4	24/30
	Post	29	93.0	24/30	N/A	2	4	25/30
	3-month f/u	28	91.0	24/30	N/A	2	4	23/30
	6-month f/u	17	87.6	21/30	N/A	2	4	6/30
	12-month f/u	14a	77	-	N/A	2	5	4/12
NFV2	Pre	28	96.0	29/30	24/25	2	0	20/30
	Post	27	94.4	28/30	N/A	2	0	21/30
	3-month f/u	28	96.2	29/30	N/A	2	0	20/30
	6-month f/u	27	94.0	30/30	N/A	2	0	17/30
	12-month f/u	28	94.6	30/30	N/A	3	0	21/30
NFV3	Pre	29	91.5	28/30	25/25	2	0	20/30
	Post	29	86.9	29/30	N/A	3	0	19/30
	3-month f/u	29	86.5	30/30	N/A	3	0	20/30
	6-month f/u	29	87.5	29/30	N/A	3	0	21/30
	12-month f/u	29	85.3	30/30	N/A	4	0	20/30
LV1	Pre	22	76.0	27/60	48/52	0	0	-
	Post	17	62.8	28/60	50/52	0	0	N/A
	6-month	4	-	-	-	-	-	N/A
LV2	Pre	20	87.2	19/60	48/52	0	0	11/12
	Post	25	82.2	17/60	51/52	0	0	N/A
LV3	Pre	23	85.9	56/60	47/52	0	0	6/12
	Post	14	73.1	27/30	-	0	0	N/A
SV1	Pre	29	90.1	36/60	45/52	0	0	12/12
	Post	30	91.3	29/60	45/52	0	0	N/A
	3-month f/u	30	90.2	27/60	45/52	0	0	N/A
	6-month f/u	29	90.3	30/60	44/52	0	0	N/A
	12-month f/u	27	89.4	25/60	48/52	0	0	N/A
SV2	Pre	21	81.3	5/60	41/52	0	0	9/12
	Post	21	77.9	7/60	39/52	0	0	N/A
	3-month f/u	21	79.8	9/60	38/52	0	0	N/A
	6-month f/u	23	75.7	6/60	35/52	0	0	N/A
	12-month f/u	14	66.2	5/60	32/52	0	0	N/A
SV3	Pre	24	90.1	27/60	46/52	0	0	9/12
	Post	28	89.1	28/60	47/52	0	0	N/A
	3-month f/u	26	89.0	24/60	48/52	0	0	N/A
	6-month f/u	25	87.0	20/60	47/52	0	0	N/A
	12-month f/u	18	82.5	18/60	48/52	0	0	N/A

Note. A dash means that data collection was planned but not completed due to participant factors. An N/A means that the researchers did not plan to administer a given test at follow-ups. NFV = nonfluent/agrammatic variant primary progressive aphasia; LV = logopenic variant primary progressive aphasia; SV = semantic variant primary progressive aphasia; f/u = follow-up; N/A = not applicable.

^aCould not administer writing tasks due to motoric difficulties.

Clinician

The intervention was provided by a speech-language pathologist (K.S.M.) with over a decade of clinical experience, including 5 years of experience with assessment and treatment of persons with PPA, and specialized training in counseling at the graduate level, including coursework in CBT, family-centered counseling, grief counseling, mindfulness, and motivational interviewing. Moreover, the clinician collaborated with CBT-trained mental health professionals while designing and implementing the intervention to ensure that the aphasia-adapted CBT provided in this study aligned with overarching CBT principles.

Experimental Design and Procedure

Treatment for each participant included speech-language intervention, counseling, and independent practice activities. Individuals with nfvPPA, with core deficits in grammar and/or motor speech, participated in Video Implemented Script Training for Aphasia (VISTA; Henry et al., 2018). Given core deficits of anomia in lvPPA and svPPA, participants with these phenotypes engaged in Lexical Retrieval Cascade Treatment (LRCT; Henry et al., 2013, 2019). Consistent with protocols reported in previous studies (Henry et al., 2018, 2019), VISTA participants completed a fixed number of 12 total sessions, while LRCT participants completed between 16 and 24 sessions, depending on performance on naming probes. Counseling was provided following speech-language treatment during a subset of eight sessions, a dosage that aligns with brief-CBT recommendations (Cully & Teten, 2008). Participants engaged in individualized, twice weekly treatment sessions with the clinician. Speech-language treatment lasted approximately 45 min to 1 hr, while counseling was provided for approximately 30 min. Moreover, if participants demonstrated emotional distress during the speech-language portion of treatment sessions, then counseling was offered as a teachable moment.

Participants also engaged in a brief, structured telephone conversation with the clinician once weekly targeting the script- or word-set-in-training, to promote generalization of speech-language skills. While we initially planned to offer in-person or virtual treatment delivery options, all phases of the study were ultimately conducted via telerehabilitation. This was due to either the participant's distance from the research site or coronavirus precautions rendering it unfeasible to conduct in-person assessments and treatment.

Selection of Treatment Targets

Prior to engaging in the script training or word retrieval intervention, all participants collaborated with the clinician to identify personalized, functional treatment targets. VISTA participants developed six scripts with the clinician, selecting topics that were functionally relevant (see Schaffer et al., 2021, or Henry et al., 2018, for further script development details). Four scripts were trained, while two remained untrained. Once scripts were finalized, videos were created for independent practice. These videos featured a close-up of the mouth of a healthy, gender-matched adult producing exaggerated articulatory gestures while reciting each script. The speech rate was tailored for each participant based on their maximum attainable speaking rate (see Schaffer et al., 2021, for script rate details). Before the active treatment phase commenced, participants were provided instructional support and practice opportunities to engage in unison speech production (or “speech entrainment”; Fridriksson et al., 2012) with the training videos. Feedback was provided by the clinician, as needed, to facilitate optimal independent practice.

