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Communication

*Communication problems are a widespread outcome of brain injury

*Problems with communication improve with time, therapy, and patience

*People can struggle with language impairment, speech difficulties, and thinking problems

*Changes will vary from person to person depending on the severity and location of the injury

*Interrupting and perseverance

Introduction

The effects of brain injury are classified under four categories – cognitive, physical, behavioural and emotional. Any, and all, of these, can play a role in communication difficulties, so, several factors can affect communication, for example: –

  • Memory – being unable to recall the information you need
  • Attention – being unable to stay focused
  • Processing – being unable to process the incoming information in a timely way that allows you to keep up
  • Judgement – can be affected by the loss of experiential memories, so people struggle with understanding their reasoning
  • Social skills – can be affected by changes in emotion and behaviour
  • Self-awareness – people can lose the ability to place themselves and their thinking within a context
  • Disinhibition – no longer understanding what is appropriate

We can see that there can be a large number of issues that can affect communication. It is important to note that many factors can exacerbate these problems, such as stress, alcohol or illicit drug use, medication side-effects, a poor diet, and so on. Reading and writing skills can also be affected – although not always together.

Language Impairment – Aphasia

Aphasia is a condition caused by injury to the language centres of the brain. Injury to the Wernicke’s area and the Broca’s area of the brain lead to the two main forms of aphasia – receptive and expressive.

The term dysphasia, which means a partial loss of language, is commonly used interchangeably with aphasia.

The complexities of language mean that the observable outcomes can be confusing to families and friends.

For example, some people:

  • can read some words but not others.
  • can struggle with writing or recognising all the letters of the alphabet.
  • might be able to read but have difficulty processing the information or be unable to recognise some words.
  • may struggle with remembering the information given in simple sentences
  • might be able to write but not read
  • speak about and be involved in one topic but be unable to engage at all in another

The importance of expression and context

Even with written information, communication can still break down. Seek expert advice from a specialist, such as a speech and language therapist, neuropsychologist, or occupational therapist.

One of the reasons for communication break-downs is language. It is almost as though there needs to be a ‘brain injury dictionary’ giving descriptors of the words people are using to try and describe how they are feeling.

For example, someone may say that they feel overwhelmed; however, what they are feeling has minimal similarity to those experiences a non-brain injured person would feel.

For someone living with a brain injury feelings of being overwhelmed are very often entirely persistent and pervasive in every waking moment.

For uninjured people feeling overwhelmed is usually only temporary because their cognitive skills kick in and quickly start to organise incoming information into manageable pieces. These processes no longer work the same following a brain injury and often the skills of filtering incoming information, being able to break this down, process and understand it, can take a long time to rebuild.

It is precisely these kinds of functions that once lost, may never fully return to what we would understand as ‘normal’ functionality. Even when someone is aware of their deficits, this doesn’t mean they can do anything about them. Knowing that any skill is lost doesn’t mean that you can include its use; it doesn’t work this way. You have to rewire, and this takes a lot of dedication, stamina, and repetition.

Effects on relationships

Communication problems can be one of the primary causes of relationship breakdowns following a brain injury.

It can be difficult for people to understand the difficulties their loved one is having with communication and also to defer automatic relational judgements. When you have known or lived with someone for a long time, the way you converse and interact becomes a habit. You intuitively know how someone expresses themselves and unconsciously pick up on all manner of cues, such as body language, inflexions, tone and even personality traits such as humour or dry wit.

These tell-tale indicators that usually enhance relationships can be changed quite drastically by a brain injury. It isn’t the person who has changed – the cognitive impairments change the way the brain operates, and this causes the differences.

It is important to make allowances for these changes but at the same time to offer gentle guidance and supportive feedback.

Very often, communication won’t feel any different to the person living with brain injury. For them, sometimes the only noticeable signs that something is awry is the inability to think of the word they want to use, or they will start a sentence and not be able to remember why. They may repeatedly interrupt other people before they have finished because they are desperate to say something and terrified they will forget.

When you have a brain injury there is a feeling that everything you want to say holds more importance than it ever did before. This panicky feeling has several causes, including a psychological need to be able to do something, anything, that feels as though it is contributory and relevant. It also results from those rare moments of clarity which people want to share as part of the desperate need people feel to fit in and to be accepted.

