Social Communication Treatment After Brain Injury

To provide meaningful social communication treatment, we first need to zoom out.

Social communication is largely determined by a person’s culture. Where do we learn what is appropriate or not? What is a normal way of interacting or not? How to be a good member of a society?

Our cultures teach us these lessons.

This is important to consider since the history of social communication treatment is fraught with ableism, racism, and classism. In the name of rehabilitation, well-meaning therapists have long pushed the dominant culture’s beliefs and values onto their patients.

We all know how bad it feels to have someone’s unwelcome expectations forced onto us. And, if you’re like me, you’ve also made the mistake of doing this to others—patients included.

So what does that mean on the job, where we serve patients with different cultures than us?

You can provide appropriate social communication treatment by first taking the time to understand your patient’s cultures and then treating based on their cultural norms.

In this post, you’ll navigate evidence-based social communication treatment that targets the underlying brain injury—but not the underlying person.

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When To Treat Social Communication?

This post is intended for the treatment of individuals who, after an acquired brain injury, demonstrate a significant, negative change in their social behavior and social skills.

This change can be really hard for patients. They may struggle with relationships, on the job, in the community, and, as a result, experience depression and anxiety.

So what can be done? Let’s dive in!

Social Communication Treatment Goals

The goal of social communication treatment post-brain injury is to facilitate the following skills (adapted from The Cognitive Rehabilitation Manual, Second Edition):

Increased:

• Awareness of social-communication deficits
• Ability to communicate thoughts and needs
• Ability to listen to and understand others
• Ability to understand and use nonverbal messages (i.e. facial expressions)
• Ability to regulate emotions
• Ability to conform to appropriate social boundaries and rules
• Ability to work with others to solve problems
• Assertiveness

Social Communication Treatment After Brain Injury

Evidence-Based Tips

Use the following evidence-based tips to improve the effectiveness of your social communication treatment:

• Individualize your treatment for each patient. Ask and listen to understand what is important to them.
• Keep treatment contextualized
• Add in real-world communication. For example, use photos from their social media when working on identifying emotions.
• Focus on self-regulation or meta-cognition

Read How to Improve Awareness

Refer to Mental Health Professional

No matter how it was acquired, a brain injury is a long and difficult road for our patients.

Many will understandably take a hit to their self-esteem as they lose abilities and roles that were important to them.

Refer patients as needed to their doctor or mental health professional to support their mental health.

Reading Comprehension Strategy (For Students)

This strategy is for students or for patients who otherwise want to improve chapter-level reading comprehension.

The Reading Comprehension Strategy has three stages:

1. Pre Reading
   • First, review the headings of a text
2. Active Reading
   • Next, choose 1-3 key ideas per paragraph (highlight the text)
   • Summarize them in your own words (take notes)
3. Review
   • Finally, reread any highlights and notes
   • Write a 3-5 sentence summary of each section

Interpreting Metaphors

After an acquired brain injury (especially post-right hemisphere injury), a patient may struggle to interpret metaphors and idioms. Many metaphors and idioms are culture-specific, so check with your patient’s family to see if they recognize the ones you plan to use with your patient.

One structured treatment to address this deficit is The Metaphor Training Program. Here are the treatment steps:

1. The therapist prepares a word association for the patient (TIGER, BOXER).
   
   
2. One at a time, the therapist introduces each target word and asks the patient to choose between 2 options (to practice finding associations).
   • Is a TIGER beautiful or strong? Passive or active?
   • Is a BOXER beautiful or strong? Passive or active?
     
     
3. Next, the therapist presents each word with 5 associations in a word web. The patient is asked to identify which associations are correct.
   • TIGER: cat, stripes, grey, fierce metal
   • BOXER: fierce, blood, apple, stripe, apple
     
     
4. Next, the patient is asked to come up with their own 5 associations for Word 1. The therapist helps them problem solve which are correct.
   
