THIS POST WAS WRITTEN SOME WHILE AGO. THE BLOG REFERENCES SOME TRAINING I. ATTENDED CIRCA. 2015 BUT THE PRINCIPLES EXTEND BACK YEARS (NOTE INFLUENCE OF YLVISAKER) AND HAVE ENDURING RELEVANCE FOR OUR WORK NOW AND INTO THE FUTURE!
Having listened to Jacinta Douglas present the evidence for the Communication Specific Coping Strategies Intervention (CommCope-I), I turned to my colleague and said ‘I must try this with Stephen!’. Using the La Trobe Communication Questionnaire (LCQ), we had recently identified cognitive communication difficulties that were barriers to Stephen’s social communication, including poor eye contact and turn-taking, distractibility and reduced memory. I felt that CommCope-I provided a methodical approach for identifying and practicing strategies that helped to overcome these barriers through graded and meaningful scenarios.
A little about Stephen ....
Stephen sustained a TBI during a competitive sporting event. He is married with a young family and ran a successful business. He had always been the ‘life and soul’ of social occasions. Following the accident, Stephen returned home with the support of his family and carer but often withdrew from family and social settings. Stephen wanted to re-establish roles in family life and improve the quality of his interactions with significant people at home and in the community.
Using CommCope-I with Stephen
Stage 1 - Facilitating Awareness
Stephen found it difficult to learn and apply new strategies but his team already knew that he used some strategies naturally, i.e. responding to a code word to prompt him to slow down his speech. When used to repair breakdown in conversation, the CommCope-I calls this a communication-specific coping strategy (Douglas et.al, 2015). Studies have shown that communication-specific coping strategies account for better social outcomes (Friedman and Douglas, 2005) than improvements in communication ability alone (Snow et. al. 1998).
Stephen, his wife and carer completed the Communication Specific Coping Scales (CommspeCS) questionnaire (Douglas & Mitchell, 2012) to identify Stephen’s existing strategies. The CommspeCS comprises two sets of forms, one for the client and one for close others. There are two sets of statements about strategies that can be used to address communication breakdown, 35 statements each for expression and comprehension, some productive and some non-productive. Using communication-specific coping strategies when communication breaks down is an experience common to us all. Difficulties arise for people with TBI when the pattern of strategies is weighted more towards non-productive (making communication more difficult) than productive strategies (making interactions easier) (Friedman & Douglas, 2005; Mitchell & Douglas, 2011; Muir & Douglas, 2007). The CommCope-I aims to accentuate the productive strategies.
There was a consensus between Stephen, his wife and the carer around the following strategies:
A key feature of CommCope-I is identifying six social scenarios to work on over twelve weeks. These scenarios were ranked according to Stephen’s perception of difficulty. Therapy began with the least challenging scenario. CommCope-I provided a workable structure but allowed the treatment to be flexible, shaped around Stephen’s unique needs.
The conversation about potential scenarios ensured that we did not neglect important aspects of Stephen’s everyday life, including those at an apparently low level. For example, Stephen is friendly and missed welcoming people into his own home. Owing to his physical difficulties he found it challenging to open the front door, exchange greetings and stay standing whilst guests entered the home. This was successfully addressed in Scenario 1.
Stage 2 - Develop skills
CommCope-I draws on two established therapeutic principles firstly cognitive behavioural therapy (CBT) and secondly context-sensitive social communication therapy (Ylvisaker, 2006).
CBT places emphasis on working with the client’s current communication behaviours and shaping them for different scenarios. One of Stephen’s productive strategies was using set phrases and he was able to apply this effectively to different scenarios.
To ensure that Stephen embedded ‘set phrases’ across his everyday communication we drew on the second therapeutic principle of context-sensitive social communication therapy (Ylvisaker, 2006). We developed scripts that Stephen practiced in the session. The carer used the scripts in role play between sessions before Stephen employed the strategies in increasingly unstructured interactions.
Stephen noticed that guests were naturally interested to find out about his recovery but that conversations quickly closed down if he answered questions about himself or if he did not feel like talking about himself. He wanted to shift the focus away from his own situation and establish more balanced interactions. He decided to respond to kind enquiries by saying “I’m fine thanks but more importantly how are you?”. This simple phrase opened up conversations because Stephen went on to ask follow up questions based on his communication partner’s answer which lead to a more satisfying interaction.
Stephen wanted to help his children with their spellings but found it difficult to manage his own frustration if the children were uncooperative. We decided that it was helpful to (a) set the right tone, (b) praise and (c) offer reward. The script comprised three key phrases:
S: Let’s do your spellings, it’s boring but everyone’s got to do it
S: You’re so good at this set, let’s continue
S: Let’s concentrate for 10 minutes then we can have a treat!
Over time, Stephen supported spelling practice with the distant supervision of his carer.
Helen, Stephen's carer, reflected on the value of the programme for their work together:
We used set phrases effectively in daily interactions, which did much to keep communication positive and light between us:
Stage 3 - Evaluate performance
The carer developed excellent candid camera skills (with Stephen’s permission) capturing social interactions as they unfolded. She also provided bi-weekly written feedback and together with self-rating from Stephen we were able to build a picture of growing confidence in social interactions.
On CommspeCS, Stephen reported positive outcomes in his everyday interactions and the carer noted a more consistent use of productive strategies and a reduction in non-productive strategies e.g. walking away from difficult situations.
Douglas, JM; Knox, L; De Maio C and Bridge H Improving Communication-Specific Coping after Traumatic Brain Injury: Evaluation of a New Treatment using Single-case Experimental Design BRAIN IMPAIRMENT (2015) volume number pages
Douglas, J and Mitchell, C. Measuring communication-specific coping: Development and evaluation of the Communication-specific Coping Scale. Brain Impairment, (2012) 13(1), 170–171.
Friedman, A. & Douglas, J. Social participation and coping with communication breakdown following severe traumatic brain injury. Brain Injury, (2005). Supplement, 50–51.
Mitchell, C., & Douglas, J. Coping with communication breakdown: A comparison between adults with severe TBI and healthy controls. Brain Impairment, (2011) Supplement, 41.
Muir, A., & Douglas, J. Coping with communication breakdown after severe traumatic brain injury. Brain Impairment (2007) 8, 83.
Snow, P., Douglas, J., & Ponsford, J. Conversational discourse abilities following severe traumatic brain injury: A longitudinal follow-up. Brain Injury (1998) 11, 911–935.
Ylvisaker, M.Self-coaching: A context-sensitive, person-centred approach to social communication after TBI. Brain Impairment (2006) 7, 235–246.