Social Communication Thinking Ahead is published by the Research

(from the June 2004 newsletter, Thinking Ahead) Department at Craig Hospital. It is a project of
the Rocky Mountain Regional Brain Injury System,
which is funded by the US Department of Education’s
Do you talk better than you communicate? National Institute on Disability & Rehabilitation
Research. If you would like more information
call: 303-789-8308
There is much more to communicating than just or email us at: HealthResources@craighospital.org
talking. To actually “communicate,” we must also
share information with another person. We The views expressed here are those of Craig Hospital and
need to be able to listen to and remember what are not necessarily those of the US Department of Education.
we hear. We need to take turns speaking, and
not interrupt the other person.
We need to be accurate and not ramble when we talk. What we say needs to be
organized and make sense. And, we must always be aware of how our words, our tone
and our emotions are affecting the other person.

Communicating takes skill! It’s something that is difficult for everyone. Often, it is made
even more difficult by a traumatic brain injury (TBI).

What happens if someone’s communication skills are not good?

All of the things we described above are part of something called “Social
Communication.” Some people with TBI struggle with Social Communication problems.
At first, they might struggle because communicating is so much work. As time goes by,
some may just stop trying to start conversations – and, others may not want to get
involved in conversations with them. Eventually, it may be hard to make or keep friends,
to find a boyfriend or girlfriend, or to get and keep a job. Self-esteem could be effected
so that the person with the TBI starts to feel a sense of failure and begins to feel
isolated.

Specific Signs and Symptoms

These are a few of the symptoms that people who have trouble with Social
Communication might have:
⌧ Their communication is confusing.
⌧ When they talk, they may give too little or too much information.
⌧ They might be disorganized, or they might not make sense.
⌧ They might ramble, repeat themselves, or get off the topic.
⌧ They might not catch and correct errors they make when talking.
⌧ What they say may not be interesting.
⌧ They may talk or process information too slowly.
⌧ The other person may have to ask a lot of question and do more than his or her
share of “the work” of keeping the conversation going.
⌧ They may not know how to use “clues” or “hints” from the other person. This
includes things like gestures, eye contact, and emotions. They may not be able to
tell if they are making the other person uncomfortable.

Re-learning Social Communication

One good way to work on your Social Communication skills is to join a treatment group
of people who are working on the same thing. Groups usually have several people with
TBI, and they are usually led by a psychotherapist or speech therapist who is
experienced in Social Communications. They usually practice communication skills in
real-life situations. If there are not any groups near you, you can still practice on your
own with a partner, friend, or family member.

Here is what you can do:

1. Review the different problems and symptoms that are described above. Make a list
of the ones that you think are problems for you. Ask a partner, friend, or a family
member for their opinions too.
2. Pick one problem that you want to work on. Think about things you can do, when
you talk, to help this problem. Set a goal.
3. Tell your partner or family member what your goal is. Ask them to give you feedback
from time to time about how you are
doing on your goal. If your goal is not Some tips to remember when you are in
to interrupt others, ask them to let you a conversation:
know when you have interrupted. • Keep good eye contact
Have them do this in a way that does • Stay on the topic
not embarrass you. For example, • Take turns talking and listening
they could give you a “secret” signal if • Ask the other person questions
you are in public, or they could talk to
• Get to the point
you privately later on. You may want
• Be friendly and relaxed
to have a time each week when you
can get more detailed feedback on how you are doing with your goal. It may be
frustrating to hear this feedback, but becoming aware of your strengths and
weaknesses is the first step toward improving your social skills.
4. Keep practicing your communication skills and goals when you are out in public, in
the “real world” – when you are shopping, at school, or at a party. If your friend or
family member is able to observe you when you are in the “real world” talking to
someone else, ask them for specific and honest feedback – especially in the area
that was your goal.
Practice, practice, practice, and then practice some more. It should get easier if you
do.

How well do Social Communication classes or group sessions work?