LRCT participants selected items that were functionally relevant and consistently difficult to name. They were encouraged to take photos of these items, if possible, to create a personalized corpus of treatment targets. For participants who were unable to generate enough items independently, supplemental photos of functional items were used. Potential target items were probed three times pretreatment. Items were selected for treatment if a participant was unable to correctly name an item on at least two of three occasions. Treatment targets were grouped into 10 five-word sets. Items were quasirandomized into eight trained sets and two untrained sets (see Henry et al., 2019, for word set balancing details).

Speech-Language Intervention

Under the VISTA treatment framework, participants completed a series of tasks designed to promote memorization and conversational usage of scripted content. Tasks provided multiple opportunities to practice rehearsing the script-in-training, use scripted content in structured conversation, and improve the grammatical integrity of sentences and articulatory accuracy of challenging words (seeTable 3; for further treatment details, see Henry et al., 2018). The primary linguistic outcome measure for VISTA was percent correct, intelligible scripted words.

Table 3.

Video Implemented Script Training for Aphasia (VISTA) treatment regimen (based on Henry et al., 2018).

Probing: Participant completes trained and untrained script probes at the start of each session. If criterion is met (during Sessions 1 and 2 for a given script) on primary linguistic outcome measure and participant successfully engages in unison speech production for trained script, then speaking rate of VISTA video is increased by 10% for independent practice.
VISTA Treatment Steps:
	1. Recall/recognize	Participant chooses each correct script sentence from four foil sentences
	2. Organize/construct	Participant puts script sentences in order
	3. Read	Participant reads script aloud
	4. Respond to questions in scripted order	Participant produces scripted sentences from memory in response to questions (in order of script)
	5. Produce script from memory	Participant recites entire script
	6. Respond to questions with scripted sentences	Participant responds to questions with scripted sentences (not in order of script)
Structured Conversation: During the second treatment session for each script, participant engages in unscripted conversation with a naive communication partner regarding the script topic.
Weekly Phone Call: On a nontreatment day, participant engages in structured conversation pertaining to script-in-training for 5–10 min with clinician.
Independent Practice: Participant engages in daily unison speech production independent practice with script-in-training.

For LRCT participants, treatment consisted of strategic tasks designed to promote naming of specific target items via guided retrieval of residual semantic, orthographic, and phonological information. The training sequence focused on self-cueing via semantic feature analysis as well as phonemic and orthographic self-cueing strategies (see Table 4; for further information regarding treatment steps, see Supplemental Material S1). The primary linguistic outcome measure for LRCT was accuracy with naming trained/untrained targets during probes conducted at the beginning of each session.

Table 4.

Lexical Retrieval Cascade Treatment steps (adapted from Henry et al., 2013, 2019).

Treatment step	Description
1. Semantic self-cue	Picture presented for naming; clinician prompts semantic description and/or episodic/autobiographical information.
2. Orthographic self-cue	Clinician prompts written form of the word.
3. Phonemic self-cue	Clinician prompts initial phoneme.
4. Oral reading	If item it not yet named, clinician provides written word form and participant reads aloud.
5. Orthographic and spoken repetition	Participant writes and says target word three times.
6. Generative naming	Participant generates items from semantic category of target item.
7. Spoken and written recall of target	Participant says the name of target word and writes it down one time.
8. Picture description task	Participant sees target item embedded in a complex picture and is instructed to describe the picture using the target item name.
9. Create sentences using target word	Participant formulates two to three sentences that contain the target word.

Counseling Intervention

During the aphasia-modified CBT intervention component, the first counseling session included psychoeducation about the basic premise of CBT and segued into goal setting. Communication-centered counseling goals were created through a process of clinician-guided, open-ended questioning about the participant's experiences, values, and particular aspects of their life they wanted to change. For the remaining counseling sessions, aphasia-modified CBT techniques were used to address specific communication-oriented challenges to collaboratively work toward the participant's established goals (see Table 5; the treatment manual may be accessed at https://doi.org/10.17605/OSF.IO/8RDC2 Schaffer Mendez et al., 2026a).

Table 5.

Aphasia-modified cognitive-behavioral therapy (CBT) components (Schaffer et al., 2021; includes procedures adapted from Beck, 2011).

Treatment step	Description
1. Mood check	Establish frequency, duration, and intensity of overriding mood that week.
2. Review previous independent practice	Ensure that independent practice task was attainable and conducted appropriately.
3. Prioritize the agenda	Collaboratively select most concerning communication problem to address.
4. Aphasia-modified CBT skills training	Clinician guides participant through CBT techniques to respond in a more helpful manner to maladaptive communication-centered thoughts.
5. Create new independent practice task(s)	Collaboratively create tailored independent practice assignment.
6. Session summary and feedback	Clinician summarizes session and participant provides feedback.
Independent practice: On nontreatment days, participant completes tailored CBT tasks.

Counseling techniques varied from person to person and included behavioral experiments (activities to test the veracity of automatic thoughts or beliefs), behavioral activation (identifying and scheduling pleasurable activities in daily life), exposure hierarchies (creating incremental steps for individuals to gradually confront feared or anxiety-inducing communication situations), and stress reduction techniques (includes visualization, diaphragmatic breathing, progressive muscle relaxation, and mindfulness practices). The clinician selected specific counseling techniques based on the communication-centered challenges faced by each participant. For example, if a participant reported that they became anxious when attending social gatherings, then stress reduction techniques were trained and practiced so that the participant could utilize those coping techniques prior to engaging in social settings. These techniques were intended to promote well-being and/or facilitate cognitive restructuring, such that the participant's thoughts, feelings, and behaviors shifted toward being more adaptive or positive. The aphasia-based modifications included multimodal supports to ensure comprehension of counseling concepts.

