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BRAIN IMPAIRMENT VOLUME 18 NUMBER 3DECEMBER pp. 321–331 c
Australasian Society for the Study of Brain Impairment 2017
doi:10.1017/BrImp.2017.20
PRESIDENTIAL ADDRESS
“So that’s the way it is for me —
always being left out.” Acquired
Pragmatic Language Impairment and
Social Functioning following
Traumatic Brain Injury
Jacinta M. Douglas1,2
1Living with Disability Research Centre, School of Allied Health, La Trobe University, Victoria, Australia
2Summer Foundation, Victoria, Australia
Our ability to interact appropriately in everyday interpersonal situations is funda-
mental to successful social integration. Impaired pragmatic competence corre-
lates significantly and substantially with indices of social function across several
domains for adults with acquired neurological disorders. In particular, evidence
supports the negative impact of pragmatic impairments on the development and
maintenance of relationships and community integration more generally.
Pragmatic language competence sits in a complex, multifactorial space charac-
terised by interacting associations with cognitive and psychological functions and
social and environmental parameters. This complexity is evident in much of the
research seeking to unravel the nature and magnitude of interactions between
pragmatic language competence and social outcomes in adults with acquired
neurological disorders.
Over recent years our understanding of the impact of pragmatic impairments on
social outcome has benefited substantially from inclusion of the insider’s per-
spective in our research evidence base. Indeed, a methodological inclusion of
constructivist paradigms has enabled the development of a rich understanding of
the devastating social impact of impaired pragmatic competence.
The aim of this paper is to review pragmatic language impairment in the context
of traumatic brain injury (TBI) and detail its impact on social functioning from the
perspectives of people with TBI and their intimate partners/spouses and friends.
With these perspectives as background, the paper concludes with consideration
of therapeutic developments and a brief look at a novel intervention designed to
reduce the negative impact of pragmatic deficits and improve functional language
use following TBI.
Keywords: brain injury, pragmatic impairment, social function, relationship, couples, friends
Introduction
Pragmatic language competence sits in a com-
plex, multi-factorial space characterised by inter-
acting associations with cognitive and psycholog-
Address for correspondence: Prof. Jacinta Douglas, Living with Disability Research Centre, School of Allied Health,
La Trobe University, Bundoora, Victoria 3086, Australia. E-mail: J.Douglas@latrobe.edu.au
ical functions and social and environmental pa-
rameters. Pragmatic skills have been variously
described as ‘the skills underlying competence
in contextually determined, functional language
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JACINTA M. DOUGLAS
use’ (Turkstra, McDonald, & Kaufmann, 1995),
‘the emergent consequence of interactions between
linguistic, cognitive and sensorimotor processes
which take place both within and between in-
dividuals’ (Perkins, 2005) and ‘the wide range
of codified but subtle ways in which language
use has evolved in a given culture’ (Snow &
Douglas, 2017). Given its multifaceted nature, it
follows that the study of pragmatic competence
is inherently multidisciplinary (Cummings, 2005)
covering scholarly endeavours across philosophy,
linguistics, speech language pathology, cognitive
science and psychology.
The multifactorial structure of pragmatic lan-
guage competence is illustrated in Figure 1:‘Acup
of competence’ (Snow & Douglas, 2017). This fig-
ure depicts the various constituent functions of
pragmatic competence (executive, language and
social cognition functions) conceptualised in the
context of individual psychological characteristics
as well as social–environmental influences. As a
result of this complexity, there are many levels at
which skills can be compromised giving rise to
substantial challenges for the reliable and valid as-
sessment of pragmatic impairment (for review see
Cummings, 2017; Douglas & Togher, 2017).
Pragmatic deficits are encountered in a range
of neurological conditions including those asso-
ciated with focal damage (e.g., unilateral stroke,
both right and left hemisphere); those associated
with more diffuse damage (e.g., traumatic brain
injury (TBI); as well as degenerative disorders
(e.g., Alzheimer’s disease, variant forms of pri-
mary progressive aphasia) (for review see Douglas
& Togher, 2017; Snow & Douglas, 2017). Each of
these acquired neurological disorders affects a sub-
stantial proportion of the adult population. In Aus-
tralia alone our prevalence rate of 2.2% (Australian
Institute of Health and Welfare, 2007) means that
one in 45 Australians are living with brain injury
related disability and almost three quarters of these
people are less than 65 years of age.
