Social Interaction

1. Introduction

To be able to communicate is fundamental for social interaction. However, to interact can be an enormous challenge for people with communicative disorders. These disorders may be caused by developmental disorders, injury, or disease (Cummings, 2023). ln Sweden, the Communication Facilitation service "Taltjänst" was established in 1986 with the aim of bridging the gap caused by communication difficulties. This service provides specialized facilitators who assist in conversations across various contexts, from healthcare visits to leisure activities.

Despite its foundational role, "Taltjänst" is currently only available in six of Sweden's 21 healthcare regions. Even more troubling is the paucity of research in the field of supportive services of this kind. To date, only one study by Larsson and Thorén-Jönsson (2007) has examined this service. Given the varied backgrounds of communication facilitators, who are predominantly speech and language therapists or occupational therapists, and the absence of specialized training for this profession, there is a critical need to understand the practices and effectiveness of facilitator interventions.

The aim of "Taltjänst" is to enable participation, independence and authority to people who live with communicative disorders (Socialstyrelsen, 1997). There are, however, very few guidelines for the communication facilitators regarding how this aim is to be accomplished. When is support beneficial and when are communication troubles better handled by the main interactants themselves, to achieve the best possible independence of people with communicative disabilities? How communication facilitators work to support conversations has not yet been investigated. The assistance they provide may be widely described as flexible, tailored to the individual needs of clients and the context of conversations. The role of communication facilitators is not easily related to the more extensively investigated companion roles of family members (cf. Wolff & Roter, 2011). In a systematic review of triadic medical consultations conducted by Laidsaar-Powell et al. (2013, p. 7), the following roles of a companion were reported as most common: logistical assistance, informational support, emotional support, and addressing their own needs. Laidsaar-Powell et al. (2013) identified a need for greater focus on companion roles in research and a need to specify different characteristics and behaviours of different types of companions. One of the studies in the review employed direct observation of companions and identified the following functions and roles: memory aid, emotional support, transcriber, aid in decision-making, advocate for patient, elaboration provider, interpreter, and company provider (Ellingson, 2002, pp. 370-375). It remains to be investigated in what ways these or other functions are fulfilled by communication facilitators. The present study represents the first exploration of actions performed by communication facilitators. Ellingson (2002) also showed how companions' roles vary during interactions, taking into account both the companions' characteristics and activity levels. Interaction analytical studies on supported, triadic interaction (e.g., Antaki & Chinn, 2019; Pino & Land, 2022), demonstrate how roles are dynamically negotiated on a moment-by-moment basis, and emerge through participants' actions, including multimodal expressions.

Communication facilitators may take part in conversations face-to-face with the other interactants or remotely by video phone calls or phone calls (audio only). Remote conversations may take two forms: either all participants (three or more) are physically separated, or two participants engage in face-to-face conversation while the third participant joins remotely via video platform or telephone. In many cases, the communication facilitator and the clients with communicative disorders utilize various aids, such as paper and pen to foster mutual understanding. Consequently, the communication facilitator often works in the presence of the person with a communicative disorder, while the other interactant/interactants take part in the conversation remotely. This scenario is consistent with the conversations investigated in the present study, where the individuals with communicative disorders interact with their conversation partners via phone while receiving assistance from co-present communication facilitators. The contexts in which "Taltjänst" is employed vary from formal institutional settings to more informal ones, often involving healthcare matters or interactions with authorities.

In this study, the actions that communication facilitators perform for supportive purposes, will be referred to as "interventions". As the disorders may affect the abilities of persons to express themselves as well as the ability to perceive what others communicate, the facilitators may intervene after any contribution to the ongoing conversation. In the present study all transition-relevant places, i.e., junctures where a turn may pass from one speaker to another (Schegloff et al., 1974), are considered potential points for facilitator interventions. Thus, communication facilitators need to make quick decisions about whether to intervene or not, moment by moment throughout the real-life conversations in which they take part. So far, very little is known about the consequences of these decisions. This may be one of the reasons why the process and development of the service have been slow and why it is not yet widespread, despite results demonstrating that the service is highly appreciated by its users (Larsson & Thorén-Jönsson, 2007). From an international perspective, there are only a few equivalent services available on-site, explicitly focusing on supporting communication. Examples are Finland, which has a nationwide service similar to Taltjänst, and Canada, where 'communication assistants' have been offered on a trial basis with positive results (Collier et al., 2010). Collier et.al (2012) highlight the need for communication assistants for people with complex communication needs to get access to society. They also stress that formal training for those who work as communication assistants is needed.

The aim of the present study is to enhance understanding of how conversations between persons with communicative disorders and their conversation partners are supported by professional communication facilitators. This will be achieved through in-depth analysis of two different phone call conversations involving two clients utilizing the service. These clients exhibit varied communication difficulties, reflecting the diverse challenges faced by communication facilitators in "Taltjänst".