Independent Practice

On days when participants did not meet with the clinician for treatment, they were instructed to engage in daily, independent practice tasks. Independent speech-language training was completed via Qualtrics, a web-based software platform that automatically recorded independent practice frequency and duration. ² For VISTA, participants were provided a practice video for their current script and were instructed to recite their script in unison with the speaker (Fridriksson et al., 2012; Henry et al., 2018; Schaffer et al., 2021) for 30 min daily.

For LRCT, participants rehearsed their current set of words using a modified version of Copy and Recall Treatment (Beeson & Egnor, 2006). Individuals were presented with an image of a treatment target and were instructed to write and say the item name 10 times, recall the name of the item from memory, and answer multiple choice questions about the item's attributes. Participants typically completed this task in 15 min.

In addition to speech-language practice, participants engaged in tailored counseling tasks on nontreatment days. These tasks served as an extension of aphasia-modified CBT sessions, so that participants could practice integrating various coping strategies into their daily life. Examples of independent practice tasks include completing Thought Records where participants wrote down thoughts, feelings, and behaviors associated with communication challenges; reading coping cards, which were words or phrases that the participants referenced when they noticed maladaptive thoughts; or practicing relaxation exercises to minimize stress.

Posttreatment and Follow-Up Testing

Following the conclusion of the active treatment phase, participants engaged in posttreatment speech, language, cognitive, and psychosocial testing. To determine the potential long-term communicative and psychosocial benefit of this intervention, follow-up testing was conducted at 3-, 6-, and 12-month posttreatment time points for six participants. Only one lvPPA participant completed a 6-month follow-up; otherwise, none of the three lvPPA participants were able to participate in follow-up testing through the 12-month time point due to significant symptom progression, unrelated medical complications, and/or personal reasons. (see Table 2 and Supplemental Material S2 for posttreatment and follow-up data).

Outcome Measures and Statistical Analyses

Treatment Acceptability. To answer Research Question 1, pertaining to acceptability, participants completed the CSQ-8 (Larsen et al., 1979) after treatment ended. This eight-question Likert scale survey allows participants to reflect on their therapeutic experience.

Treatment Feasibility. To address Research Question 2, regarding treatment feasibility, we measured participant adherence/engagement factors, an intervention implementation factor, and assessment factors. Participant adherence/engagement factors included adherence/receipt of intervention (the percentage of participants who completed the intervention; the percentage of sessions completed), engagement in intervention (the percentage completion of independent practice), and retention (overall retention rate at posttreatment and follow-up phases). The intervention implementation factor refers to structured fidelity ratings. Treatment fidelity was evaluated for all participants to assess the clinician's adherence to VISTA or LRCT treatment protocols. To evaluate fidelity, two trained undergraduate or graduate research assistants reviewed 25% of all treatment sessions. These sessions were randomly selected and independently rated for correct execution of treatment steps.

Assessment factors included completion rate (the percentage completed for each assessment measure at each time point) and reliability of the primary linguistic outcome measure (derived via interrater reliability). For VISTA participants, interrater reliability was evaluated for the primary linguistic outcome measure of percent correct, intelligible scripted words. The two raters included the treating clinician (K.S.M.) and a trained undergraduate or graduate research assistant. The clinician indicated each participant's performance during assessment and treatment sessions and reviewed video recordings, as needed, to ensure reporting accuracy. A research assistant, blinded to time point and treatment condition (i.e., trained or untrained script) performed the following: watched video probes from 25% of the pretreatment, treatment, and posttreatment sessions; typed transcriptions of the participant's scripted responses; and indicated which target words were present in their transcribed response. Point-by-point agreement was used to obtain interrater reliability. The total number of agreements between the two raters was divided by the total number of agreements and disagreements, and the total was multiplied by 100 (Kazdin, 1982). Given that the primary linguistic outcome measure in LRCT is production of a single word, we did not complete a reliability analysis for this treatment.

Speech-language Treatment Outcomes. For Research Question 3 regarding response to speech-language training components of the intervention, performance was evaluated in one of two ways, depending on the type of intervention. For VISTA participants, the primary linguistic outcome measure was percent correct, intelligible scripted words, while for LRCT participants, the primary linguistic outcome measure was percentage of items correctly named. Three probes were obtained at both the pretreatment and posttreatment time points. Each participant's performance from pre- to posttreatment was analyzed individually using hypothesis testing via simulation in R software (Version 4.4.1 [2024-06-14]; Grasso et al., 2021; Schaffer et al., 2021). A simulated distribution of either script performance accuracy or item-naming accuracy was obtained at each time point to assess the significance of change from pre- to posttreatment and from pretreatment to each follow-up time point (i.e., 3, 6, and 12 months). With the simulation, a random sampling using probabilities of correct and incorrect responses was performed on an item-by-item basis. Thus, simulated data sets resembling the actual data were created. Every simulation was run 10,000 times, generating 10,000 simulated distributions of a participant's performance for each time point (i.e., two pretreatment probes, two posttreatment probes, and one probe at 3-, 6-, and 12-month follow-ups) for trained and untrained scripts/words. Significance (p values) was determined by comparing the distributions from the two time points within a trained or untrained condition. To control for familywise error, Bonferroni correction was used (p < .0125). Furthermore, difference scores were calculated using the simulated data in order to establish 95% confidence intervals of the observed differences.