Lack of social integration and poor quality
of social relationships are common and endur-
ing experiences for many people who acquire
neurological disorders during adulthood (Barry &
Douglas, 2000; Clare et al., 2012; Galski, Tomp-
kins, & Johnston, 1998; Lefebvre, Cloutier, &
Levert, 2008; Pound, Gompertz, & Ebrahim,
1998). Further, increasing evidence demonstrates
that disorders likely to be associated with nega-
tive social outcomes are those that involve changes
in the functional use of language (Douglas, 2015;
Hilari et al., 2010). Over recent years our under-
standing of the impact of these acquired prag-
matic impairments on social outcome has bene-
fited substantially from inclusion of the insider’s
perspective in our research evidence base. Indeed,
a methodological shift to constructivist paradigms
has enabled the development of a rich understand-
ing of the devastating personal experience of im-
paired pragmatic competence and its impact on
social living.
The aim of this paper is to review pragmatic
language impairment in the context of evidence in
the field of TBI, describe its impact on social inte-
gration particularly within relationships from the
individual perspectives of those with TBI and their
intimate partners/spouses and friends. The paper
concludes with consideration of therapeutic devel-
opments and a brief look at a novel intervention
designed to reduce the negative impact of prag-
matic deficits and improve functional language use
following TBI.
Understanding the Personal
Experience: Theory, Practice and
Research
Many scholars have emphasised the personal sig-
nificance of the interplay between the individual
and society. Notable among these theorists are
those working in the tradition of symbolic inter-
actionism, considered to be one of the most endur-
ing social theories of the 20th century (Benzies &
Allen, 2001;Oliver,2012; Plummer, 2000). Sym-
bolic interactionism views the individual and the
context in which the individual exists as insepara-
ble and mutually constructed in the course of social
interactions. George Herbert Mead’s (1863–1931)
theory of the emergence of mind and self out of
the social process of communication is generally
considered the foundation of symbolic interaction-
ism. Mead described the individual as ‘taking the
attitudes of other individuals toward himself (sic)
within a social environment or context of experi-
ence and behaviour in which both he and they are
involved’ (1934, p. 203). Thus, from Mead’s view,
it is the individual’s perception or interpretation of
his/her own social world that influences the self.
Herbert Blumer (1900–1987), Mead’s student,
progressed the tradition of symbolic interactionism
during the mid 20th century stating:
The term “symbolic interactionism” refers of
course to the peculiar and distinctive character of
interaction as it takes place between human beings.
The peculiarity consists in the fact that human be-
ings interpret or “define” each other’s actions in-
stead of merely reacting to each other’s actions.
Their “response” is not made directly to the actions
of one another but instead is based on the meaning
which they attach to such actions. Thus, human in-
teraction is mediated by the use of symbols, by in-
terpretation, or by ascertaining the meaning of one
322
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ACQUIRED PRAGMATIC LANGUAGE IMPAIRMENT
FIGURE 1
‘A cup of competence’: Constituent functions of pragmatic language competence and psychological and social
influences. From Research in Clinical Pragmatics Volume 11 of the series Perspectives in Pragmatics, Philosophy &
Psychology, Chapter 23, Psychosocial Aspects of Pragmatic Disorder, 2017, pp 617–649, Snow & Douglas. With
permission of Springer Nature.
another’s actions. This mediation is equivalent to
inserting a process of interpretation between stim-
ulus and response in the case of human behavior.”
(Blumer, 1962, p. 180).
Blumer (1962,1969) went on to outline impor-
tant tenets underpinning this theoretical stance. He
described individuals as acting toward people and
things based upon the meanings they have given to
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JACINTA M. DOUGLAS
FIGURE 2
Rehabilitation and research implications of symbolic interactionism.
those people or things. Thus, meaning arises in the
process of interaction between people; it is a social
process taking place in the context of relationships.
In turn, people are assumed to have the capac-
ity to negotiate meaning through symbols giving
rise to an interpretive process that is ever chang-
ing. In other words, he described human behaviour
as emergent and continually constructed. Within
this framework then, it can be seen that pragmatic
competence, involving the use and interpretation
of codified signs, makes a direct contribution to
meaning as constructed within the interaction.