2. Communicative Disorders and Participation, Independence, and Authority

The World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) (World Health Organization, 2001) provides a framework for terminology as well as for an increased understanding of disorders and disability. In the ICF, disability is viewed as a complex construct of several factors in combination: not only the type and severity of disorder. Using the ICF framework, limitations on participation are seen as a fundamental part of what constitutes a disability. Participation is defined as "involvement in life situations" within the framework. Building on this definition and further descriptions of disability components in ICF, Eadie et al. (2006, p.4) define communicative participation as follows: "taking part in life situations where knowledge, information, ideas, or feelings are exchanged. It may take the form of speaking, listening, reading, writing, or nonverbal means of communication".

Communication disorders may have major negative impacts on participation and although the underlying causes of the disorders differ, individuals with communication disorders often experience comparable limitations in communicative participation, regardless of the specific underlying causes (Baylor et al., 2011). Limitations in participation also often affect participation and authority (WHO, 2001). In the present study, the clients who utilize the service have aphasia and dysarthria respectively. Both these conditions often result in restrictions when communicating with others in everyday life (Baylor et al., 2011). Aphasia and dysarthria are described in some more detail in the method section when the specific challenges of the participants are presented.

How communication disorders affect everyday interaction has been widely investigated in the field of conversation analysis and multimodal interaction analysis (Wilkinson et al., 2020). This field of research emphasizes the role of the conversation partner to the person with communicative disorders, and how speech is co-constructed to a higher degree than in "typical" conversation. People often engage in repair, i.e., they seek ways to adapt to problems in speaking hearing or understanding (Schegloff et al., 1977). In a typical interaction, there is normally a preference for self-repair when trouble occurs (Schegloff et. al., 1977) and other-corrections may be perceived as offensive or face-threatening (Lerner, 1996). In conversations where the person being corrected has a communication disorder, however, other-initiated repair or even other-correction may not expose face threat (Bloch & Beeke, 2008; Ferguson & Harper, 2010; Simmons-Mackie & Kagan, 1999). Barnes and Ferguson (2015) further demonstrate how conversation partners' reluctance to co-operate in repair activities can significantly hinder the participation of individuals with aphasia in social interactions.

2.1 Communication disorders and telephone support services

In phone call conversations that are only audio mediated, communicative disorders are often particularly troublesome due to the lack of multimodal cues such as gestures and other visual means of communication (Goodwin, 2003). Garcia et al. (2002) identified the demand to use the telephone as a major barrier against managing vocational roles for people with communicative disorders, regardless of diagnosis.

Professional assistance specifically aimed at supporting communication for individuals with speech, language, or voice disorder, such as the Swedish Communication Facilitating Service, remains uncommon worldwide, as previously mentioned. There are similar assistances, but services differ in their contents. Some countries offer so-called voice-to-voice relay services, i.e., the possibility to get remote assistance by a communication assistant during phone calls (International Telecommunications Union, 2021). Telephone relay services to people with communication disorders other than deafness and hearing loss have been mentioned briefly in scientific journals but with no studies of the service to rely on (Silverman, 1993; Silverman, 1997; Silverman & Schauer, 1996). More common are video relay services and speech-to-text services, enabling phone calls to people with deafness or hearing loss (cf., Warnicke & Granberg, 2022). The Swedish Video Relay Service has been studied from an interaction analytical perspective (e.g., Warnicke, 2017; Warnicke & Plejert, 2021), and similar to the Communication Facilitating Service, results demonstrate how the service enables increased autonomy and independence for its users. The identification of recurring interactional practices by the professionals working within the service has also been useful in developing education for Video Relay Service interpreters. Similarly, a close examination of interactional practices within communication-facilitated phone calls is assumed to be beneficial for the future training of communication facilitators and, consequently, for the development of the service.

3. Aims

The aim of this study is to contribute to the development of communication facilitation services. This will be conducted by investigating the involvement of the communication facilitator in two phone calls between two clients with different communicative disorders, one with dysarthria and one with aphasia, and their conversation partners. This study is guided by the following questions:

• When does the communication facilitator intervene in the conversations?
• When does the communication facilitator not intervene in the conversations?
• What are the similarities and differences in patterns of interventions between the call of the client with aphasia compared to the call of the client with dysarthria?

4. Method

4.1 Data and participants

The data consists of video recordings of two phone calls, which are summarized in Table 1. The calls were collected in the regular Swedish Communication Facilitation Service "Taltjänst". The research project was approved by the Swedish Ethical Review Authority (2017/591-31). Participants with communicative disorders received information and consent forms, which were supplemented with picture symbols in addition to the text. Additionally, communication facilitators verbally provided participants with information about the study, ensuring informed consent, based on their knowledge of their client's communicative disorders. Pseudonyms are used for the clients, the two participants with disorders: Rebecca and Olof. They were both in their fifties and well-known to the communication facilitators.