Psychosocial and Communicative Functioning Outcomes. To answer Research Question 4, regarding psychosocial benefits of treatment, we used mixed-methods analyses to contextualize outcomes. To minimize the potential for bias, across all time points, all psychosocial and communicative functioning measures were administered by a researcher (L.D.W.) who was unfamiliar to the participant.

Psychosocial and communicative functioning scales or subscales were administered to participants at pre- and posttreatment to evaluate change (or stability) across time points. These scales/subscales included the Communication subscale and Psychosocial subscale of the Stroke and Aphasia Quality of Life Scales (Hilari et al., 2003), which measures health-related quality of life; the Positive and Negative Affect Schedule (PANAS; Watson et al., 1988), which measures mood; the Communication subscale, Social Relationships subscale, Negative Feelings subscale, and Positive Feelings subscale of the Burden of Stroke Scale (BOSS; Doyle et al., 2004), which measures functioning and well-being in survivors of a stroke; and the Aphasia Communication Outcome Measure (Hula et al., 2015), which was designed to evaluate communicative functioning poststroke. Given that we did not have specific predictions regarding differential psychosocial response to intervention across VISTA and LRCT arms of the study, we evaluated change on psychosocial and communicative functioning assessments at the whole group level. While this Phase 1B pilot sample was not intended or powered to detect statistically reliable change, we used Wilcoxon signed-ranks tests to compare performance at pre- versus posttreatment. The analysis was performed using the stats package in R (Version 4.4.1 [2024-06-14]). False discovery rate (FDR) correction was applied to adjust for multiple comparisons.

We also evaluated psychosocial functioning qualitatively through a phenomenological analysis of pre- and posttreatment interviews. For qualitative outcomes from this study, see Schaffer Mendez et al. (2026b).

Results

All data reported in this article were collected between August 2020 to February 2023.

Treatment Acceptability

Research Question 1 addressed treatment acceptability. Participants reported an average satisfaction rating of 28.67 out of 32 possible points on the CSQ-8 (see Table 6 for individual participant responses and survey questions). Following assessment interpretation guidelines, scores between 0 and 23 indicate poor to fair satisfaction, while scores ranging from 24 to 32 indicate moderate to high satisfaction (Skidmore et al., 2014). Thus, averaged responses across participants indicate that this intervention was acceptable at the group level. On an individual level, eight participants reported moderate to high satisfaction, and one participant (LV3) reported fair satisfaction (score of 20).

Table 6.

Individual participant responses and total scores on the Client Satisfaction Questionnarie–8 (Larsen et al., 1979).

Participant ID	Survey question
	#1.	#2.	#3.	#4.	#5.	#6.	#7.	#8.	Total score
NFV1	4	3	4	4	4	3	4	3	29
NFV2	4	3	3	4	3	3	4	3	27
NFV3	4	4	3	4	4	4	4	4	31
LV1	4	4	4	4	4	4	4	4	32
LV2	3	4	3	4	3	3	4	4	28
LV3	3	1	3	4	1	2	3	3	20
SV1	4	4	4	4	4	4	4	4	32
SV2	4	3	3	4	4	3	3	4	28
SV3	4	4	4	4	4	3	4	4	31

Note. Responses ranged from 1 to 4, with 4 indicating the most favorable response. Questions included the following: #1. How would you rate the quality of rehabilitation you received? #2. Did you get the kind of rehabilitation you wanted? #3. To what extent has our rehabilitation program met your needs? #4. If a friend needed similar help, would you recommend our rehabilitation program? #5. How satisfied are you with the amount of rehabilitation assistance you have received? #6. Have the services you received helped you to deal more effectively with your challenges? #7. In an overall, general sense, how satisfied are you with the rehabilitation you have received? #8. If you were to seek help again, would you come back to our rehabilitation program? NFV = nonfluent/agrammatic variant primary progressive aphasia; LV = logopenic variant primary progressive aphasia; SV = semantic variant primary progressive aphasia.

Treatment Feasibility

Research Question 2 addressed treatment feasibility (see Table 7). With respect to participant adherence/engagement factors, 100% of participants completed the intervention and 100% of participants attended all sessions (adherence/receipt of intervention); 100% of participants engaged in counseling independent practice and, on average, participants demonstrated a 76.16% completion rate of speech-language independent practice (engagement in intervention). The retention rate relative to pretreatment was 100% at posttreatment, 66.67% at the 3- and 12-month follow-ups, and 78.78% at the 6-month follow-up. Regarding the intervention implementation factor, fidelity was high, at 100% for VISTA and 99.94% for LRCT. With respect to assessment factors, the average completion of speech-language assessments and psychosocial/communicative functioning measures was 100% at pre- and posttreatment, 66.76% at 3- and 12-month follow-ups, and 77.78% at the 6-month follow-up. Interrater reliability across VISTA participants was high at 99.73%.

Table 7.

Acceptability and feasibility metrics.