The theoretical tenets of symbolic interaction-
ism have some important implications for prac-
tice within therapeutic or rehabilitation and re-
search domains (Douglas, Drummond, Knox, &
Mealings, 2015)(Figure 2). In rehabilitation, ap-
preciating the client’s experience requires the clin-
ician to understand the meaning of the situation
from the perspective of the injured individual and
those with whom the individual relates. In a sym-
bolic interactionist framework, understanding can-
not be fully developed based on what is typically
captured through test administration; it requires
shared interactions with the injured individual and
close others and direct consideration of the role/s
valued by that individual. In short, viewing the
world as much as possible from the client’s per-
spective. Similarly in the domain of research, sym-
bolic interactionism demands the use of construc-
tivist interpretivist approaches with a focus on ex-
ploring the lived experience of the person with
injury and those with whom they interact.
Exploring Pragmatic Deficits in the
Context of TBI
Globally TBI will surpass many diseases as the ma-
jor cause of disability by 2020 (Hyder, 2007). As
many as 70% of these people will report difficulties
with communication including motor speech im-
pairment (Wang, Kent, Duffy, & Thomas, 2005),
word finding problems (Bittner & Crowe, 2006;
Olver, Ponsford, & Curran, 1996), comprehension
difficulties (Olver et al., 1996) and pragmatic im-
pairment (Channon & Watts, 2003; McDonald,
1993; Snow, Douglas, & Ponsford, 1997,1998;
Turkstra et al., 1995). Further, longitudinal stud-
ies demonstrate that these communication deficits,
particularly in the domain of pragmatics, persist
into the long term and result in substantial ongo-
ing demands on therapy resources (Snow et al.,
1998). In fact data from one of our early studies
showed that problems in conversation continued
to be evident in 96% of speakers with moderate–
severe TBI who were followed up over 2-years, de-
spite having had considerable therapy (Snow et al.,
1998).
While incidence and prevalence statistics illus-
trate the scope of the problem, personal descrip-
tion powerfully evokes the experience of prag-
matic impairment faced by people with TBI ev-
eryday as they go about negotiating life in so-
cial settings. Tab le 1 presents a summary of quotes
from research participants outlining the pragmatic
communication behaviours that they perceive as
challenging (Bracy & Douglas, 2005; Douglas,
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ACQUIRED PRAGMATIC LANGUAGE IMPAIRMENT
TABLE 1
The Personal Experience of Pragmatic Deficits
Personal Experiences#Pragmatic Problems
What the hell do I say? I don’t know, so I don’t speak
Generating topics
I do have problems starting up a conversation . . . specially when it comes
to women
Initiating conversation
I don ’ t say the right thing - I say ridiculous things
Inappropriate comments
I go on and on about things, I don’t know when enough’s enough
Ver bosit y
I can’t seem to pick up even their facial expressions or their voice to know
when to say something or even if I should say something
Reading non-verbal cues
I don ’ t seem to show people I ’ m interested in what they ’ re saying
Using non-verbal cues
You’ve got to be trying to think about two things, that you’re actually doing
the actual communication stuff, but then at the same time remember the
stuff you’re saying
Simultaneous pragmatic and
cognitive demands
#Note: Participant quotes from (Bracy & Douglas, 2005;Douglas,2010;Douglas,2015; Mackey et al., 2007; Shorland &
Douglas, 2010).
2010; Douglas, 2015; Mackey, Sloan, Starritt, &
Douglas, 2007; Shorland & Douglas, 2010). These
quotes show that people with TBI are well aware
of the functional communication challenges they
grapple with on a daily basis ranging from knowing
what to say, when and how to say it, and keeping
track of the interaction. Given the enormous chal-
lenges so effectively captured by these statements,
it is unsurprising that many people with TBI expe-
rience social interaction as an anxiety provoking
activity: ‘I get so anxious . . . there’s so much hap-
pening, I never knew’ (Michael) (Douglas, 2015,
p. 207).
The consequences of impaired communication
skills following TBI are also well illustrated across
several studies that have directly investigated the
association between functional use of language
and community integration (Dahlberg et al., 2006;
Galskietal.,1998;Snowetal.,1998; Struchen
et al., 2008; Struchen, Pappadis, Sander, Burrows,
& Myszka, 2011). Although these studies show
variable findings with respect to the magnitude
of the association, they generally yield modest to
strong statistically significant correlations account-
ing for as much as 18.5% of variance in community
integration scores.
