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COMMUNICATION WITH PEOPLE LIVING WITH AN ACQUIRED BRAIN INJURY Steve Shears MSc [email protected] Headway UK – the brain injury association WWW.HEADWAY.ORG.UK Headway UK – a registered charitable organisation in the UK supporting and providing information to people living with acquired brain injury and their relatives. We also provide information and training about acquired brain injury to health and social care professionals. We deliver this service through a network of 117 local support groups in all four countries of the UK. WHY WE EXIST 1 Headway partly owes it’s existence to the fact that the medical profession had become very good at the acute stage of the management of head trauma and other forms of ABI. More patients were surviving the acute phase due to this expert treatment. Unfortunately this was not matched by rehabilitation and support services for a condition that in many cases is long term. Headway Publications Communication Basics Communication – mixture of verbal and non verbal skills. Verbal skills include – Choice of words, tone of voice, speed of voice, order of words. The majority of communication is non verbal – such as facial expression, nodding our heads in agreement (variations in this in different parts of the world) and looking at people when they talk to us. (Argyle 1983. Mehrabian 1971) Communication following brain injury In the acute phase following brain injury the patient may have assistance to breathe via a tracheostomy. Communication issues in later recovery may include. Physical injuries causing weakness to speech muscles. Damage to specific areas of the brain that control speech and language. Damage to the frontal lobes, which control behaviour and personality. Problems with concentration, memory or other cognitive problems. Following brain injury people may have two or more of these problems. Therapy for communication disorders In the early stages of recovery patients who present with communication difficulties should be referred to a Speech and Language Therapist Dysarthia: (weakness/injury to speech muscles) Dysphasia (expressive and receptive) Lack of attempts to communicate Cognitive difficulties Difficulties with non verbal skills Communication in a therapy setting The latter two issues on the previous slides as regards communication is something that I am keenly aware off as a counsellor working with people who are living with brain injury and their families/partners/children. Generally speaking the ‘talking therapies’ were developed and designed around people who did not have major cognitive deficits as to information processing, memory, executive functions and attention! Therefore there is a certain challenge not only in therapy but i n general communication situations with people living with abi. Sites of injury in the brain and communication Other Helpful information As a counsellor who has his practice partly in the brain injury field, I am interested in gaining information about the type and site of injury in the brain in order to inform my interventions. Good neuropsychology reports and reports from Speech and Language Therapists and Occupational therapists also are very helpful. Cognitive Domains and Communication The issues I have to be aware of related to domain: Attention Memory Information processing Executive Functions Visospatial processing There may also be an overall diminishes ability to be aware of the nature of one’s own cognitive deficits – anosognosia. Crosson et al model of awareness following ABI Slide courtesy of Malia and Brannagan Maximal Maximal Full Acceptance Cognitive Executive Metacognitive Skills Growing Acceptance Anticipatory Awareness Emergent Awareness None Personal happiness Self esteem etc. Intellectual Awareness Minimal Minimal Attention and Information processing There are various types of attention skills and damage to the neural networks serving these may result in diverse attention problems. Information processing may also be impaired and the person might take longer to process information and have reduced capacity as to how much they can take in. If this is the case then the following strategies may help. Strategies for Attention and information processing problems Speak to the person in a place that is quiet and free from distractions. Simplify information. Reduce the amount to be remembered. Ask the person to repeat it back to check their understanding. Link the information to something the person already knows. Little and often – as a rule. Ask the person to organise the information for themselves. Put things into categories. Memory Mostly my clients have problems with everyday working memory such as remembering what they have just heard or read or that they have something that they need to remember to do (prospective memory). So communication in this case may be interupted by the client’s difficulty with being able to remember what we have been talking about or what the homework is that I Strategies for memory Present information in different formats. Educate about brain injury. Ask client to repeat back information immediately and then at lengthening intervals. Use of video/audio recording – give them a copy. Take notes in session and ask client to write down their own understanding of what was important to them in the session. Give them a copy. Sometimes modify confidentiality so client can review the content of the session with someone they trust. Give written homework for client to fill in. Executive functions I tend to see clients when they are in an emergent awareness stage and the organic denial has diminished. Sometimes tasks are around alternative viewpoints and increasing awareness of behaviours/consequences. I sometimes use group work to teach new strategies/skills in dealing with other people. Establishing a client’s motivation to engage in therapy/make changes is vital. Issues in facial affect recognition Finally, another dimension that I need to be mindful of during therapy is the research into diminished performance of traumatic brain injury survivors on the recognition of facial expressions of emotion. More particularly the more negative emotions with the view from some researchers that negative emotions may be processed by different neural circuits in the brain. Basic Facial Expressions of Emotion - Ekman Summary Special consideration needs to be given to the modification of traditional therapeutic approaches when working with clients who have sustained brain injury. Communication in therapy needs to take into account cognitive strengths and weaknesses. Compensatory strategies are required in a counselling situation with people who have had a brain injury in order to maximise the benefit of this therapeutic approach. References Babbaage et al (2011) Meta-analysis of facial affect recognition difficulties after traumatic brain injury. Neuropsychology. 2011 May;25(3):277-85. Croker,V and McDonald,S (2005) Recognition of emotion from facial expression following traumatic brain injury. Brain Injury, September 2005; 19 (10): 787-799. Ekman, P. (1999) Facial Expressions In T. Dalgleish and T. Power (Eds.) The Handbook of Cognition and Emotion. Pp. 301-320. Sussex, U.K.: John Wiley & Sons, Ltd. Powell, T (2004) Head Injury – A Practical Guide. Speechmark. Shears/Headway (2010 Cognitive Rehabilitation Issues Workshop Notes and Slides. Wilson,B (2009) Memory Rehabilitation Your views or questions to : [email protected] (+44)115 9240800