Table 1. Data

Rebecca has congenital dysarthria and very unclear speech. She uses some signs and finger spelling to support the intelligibility of her oral speech. However, her signs are difficult to distinguish because her motor impairments also affect the functions of her extremities. The phone call was made on Rebecca's initiative. She booked the communication facilitating service to make a call to a co-member of a disability rights organisation. In the call, Rebecca has some questions regarding the upcoming agenda of the organisation and shares some thoughts about the agenda with the conversation partner. The communication facilitator supporting Rebecca's speech has worked within the service for more than 15 years and is an occupational therapist by education. The duration of Rebecca's phone call is 6 minutes and 58 seconds, and it was recorded in 2016. The video camera captures Rebecca sitting at a table. The communication facilitator sits opposite Rebecca and is only occasionally and peripherally visible, but she is clearly audible throughout the interaction. They utilize a loudspeaker phone, allowing the conversation partner to also be audible in the recording.

Olof has aphasia, which impacts both his ability to produce and understand language. He experiences difficulty in generating utterances, which tend to be brief and require considerable time and effort. He frequently encounters word-finding problems, resorting to alternative, less specific words. His aphasia resulted from a stroke that occurred more than 10 years before the recording. Additionally, Olof experiences limited bodily functions due to hemiplegia. The duration of the phone call is 38 minutes and 39 seconds, recorded in 2019. The communication facilitator supporting this phone call is also an occupational therapist by training and has over 10 years of experience working in the service. Olof has not previously communicated to his conversation partner. Before the phone call, the communication facilitator contacted the conversation partner to explain that she was going to sit together with Olof and support him to express himself verbally if needed and explain what the conversation partner said to Olof in case he showed a lack of understanding. This phone call is planned as an interview conducted by an administrator from the Swedish Social Insurance Agency. The purpose of the interview is to gather information from Olof to process an application he has submitted for an allowance to cover extra costs resulting from his disabilities. Such interviews are standard procedures for processing these types of applications at the agency. During the phone call, Olof is seated at a small square table, facing the camera, with the communication facilitator seated on his right side. The phone is placed on the table with the loudspeaker function activated (See Figure A).

The choice of phone calls of clients with dysarthria and aphasia respectively represents. to some extent, the two primary user groups of the service: speech and language disorders. While many users exhibit a combination of these disorders, individuals with voice disorders, the third target group of the service, rarely utilize it.

Figure A. Illustration of the communicative setting: The communication facilitator can be seen together with the participant with communication disorder to the left and the conversation partner can be seen to the right. In Rebecca's phone call, the communication facilitator is sitting opposite Rebecca, facing her across the table.

4.2 Procedure

The recordings were made using small video cameras mounted on tripods, which were positioned by the communication facilitators prior to the conversations. Subsequently, the recordings underwent transcription and analysis through multimodal interaction analysis. This method builds upon Conversation Analysis, a well-established method for analysing interactional patterns. By studying the details of interaction, these methods reveal the moment-by-moment unfolding interaction and uncover how the participants themselves orient to each other's actions (Hutchby & Woffitt, 2008). The term multimodal encompasses the diverse resources utilized by interactants to organize their actions including language, gesture, gaze, body movements, and manipulations of objects (Mondada, 2014). Thus, Multimodal Interaction Analysis adopts a holistic theoretical and methodological perspective that integrates all available resources in interaction, without imposing a hierarchical order, such as prioritizing spoken language over embodied interaction (Mondada, 2016).

This approach has proven effective in demonstrating how communication disorders affect every day talk and social interaction (Wilkinson et al., 2020). Particularly relevant to this study is the branch of applied Conversation Analysis, in which it is common to use practice-based data to inform and alter how practitioners interact in organizations (Antaki, 2011). The Jeffersonian transcription system (Jefferson, 2004) was utilized, augmented with conventions for transcribing multimodal actions, as developed by Mondada (2022). The analysis encompassed full phone call conversations to process both sequences where the communication facilitators intervene in the conversations and sequences of the conversations where the communication facilitators do not intervene. Specific sequences from the two conversations were scrutinized in data sessions involving experienced interaction analytic researchers. Rebecca's speech is notably unclear, with most of it being unintelligible to the researchers. Rather than leaving parentheses indicating unintelligible speech empty, the number of syllables in her speech is represented by a corresponding number of the letter "x" (see the Appendix for a key to transcription symbols).

5. Findings

The findings are presented in alignment with the three research questions that guide this study. Representative extracts from the calls are provided to illustrate examples of identified practices. Findings pertaining to the first two questions are organized into subsections, with results from Rebecca's phone call presented first, followed by results from Olof's phone call. Subsequently, the findings are integrated in the section addressing the third question, accompanied by an analysis of the differences and similarities observed in the two phone call conversations.

5.1 When do the communication facilitators intervene in the phone calls?

Rebecca

In Rebecca's phone call, the communication facilitator intervenes after most of Rebecca's utterances. The facilitator does not wait for signs of trouble before intervening after Rebecca's turns. This approach may stem from an assumption that Rebecca's speech is unintelligible to the conversation partner, a co-member of a disability rights organisation (hereafter CMD), and thus likely requires clarification most of the time. The communication facilitator thereby pre-emptively addresses potential understanding difficulties (cf. Svennevig, 2010; Svennevig et al., 2019). The conversational structure resembles that of an interpreter-mediated conversation, albeit with a crucial distinction: all participants share the same language. Consequently, most of the communication facilitator's interventions take the form of renditions, which are more or less verbatim repetitions of Rebecca's utterances. This type of rendering aligns with the concept of "voicing" as described by Rasmussen and Pilesjö (2011). Voicing refers to the act of articulating aloud what a person with complex communication needs indicates by using Augmentative and Alternative Communication (AAC) tools, without claiming authorship or responding to the turn. The renditions by the communication facilitator are regularly prompted by Rebecca's eye gaze, as demonstrated in Extract 1 below.