Snow et al. (1998) reported that clinician-rated
discourse errors correlated significantly with (r=
−0.36, p=.04) and accounted for 13% of the
variance in social integration scores as measured
by the Craig Handicap Assessment and Reporting
Technique (CHART; Whiteneck, Charlifue, Ger-
hart, Overholser, & Richardson, 1992) in a group
of 26 adults with severe TBI followed up 2 years af-
ter injury. In that same year, Galski et al. (1998)re-
ported similar findings between clinician-rated dis-
course parameters and the CHART (rranging from
.06 to .41) in a group of 30 participants with mod-
erate to severe injuries. More recently, Dahlberg
et al. (2006) showed that self-rated but not close
other-rated social communication ability was sig-
nificantly associated with social integration in a
group of 60 participants with moderate to severe
brain injury sustained 1–21 years previously. Cor-
relation coefficients between self-rated social com-
munication abilities and both the CHART and the
Communication Integration Questionnaire (CIQ;
Willer, Ottenbacher, & Coad, 1994) ranged from
0.28 to 0.43. In 2011, Struchen et al. reported
the findings of their evaluation of the contribu-
tion of self-rated social communication skills (La
Trobe Communication Questionnaire (LCQ) self-
report; Douglas, Bracy, & Snow, 2007; Douglas,
O’Flaherty, & Snow, 2000)topredictionofso-
cial integration outcomes (CIQ) using hierarchi-
cal multiple regression on data from 184 adults
with TBI at least 6 months after discharge from
acute care. After accounting for demographic and
injury-related characteristics, social communica-
tion and affective/behavioural variables accounted
for a statistically significant amount of variance in
social integration functioning. Social communica-
tion measures accounted for 11.3% of the over-
all explained variance in social integration and the
LCQ total score made a statistically significant and
unique contribution to the prediction of CIQ scores.
Significant association between communica-
tion and social participation can be expected given
that communication is the means by which we ne-
gotiate daily activities and relationships. Indeed,
interpersonal communication skills contribute to
vocational outcome in their own right, separable
from the contribution made by executive cogni-
tive function (Struchen et al., 2008). In addition,
while executive control processes influence social
communication competence, they do not explain
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JACINTA M. DOUGLAS
pragmatic deficits and research shows that execu-
tive function measures leave a substantial propor-
tion of variance (almost two thirds) in pragmatic
impairment unexplained (Douglas, 2010).
The Experience of Pragmatic Deficits
Within Relationships
Friendships
Friendship is characterised by mutual help and sup-
port. Willmott (1987) defined a friend as someone
you can trust, someone whose company you enjoy,
and someone with whom you can discuss things
freely. Friends typically have similar attitudes, be-
liefs and interests (Nussbaum, 1994). They also
demonstrate similar values concerning communi-
cation (Burleson, Samter, & Lucchetti, 1992). In
particular, Burleson et al. (1992) found that pairs of
friends rated the ability to ‘comfort’ as a communi-
cation skill important to maintaining their friend-
ships. Thus, it can be anticipated that negative
changes in a person’s communication behaviours,
especially those that convey mutuality and sensitiv-
ity, will have a negative impact on existing friend-
ships. Further, if a person’s communication be-
haviours reflect socially inappropriate behaviour,
that person’s ability to develop new friendships is
likely to be reduced (Snow & Douglas, 2017).
The negative impact of changed pragmatic
competence on friendship after TBI has been high-
lighted by the findings of several qualitative studies
(Karlovits & McColl, 1999; Paterson & Stewart,
2002; Shorland & Douglas, 2010)). People with
TBI identified social interaction as one of nine
sources of stress in Karlovits and McColl’s (1999)
study. They described feeling that they no longer
had ownership over what and howthey contributed
to conversations:
At times I tend to monopolize the conversation.
I’m trying to keep an eye on that. I’d be roughly
corrected in the past and I realize it doesn’t win too
many friends (Karlovits & McColl, p. 852).
Paterson and Stewart (2002) analysed focus
group data from 11 participants deriving themes re-
lating to how participants viewed their interactions
and relationships. Participants linked lost friend-
ships with their changed communication: ‘When
you go somewhere, aye, they look at you, ‘oh he’s
alright.’ And as soon as you speak, it all flips over
one side’ (Paterson & Stewart, 2002, p.16). They
identified strain on their day-to-day interactions
particularly due to lost or reduced ability to be
tactful: ‘You just say straight away what you want,
there is no tactfulness involved’ (Paterson & Stew-
art, 2002, p.16).