   
5. Next, the patient identifies whether the associations they made for Word 1 can also be associated with Word 2.
   
   
6. Finally, the therapist presents three meanings of a metaphor using Word 1. Only one is correct. The patient is asked to identify which of the meanings matches the metaphor.
   • The boxer is a wild animal
   • The boxer is a fierce competitor (correct)
   • The boxer gets paid for fighting

See the University of North Carolina at Greensboro’s PDF (below) for printable therapist instructions.

Emotional Perception: Identifying Emotions

For patients who struggle with emotional perception, consider helping them to identify emotions in hypothetical situations.

Interview their family to get an idea about what your patient’s pre-injury emotions would likely be and compare them with your patient’s response.

For example, you could help patients identify how a person would feel:

• When they graduate from college
• If a pet runs away
• If they get a gift
• If scolded by their boss
• The difference between how a person would feel if the pet that runs away is one they hate versus one they love
• The difference in how a person would feel if they get a gift they like versus a gift they don’t like
• The difference between similar emotions (angry vs disappointed)
• Based on a picture (body language, facial expression)
• Based on a video (tone of voice, body language, facial expression)

Emotional Perception: Facial Affect

For patients who want to improve their emotional perception and struggle to read facial expressions, consider helping them become better at identifying facial affect. Research has shown that the following treatment can improve this skill.

Using photos, you’ll introduce the task by teaching your patient how to identify relevant facial features and associate them with a specific emotion. For example, an open mouth and lifted eyebrow mean someone feels “surprised.”

Start with photos of obvious emotional facial expressions. Then, increase the challenge to more subtle emotional facial expressions.

Encourage your patient to talk about emotional events from their own life. If you’re working on identifying a surprised expression, for example, have them talk about a time they felt surprised.

See this article by the American Psychological Association for images of the seven basic emotions and their universal expressions (joy, surprise, contempt, sadness, anger, disgust, fear).

Emotional Perception: Prosody

If your patient has difficulty recognizing the emotion in others’ voices, consider treating emotional prosody.

Emotional prosody recognition includes the ability to notice and understand the emotional reason for someone’s affective tone, word stress, volume, and speech rate.

This skill can help patients better understand the intent of a message (e.g. sarcasm) and identify if someone else is becoming angry or uncomfortable, among other emotions.

As always, make sure that the target prosodic patterns are based on your patient’s culture. If you believe it would be meaningful for your patient to work on the mainstream culture’s patterns and if your patient/their family want to work on it, then go for it.

An example treatment is to:

• First review common emotions and the words associated with them
• Identify behaviors common with each emotion
  • Laughing when happy, etc.
• Expand to identify prosodic patterns associated with each emotion
  • Via therapist modeling, watching videos/listening to audio, etc.

Communication Partner Training (CPT)

Communication Partner Training has been proven to help patients improve their social communication skills.

Read our article, Communication Partner Training for Adult Speech Therapy, for step-by-step guides and reviews of evidence-based treatments.

Speech Therapy Materials

For pre-made patient handouts, worksheets, templates, and much more, check out the bestselling Adult Speech Therapy Starter Pack!

References

• _{American Speech-Language-Hearing Association (n.d.). Traumatic Brain Injury in Adults (Practice Portal). Retrieved April, 20, 2023, from www.asha.org/Practice-Portal/Clinical-Topics/Traumatic-Brain-Injury-in-Adults/.}
• _{Cicerone, K. et al.(2019). ACRM Cognitive Rehabilitation Manual & Textbook Second Edition. American Congress of Rehabilitation Medicine. https://acrm.org/meetings/cognitive-rehab-training-second-edition/}
• _{MacDonald, S., & Wiseman-Hakes, C. (2010). Knowledge translation in ABI rehabilitation: A model for consolidating and applying the evidence for cognitive-communication interventions. Brain injury, 24(3), 486–508. https://doi.org/10.3109/02699050903518118}
• _{Neumann, D., Babbage, D. R., Zupan, B., & Willer, B. (2015). A randomized controlled trial of emotion recognition training after traumatic brain injury. The Journal of head trauma rehabilitation, 30(3), E12–E23. https://doi.org/10.1097/HTR.0000000000000054}