Factors	Components	Measurement	Criteria for success/outcomes
Acceptability factor	Acceptability rating	Client Satisfaction Questionnaire–8 (CSQ-8; Larsen et al., 1979)	Criteria: A group mean of > 28 (out of 32) will indicate treatment acceptability (Skidmore et al., 2014) Outcome: Group mean = 28.67
Participant adherence/engagement factors	Adherence/receipt of intervention (Diaz Baquero et al., 2022; Di Lorito et al., 2020; Mosca et al., 2020; Rossetto et al., 2023)	− % participants who complete intervention − % sessions completed	Criteria: − 80% completion − 80% attendance across sessionsOutcome: − 100% intervention completion − 100% attendance across sessions
	Engagement in intervention (Bowen et al., 2009; Shafayat et al., 2019)	− % completion of independent practice	Criteria: 90% completion rateOutcome: − 100% engagement in counseling independent practice across participants − 76.16% averaged speech-language independent practice completion
	Retention	− Number of dropouts, reasons for dropout (related to intervention or not) − Overall retention rate at final assessment and follow-ups	Criteria: 90% retention at posttreatmentOutcome: − 100% retention at posttreatment − 66.67% retention at the 3-month follow-up − 77.78% retention at the 6-month follow-up − 66.67% retention at the 12-month follow-up − All participants completed the treatment phase and follow-up testing − 6/9 participants completed 3-month follow-up − 7/9 completed 6-month follow-up − 6/9 completed 12-month follow-up − Reasons for dropout: PPA progression, unrelated medical concerns, and/or personal reasons
Intervention implementation factor	Delivery of intervention (Fidelity)	− Structured fidelity ratings by blinded rater	Criteria: 80% correct = acceptableOutcome: − 100% for VISTA − 99.94% for LRCT
Assessment factors	Completion rates	− % completed for questionnaires and assessment measures at each time point	Criteria: 90% completion rate at posttreatmentOutcome: − 100% completed pre- and posttreatment measures − 66.67% completed 3-month follow-up measures − 77.78% completed 6-month follow-up measures − 66.67% completed 12-month follow-up measures
	Reliability of primary language outcome measures	− Interrater reliability (percent agreement)	Criteria: 80% agreementOutcome: − 99.73% for VISTA

Note. PPA = primary progressive aphasia; VISTA = Video Implemented Script Training for Aphasia; LRCT = Lexical Retrieval Cascade Treatment.

Immediate and Long-term Speech-Language Response to Treatment

With regard to Research Question 3, hypothesis testing via simulation indicated a significant, positive difference (see Table 8) on the primary linguistic outcome measure from pre- to posttreatment for all participants for trained targets (i.e., scripts; naming of items). Additionally, two VISTA participants also demonstrated a significant, positive difference on untrained targets from pre- to posttreatment. Follow-up data indicated a significant positive difference on the primary linguistic outcome measure from pretreatment to the 3-, 6-, and 12-month follow-up time points for five out of six participants (see Table 9).

Table 8.

Comparison of pre- versus posttreatment performance for trained and untrained scripts/word sets using hypothesis testing via simulation.

Condition	Trained				Untrained
Participant ID	Pre-Tx trained targets	Post-Tx trained targets	p	95% Confidence interval for change scores	Pre-Tx untrained targets	Post-Tx untrained targets	p	95% Confidence interval for change scores
NFV1	18.36%	94.06%	< .0001	[69.91, 81.94]	14.06%	51.61%	< .0001	[26.79, 49.11]
NFV2	10.44%	78.74%	< .0001	[63.18, 74.66]	13.22%	46.88%	< .0001	[24.31, 43.75]
NFV3	56.14%	99.78%	< .0001	[37.61, 50.44]	52.34%	58.11%	.17	[−6.84,18.80]
LV1	5.00%	78.82%	< .0001	[60.00, 87.50]	6.67%	30.00%	.08	[−10.00, 60.00]
LV2	4.17%	50.59%	< .0001	[30.00, 62.50]	3.33%	5.00%	.43	[−10.00, 20.00]
LV3	8.33%	51.77%	< .0001	[27.50, 62.50]	6.67%	10.00%	.41	[−20.00, 30.00]
SV1	5.83%	100%	< .0001	[85.00, 100.00]	0.00%	25.00%	.03	[0.00, 50.00]
SV2	0.00%	22.35%	< .001	[10.00, 35.00]	0.00%	5.00%	.30	[0.00, 20.00]
SV3	7.50%	75.29%	< .0001	[50.00, 82.50]	0.00%	15.00%	.10	[0.00, 40.00]

Note. Tx = treatment; NFV = nonfluent/agrammatic variant primary progressive aphasia; LV = logopenic variant primary progressive aphasia; SV = semantic variant primary progressive aphasia.

Table 9.

Comparison of pretreatment versus follow-up performance for trained scripts/word sets using hypothesis testing via simulation.

Participant ID and time point	Pre-Tx trained targets	Follow-up trained targets	p	95% Confidence interval for mean simulated treatment effect
NFV1: 3-month f/u	18.36%	90.55%	< .0001	[66.2, 79.12]
NFV1: 6-month f/u	18.36%	57.60%	< .0001	[31.48, 48.15]
NFV1: 12-month f/u	18.36%	29.97%	< .01	[3.70,19.91]
NFV2: 3-month f/u	10.44%	94.24%	< .0001	[79.39, 88.18]
NFV2: 6-month f/u	10.44%	92.20%	< .0001	[77.36, 86.49]
NFV2: 12-month f/u	10.44%	96.61%	< .0001	[82.77, 90.88]
NFV3: 3-month f/u	56.14%	100.00%	< .0001	[37.61, 50.44]
NFV3: 6-month f/u	56.14%	100.00%	< .0001	[37.61, 50.44]
NFV3: 23-month f/u	56.14%	100.00%	< .0001	[37.61, 50.44]
LV1: 6-month f/u	5.00%	30.00%	< .001	[10.00, 40.00]
SV1: 3-month f/u	5.83%	92.50%	< .0001	[75.00, 97.5]
SV1: 6-month f/u	5.83%	92.50%	< .0001	[7.50, 30.00]
SV1: 12-month f/u	5.83%	97.50	< .0001	[82.50, 100]
SV2: 3-month f/u	0.00%	22.50%	< .0001	[10.00, 37.50]
SV2: 6-month f/u	0.00%	17.50%	< .001	[7.50, 30.00]
SV2: 12-month f/u	0.00%	2.50%	.15	[0.00, 10.00]
SV3: 3-month f/u	7.50%	77.50%	< .0001	[55.00, 85.00]
SV3: 6-month f/u	7.50%	37.50%	< .001	[12.50, 47.50]
SV3: 12-month f/u	7.50%	32.50%	< .01	[7.50, 42.50]

Note. Tx = treatment; NFV = nonfluent/agrammatic variant primary progressive aphasia; f/u = follow-up; LV = logopenic variant primary progressive aphasia; SV = semantic variant primary progressive aphasia.