In 2010, we (Shorland & Douglas, 2010) high-
lighted similar difficulties in the experiences of two
young adults, Rachel and Dave, following severe
TBI. Three key themes emerged from analysis of
the in-depth interview data: evolution of friend-
ships following TBI; perceptions of communica-
tion; and opening up to others. The participants’
perception of their ability to communicate con-
tained many examples of their experiences of im-
paired pragmatic competence. Rachel commented
on difficulties with interpreting turn-taking cues,
leading to her tendency to interrupt:
Sometimes I have trouble if someone’s speaking
and I’m not quite sure when they’ve finished, like
if they have a pause for a moment and then I want
to go and say something but they actually haven’t
finished saying something so I butt in (Shorland &
Douglas, 2010; p. 574).
Rachel also remarked on problems with man-
aging discourse structure and difficulties modify-
ing prosody to convey emotional tone:
Sometimes I start with saying something then I
go back to the beginning of what I should be ac-
tually saying to make, make more sense in my
mind but I’m sort of speaking that out loud; I sup-
pose I try and correct it [disjointed discourse] as
best as possible. But yeah it happens sort of as
I’m, as I’m speaking because my brain doesn’t
sort of do it beforehand like un-brain injured peo-
ple’s brains.’. . . ‘She [friend] could tell by what I
was saying that I was sincere, but not by the tone
of my voice. (Shorland & Douglas, 2010; p. 574).
Both Rachel and Dave highlighted difficul-
ties with managing their contributions to conver-
sations:
I had trouble with continuing a conversation. You
say ‘hi how are you’ and then where do you go
from there? (Rachel). (Shorland & Douglas, 2010;
p. 574).
. . . .sometimes I sort of run out of things to say
and then, then sort of the other person doesn’t,
bring anything new into the conversation, you sort
of get stuck (Dave). (Shorland & Douglas, 2010;
p. 574).
Approaching someone, initiating, is a little like
strange, or unfamiliar to me and bringing conver-
sations to a close I don’t always know how to, how
to end a conversation or how to leave a conversa-
tion in a, in a correct manner . . . (Dave). (Shorland
& Douglas, 2010; p. 574).
Although Rachel acknowledged that her com-
munication might affect her friendships: ‘So the
way I speak to people and communicate with
them I suppose would affect the friendships that
I have and am trying to make’ (Shorland & Dou-
glas, 2010; p. 574), she was surprised when her
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ACQUIRED PRAGMATIC LANGUAGE IMPAIRMENT
friends discussed changes in her communication
that could impact the quality of their relationships:
‘I think it’s the same but [my friends] were telling
me things that they noticed that my communication
is different . . . When they were telling me these
problems, it made me feel a bit disheartened, a bit
miserable.’ (Shorland & Douglas, 2010; p. 574).
Dave described the impact of his communication
difficulties on relationships by reference to his lack
of confidence: ‘Confidence is a big issue, when it,
when it goes to walking up and talking to someone’
(Shorland & Douglas, 2010; p. 574). His response
is consistent with evidence that people with TBI
take a passive role in conversation (Bogart, Togher,
Power, & Docking, 2012). Dave described himself
in this manner but also noted that his passivity var-
ied according to particular communication partners
and settings. Finally, both Rachel’s and Dave’s ex-
periences supported the importance of addressing
the communication difficulties of this population
using context-specific approaches that include so-
cial activities with friends and peers.
Intimate Relationships
Acquired communication impairments impact on
relationships in general, and most significantly,
on intimate spousal/partner relationships. Sustain-
ing emotional intimacy in partner relationships re-
lies on dialogue, transparency, vulnerability, and
reciprocity (Perlman, 2008). Indeed, relational
problems in couples have been conceptualised
as a function of deficiencies in communication
skills, resulting in dyadic distress and dissatisfac-
tion (Rogge & Bradbury, 1999). As two-way con-
versations are the currency for sustaining intimacy
in healthy partner relationships (Duck, 1988), neg-
ative changes in pragmatic ability are likely to
threaten the spousal bond. Evidence to support this
contention can be found in the literature examining
the experience of couples following TBI (Bracy &
Douglas, 2005; Gill, Sander, Robins, Mazzei, &
Struchen, 2011; Godwin, Chappell, & Kreutzer,
2014; O’Flaherty & Douglas, 1997).