Rebecca (REB) sometimes invites the facilitator (FAC) to intervene by gaze, which is illustrated in Extract 1. Gaze has been recognized as a crucial cue in regulating turn-taking behaviours during conversations, with individuals typically shifting their gaze towards the next speaker (Degutyte & Astell, 2021). Throughout the call, Rebecca has a calendar and some papers positioned on the table in front of her, while the communication facilitator sits opposite her. During extended segments of the conversation, Rebecca's body and gaze are often directed towards the papers on the table (figure B).

Extract 1. Rebecca (6:21-6:36)

Preceding this extract, Rebecca had posed a series of questions to the CMD. The CMD had just provided a lengthy response regarding the contents of the organisation council's meetings. During this response, Rebecca occasionally interjected with confirming sounds. Half a second after the CMD's response is concluded, Rebecca initiated her turn spanning lines 1-5. As her turn progressed, Rebecca directed her gaze to the communication facilitator (lines 5-9, see Figure C.). Within 0.4 seconds of this gaze shift, the facilitator rendered Rebecca's turn (line 7). Subsequently, the CMD responded to Rebecca's comment (lines 9-10). This scenario, in which Rebecca shifts her gaze to the facilitator as she nears the conclusion of her turn, recurs 13 times out of her total 25 turns in the phone call. In each instance of Rebecca directing her gaze to the facilitator, except for one instance of overlapping talk between Rebecca and the CMD, the facilitator intervened.

The facilitator intervenes after Rebecca's turns on eight occasions, even in the absence of an eye gaze invitation. An example of this occurs at the beginning of Rebecca's phone call, as illustrated in Extract 2.

Extract 2. Rebecca (00:17-00:38)

In this instance, Rebecca speaks while directing her gaze downward (lines 1-2). Her utterance concludes with a falling intonation and can be considered grammatically complete. This prompts the communication facilitator to intervene immediately (lines 3-4), seamlessly latching onto Rebecca's turn (lines 1-2). Rebecca's turn is rendered as a question and despite a long pause (line 5) following the rendition, neither the communication facilitator nor Rebecca attempts to repair, suggesting Rebecca's satisfaction with the rendition. The CMD confirms Rebecca's turn as a question in line 6.

At some instances, the facilitator intervenes without invitation, but the rendering is not latching to the original utterance, as in Extract 3.

Extract 3. Rebecca (3:24-3:37)

In Extract 3, there is a pause of slightly more than a second (line 5) after Rebecca's turns in lines 2 and 4 before the facilitator renders Rebeccas turn in line 6. This pause may arise from the facilitator's hesitation regarding the completion of the turn or from the need to determine the best approach to rendering Rebeccas turn. This pause provides an opportunity for Rebecca to add something, to repair her speech, or for the CMD to respond to Rebecca without intervention by the communication facilitator.

It is noteworthy that Rebecca continues to look at her paper, which the facilitator may interpret as an indication that she is searching for the necessary information, such as the content of the question regarding the 12th of June. Nonetheless, the facilitator chooses to intervene in line 6, anticipating either an expansion of the turn or a response from the CMD.

Overall, Rebecca's phone call contains numerous silences, many of which are within-turn silences and may be attributed to her speech disorder. Additionally, there are extended silences between the facilitator's renditions and the conversation partner's responses. However, there are no indications that these silences result from issues with intelligibility of preceding turns. Instead, they may stem from hesitation or indecisiveness on the part of the conversation partner, as observed in Extract 2, where the conversation partner acknowledges, "it's a very good question you raise, Rebecca" following a 3.7 second pause.

Apart from the example in Extract 3 and one additional case, there is generally a smooth flow between Rebecca's turns and the facilitator's renditions. The length of silence between Rebecca's turn and the facilitator's rendition cannot be attributed to any gaze cues in this conversation.

Olof

Olof's phone call presents a more intricate picture of the facilitator's interventions, showcasing various patterns of interaction.

Similar to Rebecca's phone call, the facilitator in Olof's conversation is frequently invited to intervene by Olof's eye gaze. There are 42 instances where Olof directs his gaze to the communication facilitator, resulting in an intervention.

In Extract 4, Olof (OLO) shifts his gaze towards the facilitator before completing his turn, mirroring a pattern observed in Rebecca's phone call (cf. Extract 1). At the onset of the sequence, Olof's gaze is fixed on the telephone on the table, while the facilitator takes notes in a notebook also placed on the table.