Psychosocial and Communicative Functioning Outcomes

Regarding participants' psychosocial and communicative functioning outcomes (Research Question 4) from pretreatment to posttreatment, Wilcoxon signed-ranks tests did not reveal any significant changes from pre- to posttreatment (ps > .05 with FDR correction; see Table 10). While not statistically significant, both the BOSS Negative Feelings subscale and PANAS Negative Affect subscale showed numerical increases at posttreatment and large effect sizes, consistent with an increase in negative affect/feelings at posttreatment. Comparisons with follow-up time points were not possible due to missing data in three of nine participants.

Table 10.

Comparison of psychosocial and communicative functioning outcomes at pre- versus posttreatment using Wilcoxon signed-ranks tests.

Measure	Time point	M (SD)	Statistic (W)	FDR-corrected p value	Effect size (rank biserial correlation)
SAQOL Communication subscale	Pre	3.72 (0.86)	20	.79	−.43
	Post	3.51 (0.93)
SAQOL Psychosocial subscale	Pre	3.76 (0.66)	19	1.00	−.06
	Post	3.65 (0.63)
PANAS Positive subscale	Pre	28.00 (10.40)	13.5	.79	.40
	Post	32.22 (8.48)
PANAS Negative subscale	Pre	15.11 (4.57)	9	.54	.60
	Post	16.78 (2.99)
BOSS Communication subscale	Pre	41.67 (14.94)	10	.88	−.33
	Post	39.68 (15.91)
BOSS Social Relationships subscale	Pre	26.67 (16.20)	17.5	1.00	.03
	Post	27.78 (13.49)
BOSS Negative Feelings subscale	Pre	23.61 (19.96)	0	.12	1.00
	Post	40.28 (14.36)
BOSS Positive Feelings subscale	Pre	47.22 (17.43)	11.5	1.00	−.10
	Post	44.44 (16.96)
ACOM T score	Pre	52.08 (6.35)	23	.88	−.28
	Post	50.76 (6.72)

Note. FDR = false discovery rate; SAQOL = Stroke and Aphasia Quality of Life Scales; PANAS = Positive and Negative Affect Schedule; BOSS = Burden of Stroke Scale; ACOM = Aphasia Communication Outcome Measure.

At least half of the participants in the current study reported stability or a positive change on seven out of nine psychosocial and communicative functioning scales and/or subscales from pre- to posttreatment (see Supplemental Material S2). Overall, however, variability in scores was observed across participants, measures, and time points. That is, psychosocial functioning outcomes varied from pre- to posttreatment in the positive or negative direction. Additionally, some participants reported stability over time (meaning that their scores were unchanged from one time point to another). Thus, no clear pattern emerged relative to changes in psychosocial and communicative functioning immediately following intervention or longitudinally. This contrasts with qualitative findings from this study, in which participants reported positive psychosocial and communication changes following the intervention (Schaffer Mendez et al., 2026b).

Discussion

Results from this small-group Phase 1B pilot study indicate that pairing aphasia-modified CBT with interventions targeting core speech-language domains (i.e., VISTA; LRCT) is acceptable and feasible for individuals with mild to moderate PPA. Exploratory analyses indicate preliminary positive communication outcomes and suggest that an alternative psychosocial measure is warranted for future phases of this research. This study also contributes to the modest body of evidence in PPA treatment research supporting the use of telerehabilitation as a service delivery option (Dial et al., 2019; Henry et al., 2018, 2019; Schaffer et al., 2020, 2021).

Active Ingredients and Mechanisms of Change in Treatment Model

The decision to pair aphasia-modified CBT with the specific speech-language interventions of VISTA or LRCT was intentional and motivated by several factors. Both communication approaches are personally tailored and are yoked to core PPA impairments. Importantly, these interventions differ from errorless learning approaches or script training with standardized scripts that do not hold personal relevance. With VISTA, scripts are designed to contain personally relevant material, some of which may be emotionally laden (e.g., PPA disclosure and former careers). Thus, individuals may notice that automatic maladaptive thoughts or distressing feelings arise during treatment sessions or independent practice with their scripts. With LRCT, individuals are trained to use self-cueing strategies when they encounter word-finding difficulties. As such, their success with implementing these strategies in sessions or in daily life may also provide opportunities to reflect on the CBT triad of thoughts, feelings, and behaviors associated with anomia. Both approaches, therefore, offer direct opportunities for individuals with PPA to face maladaptive thoughts and difficult feelings and work toward adopting more adaptive responses.

We propose that a key component of this combined intervention is the opportunity to provide in-the-moment counseling when individuals encounter challenging thoughts or emotions during the speech-language portion of treatment. These moments serve as teachable instances for practicing the application of CBT principles. These teachable moments may illuminate the value of CBT to individuals with PPA and make the principles of this counseling approach more tangible and relatable than a hypothetical discussion about prospective use of CBT in different communication contexts.

