There has been a buzz around MacDonald Model of Cognitive Communication Competence (MoCCC) since it was published in 2017. Sheila MacDonald explained how the model supports assessment and treatment for people with acquired brain injury (ABI) at the inaugural Cognitive Communication Difficulties (CCD) Symposium in 2018. Speech therapists cite the model as a ‘go-to’ reference for understanding CCD and allied health professionals in my teams also connect with the model.
The model captures the breadth and complexity of impairments following ABI as well as the ways in which impairments limit participation in everyday life. It was developed from the evidence spanning the last 4 decades but also selective; only including factors that:
During referral and assessment, the MoCCC supports the gathering and assimilation of meaningful information from a new client and their team (family, professionals, friends and carers). By asking referrers to tick which behaviours they have observed on the Cognitive Communication Checklist for Acquired Brain Injury (CCCABI) also written by MacDonald (2015), I can identify subtle communication changes and map them onto the MoCCC. This information enables me to tailor my initial interview to understand more about these observations. At the same time the layout of the model ensures that I explore the breadth of issues pertaining to each case by prompting discussion about each domain, for example:
With referral information and feedback from the initial conversation, I annotate a copy of the model. Representing a client’s perspective in this way highlights domains and/or skills within each domain that are particularly problematic. This is a model of competence, so we also start to see areas of strength, which can be encouraging for the client when so much seems to have become more difficult. We identify which areas of ‘Communication Competence’ are priorities and which can be consider for future episodes of care.
The MoCCC helps me to determine my rationale for including (a) formal assessments, (b) informal assessment and observation or (c) close work with professionals, as well as the timing for each assessment.
The formal assessment tool kit available to SLTs working with CCDs is growing. However, front-loading an episode of care with a raft of formal assessments is often counterproductive for someone with an ABI. It can be most helpful to start by addressing the client’s expressed needs, for example, if a client reports that they take everything literally ‘The Awareness of Social Inference Test’ is indicated but ‘The Functional Assessment of Verbal Reasoning and Executive Skills’ might not be so useful, as wonderful as that assessment is!
Formal assessments are administered strategically but I find that the MoCCC helps me to continuously assess my clients, especially in a team where there is a constant flow of new information to fit into the picture and work with. I routinely give out social observation sheets that allow team members and sometimes clients to report notable interactions, commenting on strengths, weaknesses, risks and support needs. Since most of the communication challenges occur outside of speech therapy sessions, this information is invaluable for detecting and analysing where the real difficulties lie. For clients, it means we can bring real life events back into the therapy room, discuss them with reference to the MoCCC and consider how to improve competence in any given situation before sharing this with the team and conversation partners or going out into the community to apply the strategies.
Increasingly, I use the MoCCC to visualise the plan for the session. I invite clients to mark the model (using pens or annotation tools) to share their own insights and make sense of their personal experiences since the last session. The annotated images are saved and referred to over the course of the intervention, which allows us to review patterns that emerge and identify the key factors at the root of these patterns as well as charting progress over time.
When the key factor is a communication skill, the intervention looks familiar. Often the root of the problem is found in another domain and requires close work with other professionals. In this situation referring to the MoCC helps a client to see how something they are working on in another discipline has a bearing on their communication. By way of example, a client had completed an assessment of reading comprehension that revealed good comprehension skills but some mild difficulties with increasing volume of text. The client continued to report reading difficulties and the habit of resorting to educated guesses when they could not understand the information. Fatigue exacerbated reading comprehension, leading to frustration and anxiety. The team physio explained how vestibular difficulties meant that the client was using their eyes so constantly and intensely to maintain balance that when they were reading (particularly on computers) the client did not have the extra capacity to scan the page so missed information. Reading skills improved when we addressed posture, seating, physical stability, equipment and when therapeutic lens’ were prescribed.
Alongside therapy, the model can be useful for supporting conversation with family members as I help them to make sense of their experiences, to understand the rationale for strategies and encourage them to understand how their feedback is insightful, even when not focused on communication skills. As I mentioned earlier, the model outlines communication competence so it is grounding for carers and family members to start by exploring the impact of different skills on their own communication, e.g. fatigue, worries or perhaps a temporary lapse in memory. Starting from this point can lead, more quickly, to that eureka moment when the complexities of ABI start to be demystified and carers acknowledgement that their loved one needs support to communication.
Negotiating with funders
Advocating for and justifying funding for ongoing therapy has become a larger proportion of my work, especially when I am proposing interventions that do not directly relate to the original referral.
For example, a recent initial referral identified impaired speech as the salient communication difficulty. Following the initial episode of SLT, the client made significant gains and was able to read aloud with very clear speech for some time. However, his spontaneous speech was still brief. This was all the more perplexing as it was clear that the client wanted to share lots of interesting topics. Having completed a full language assessment (no difficulties) and discussed the case with the OT, we identified memory and planning impairments as the main difficulties limiting the client’s ability to generate narrative and discourse. Even as speech had improved, the client had hit an expressive ceiling owing to these CCDs. With support from conversation partners, the client is now able to converse by using 5Ws & H to structure narrative or conversation, which has lead to much more fulfilling communication amongst the family.
The funder was willing to support ongoing speech therapy in a new direction because the rationale was evidenced and explained using the MoCCC.
It seems impossible to overstate the depth, breadth and complexity of changes that occur following ABI, not only for the individual with the injury but also for family members, friends and colleagues. As the model shows, there are so many variables that no single client is the same as the next. In post-acute rehabilitation, my clients are living at home, engaging in multiple relationships and seeking to re-establish work and leisure roles. There is a lot to consider on so many different levels; sometimes it feels overwhelming!
Yet, the MoCCC has been for me a tool that reduces that sense of overwhelm and helps both to contain and expand my thinking. It is containing because I can organise and make sense of the information that comes from many different sources, information that rarely comes as norms and standard deviations but as real experiences, feelings and stories. The psychologists might call this a formulation, a process by which problems can be understood in a theoretical framework so that meaningful plans are made for therapy. This is where the model is expanding! By providing a firm foundation for understanding the issues at play, I am able to draw on evidence and my experience working with different aspects of communication. I can collaborate with the team and work creatively with each individual on their journey towards communication competence.
I wanted to start by discussing the MoCCC because I hope that future posts will refer back to the model and expand some of these ideas, for example using Communication Coping Strategies Intervention to promote strengths-based strategies.
In the spirit of this blog, please share your thoughts about how the MoCCC influences your practice.
MacDonald, Sheila (2015) Cognitive Communication Checklist for Acquired Brain Injury (CCCABI) CCD Publishing; Guelph, Ontario, Canada, N1H 6J2 , www.ccdpublishing.com
MacDonald, S (2017) Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury, Brain Injury, 31:13-14, 1760-1780, DOI: 10.1080/02699052.2017.1379613