11

Chapter

Communication Group

Clare Keohane

It is now widely acknowledged that the communication difficulties experienced following a

traumatic brain injury (TBI) are fundamentally different to those associated with aphasic
syndromes and consequently require different types of assessment and interventions
(Holland, 1982). Milton and Wertz (1986) highlighted these differences suggesting that
‘Individuals with Aphasia usually communicate better than they talk and TBI patients
frequently talk better than they communicate’ (p. 223). The most common injury aetiology
of clients attending the Oliver Zangwill Centre for Neuropsychological Rehabilitation is
TBI and therefore clients more commonly present with this latter type of cognitive com-
munication impairment, rather than the more specific aphasic syndromes. Working with
these clients requires awareness of the interplay between impairments in psycholinguistic
processing and other cognitive domains in relation to communication.
The cognitive communication disorders observed in clients at the Oliver Zangwill
Centre are typified by:

Difficulties in language processing – in particular with inferential or metaphorical
language.

Difficulties with discourse – e.g. over inclusion of information, tangential output,
irrelevant responses, inability to maintain a topic, difficulty turn taking, increased self-
disclosure, reduced initiation.

Pragmatic difficulties – i.e. adapting language to different environments, and different
people, reduced flexibility in adapting language.

Naming difficulties.
It is common for clients to present as socially isolated, with difficulties in relating to
others and maintaining good work or social relationships. This is thought to significantly
reduce life satisfaction (Dahlberg et al., 2006).
Although the majority of communication problems of clients attending the Centre fall
into the broad category of ‘cognitive communication’ difficulties, a proportion of clients
present with dysarthric difficulties and, less frequently, problems of an aphasic nature.
A substantial number of clients present with dyslexic difficulties. These are usually
addressed in individual sessions usually through identification of a functional goal relating
for example to study, reading with children or dealing with correspondence.

Neuropsychological Rehabilitation: Theory, Models, Therapy and Outcome, Barbara A. Wilson, Fergus Gracey,
Jonathan J. Evans and Andrew Bateman. Published by Cambridge University Press. © B. A. Wilson, F. Gracey, J. J.
Evans and A. Bateman 2009.

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 Section 2: Group interventions

Recently, there has been significant development of knowledge in the area of socio-
emotional processing, or social communication (e.g. MacDonald and Flanagan, 2004). This
refers to an individual’s ability not only to understand his/her own emotion and behaviour,
but also to be able to regulate emotions and understand others’ emotions and behaviours.
Assessment of these skills and the impact of deficits on social interactions are explored
jointly from both speech and language therapy and clinical psychology perspectives,
reflecting the need to refer to a range of relevant social cognitive communication models
and draw on the clinical skills of both professions.

Inclusion in the Communication Group

The process of addressing communication difficulties begins during the clients detailed
assessment with exploration of the client’s ability using standardized tests of cognitive
communication skills. During this period, all clients are assessed using the Measure of
Cognitive Linguistic Ability (MCLA; Ellmo et al., 1995). If required, specific measures of
object naming are also used (e.g. Boston Naming Test; Kaplan et al., 1983; Graded
Naming Test (first published in 1983); McKenna and Warrington, 2007). The intro-
duction of The Awareness of Social Inference Test (TASIT: MacDonald et al., 2002),
which assesses facial emotion perception and the ability to make appropriate inferences
from facial and voice communication in others has proved useful in determining areas of
deficit in social communication. The results of this assessment are explored alongside
other assessments relevant to social communication such as the Bangor Gambling Task
(Bowman and Turnbull, 2004) and the Mind in the Eyes Test (Baron-Cohen et al., 2001).
The aim is to clarify whether functional communication and interaction difficulties are
related to general cognitive impairments, e.g. with inhibition, speed of processing, or
traceable to specific deficits in social processing, such as emotion identification, social
inference, theory of mind, emotion-based decision-making, social knowledge, or emo-
tional semantics.
As described elsewhere, due to the interactive nature of the clients’ difficulties any
information is shared with the team at the summary of assessment and links between other
cognitive functions or mood issues and language discussed, e.g. attention difficulties
impacting on language comprehension, anxiety affecting word naming skills.
Often, a formulation of clients’ difficulties will include a description that the individual
lacks ‘communicative competence’. This is defined as ‘a knowledge of how to converse with
different partners and in different contexts and a knowledge of rights, obligations, and
expectations underlying the maintenance of discourse’ (Chapey, 1986). This communi-
cative competence relies on a ‘dynamic relationship between cognitive, linguistic, envir-
onmental and psychological processes’ (Beukelman and Yorkston, 1991).
It is this area that is the focal point for the communication work in the rehabilitation
programme and any deficits in this domain would lead to involvement in the Communi-
cation Group.