Combining these approaches may yield a synergistic benefit that leads to not only improved psychosocial adjustment but also improved effort, motivation, and engagement (vs. avoidance) during speech-language treatment and daily life. However, it may also be the case that, in accordance with the common factors theory in psychotherapy (Cuijpers et al., 2019; Rosenzweig, 1936), different evidence-based approaches may yield similar outcomes. These common factors, which are universal across treatment types, may include the therapeutic alliance, an acceptable intervention rationale, an understanding of treatment expectations, and the provision of hope. Participant-generated feedback reported in a complementary paper (Schaffer Mendez et al., 2026b) support the notion that these common factors were upheld in treatment. Further research is needed to characterize potential interactions among various treatment components.

Exclusion Criteria and Participant Representation

We excluded individuals with acute onset of a mood or anxiety disorder requiring immediate intervention by a mental health professional. Relatedly, recent placement on psychotropic medication was also exclusionary. Consistent with standard practice in psychotherapeutic studies, participants were required to demonstrate 3 months of stability on a psychotropic medication before being offered enrollment (e.g., Clark et al., 1999). While these procedures were in place to ensure that an individuals' mental health needs were being comprehensively met and to achieve experimental control, it is likely that certain individuals were excluded from this study who are representative of the PPA population, and these individuals may have also benefited from the intervention. Given that depression and anxiety are common in PPA (Medina & Weintraub, 2007; Rohrer & Warren, 2010), the exclusionary barriers enforced in the current study may have resulted in a participant sample that is not fully representative of the PPA population.

Moreover, the individuals recruited in the current study presented with mild-to-moderate communication impairments. Future studies are warranted, wherein counseling is provided for individuals with PPA who demonstrate more severe impairments to inform clinical practice across the full continuum of clinical severity. Consistent with CBT for individuals with dementia (e.g., Spector et al., 2015; Tay et al., 2019), treatment modifications may include increased scaffolding, spaced retrieval to facilitate retention of new concepts, and care partner involvement during sessions. Involving care partners in the treatment dynamic may facilitate functional use and carryover of coping strategies into daily life, and investigating the potential psychosocial benefit experienced by care partners may be an additional area of investigation.

Participant Removed From Current Study

Notably, there were originally 10 individuals enrolled in this study. However, one participant with lvPPA was removed from the cohort, given a steep decline in cognitive status including disorientation, paranoia, and short-term memory deficits, which required treatment protocol modification and simplification to the LRCT and aphasia-modified CBT components midway through the intervention. The participant's spouse was present during sessions and independent practice to facilitate the participant's success with treatment and to ensure carryover of recommended communication and coping strategies in daily life. At posttreatment, the participant completed the CSQ-8, with a score of 30 (out of 32), indicating high satisfaction with and acceptability of the intervention. The spouse reported that the intervention was beneficial, indicating that different CBT coping strategies were helpful for his wife and stating that he could not envision any adjustments to the treatment that could have improved their experience. Treatment modifications made with this participant may be considered in the future, when enrolling individuals with moderate–severe linguistic profiles and/or concomitant cognitive, behavioral, or motoric impairment (“PPA-plus”) presentations.

Emotional Attunement, Personality, and Cultural Considerations

This intervention provided an opportunity for participants to face difficult thoughts, feelings, and behaviors associated with their diagnosis. Several of the participants and their care partners reported that the person with PPA was not attuned to their emotions prior to engaging in the treatment program. There is a possibility that participants demonstrated the “response shift” phenomenon, whereby their internal scale regarding a given construct changed over time (Howard et al., 1979). In this study, some participants may have underestimated their status on psychosocial measures at pretreatment and indicated higher levels of psychosocial impact at posttreatment in the context of processing their diagnosis and grieving. This phenomenon may explain the observed increase in numerical ratings (and large effect sizes) from pre- to posttreatment on the BOSS Negative Feelings subscale and the PANAS Negative Affect score.

Additionally, while most participants were open to discussing all three elements of the CBT triad of thoughts, feelings, and behaviors, three participants (i.e., NFV1, LV2, LV3) demonstrated reluctance to talk about their innermost thoughts and feelings. These individuals also developed communication–counseling goals that were more oriented toward behaviors/actions rather than introspection. All three participants who gravitated toward the more behaviorally focused CBT approach were octogenarians and represented the oldest participants in this study. These individuals also reported that they had never received psychotherapy in the past. Moreover, the care partners of all three participants anecdotally reported that factors such as personality (e.g., being stoic, practical, and/or not emotionally expressive) and culture (i.e., being Scandinavian) likely influenced these individuals' mindset toward the counseling process. Thus, it is possible that adapting other psychotherapeutic approaches, such as positive psychotherapy (Seligman et al., 2006) or solution-focused brief therapy (de Shazer et al., 1986) may have been a better fit for these individuals, as these treatments are less oriented toward thoughts and feelings.

Stage of Research and Implications for Design of a Future Efficacy Trial

While results from this study are promising, several issues must be addressed in considering next steps for clinical trial progression. Given that PPA is rare and that the current study was a pilot and feasibility study, the small sample size is justified. However, future studies, recruiting larger and more diverse samples, are warranted to support the generalizability of these findings and to ensure that the enrolled participants represent the PPA population at-large.

With respect to feasibility, we did not achieve long-term retention past the posttreatment time point for participants with lvPPA. Given the progressive nature of this disorder, longitudinal follow-ups are challenging and will be considered with caution in future research.