Throughout the conversation, there are prolonged pauses. Some can be attributed to the administrator writing on her computer, evidenced by faint tapping sounds heard through the telephone. However, it is also apparent that the administrator allows ample time for Olof and the facilitator to collaborate in responding to interview questions and to offer comments or ask questions of their own.

In this particular sequence, the administrator is clarifying an issue related to the application process, which serve as the basis for the interview. Olof, aware of the absence of a medical certificate in his application, inquiries about the urgency of obtaining it.

Extract 4. Olof (09:56-10:23)

In extract 4, Olof attempts to ask a question (lines 4-8), but encounters difficulty in finding the right words. By line 8, it becomes evident that he is struggling, prompting him to turn his gaze towards the facilitator as a request for support (see figure D). Research has shown that shifts in gaze towards a recipient during word searches actively engage the recipient in the process of finding missing words (Goodwin & Goodwin, 1986).

Recognizing Olof's request for assistance, the communication facilitator responds by offering a clarification of his attempt in lines 10 and 11. Olof acknowledges this clarification affirmatively (line 12), followed by additional affirmations from both the facilitator and Olof (lines 14 and 16). Together, Olof and the facilitator co-produce the question (lines 4-16), which is then addressed by the administrator (lines 18-19).

In Olof's phone call, the facilitator initiates interventions in nine instances where Olof does not respond promptly to questions from the administrator. Extract 5 illustrates one such instance.

Extract 5. Olof (5:25-5:39)

The facilitator supporting Olof's phone call typically takes notes while the administrator speaks. Simultaneously, she closely observes Olof during pauses, indicating her readiness to provide support. This gesture may aid Olof in initiating his turn, as demonstrated in Extract 5 above. In line 4, there is a 1.5-second pause, after which the facilitator directs her gaze towards Olof, prompting him to respond. Given that aphasia affects both Olof's ability to produce and comprehend language, his delayed response may stem from difficulty understanding the conversation partner's utterances in lines 1-3 or from word-finding problems caused by his aphasia. Regardless, the facilitator's gaze (line 4) serves as a prompting intervention in response to Olof's delayed reply.

In Extract 6, the facilitator intervenes to clarify the meaning of Olof's turns.

Extract 6. Olof (22:03-22:02)

Olof attempts to explain that he goes to aquatic therapy (lines 1-4). He shows word-finding problems by "eh"-sounds and pauses. Except for two quick glances at the facilitator, he gazes away, which may be indicative of a preference for self-repair (Goodwin & Goodwin, 1986). Yet, the facilitator makes a clarifying rendition of Olof's explanation (line 6), just 0.4 seconds (line 5) after his turn completion in line 4. It may be argued that the administrator has had plenty of opportunities to reply to Olof's attempts and as she does not, the communication facilitator is quick to make an interpretation of Olof's turns, possibly to make the conversation progress. It may also be the case that the facilitator judges Olof's way of conveying that he goes to aquatic therapy as semantically difficult to decipher. Olof confirms this interpretation, and in further absence of a response from the administrator, the facilitator makes another clarifying intervention in line 13, which is also confirmed by Olof. What follows this episode is a long pause in the conversation, with the sounds of the conversation partner typing on her computer. The sometimes sparse responses and confirmations by the conversation partner (which might be due to her typing) in this phone call may be a factor probing the facilitator to intervene more than would be the case with a more active conversation partner. Conversation partners of persons with aphasia generally need to take a more active role in solving trouble to reach intersubjectivity (cf. Goodwin, 1995; Laakso & Klippi, 1999; Oelschlaeger & Damico, 2003). In this and other examples from Olof's phone call conversation, it is the communication facilitator who takes on the responsibility of co-solving trouble with the person with aphasia.

In some cases, in Olof's phone call, it is difficult to disentangle any clear pattern for intervention. In Extract 7, the communication facilitator starts a language-facilitating intervention despite no invitation or obvious trouble.

Extract 7. Olof (7:09-7:29)

When the administrator has explained something in a rather formal and "institutional" language (lines 1-7), Olof responds with a "yes" (line 9). Still, the facilitator chooses to ask Olof whether he understands (line 10) and offers an alternative explanation of what the communication partner just said (lines 10,11 and 13). The reason for the intervention might be the degree of semantic complexity of the information provided in a formal speaking style, and the facilitator's established experience of Olof's impressive language problems. Although Olof's "yes" (line 9), is slightly more silent than he usually speaks, it has a falling intonation, and he does not show trouble in any other respect at this point. After the facilitator's intervention (lines 10-13), Olof's response is an upgraded "yeah, right" with additional smiling and nodding, indicating appreciation of the intervention by the facilitator.

Extract 8 depicts another example of intervention initiated by the facilitator in Olof's phone call, where it is difficult to identify the reason for the rendition.

Extract 8. Olof (14:03-14:23)

Here, the facilitator adds the information about Olof's car being an adjusted one. She can do so based on prior knowledge about his car and possibly knowledge about what may be institutionally relevant in the ongoing inquiry. The intervention may also be based on agreements between Olof and the facilitator. They have spent time preparing meetings and have discussed and made agreements about the features of the support from the communication facilitator. The provided intervention from the communication facilitator is hedged in line 12, revealing hesitance about her own intervention. This is then followed by Olof trying to explain what has been adjusted on his car, starting in line 13. This explanation goes on for quite a while with the conversation partner neither rejecting nor confirming the relevance of the description of the car adjustments.