Communication Group
The Communication Group runs during the intensive phase of the programme and
begins with an educational session pertaining to the clients’ understanding of their brain
injury. Specific links are made to the anatomy sections of the Understanding Brain Injury
Group (Chapter 5) with particular discussions with regard to the areas involved with
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 Chapter 11: Communication Group

language. An overview of the types of language difficulties clients might experience fol-
lowing any injury is given by staff, and clients are encouraged to discuss their own
experiences and why they might have experienced certain difficulties. Clients are
encouraged to explore through discussions and links to other groups how their com-
munication problems may be linked to other cognitive difficulties.
In the initial Communication Group session the importance of gaining information
from others’ perspectives is discussed and agreement is sought to obtain information
from relatives as to their perception of any changes or difficulties in the communications
skills of the client. This is usually done through face-to-face or phone discussions with
the relatives/carers. We devised a communication skills questionnaire related to the area
of social communication. This is routinely given to relatives to enable us to explore
premorbid communication styles more objectively (see Appendix 11.1).
In the second week clients are presented with a question ‘What is communication?’
and asked to brainstorm their thoughts. Following this a number of communication
principles are listed to debate (McGann et al., 1997; see Appendix 11.2). These principles
are proposed to be ‘constant and existing independently of personal skills and com-
munication abilities’ and ‘serve as the universal precepts which underlie human com-
munication’. It is recognized that clients will have developed, prior to their injury, a set
of rules, beliefs and attitudes which defined how they interacted with those around them
and that these will differ between clients. Over time, clients begin to recognize how
communication can differ between people, but still be ‘normal’, and how it is affected by
people’s culture, environment and beliefs. Also discussed are how communication
skills may be affected by brain injury and how communication behaviours may then
not be consistent with communication principles. If for example a client presents
with interrupting behaviours this might be explored in relation to the principle that
‘communication is a shared experience’, with a discussion of how interrupting
might affect that principle. Discussion can then focus on why interrupting behaviours
may be occurring and what cognitive difficulties might be contributing to this. At this
point the term ‘communicative flexibility’ is introduced as an ideal skill to enable
adjustments in communication to be made dependent upon either the situation we are
in or the people with whom we are interacting. This usually leads onto a discussion
about how the remaining group sessions will be used, and how the sessions will relate to
work being undertaken in individual sessions (see below for details). Clients agree on the
aims of the group and how feedback is used in the group context. Video feedback is felt
to be the most useful tool in gaining awareness of difficulties and learning ways of
managing them and clients are asked to sign a consent form for video to be used in their
treatment.
Over the years the Communication Group has focused on differing aspects of com-
munication depending on the needs of the clients. The most frequent themes covered have
been work on assertiveness skills, conversational skills and social problem solving. Topic
areas commonly worked on within the assertiveness skills module have been exploring the
different behaviour types (passive, aggressive, indirectly aggressive, and assertive) and the
underlying beliefs associated with assertive behaviours (Holland and Ward, 1990). Role-
plays and discussion of real-life scenarios are fundamental to this work and both staff and
clients engage in these activities together. This type of work often leads into the topics
covered in the social problem-solving module where clients begin with bringing a real-life
problem experienced in a social setting and explore alternative ways of dealing with a
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 Section 2: Group interventions

problem incorporating communication, cognitive skills and discussion of the emotional

impact certain situations can lead to.
The conversational skills module includes work on listening skills, initiating
conversations, turntaking, maintaining and repairing conversations and the effects of
interrupting, tangential speech and passivity on interactions. On occasions, debating
sessions have been utilized to target specific communicative styles and difficulties in
self-monitoring and organization of discourse. On other occasions the focus has been
on communication in the workplace or at interviews – often incorporated into the
Vocational Skills Group (See Chapter 12). Specific aims/objectives of the group are
always highlighted with individuals’ goals being linked to work being undertaken in
individual therapy sessions. Evaluation of the group is through readministering
rating scales and through goal achievement. Recently we have moved to using the La
Trobe communication questionnaire (Douglas et al., 2000) to aid us in evaluating
progress.
Examples of the general aims of the groups have been:

To identify our own communication behaviours and how they differ in the different
roles we find ourselves in

To identify and understand the principles of communication

To improve communicative flexibility

To apply our knowledge of communication to situations we find ourselves in

Provide opportunities to practise and utilize effective communication skills.

Structure of sessions
The Communication Group is always an interactive group making use of role-plays and
video or audio feedback to help clients evaluate their performance. All the sessions begin
with a reflection on the topics covered the week previously and any homework set.
Initially the focus is on clients’ observation of others’ communication – clients are asked
to report back examples of where they have observed certain behaviours in others and the
effect of these behaviours. As the group programme progresses the focus shifts to the
clients’ own communication skills and they are encouraged to seek feedback from each
other before staff offer comments or feedback. In this way peers usually highlight
any problem areas, which for many clients has more impact than if they are highlighted
by staff.