Individuals with TBI frequently struggle
within intimate relationships as a result of commu-
nication challenges, information processing dif-
ficulties, and frequent emotional and sexual inti-
macy issues (Godwin et al., 2014). Similarly, their
partners also experience communication difficul-
ties as barriers to intimacy. Gill and colleagues
(2011) interviewed 18 couples at a mean length
of 4.78 years post-injury. Most participants iden-
tified good communication as critical to maintain-
ing their intimate relationship and negotiating the
injury related changes they encountered. Partners
noted that communication seemed to take place
on a different level after TBI, with conversations
lacking intellectual and emotional depth: ‘I think
an intimate moment is when you pour your heart
out. And we can’t do that anymore’ (Gill et al.,
2011, p. 62). Some also reported that their injured
partner tended to avoid discussing issues that af-
fected the relationship. Bracy and Douglas (2005)
also noted topic avoidance in their study of cou-
ples following TBI. However, avoidance tended to
be used as a coping strategy by partners to steer
clear of topics that were likely to trigger negative,
difficult or angry interactions.
Using a model of interpersonal communica-
tion, O’Flaherty and Douglas (1997) explored the
subjective experience of living with the conse-
quences of TBI. The married participants in the
study described fundamental changes to the dy-
namics of their relationship as a couple. Partici-
pants reported a substantial decline in social and
leisure activities, with married dyads reporting a
progressive tendency for the uninjured spouse to
socialise alone. Participants identified increased
tension in situations in which wider family and/or
friends were together as one of the reasons for
this outcome. Further, the injured partner’s un-
predictable and inappropriate communication was
seen as the source of this tension for spouses,
while injured partners reported feeling unable to
‘keep up’ in fast-moving and busy social situations,
and therefore consciously chose to avoid them:
‘ . . . as I said I just don’t go [to social activ-
ities at his wife’s workplace] because I’m more
of a hindrance or make it harder for her to enjoy
herself’ (O’Flaherty & Douglas, 1997, p. 900).
Spouses also identified insensitive or violent
outbursts, and difficulties with implicature and
social banter as particularly challenging in their
relationships:
. . . it’s still very hard when someone’s screaming
and shouting at you (O’Flaherty & Douglas, 1997,
p. 901).
. . . you know, if there’s a trick in it. And she just
won’t get it. Won’t get it; Some of the problem with
friends...partofthefriendshipwasalwaysbanter.
Banter that you used to . . . and you [directed at
injured partner] can’t keep up with that now . . .
You know jokes and asides (O’Flaherty & Douglas,
1997, p. 903).
Evidence not only in the TBI literature but
also in the stroke (Bakas, Kroenke, Plue, Perkins,
& Williams, 2006; Grawburg, Howe, Worrall, &
Scarinci, 2013) and dementia (Eloniemi-Sulkava
et al., 2002; Pozzebon, Douglas, & Ames,
2016) literature shows that intimate relationships
are vulnerable to pragmatic impairments that
result in even subtle changes in interpersonal
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JACINTA M. DOUGLAS
communication. Further, these changes can
progressively erode the fabric of a couple’s rela-
tionship and pose a direct threat to the cohesion
of that relationship. Consequently, it is important
that we focus therapeutic attention on pragmatic
competence, particularly in the context of intimate
partnerships.
Communication Rehabilitation
Following TBI
Despite the overwhelming negative impact of com-
munication disability after TBI, high quality evi-
dence to inform clinical management of this prob-
lem continues to be relatively scarce. To date only
five randomised controlled trials (RCTs) of com-
munication rehabilitation for adults with TBI have
been published. In 2014, the international recom-
mendations for management of cognition follow-
ing TBI (INCOG guideline) (Bayley et al., 2014)
included seven recommendations regarding best
practice for the assessment and management of
communication disorders following TBI (Togher
et al., 2014). Only three are based on evidence from
at least one randomised trial with a relevant con-
trol group. Evidence currently available supports
the effectiveness of context-sensitive interventions
embedded in the person’s everyday life, communi-
cation partner training, and metacognitive strategy
training (Togher et al., 2014).