Olof sometimes uses paper and pen to write or illustrate what he wants to say as in Extract 9 below.

Extract 9. Olof (13:16-13:37)

In this extract, the administrator asks about the age of Olof's daughter in line 1. The communication facilitator is quite quick to offer pen and paper to Olof (line 3), probably from experience of Olof having difficulties using numbers in speech. Olof writes down the year of his daughter's birth (line 6) when he does not manage to verbalize how old she is. The facilitator reads the written information out aloud to the administrator (line 8). The written information is obviously not available to the administrator as she is participating in the conversation on the telephone. It is possible, however, that the communication facilitator would offer assistance also with the administrator present, as the numbers Olof writes down do not directly correspond to the question, i.e., he writes his daughter's year of birth, rather than her age.

There is also one example when the facilitator describes the body orientation of Olof to the administrator.

Extract 10. Olof (23:34-23:55)

In Extract 10 above, Olof starts to explain how his motor disorder affects his arm. While trying to find words (lines 5-6), he strokes different parts of his arm (lines 5-10). The communication facilitator starts to ask Olof a question (line 7) but then changes to explain to the administrator what Olof is doing. This intervention is a consequence of the conversation being phone mediated and in this way, the facilitator makes Olof's non-verbal communicative action transparent also to the administrator. This is similar to a phenomenon described as "defining the situation", found in video relay services offering sign language interpreting in phone calls (Warnicke & Plejert, 2012, pp. 1323-1325). By describing what is happening to the conversation partner who cannot see the others, the interpreter in the video relay services can increase the fluency of the interaction and keep the turn.

5.2 When do the communication facilitators not intervene in the phone calls?

This section depicts sequences where the communication facilitators leave to the persons with a communication disorder and their conversation partners to manage the conversations, including trouble and repair, without support. As the communication facilitator makes frequent interventions in Rebecca's phone call, findings in relation to this research question are sparse in her case. Analysis of Olof's phone call, again provides a more diverse picture in terms of the absence of actions by the communication facilitator.

Rebecca

Only a few utterances by Rebecca are left without intervention from the facilitator. Turns that are sometimes not followed by rendering are minimal responses such as "mm", "ja" and "a" (as in yes) and politeness tokens, such as "tack" (thank you). Even though these short turns, as second-pair parts to a prior turn by the conversation partner, are sometimes followed by longer silences, they are not rendered by the facilitator. This indicates that the facilitator assesses these turns by Rebecca as intelligible to the CDM.

Excerpt 11 starts with a request for clarification by the CDM (line 1):

Extract 11. Rebecca, (5:36-5:43)

Rebecca responds to the question with "a" as in yes (line 3) and although she uses fingerspelling to support her affirming verbal response, that is not visible to the CDM, the facilitator does not render the turn. In addition, some trouble appears to occur, and a quite long silence (line 5) prompts Rebecca to repeat her "a", this time with a vowel prolongation, making it somewhat upgraded (line 6). This is followed by a more confirming response by the CDM (line 7). Still the repair work is left to Rebecca and the CDM to manage without intervention by the communication facilitator.

Apart from the brief confirmations mentioned above, there are two more turns not rendered by the facilitator. These are turns overlapping with the talk of the CDM. An example is provided in Extract 12, below:

Extract 12. Rebecca (00:26-00:44)

In lines 1-2, the facilitator renders a question posed by Rebecca. This is followed by a silence in line 3. The CDM starts her response with commenting on how difficult the matter is in line 4 and then starts to laugh at the same time as Rebecca attempts to say something (lines 5-6). Although Rebecca starts to talk at the same time as the CDM laughs in line 5-6 and it may be questioned who is interrupting who, the second part of line 6 "one one one little moment" is quite interruptive of Rebeccas turn. Her attempts to communicate something in line 5 are not sanctioned by the facilitator, as can be observed in the extract; neither is it picked up later in the conversation by the facilitator. Rebecca's turn not being heard or attended to is not noticeably treated as problematic by any of the participants.

Olof

Unlike Rebecca's phone call conversation, where few utterances are not rendered, there are long passages of talk between Olof and the administrator in which the communication facilitator does not intervene. These are often characterized by a relative flow, although the tempo of the whole conversation is slow and affected, both by Olof's aphasia and the context of the talk; a quite structured interview with the administrator typing the information given by Olof. Semantic or grammatical inaccuracies and unclarities by Olof are most of the time not corrected by the facilitator unless causing unintelligibility as in Extracts 4 and 6.

In some cases, Olof's responses are not well aligned with the questions of the administrator.