Links to other sessions

Work carried out in the Communication Group needs to be linked into the individual
therapy sessions that are carried out in the Centre. As noted previously the interplay
between deficits in cognition and communication behaviours is an important area to
highlight for the client.
As part of these sessions the communication questionnaires mentioned previously are
discussed. This is particularly helpful with clients who lack awareness of their communi-
cation difficulties. Questionnaires are compared and priorities for therapy are identified.
This process requires sensitivity on the part of the therapist and strengths as well as
weaknesses are always highlighted with the client. Following the evaluation of these
questionnaires, clients may decide to monitor one particular communicative behaviour for
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 Chapter 11: Communication Group

a week or two and gain information about the situation in which the behaviour occurred
and factors that might have impacted on it. Clients then move onto discussion about
strategies that may help them improve communication skills and manage particular
communication problems. Next, clients are encouraged to practise strategies within the
Communication Group and other targeted sessions within the Centre before moving onto
generalizing strategies to wider contexts.
Specific goals are agreed and set during these individual sessions and linked to the group
work. Any sensitive issues that may have arisen can therefore be discussed outside of the
group context.

Relative and other involvement

Clearly, any intervention in the area of communication after brain injury must take into
account premorbid communicative performance. Often clients will present with a com-
munication style that they report has always been ‘part of them’. To this end it is vital that
we draw on the observations of close relatives and friends in determining appropriate
communication goals. Often when discussed with relatives a specific behaviour is noted to
indeed have been part of previous personality, or communication style, but may have
become exaggerated. Clients are encouraged to seek information from family and friends
either through communication rating scales/questionnaires as noted previously or
through joint sessions with the speech and language therapist. During the integration
phase of the programme, where clients are beginning to utilize strategies, involvement of
work colleagues, a college tutor or family/friends is helpful in providing feedback on
performance.
If a client has returned to work or is involved in a work placement, communication
skills are a focus for feedback as part of the work evaluation form. Similarly, clients may
have partners who are involved in specific feedback sessions on a regular basis in order to
ensure strategies are utilized effectively or adjusted accordingly.

Generalization
The Oliver Zangwill Centre programme is split into intensive and integration phases,
which allows continued monitoring of how skills may generalize into other settings
during the latter part of the programme and beyond. Clients can target specific situations
during the integration phase where they wish to evaluate their use of strategies or skills
developed and can continue to discuss any areas of difficulty with these during the days
they still attend the Centre. Clients’ predictions of communication behaviour and skills
can be reflected upon in light of objectively gathered information about a situation. In
this way, awareness and generalization can be developed through experiential learning
cycles (see Chapter 4), and clients can be supported to develop more realistic, adaptive
and confident perspectives on their communication. Usually clients are encouraged to
continue to gain feedback from people in other settings following discharge from the
programme and any issues discussed at the review appointments, 3, 6 and 12 months after
completion of the programme.

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 Section 2: Group interventions

Appendix 11.1: Communication rating scale

Please rate how you see … … … … … … …. performing in the areas below. Use the
following rating scale and record your answers in each box provided.
1 = No difficulty. Never any problem.
2 = Minor Difficulties. Occasional Problem.
3 = Moderate Difficulties.
4 = Major Problem noted by others.
5 = Continual Difficulty. Occurs every day at least.

Circle the appropriate rating

Think about whether or not what he/she says is 1 2 3 4 5

understood by the listener. How often does he/she
need to repeat what he/she has said?
Is the volume of speech ever too loud or too quiet? 1 2 3 4 5
How smooth is his/her speech and is it even? 1 2 3 4 5
Does he/she ever have difficulty in finding the correct 1 2 3 4 5
word?
How easy is it for him/her to find appropriate topics of 1 2 3 4 5
conversation?
How easy is it for him/her to introduce new topics 1 2 3 4 5
into a conversation?
How easy is it for him/her to stick to one topic in a 1 2 3 4 5
conversation? Do they wander off the point?
How equal or one-sided are conversations? 1 2 3 4 5
How easy is it for him/her to repair a conversation or 1 2 3 4 5
misunderstanding?
Think about how often he/she interrupts another 1 2 3 4 5
speaker.
Think about how easy it is for him/her to give both 1 2 3 4 5
verbal and non-verbal feedback in a conversation.
Think about how well he/she listens to others. 1 2 3 4 5
Think about how easy he/she finds it to state how 1 2 3 4 5
they feel.
Think about how easy he/she finds it to question 1 2 3 4 5
things said or to ask questions spontaneously.
Think about how easy it is for him/her to use non- 1 2 3 4 5
verbal skills e.g. eye contact, facial expression and
how easy he/she finds it to converse.
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE

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Appendix 11.2: Communication Group: communication principles
1. Communication is a shared experience
2. Communication is uniquely individualized
3. Communication reflects an accumulation of attitudes, values, beliefs and experiences
4. Communication can have as much impact on the environment as the environment has
on communication
5. Communication is subject to interpretation.
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