People who both lead and participate in Social Communication groups say that
they are very helpful, but no one has ever studied them scientifically to learn if there
really are measurable improvements in not only communication, but also in self-
esteem, quality of life, and in participants’ relationships with others. Our Rocky
Mountain Regional Brain Injury System research project will help us figure this out.
So far, 60 people with TBI have completed or are actively enrolled in Social
Communication Groups. All are former patients at Craig Hospital or Denver-area
residents. All were injured at least one year, are 18-65 years old, and have memory,
comprehending, and speaking abilities that are good enough to make them
successful group participants. In addition to participating in the free course, every
participant also completes a battery of tests and evaluations before the course
begins, right after the course ends, and again three and six months later. And, all of
the participants have videotaped, one-on-one conversations with another person.
Researchers who don’t know the participants, but who have been trained in special
scoring techniques then rate the videos, looking for specific improvements that each
individual has made. The course itself lasts 12 weeks, and meets every week for
about 1½ hours. They are led by a Speech and Language Pathologist and a Social
Worker who are experienced in treating people with social communication problems.
The last group has begun meeting already. After this group has finished its course
and then completed its final follow-up testing, we will begin analyzing the data. In a
future issue of Thinking Ahead, we will tell you about what we found!
Social Communication: Update
(from the January 2006 newsletter, Thinking Ahead)

A while ago, in our June 2004 issue of Thinking Ahead, we told you about a research
project that we are doing. That project studied Social Communication.

Social Communication has to do with things other than talking. People who have trouble
with Social Communication may speak or talk very well, but they may not listen to others
when they are speaking. They may interrupt and not take turns when talking. Some
ramble on and on. Other people may not make sense when they speak, or they may get
their facts wrong. All of these problems have one thing in common: they leave the
listener confused, disappointed, or maybe even uncomfortable.

Many people with TBI have problems with Social Communication. Their problems with
Social Communication can affect their social life. They can make it harder to make
friends. Social Communication problems can make it hard to find someone to date.
They can make it hard to have a successful job interview. Over time, Social
Communication problems can make someone isolated.

Many people who read our June 2004 newsletter about Social Communication told us
then that they wanted to learn more about this project. So this is the second of what will
be three newsletters about Social Communication. In this one we will tell you about the
60 people with TBI who participated in the project. In a future newsletter we’ll tell you
about how successful the groups and classes were. We hope all of these newsletters
will give you information you can use.

First, here is some information about the 60 people in the study. We’ll call them
“survivors” here.
• 83% of the survivors were men, 17% were women.
• Their average age was 39 years. (The youngest was 20 years old; the oldest: 63
years old).
• The survivors were injured an average of seven years (The shortest amount of time
anyone had been injured was 1 year; the longest was 21 years).
• 65% of the survivors had severe injuries. The rest were milder or moderate.
• Their average length of inpatient rehab was 74 days (The shortest was 15; the
longest was 244 days).
• 80% of the survivors had completed at least some college.
• Only 20% were working for pay when the study started. Another 5% were students
or homemakers.
• All of the survivors had pretty good memories. Their comprehension and speaking
skills were also pretty good at the time they signed up for the research.

These 60 people took several different tests. (These are listed at the end of this
newsletter.) They rated their communications skills. They told us how active they were
socially and in their communities. They also rated their life satisfaction. Family
members, spouses, boyfriends, girlfriends, or partners also rated the 60 survivors. We’ll
call these people “significant others” or “SOs.” In addition, we videotaped each survivor
as he or she had a conversation with another person. The researchers then watched this
video and rated the survivors’ communication skills and problems.
Here is a summary of what we found. It is a description of what the people were like
before they even started their group discussion course to try to improve their Social
Communication skills. It gives you some idea of how they saw themselves, and how
thier SOs saw them.

1. The survivors were able to identify some of their own communication problems. The
problems they saw had to do with:
• keeping the conversation going, thinking of new things to talk about or coming up
with new questions to ask
• knowing when and how to end a conversation
• changing subjects smoothly
• interrupting the other person smoothly
• keeping their thoughts organized.

2. SOs reported even more problems. Families and SOs thought the problems were
more severe than the survivors did. And, they often did not agree with what the
survivors saw as problems.
What does this mean? You probably already know if Social Communication is a
problem for you. Your own rating of your problems may be pretty correct. But, the
opinions of others around you are also helpful. They may go a step further and give
you even more information. They might help you identify other areas to work on to
improve your communication skills. Talk with your friends and family members.
Listen to their suggestions. Work on the areas where they tell you improvement is
needed.