Extract 13. Olof (14:23-14:44)

In Extract 13, Olof does not reply to the question by the administrator in line 7. The question deals with whether he has received financial support to adjust his car due to his motor problems. Before the question arises, he has started to explain adjustments of the car; something about the windscreen wiper (line 1). Instead of replying to the question (line 7), he goes on to explain what kind of adjustments have been made to his car (lines 9-16). Despite Olof not directly answering what the administrator is asking for, the facilitator does not intervene to support Olof's understanding of the question. She just supports what Olof is trying to explain. In addition, the administrator does not attempt to repair, and her question is left without the kind of reply that might have been more conditionally relevant, for example a "yes" or "no" answer to "have you been granted a car support for it" (line7). This stands in contrast to extract 8, where the facilitator intervenes to add information potentially relevant to the aim of the conversation. In Extract 13, she does not inhibit Olof from providing information not directly addressing the administrator's question, which would only require a yes- or no answer by Olof.

There were nine occasions of gaze invitations to intervene, not adhered to by the communication facilitator in Olof's conversation. Generally, the conversation progresses despite the lack of intervention from the communication facilitator, but the case illustrated in Extract 14, below is potentially problematic.

Extract 14. Olof (10:50-11:22)

Olof is clearly inviting the facilitator to intervene by eye gaze (lines 12-13), a puzzled face (line 13, fig E) and hesitation marks (lines 13 and 15). The facilitator, however, only shuffles the telephone in the direction of Olof (line 8) to demonstrate that he can do this himself. This may be viewed as the facilitator orienting to the preference for self-repair (Schegloff et.al, 1977). This results in Olof trying to explain how difficult it is for him to speak (line 17), thus putting his deficit into focus. This further seems to lead the administrator to take part of the requested information about his income available on her computer, as she finds out that she has access to his personal information about these matters. The lack of intervention might thus be due to several factors, such as the institutional setting and access to relevant information for the question on a computer, and the fact that the facilitator orients to the preference for self-repair (despite its potentially threatening Olof's face in this case).

5.3 What are the similarities and differences in patterns of interventions between the call of the client with aphasia compared to the call of the client with dysarthria?

Results relating to the first two research questions of this study, show the active role of the communication facilitator in the two investigated phone calls. The activities are, however, quite distinct. In this section, the third research question is targeted and commonalities as well as distinctions related to differences in the clients' communicative disorders are investigated more closely. The comparison provides knowledge about the diversity in the types of challenges encountered by facilitators in their execution of the service.

While there is an identifiable basis for intervening after all non-interrupted turns made by Rebecca that contains more than acknowledgments/ continuers, there is a less obvious pattern in Olof's conversation. Ways of intervening also differ significantly between the two phone calls, where rendering in Rebecca's phone call runs smoothly with close to verbatim repetition of the original utterance, whereas interventions in Olof's phone call are more diverse and complex. The way interventions are completed will however not be studied in detail here but is the subject of future study.

In Olof's phone call, there are several different patterns preceding the communication facilitator's interventions. Olof's phone call also differs from Rebecca's by longer sections of conversation, without intervention by the communication facilitator. Although Olof displays plenty of trouble, the conversation progresses, and the institutional aims of the call seem to be fulfilled.

Basically, all three extracts from Rebecca's phone call show intervention in transition-relevant places following Rebecca's turns, but when the turn is given to the communication facilitator by gaze in the first extract, the facilitator self-selects to render Rebecca's turn in extracts 2 and 3, possibly due to established routines between Rebecca and the communication facilitator and an awareness that most people do not manage to comprehend Rebecca's speech, which leads to a need to consequently render all utterances. There are, however, exceptions to this as demonstrated in the previous sections regarding absences of interventions in Rebecca's phone call.

6. Discussion

The aim of this study was to investigate the involvement of the communication facilitators, regarding when they do and do not intervene in phone calls to support conversations in which one interlocutor has a communication disorder. A further aim was to compare the patterns of interventions between two conversations. In sum, results show that the communication facilitators commonly intervene in both conversations but on different grounds and instances in the two conversations. In the conversation with the participant who has aphasia, Olof, the facilitator often leaves to the other interlocutors to interact themselves. However, the facilitator also chooses to intervene in this conversation at some instances, intervening without invitation by the participant with aphasia and sometimes even introducing new information that has not been initiated by the participant with aphasia. In this section, results are discussed in light of their relevance for the training of communication facilitators, and in fact, for people who work with communication facilitation overall, and the development of Taltjänst as a service for the benefit of its users.

Two phone calls, with representative participants and types of conversations, were considered sufficient for exploring communication facilitators' actions in this very first interaction analytical study of the service. The variety between the two phone calls, however, reflects only a part of the diversity of clients that communication facilitators encounter. The target group of "Taltjänst" is broad and diverse. As demonstrated in this study, there are consequently various reasons for interventions by the communication facilitator. In line with previous CA-work on companions in healthcare interactions (e.g., Antaki & Chinn, 2019; Pino & Land, 2022), it was demonstrated how the roles of the communication facilitators are dynamic and collaboratively constructed throughout the conversations. The analysis of the phone call with Olof, who has aphasia, reveals a pattern of intervention that is not very clear-cut and might even appear a bit arbitrary. Most interventions seem to facilitate, or at least make the conversation progress and thus meet the participatory goal of the service (Socialstyrelsen, 1997). Enabling participation is likely to be an important aim of most companions to people with communicative disorders. Thus, these findings are of interest to companions beyond the communication facilitators of Taltjänst.

