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Communication Environment & Cognition

Issues Related to the Communication Environment

Survivors with functional limitations in cognition can experience several barriers to effective communication.  Many providers do not possess universal communication techniques or tools to clearly communicate with someone with cognitive limitations.  Additionally, people with cognitive limitations may experience poor concentration and distractibility. Many survivors with cognitive limitations may be too upset to advocate for the exact communication method they need for effective communication.  Providers may not realize that they have to reach out to survivors and openly discuss their needs and preferences, treating the expressed communication preferences as key assets in meeting the survivor's needs. 

Examples of Problems

• A woman is having trouble integrating the information she is learning about sexual abuse. Overloaded with information, she becomes anxious. The anxiety leads to frustration and she starts to move repetitively, not really listening anymore.  The provider assumes that she is no longer interested in the topic and ends the session or moves on to another subject.
• A survivor has a brain injury and has repeatedly missed appointments. After her fifth missed appointment, the provider cancels all future appointments.  The receptionist calls and explains that her future appointments have been canceled and she should call to arrange a time that is more suitable to her.

Suggested Solutions

• A survivor may have trouble focusing or may have tangential thoughts. Jane Doe, Inc. recommends remaining patient and rephrasing questions while also offering reminders about which subject is being addressed. Let her know that you are trying to keep the discussion structured or on topic. State what subject you just discussed and which you have moved on to. The survivor may know that others have to guide the conversation to help her stay on topic.
• As a universal design strategy, learn to speak in plain language. Speak in plain language without use of acronyms, jargon, slang, metaphors, and irony. This is important for people who do not speak English as a first language, to simplify communications for those under a lot of stress, and to assist people with poor concentration or other cognitive limitations due to head injury, fatigue, medication side effects, disease, mental retardation, autism, among other conditions.
• MENCAP’s Make It Clear Guidelines shows providers how to improve communications for everyone. These guidelines are naturally universal in scope – they benefit anyone having limited attention, distractibility, memory difficulty, low literacy, or that do not speak English as a first language. The guidelines were developed with people who have developmental disabilities (called “learning disabilities” in the UK).
• Allow sufficient waiting time after asking a question for the person who might process statements or questions slowly. Practice speaking slowly. Have all staff and volunteers learn a pace of speaking that is acceptable. Some people need to practice this. Do not expect stressed out, vulnerable people to ask you to slow down.
• As a universal design strategy, consider having a collection of visual aids for the topics you discuss with survivors. Visual Aids have been developed for people with intellectual limitations or people who are speech-impaired for use with communication boards. Pictography can be adapted from such aids, so that your services have a collection to assist communication in any number of situations - people who do not speak English as a first language, fatigue, learning disability, etc. - where clarity of communication is your utmost concern. See the Creating Welcoming Environments section for Communication Environment that deals with Using Visual Aids to Communicate.
• Some people never develop the ability to remember sequential time. Not having a strong understanding of time concepts can interfere when the sequence of events is important to know. However, it is still possible to determine past events. Associations with events help to determine context and timing when there is no direct memory of time. Jane Doe, Inc. recommends when it is difficult remembering the order or timing of events, use cues to help determine the order of events – find out her daily routines, sunlight patterns, TV patterns, internet habits, cooking patterns, that have times of day associated with them. Check if there is an event before or after – has she already eaten lunch? This interactive dialogue may trigger her memory for when certain things occurred.
• Many people with learning limitations and differences depend upon technology to manage communication effectively. A survivor may benefit greatly by have the use of a computer to take notes or to write our her thoughts.
• To prevent working memory overload when giving verbal instructions, ensure that the survivor has a quiet location to receive them. Patience and repetition are needed in order to ensure that instructions are understood. Practical suggestions for making sure that important communication is received:
  • Provide one instruction at a time. Do not move on until it is clear that the instruction is learned and understood.
  • If the instruction is something that can be demonstrated, then demonstrate and have the survivor demonstrate back to you her understanding. Confirm that she understands.
  • If the instruction is something that cannot be demonstrated, then both speak it and write it. If it is already written, have the survivor tell you what she understands has to be done. Writing it herself may help her to remember it. Confirm that she understands.
  • Allow someone to take a break to deal with frustration.
  • Allow a person more time, even additional meeting time on another day, if necessary.
  • Use rehearsal or role-play strategies.
  • Mnemonics or rhymes or images might be used to create associations with an instruction to assist memory.
  • Consider tape recording important instructions, so that the survivor can play back and review them.
• People with brain injury or some learning limitations and differences may need support with functions like planning and scheduling. A person with a recent injury may be unaware of how difficult these functions have become. You can offer to provide her with a reminder call or help her to acquire an electronic calendar.  Expect and support the use of external memory aids – lists, visual cues, calendars, flow charts, electronic reminders and organizers.
• See Aiding Comprehension of Individuals with Autism Spectrum Disorders During One-on-One Interactions for advice on communication with people who have autism-spectrum disorders.
• See Fall 2005 Technical Assistance Bulletin, Working with People with Cognitive Disabilities for advice on communication with people with cognitive differences.
• A person with a "development disability" may request that her caregiver be present and/or may use assistive technologies so that she can communicate with you. Be sure to inquire about her relationship with her caregiver (as it is possible that her caregiver is her abuser).  If she insists on having a caregiver present Keep in mind the likelihood that the survivor knows her abuser. Estimates range over 90%. When identifying what type of interpreter is her preference - professional or someone she knows - it is best for her to share that information in the safest context, without a caregiver present, if possible.
• For information on aspects of communication related to assistive technologies see the Creating Welcoming Environments section on the Communication Environment that deals with Assistive Technologies for Communication.
• In a shelter environment, if a survivor arrives without communications equipment (her assistive technology was either harmed or she made a quick escape) there is the potential to get an assistive technology loan. The purpose of loan programs is for a person to test what works best using 30-day trials. You cannot count on this resource in every state but it is a growing trend. See the subsection on Replacing Technology in Creating Welcoming Environments section on the Communication Environment that deals with Assistive Technologies for Communication.
• During workshops:
  • Follow the suggestions in the Creating Welcoming Environments section on the Communication Environment for
  • Provide paper or digital copies of overheads, powerpoint slides.
  • Have a clear schedule of the workshop always available and clearly indicate when one section ends the next begins.
  • Tape each large-format flip chart paper (or use self-stick) to wall when completed before starting a new page.
  • Some people may need to tape record what workshop leaders say. The workshop leaders should indicate when it is safe to tape and when and why it is not (because of confidentiality issues among participants speaking up).
• A provider’s Job Application and Hiring Process should take into account communication issues during the hiring and interviewing of people with cognitive difficulties. The following documents may help. Working Effectively with Persons Who Have Cognitive Disabilites by the The Cornell Program on Employment and Disability. It is part of their Brochure Series on Reasonable Accommodation in the Implementation of the ADA, a series of 19 brochures.
  
  Job Accommodations for People with Cognitive Impairment The Job Accommodation Network provides an A to Z list of disabilities and documents on how to provide reasonable accommodations.

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