Connect with us
  • Elysium

Insight

Delivery of neuropsychological interventions for a communication disorder

Ellie Knight, assistant psychologist at Renovo Care Group, discusses the importance of collaborative working to deliver support

Published

on

After a brain injury it is not uncommon for individuals to find that their ability to communicate has been affected.

Whilst communication does include ‘spoken’ language, it is also more than just words. It can include understanding language and non-verbals such as gesture, body language, facial expressions and so on.

Depending on the severity and location of the brain injury and individual factors – e.g., level of education, access to rehabilitation – will determine the long-term effects of an individual’s ability to communicate. One of the most prevalent communication disorders is aphasia. This is a language impairment that affects an individual’s ability to understand what is being said and/ or expressing what they want to say including reading and writing skills.

It is also not uncommon for individuals with communication disorders to require cognitive, emotional, or behavioural support during their rehabilitation journey. For example, research has found that up to 70 per cent of individuals with stroke and aphasia have depression. This type of intervention is often provided by a Clinical Neuropsychologist, if there is access to one, to assess, formulate and implement strategies/ intervention to support this manifestation.

Cognitive work may include psychometric testing, emotional work may include psychological therapies such as Cognitive Behavioural Therapy (CBT), Compassion Focused Therapy (CFT), Acceptance and Commitment Therapy (ACT) and mindfulness, and behaviourial work may include a functional assessment of the distress. 

Ellie Knight, assistant psychologist at Renovo Care Group

Historically, communication difficulties have posed a significant barrier in accessing such neuropsychological support. For example, many mental health studies will typically exclude individuals with aphasia because research procedures, outcome measures or treatments are determined to be inaccessible to them.

The presence of communication difficulties can also create difficulties for completing standardised neuropsychological assessments as many as not fully adapted to cater such impairments. Considering that many psychological therapies in mental health settings are akin to those used in neuropsychology, e.g., CBT, CFT, ACT, mindfulness, this finding may also be valid. The impact of this exclusion is not only ethically wrong because it does not promote equality within care, but also it creates a false premise that people with communication difficulties cannot engagement in any kind of psychological intervention in the basis of their impairment

A recent book (Psychotherapy and aphasia: intervention for emotional wellbeing and relationships’, 2020) highlighted that regardless of their communication, individuals can still engage and make good therapeutic outcomes. Many of the standardised psychological interventions that we would use in the absence of communication disorders were adapted with the support of specialist Speech and Language Therapists (SLT’s).

The move away from structured, manualised interventions towards co-designed, individualised ones, highlights the practice of person-centred care. This gold standard, holistic approach makes the individual the expertise of their own care and strives to deliver better outcomes and experiences.

As an assistant psychologist working in a neurorehabilitation hospital, I view the development of individualised interventions as a way to embody person-centred care.

Recently I was working with a gentleman who we will call “T”. He had a history of a severe traumatic brain injury from 18 months previous and significant mental health history which was being managed via medication. Upon admission, T also had moderate receptive and moderate-severe expressive aphasia. On top of this, T had what is known as a cognitive communication disorder (CCD). This is a difficulty with communication due to an underlying cognitive deficit rather than a primary language or speech problem. It can result in impaired functioning for one or more cognitive processes including attention, memory, processing speed, executive functions, perception, insight.

T’s CCD was assessed by the SLT who concluded that he had difficulties processing complex language including taking things literally and being unable to understand abstract information. He also had difficulties with his attention, particularly selective, which in turn hindered his ability to retain information. 

Whilst T had engaged in rehabilitation at a previous service since his injury, the primary focus had been indirect behaviour work. When T was admitted onto our rehabilitation pathway, it appeared that due to the environment and established routine this work was no longer required, and hence more focus could be placed on cognition.

It was decided alongside T that we would start a piece of work called the ‘Brain Injury Awareness’ intervention. The intervention consisted of 12, one-hour long sessions with the aim of building insight and knowledge into his brain injury and associated long-term effects, e.g., the impact on communication, emotions, cognition. 

As standard practice the Brain Injury Awareness intervention, which was created by the services’ Clinical Neuropsychologist, can be adapted to incorporate the individuals type of brain injury and examples of how this has affected them. However, T was an interesting case because most individuals that we have previously conducted this intervention with did not have moderate to severe aphasia and/or CCD.

Given that we felt T could benefit from the intervention, we decided to further adapt it to meet his communication and language needs. Much of this was conducted in conjunction with the SLT department and the intervention was co-delivered with T’s SLT. Together we adapted the “standard” intervention to include more pictures, fewer words, simple sentences, concrete examples of T’s rehabilitation etc to support his aphasia. We also provided T with his own folder, so he had visual handouts of the information (both for reference and also for memory aid), used errorless learning (provided him with an opportunity to avoid mistakes), worked in a quiet environment, and repeated/ summarised information for him, to support with his CCD.

At the end of the 12 sessions, we found that T had a better understanding of his brain injury and the impact of some longer-term effects. T was able to recognise his fatigue and acknowledge that he needed regular breaks and was also able to manipulate the environment to aid his attention.  

Upon reflection, without the support of a SLT, adapting this intervention for T would have been so much harder. Largely due to my own inexperience of providing a psychological intervention to someone who could cognitively understand the information but required adaptation to meet their communication needs.

Joint working with a profession who understands the communication and language needs of T, alongside the neuropsychology expertise, worked in his favour and it is definitely something that I will be doing more of. It also highlighted to me that providing a gold standard, manualised intervention within the neurorehabilitation domain is nearing impossible when you have other factors to consider and therefore it is imperative that psychological interventions, and all rehabilitation interventions for that matter are individualised.

Just because an individual has a cognitive communication and language disorder should not mean that they do not receive the support they require, and in my own opinion, it emphasises the importance of collaboratively working for the individual. 

References

Meredith, K., H., & Yeates, G. N. (2020). Psychotherapy and aphasia: interventions for emotional wellbeing and relationships. New York: Routledge.

Newsletter

Sign up for the NR Times newsletter
I would like to receive by email other offers, promotions and services from Aspect Publishing Ltd and its group companies.*

Trending