However, there are instances of both interventions and lack of interventions that may pose challenges in achieving the service's goals of promoting authority, participation, and independence. The non-rendering of Rebecca's speech by the communication facilitator on two occasions might be perceived as a form of overlapping talk that can occur in any conversation and is not necessarily problematic. However, the observation that Rebecca seemingly cannot make herself heard without the facilitator's intervention warrants consideration within the context of the service. Differences in the communicative abilities of interlocutors may require the communication facilitator to safeguard the interactional space for individuals with communication disorders, a consideration that becomes particularly pertinent when examining instances like this in Rebecca's phone call.

The differences revealed in this study imply quite different challenges to the persons working as communication facilitators. Working with Rebecca, the communication facilitator can focus on the speech and to some extent the turn taking in the conversation. In a conversation with a client like Olof, the communication facilitator faces challenges relating to a variety of trouble and potential trouble; the semantics of both Olof and the administrator, his conversation partner; progression, turn taking, information conveyed in relation to institutional aims of the conversation, body language and handling of a communication aid. Several of the facilitator's interventions may stem from assumptions and experiences related to Olof's disorder and its impact on his daily life, which are not directly observable in the data. In this way, the facilitator takes on many responsibilities for the conversation, not only the aphasia per se but also the consequences of the disorder in a larger sense. These responsibilities may indeed be relevant for enabling Olof's communicative participation in society, but they are not clearly outlined in the description of the communication facilitator's professional role. While the role of the communication facilitator demonstrates flexibility in relation to issues emerging in the conversation, it appears narrower in comparison to the roles revealed by Laidsaar-Powell et al. (2013, p. 7). Among the roles of logistical assistance, informational support, emotional support, and addressing their own needs that were found in triadic medical consultations - "informational support" best captures the role of the communication facilitator when intervening in conversations in Taltjänst. Through multimodal interaction analysis, the characteristics of the informational support provided by communication facilitators have been elucidated, revealing factors that prompt interventions.

Our results indicate a need for more extensive preparation work to facilitate conversations with persons with aphasia. Results also suggest that there is a need to immerse in the communicative difficulties of the person with aphasia and stress the importance of the context and aim of the specific conversation in need of facilitation.

The monitoring of very different aspects of the conversation, especially Olof's, without clear guidelines can be demanding to communication facilitators. This situation can lead to uncertainty and distress among facilitators. It may also make it challenging to explain the service and its possible benefits to users. Communication facilitators would benefit from knowing in greater detail what triggers intervention, and contexts where interventions can or should be avoided. This may need to be done in close cooperation with the individual persons with communicative disorders and their conversation partners to ensure the best possible independence and authority. Results show that gaze shifts to the communication facilitator seems successful as a way of indicating a need for assistance. This is particularly evident in the example where Olof requests support in Extract 14 but does not receive it, leading to a potentially problematic situation. As shown in previous research, other-initiated repair or correction may not at all risk face threat in the context of assisting persons with communication disorders (Bloch & Beeke, 2008; Ferguson & Harper, 2010; Simmons-Mackie & Kagan, 1999). In this study, it's rather the lack of intervention in Extract 13 that constitutes face threat. Barnes and Ferguson (2015) demonstrated, with similar findings, how participants with aphasia became curtailed in their participation and their status as linguistically incompetent was made relevant when conversation partners resisted assisting in conversational repair. Communication facilitators need to be aware of this risk and, consequently, must remain vigilant to assist their clients.

The use of gaze to signal a request for support is potentially an important tool to communicate to the users of the service. While interlocutors typically employ gaze to signal turn transitions (Degutyte & Astell, 2021) or seek assistance in word searches (Goodwin & Goodwin, 1986), communication facilitators may not be fully aware of the efficiency of gaze as a tool for regulating turn-taking. If interlocutors in communication-facilitated conversations are instructed about gaze shift as an effective way to signal a request for support, the workload of communication facilitators is eased and the authority of the person with a communication disorder is strengthened. Auer and Zima (2021) present interesting findings on how to increase the efficiency of gaze in collaborative word searches that may contribute with insights for example on how to place the communication facilitator in relation to the interactant with communication disorder. This kind of reasoning between a person with a communication disorder and a communication facilitator about ways to signal requests for support could further be beneficial also to other persons working to enable conversation with interlocutors who have communication disorders. The findings regarding challenges and potential recommendations of how to handle challenges, however, require closer investigation. Apart from further interactional studies, gathering opinions from interlocutors regarding the effects of communication facilitators' actions would enhance our understanding.

The present study represents the initial phase of a larger research project that includes data with both phone calls and face-to-face conversations. Although the focus of this study is when communication facilitators intervene and when they do not intervene, eventually also how they intervene will be analysed within the larger scope of the project.

Appendix

Key to transcription symbols