People are very keen to present well for the same reasons – to fit in and be accepted – and the importance of this cannot be stressed enough. When everything you do from the second you wake up, until the second you go to sleep takes enormous amounts of effort, and you are afflicted in every moment by strange, confusing and frustrating thoughts and feelings that the brain itself cannot understand,  feeling that others are supportive is crucial.

Communicating with someone who has a brain injury can take a lot of conscious effort as well. People need to give more time, be patient and listen and respond. In many ways taking this stance can help reduce perseverance where someone will use multiple means of saying the same thing to feel understood.

Talking helps people to practice many skills, such as, maintaining their attention, switching topics and keeping their focus, organisation of thoughts, understanding relevance, listening, and so much more. Conversations can also improve memory as the activity necessitates maintaining awareness of the subject.

What is genuinely happening?

From the inside, having a conversation can feel very much the way it did before the brain injury. The familiarity happens because the ‘drivers’ are still the same. The same part of the brain is doing the same work, even though this too may be injured. The problems come when the outgoing communication gets caught in the crossfire of neurological injury in the speech and language centres and also by other cognitive deficits.

For this reason, many people don’t understand that there are problems and they may take it personally or even deny issues vehemently when pointed out. Usually, the best signs that something is going wrong with their communication skills comes when people practice reflective techniques, which enables them to spot problems themselves.

Even when corrected, for example, letting someone know that they are discussing a different topic to you, it can take people several minutes to figure this out. Some people are uncomfortable with long pauses, but it is essential to let people take their time. Let them know you are not in a hurry and it is okay for them to relax.

It can help if people on the outside make a brief introduction to the topic they want to discuss, and it can also help to let people know that you have finished what you wanted to say.

When someone is struggling with word-finding, it can be helpful when they are given a little space before you begin to help. There are prompts that you can use, such as, asking people what other words are similar or what letter the word starts with as this can help them work things out on their own. People may also be able to describe the meaning or description of the word they are trying to think of and encouraging this also helps improve cognitive flexibility and independence. When people on the outside help, this assistance can feel like interference or a lack of trust or patience.

Try and keep conversations short and make allowances for fatigue.

If you can get a referral to a speech and language therapist, who will also be able to offer a lot of support and will teach everyone strategies that can help.

Navigating confusion

It can be unhelpful to be worried about what not to say to someone living with a brain injury. Focusing on the pitfalls can make it difficult to know how to help and can leave people stumped as they struggle to find alternatives.

Even though those on the outside will have a clear idea of their intentions and will consciously know precisely why and how they are addressing someone, the person living with brain injury may have difficulty reaching the same levels of comprehension.

Even the best-meant comments can leave people feeling misunderstood. A useful place to start is to acknowledge that your life experiences are not comparable to the life changes your loved one or friend is living. For example, you may have misplaced your keys several times in your life, but you don’t do it many times every day with almost all the articles you need.

Many of the statements we make to be empathetic use comparison as a method of communicating how much we care. For example, saying ‘I know how you feel’ is only genuine if you have honestly been through the same thing. Empathy isn’t always necessary, sometimes caring, understanding or wanting to listen is more helpful so we might say, ‘do you want to talk about it,’ rather than making proclamations that you have been through something similar.

Try to switch your internal agenda from wanting to be helpful, to wanting to learn. Focus on listening and the practical aspects of what you are there for and try to accept that the people most likely to understand are those who are also going through recovery from brain injury.

Comparing people to others who are also living with disabilities or disease is also unhelpful. People will find their intrinsic routes to inspiration and will understand that life is tough for other people in different ways. Helping people to remember what is personal to them and reminding them about things they believe in is a much better strategy, but again, needs to be used with compassion. Let people know that you are on their side and try asking people if they want to talk about whatever it is that they are struggling with rather than trying to interpret their answers for them.

Sharing personal anecdotes or parts of your life story as a comparison will very likely create confusion and increase stress. Listening to others and trying to fathom their point while trying to solve a particular problem can overload the processing abilities of the injured brain. 

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