Qualitative analysis of participant interview data, reported elsewhere (Schaffer Mendez et al., 2026b), showed a clear pattern of psychosocial benefit following this treatment. By contrast, the psychosocial and communicative functioning measures used in this study did not document improved psychosocial and communicative functioning. Importantly, these scales were not normed for individuals with PPA, as there are no dedicated, psychometrically validated psychosocial scales that are publicly available. Given the discrepancy between qualitative and quantitative findings, future research in this area will require a reappraisal of the evaluation strategy (Czajkowski et al., 2015). This could involve validation of alternative psychosocial measures or CBT-specific measures (e.g., Aphasia Impact Questionnaire [Swinburn et al., 2019]; Cognitive-Behavioral Therapy Skills Questionnaire [Jacob et al., 2011]) in the PPA population or development of a bespoke measure comprising questions specifically targeting the anticipated improvements in psychosocial functioning that may result from counseling treatment.

Next Research Stage

This study is situated as Stage 1B research (Onken et al., 2014), with primary aims of pilot testing with a small group of individuals to establish acceptability and feasibility and with secondary aims of confirming preliminary evidence of treatment benefit and identifying appropriate outcome measures for this novel intervention. Given the findings from this study, this project is well positioned to enter a Stage II level of research to systematically evaluate treatment efficacy in a controlled research setting. However, the research could also benefit from additional preefficacy investigations, including an examination of more specific treatment outcome domains (e.g., mood, coping skills usage, quality of life) or alternative outcome measures. Additional preefficacy studies may also aim to better characterize treatment ingredients (e.g., dosage, altering complexity of treatment stimuli) to see how changes in the intervention framework impact patient response.

To date, only one clinician has provided this intervention. Thus, it is proposed that in Stage II research, different clinicians administer the treatment to further broaden the scope in determining treatment utility. Furthermore, since all participants in the current study received treatment via telerehabilitation, a key next step for Stage II research will be to recruit both local participants for in-person services and those using videoconferencing. This will help characterize the relative benefits of the treatment framework across different service delivery settings.

Limitations

Influence of the Pandemic

Given that this study was conducted at the height of the coronavirus pandemic, it is possible that the pandemic may have impacted psychosocial functioning more broadly. Research has shown that individuals in the general population face increased stress, anxiety, and depression amidst the uncertainty associated with a global health crisis (Mahmud et al., 2023). While the mechanisms are not well understood, reports of accelerated disease processes have been found in those with progressive disorders in the context of the pandemic (Hu et al., 2021). Several participants in the current study reported social isolation due to a combination of factors, including aphasia and the need to follow pandemic precautions. Moreover, two care partners anecdotally reported observing a more rapid decline in the communication functioning of their family member after the onset of the pandemic.

Notably, one of the participants (LV3) likely contracted COVID-19 during the treatment phase. Following the resumption of services, her daughter reported that the participant presented with more noticeable language and cognitive impairments and increased anxiety levels. These impressions were corroborated by the treating clinician, with the participant benefitting from increased support and instruction from research personnel and family to complete the treatment program.

Furthermore, this participant's responses from the acceptability survey and posttreatment interviews (see Schaffer Mendez et al., 2026b, for qualitative findings) diverged relative to other participants in this study. She demonstrated a high degree of frustration during posttreatment testing, and her responses on the acceptability survey revealed that, while she enjoyed working with the clinician and would recommend the program to a friend, she acknowledged a lack of improvement in PPA-related symptoms in the context of overall disease progression.

Training Needs of Speech-Language Pathologists

The clinician in the current study underwent specialized training in counseling beyond what is offered to graduate students in speech-language pathology. This training was a part of a doctoral coursework concentration in counseling, which complemented her major in speech, language, and hearing sciences. Extended training was instrumental for the clinician in comprehensively understanding and implementing CBT in its traditional form. This training provided a solid foundation for the clinician to pair CBT knowledge with an understanding of the needs of individuals with PPA, which informed the creation of an aphasia-adapted version of CBT. Currently, an estimated 40% of graduate programs in speech-language pathology offer counseling coursework (Doud et al., 2020). As such, most speech-language pathology students and practicing clinicians have not received sufficient training to provide specialized counseling. Therefore, when considering clinical implementation in the future, delivery of aphasia-adapted CBT will require that clinicians undergo training on the basic philosophy, tenets, and implementation of CBT before ethically providing such services to patients. Ideally, this type of training will be woven into speech-language pathology graduate curricula in the future or will be provided as continuing education opportunities to practicing speech-language pathologists.

Conclusions

Findings from this study support the acceptability and feasibility of a novel intervention that combines speech-language treatment with aphasia-modified CBT for individuals representing each of the canonical PPA subtypes. Results from this study also provide preliminary indication of the positive impact of this intervention on targeted communication skills. The mismatch between the quantitative and qualitative psychosocial outcomes (Schaffer Mendez et al., 2026b) suggests that the current evaluation strategy should be re-evaluated to support future efficacy research.

Data Availability Statement

De-identified data analyzed from this study may be shared by the corresponding author upon reasonable request.

Funding Statement

This work was funded by the National Institutes of Health through the National Institute on Deafness and Other Communication Disorders (1F31DC019044, principal investigator: Kristin Schaffer Mendez; R01DC016291 and R56DC016291, principal investigator: Maya L. Henry), the Council of Academic Programs in Communication Sciences and Disorders (awarded to Kristin Schaffer Mendez), and the American Speech-Language-Hearing Foundation (awarded to Kristin Schaffer Mendez). We are sincerely grateful for the participants and their families for their time and commitment to this research. We appreciate the statistical analysis support provided by Rachel Tessmer.