3. Families, SOs, and rehab people often see two types of problems that the survivor is
not aware of. One problem has to do with the survivor’s nonverbal cues. These
include facial expression, tone of voice, and emotions. Sometimes any or all of these
are not appropriate for the situation. The other problem has to do with how well the
survivor pays attention to the other person when having a conversation. The
survivor may not take turns. She may not ask the other person about him or herself.
He may not give the other person a chance to answer. She may not pay attention
when the other person talks. He may talk about himself too much.
What does this mean? – First, non verbal cues
are very important. What you are saying with your body can be just as important as
the words that come out of your mouth. If the two don’t “match,” the listener can be
confused or uncomfortable. Ask someone you trust to tell you about your body
language, your gestures, and your facial expression when you talk. Second, try to
be very aware of the other person when you are having a conversation. Yes, it is
very hard to worry about the other person when you are already working very hard
just to communicate what you need to. But, this is a very important area. Try to
work on it. Get help. Practice. A person who talks less – or even one who talks
poorly – will probably still be more successful if he pays close attention to the cues
from, and the needs of, the person he is communicating with. People like very much
to know that you are listening and paying attention to them. They also like it when
you are not just talking about yourself. They want you ask them about themselves
also. They like it best when conversations are 50-50.

4. The longer survivors are hurt, the more they seem to notice communication
problems.
 What does this mean? This probably does not mean that your communication only
gets worse over time. Instead it means that people’s insight increases, at least for
the first several years after the injury. As a result, their ablity to see their own
problems and concerns may improve. This is a no lose situation for you: it means
that, for a few years after your injury, you will probably become more and more
aware of how other people see you. So, there is good reason to be hopeful. But, we
also said above that SOs and rehab staff can identify more communication problems
right now. This means that you don’t need to wait to get help until a problem
becomes obvious to you. You can begin now to work on problems that other people
help you identify. The bottom line: ask people you trust for advice. Ask them what
would make them enjoy conversations with you more. Practice improving the things
they identify.

5. We also found that survivors who thought they had problems with Social
Communication also reported lower satisfaction with their lives. They also tended to
be less active in their communities. They were less likely to be working or going to
school.
What does this mean? This is a very important finding. Your communication skills
can affect all areas of your life. Many, many things can affect your social life. A lot
of them can be related to your TBI. Could your social life be better? Could you be
happier with your life? Could you be more active in your community? Think about
this: Regardless of how good you think your communication skills are now, maybe
improving them could improve other areas of your life as well. It doesn’t really matter
if you have a problem with communication. What really matters is this: Better
communication skills could make you more confident, more social, and more
involved in life. Look for ways to get help and practice. Use your friends and
families. In our next newsletter, we’ll also tell you about how effective special
communication groups might be.

These are the surveys the participants completed: The Social Communication
Questionnaire (McGann W, Werven G, Douglas M. Social competence and head injury:
a practical approach. Brain Injury 1997; 11:621-628); The Profile of Functional
Impairment in Communication (Linscott R, Knight R, Godfrey H. The profile of functional
impairment in communication (PFIC): a measure of communication impairment for
clinical use. Brain Injury 1996; 10:397-412); The Craig Handicap Assessment and
Reporting Technique – Short Form ; (Whiteneck GG, Charlifue SW, Gerhart KA,
Overholser JD, Richardson GN. Quantifying handicap: a new measure of long-term
rehabilitation outcomes. Arch Phys Med
Rehabil 1992; 73:519-26); Thinking Ahead is published by the Research
The Community Integration Questionnaire Department at Craig Hospital. It is a project of
(Willer B, Rosenthal M, Kreutzer J, Gordon the Rocky Mountain Regional Brain Injury System,
W, Remple R. Assessment of community which is funded by the US Department of Education’s
integration following rehabilitation. Journal of National Institute on Disability & Rehabilitation
Research. If you would like more information
Head Trauma Rehabilitation 1993; 3:75-79.); call: 303-789-8308
The Satisfaction with Life Scale (Diener E, or email us at: HealthResources@craighospital.org
Emmons R, Larsen J, Griffin S. The
satisfaction with life scale. J Personality The views expressed here are those of Craig Hospital and
are not necessarily those of the US Department of Education.
Assessment 1985; 49:71-75.)
Social Communication Classes: Do They Work?
(from the January 2007 newsletter, Thinking Ahead)

As part of our TBI Model System project, we ran special communication groups or
classes. We wanted to see if they could help improve Social Communication for people
with TBI. This is our third newsletter about Social Communication research. The first
one explained the problem (June 2004). The second newsletter described the people
who were in our study (January 2006). This one will tell you what we learned. It will tell
you if and how the classes helped. But, before we go on, let’s review a little bit.

What is Social Communication?