We have recently developed and completed
preliminary evaluation of a new approach to in-
tervention for communication disability (Douglas,
Knox, De Maio, & Bridge, 2014; Douglas et al.,
in press). This approach focuses on coping in the
context of communication breakdown which as
we have seen is a frequent and stress provoking
experience for people with TBI (Bracy & Dou-
glas, 2005; Douglas & Spellacy, 2000). Typically,
people use communication-specific coping strate-
gies in situations characterised by communica-
tion breakdown (Douglas et al., 2014). Produc-
tive coping strategies enhance message transfer, re-
duce stress and improve participation. In contrast,
non-productive strategies do little to resolve prob-
lems, frequently exacerbate stress and promote so-
cial isolation. In a series of studies, our research
has shown that people with TBI exhibit a pattern
of communication-specific coping that deviates
markedly from the norm (Friedman & Douglas,
2005; Mitchell & Douglas, 2011; Muir & Douglas,
2007). We found TBI participants used signifi-
cantly more non-productive coping strategies (e.g.,
Get angry and shout; Stop talking to the person)
and significantly fewer productive strategies (Find
out what the person is having trouble with; Use ex-
amples) than control participants matched for age,
sex and education. We also found that the ability to
cope with communication breakdown was signif-
icantly associated with improved social outcome
(r=.51, p<.05) (Friedman & Douglas, 2005).
These findings support the functional importance
of communication-specific coping. Indeed, our
findings show that communication-specific cop-
ing accounts for more variance in social outcome
(25%, Friedman & Douglas, 2005) than commu-
nication impairment (Snow et al., 1998).
Given our results, we reasoned that an in-
tervention developed to increase productive and
reduce non-productive communication-specific
coping strategies would have a substantial and
measurable positive impact on functional commu-
nication, stress, and emotional wellbeing for those
with communication problems. Consequently, we
developed a new treatment, Communication-
specific Coping Intervention (CommCope-I). We
have now completed proof of concept testing us-
ing single case experimental design (SCED) with
replication (Douglas et al., 2014) and a small fea-
sibility trial (n=13) (Douglas et al., in press), both
of which have shown clinically and statistically
significant results supporting the effectiveness of
the approach. Indeed participants in both stud-
ies showed substantial improvement on measures
of communication-specific coping, psychological
distress and functional use of communication with
improved scores maintained 1 and 3 months later.
The CommCope-I program represents an in-
novative approach to functional communication
problems. It is systematically underpinned by treat-
ment principles with supporting evidence from
multiple disciplines and areas of practice includ-
ing cognitive behavioural therapy, self-awareness
training, context-sensitive communication therapy
with everyday communication partners, and self-
management. It focuses on increasing positive be-
haviours rather than attempting to extinguish nega-
tive behaviours and as captured by Amanda, one of
the participants, it produces results that make a dif-
ference to everyday functional language use: ‘now
I see what strategies I’ve done, and I like watch-
ing it. I feel like, ‘That’s me and I did it.’ I didn’t
like going into shops, I didn’t like talking on the
phone . . . but I think, I definitely know there’s
improvements, seeing myself at the start and
finishing’.
Concluding Comments
People who display poor pragmatic language com-
petence typically have difficulty engaging in so-
cial situations, leading to uncomfortable interac-
tions with others. Such interactions contribute to
328
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ACQUIRED PRAGMATIC LANGUAGE IMPAIRMENT
rejection by others and poor community integra-
tion, which can in turn contribute to negative
self-concept, depressed mood, loneliness, and
withdrawal from efforts to engage in community
activities. In turn, withdrawal from community ac-
tivities further reduces opportunities for social en-
counters contributing to a vicious circle of con-
tinuing and increasing social isolation, loneliness
and depression. Ongoing research and treatment
development efforts with a focus on improving
pragmatic competence and reducing the negative
effects of pragmatic impairment continue to be es-
sential to maximise long term social gains for the
large number of people with pragmatic deficits ac-
quired as a result of brain injury.
Acknowledgements
Much of the work referred to in this presiden-
tial address reflects collaboration with a num-
ber of researchers and clinicians who I would
like to thank for their much valued contributions:
Sandy Barry, Christine (O’Flaherty) Bracy, He-
len Bridge, Carren (Mitchell) De Maio, Melanie
Drummond, Abby Friedman, Amy (Muir) Ford,
Lucy Knox, Jan Mackey, Margaret Mealings, Katie
Pennycuick, Margaret Pozzebon, Joanna Shorland,
Pamela Snow, Leanne Togher and Jo Whiteoak. I
would also like to extend my thanks to those who
have so generously participated in our research and
provided such important input.
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