Challenges Post ABI
- Difficulities with conversation (topic introduction, topic maintenance, topic choice, turn taking and perspective taking) CASLPO 2002
- Issues may present in either verbal or nonverbal communication skills
Pragmatics “describes a person’s ability to perceive, interpret and respond to the contextual and situational demands of conversation” (Wiseman-Hakes et al., 1998).
Pragmatics has also been referred to as the interaction between language behavior and the context in which language occurs (Strauss et al., 1994). In general, pragmatics deal with the intentions and attitudes that are expressed while speaking in addition to the prosodic or paralinguistic and gestural characteristics that accompany speech (Newhoff & Apel, 1990; Weylman et al., 1988).
In a number of studies, the conversations of those with ABI have been rated as significantly less interesting, less appropriate, less rewarding, more effortful, and more reliant on conversation partners to maintain the flow of the conversation than their non-injured counterparts (Bond & Godfrey, 1997; Coelho et al., 1996). Since it is through conversation that we form and maintain relationships, impaired communication can have a significant negative impact on social competence, vocational competence and academic competence. Social communication deficits in ABI can result in social isolation and lead to “failure, frustration, and a sense of helplessness” (Sarno et al., 1986). This is consistent with the assertion by Kilvoc et al. (2009), that “there is general consensus in the literature reporting poor communication and social outcomes for individuals with ABI”.
However, Ylvisaker and Urbanczyk (1990) caution that, in conducting interventions to improve social communication, “careful attention must be paid to the ecological validity of the treatment. Intervention that is insensitive to the specific settings and challenges that define the individual’s communication environment is unlikely to yield noteworthy results”. Research to date has tended to focus on a combination of strategies and forms of interventions and no one program or means has been emphasized in the literature (McDonald et al., 2003).
Goals of Treatment
- To initiate conversation with others;
- To learn to read the unspoken language (body language) of others;
- To learn to understand the emotion presented in verbal language;
- To respond appropriately (reciprocity of conversation);
- To show interest in what others are saying;
- To maintain conversations
- Environmental modification
- Cognitive rehabilitation
- Behaviour modification designed to increase the repertoire of positive interactive skills
- Counselling and support
- Pragmatic skills training and
- Targeted speech and language therapy
Materials and Devices
- Positive reinforcement of the appropriate responses
- Auditory feedback or visual feedback by self and others
Treatments to Improve Social Communication and Pragmatics
Training Emotional Processing
In an RCT conducted by Radice-Neumann et al. (2009) demonstrated that emotional processing can be effective when introduced to a group of individuals who had sustained an ABI. They assert that individuals with ABI can re-learn affective recognition skills. Two interventions to enhance emotion processing were utilized. The first intervention (Facial Affect Recognition - FAR), focused on training attention to important visual information and attention to the participant’s own emotional experience. The second intervention (Stories of Emotional Inference – SEI) taught patients to read emotions from contextual cues presented in stories and then relate these stories to personal events.
Participants who received FAR training had more positive outcomes. They were better at reading faces (emotions) and were more descriptive in relating how they or others would feel in a similar situation. Decreased level of aggression was an additional finding. The SEI group produced fewer improvements however they were able to make more emotional inferences about how they would feel in a given context. They did not however make improvements in their ability to infer how others would feel in a given situation. The authors hypothesized that this might be related to self-centeredness, a trait often attributed to individuals post ABI.
Remediation of Emotional Prosody
In a recent study conducted by McDonald et al. (2012), 20 individuals who had sustained an ABI (n=10) were randomly assigned to either the treatment group (n=10) or the control group (n=10). Those in the treatment group received a 2 hour treatment session each week for 3 weeks. Those in the treatment group were divided into smaller groups resulting in 2 working with one therapist during each session. Those in the control group were offered treatment, at the one month follow-up.
Activities consisted of mostly games designed to focus on “prosodic cues present in the expression of emotion” (McDonald et al., 2012). Study results indicate no significant differences in the treatment groups from the pre-test to the initial post-test assessment and the follow-up assessment 30 days later. Study authors noted “there was no indication for an effect on reaction time, and no change in relative report of communication competence”. Individually, those in the treatment group did report changes with 5 indicating they felt there was improvement on one measure and one indicating improvement on three measures (McDonald et al., 2012).
Social Communication Skills Training
Ina RCT conducted by Dahlberg et al. (2007), it was found that subjects in the experimental group when exposed to twelve 1.5 hour communication sessions, significantly improved their scores on 9 of the 10 subscales on the Profile of Functional Impairment in Communication, (PFIC) scale (p<0.01 - p<0.001) and the Social Communication Skills questionnaire-adapted (SCKQ-A) (p≤0.001) at the end of the 12 week period. These improvements were also noted at the sixth and ninth month follow up periods.
Group treatment may be an efficient means of intervention for ABI patients with cognitive-communication deficits while also promoting generalization. Group treatment may be used to target more complex and higher-level skills within the communication domain and with a wide array of communication partners. Within a group treatment setting, patients with ABI gain support and benefit from the experience of their peers within a non-judgmental environment to experiment with compensatory strategies and acquisition of appropriate interaction skills (CASLPO 2002).
The Braden et al. (2010) study of social communication in group therapy examined the efficacy of the Group Interactive Structured Treatment (GIST) for social competence in a cohort study examining 30 individuals greater than 1 year post ABI. Treatment involved 13 weeks of social communication skills training in a group setting. The one and a half hour session topics included: “orientation meeting, skills of the great communicator, self-assessment and goal setting, starting conversations, keeping conversations going and using feedback, assertiveness in solving problems, practice in the community, social confidence through positive self-talk, social boundaries, videotaping, video review, conflict resolution, closure and celebration” (Braden et al. 2010). Overall, data gathered from several subjective social communication tools supported the hypothesis that social communication skills and social competence can be improved several years post injury with positive effects on satisfaction on quality of life. It also lends further support of the benefits of positive group dynamic in the treatment of social communication issues.
The reader is encouraged to review the aforementioned studies within Table 7.4 at the end of this module for further details
Results of the study conducted by Radice-Neumann et al. (2009) indicatethere is Level 1 evidence from one RCT to show that social communication skills training improve communication skills.
There is Level 1b evidence from one RCT to suggest interventions designed to improve the ability to recognize emotional prosody were minimally effective (McDonald et al., 2012).
There is Level 2 evidence from Dahlberg et al. (2007)to show that pragmatic interventions including role-playing, improve a variety of social communication skills as well as self-concept and self-confidence in social communications.
Based on the study conducted by Braden et al. (2010) there is Level 2 evidence that conversation group therapy has a beneficial effect on pragmatic and quality of life concerns in ABI patients.
Training in social skills, social communication or pragmatics is effective in improving communication following brain injury.
Conversation group therapy appears to have a beneficial effect on pragmatic and quality of life concerns; however, more research is required exploring these benefits.