Social communication is not about “talking.” Most people with Social Communication
problems speak or talk very well. But, they may not pay attention when others are
speaking. They may interrupt and not take turns. Some ramble on and on. They may
get their facts wrong. The people who listen to them may be bored or confused.
Sometimes other people even feel uncomfortable. This can be a common problem for
people with TBI. It can affect their social lives. It can make it hard for them to make
friends or to find someone to date. It can make it hard for them to do well in a job
interview or to keep a job. People with TBI who have Social Communication problems
can end up feeling isolated. They can have low self-esteem or a poor quality of life.
And, when Social Communication problems keep them from interacting and working
successfully, they can have financial problems.

Who was in the study?

We enrolled 52 people with TBI. They were between 18 and 65 years old. They had
all finished inpatient rehab at least a year before being in the study. They had to have
good speaking and understanding skills, and a pretty good memory. They couldn’t have
any major psychological, alcohol, or drug problems.
They were randomly divided into groups of about 8 people each. Half of the groups
started right off participating in our special 12-week communication class, which is
described below. We gave them several tests before the first class started. When the
last class was over, we tested them again. One of the tests was to videotape an actual
conversation they had with a trained “communicator.” These videotapes were reviewed
by trained raters. We compared their before and after ratings to see if they had
improved.
The other half of the group did not take the class, but we tested them too. This let us
compare people who did have the class to those who did not. Then, when all the
comparing was done, all the people in the second group got to take the class also and
take the tests again. This let us see if each person improved after taking the class.
Finally, because we wanted to see if the effects of the class lasted over time, we
tested both groups three, six, and nine months after they finished their last class. (The
names of all the tests we used are in our January 2006 newsletter.)

What were the classes like?

Participants went to one-90 minute class each week for 12 weeks. The classes were
led by a social worker and a speech therapist. People who attended used a special
workbook called Social Skills and Traumatic Brain Injury: A Workbook for Group
Treatment. In the first several classes, participants assessed themselves and set goals.
They learned about how to be a good communicator. In the next classes they practiced
new skills and strategies. Participants worked on their own goals, and on giving and
getting feedback. They also practiced with friends and family members at home. In later
sessions they learned how to problem-solve in other social situations. Each group went
on a community outing to practice what they had learned. Each week they shared
experiences from the previous week. They reviewed their homework and discussed the
day’s topic. They practiced in small groups, and then had a large group discussion.
There was always a homework assignment for next week.

What were the results?

First, we compared the group that took the 12-week course right away to the group
that waited to take the course. For the first 12 weeks, this second group did not do
anything special to improve their communication problems. All they did was take the
same tests as the first group. This included the video of them having a conversation. At
the end of the 12 weeks, the reviewers looked at everyone’s videos and rated them.
The reviewers did not know whether the people in the videos had taken the classes or
not. In 7 of the 10 areas that they rated, the people who had taken the 12 classes
scored significantly better than those who did not have the classes. They had improved
most in their ability to participate actively and appropriately in conversations. The people
who had taken the classes themselves also felt that they had improved during the 12
weeks.
Next, we looked at improvements over time. For this it didn’t matter when people
took the class; we evaluated everyone the same. We found that six months down the
road, those who had taken the class were much more satisfied with their lives. The
participants with TBI, their families and even their group leaders all rated the participants
as having made significant progress on the communication goals they had set.
Finally we found that the improvements people made in their communication stayed
with them over time. In just about 3 out of every 4 areas that we measured, people
tested better than when they had before the study started. Almost half of the areas
were significantly better. When it came to reaching the goals they had set, we found that
people actually continued to improve over the 9 months after their class ended.

What does this mean?

People who participate in a Social Communication class – at least one that has been
designed and taught by the two people who taught this one – do improve in their Social
Communication. They join in more often and more appropriately in conversations with
others. Does this mean that they will meet more new people? Does it mean they will
make new friends? Does it mean they will Thinking Ahead is published by the Research
find and keep a job? This we don’t know Department at Craig Hospital. It is a project of
yet. More people will need to participate the Rocky Mountain Regional Brain Injury System,
in the classes to learn this. They will need which is funded by the US Department of Education’s
to be studied over many years, not just National Institute on Disability & Rehabilitation
one year. In any case, this study does Research. If you would like more information
seem to tell us this: Social call: 303-789-8308
Communication skills can be improved, or email us at: HealthResources@craighospital.org
and those improvements will last. And,
The views expressed here are those of Craig Hospital and
people who improve their Social are not necessarily those of the US Department of Education.
Communication can feel better about
themselves as a result.