Introduction

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Conducting a conversation for someone with a brain injury or having a conversation with someone with a brain injury can have many obstacles. There is no unwillingness on the part of the person with brain damage. Often it is inability.
Many brain areas are active at the same time for a conversation. This requires fine-tuning between brain areas and sending information back and forth, sometimes with priority and sometimes to remember what needs to be remembered for later.
The affected brain area causes delay. Speaking and listening are higher thinking functions. It takes an incredible amount of effort. Distracting factors can be an additional hurdle.

We try to describe some of the difficulties so that there is faster recognition of what may be going on and greater understanding of each other. We also provide tips on this page.

Listening

For some people, listening is more effortful because there is so much information that needs to be paid attention to or remembered, and that person will prefer to keep speaking.

Speaking

For others, speaking itself takes so much effort. Searching for words requires hard thinking. The brain feels heavy and not a thought comes, let alone a word. Or there are so many thoughts at once that a person cannot choose what is most important. Properly controlling the lips and mouth requires a lot of effort. Articulate properly and breathe at the right time. After all, nothing happens automatically anymore.

Information processing

The brain no longer works as fast as before the brain injury. If we compare the healthy brain with a big city and especially the traffic in a big city, we see that there are a lot of road closures and roadworks. Many road diversions are being constructed along the part of the brain that has broken down.
As a result, traffic may move slowly or not at all. The message sometimes arrives delayed or not at all.

It may get better with time
Not for everyone, and unfortunately not for people with a degenerative brain disorder, but fortunately we do know practical stories that communication can improve over time. New 'pathways' can be created in the brain and with a lot of practice they can also be put into use. 

Cognitive communication disorders

• Difficulty with the speed of information processing

It is important to realize that several brain areas must be active during a conversation. The stimuli from hearing, listening, feeling, thinking, etc. must make connections through the damaged (dead) part of the brain. The brain areas of the emotions (limbic system), the memory of the emotions (hippocampus/seahorse), the verbalization of the emotions (language areas in the parietal lobe), the thinking prefrontal lobe and control over what is said in the cerebellum, make communication is very complex anyway. It takes time. It certainly takes effort and it causes fatigue. Seven to eight brain areas are active during an emotion alone.

• Keeping the attention on the conversation partner while having to remember something in the head to say or respond to. That is
  having to do two things at the same time. It is multitasking, dividing attention, so it is a cognitive task. This is often impossible after brain injury.
• Problems switching from one topic of conversation to another. People are still thinking about something or searching in the mind for a word, something that has been noticed, an association.
• Problems with social communication. For example: talking out of turn, interrupting someone, not letting someone speak. There are often logical explanations behind this from the perspective of the person with brain injury: fear of forgetting something important if the conversation continues or the subject moves on. The working memory is overloaded. The speaking speed of the conversation partner is too high, the conversation partner speaks too much in subordinate clauses, too much information is received by the person with brain damage, association takes place. That can hardly be suppressed. Everything seems to be equally important. Difficulty prioritizing. There may be a lack of overview. There is less sense of time and that is why someone tries to say as much as possible: what seemed important to stay within time, like a balloon that is deflating. One's own emotions feel so important. It must be flushed first. One's own emotions are triggered by something, making it impossible to listen to anything else.
• Difficulty recognizing intonation of the conversation partner. For someone with a brain injury, there are too many things to pay attention to.
• Difficulty understanding and interpreting body language, facial expressions, and reading emotions from the conversation partner. Different brain areas are active for all these things. Switching on many brain areas at the same time can be difficult.
• There is little facial expression. This makes feelings more difficult to recognize. The person with brain damage cannot use body language due to paralysis, too little dopamine or due to a defect in the control of the eyes.
• There may be frowns. The effort it takes to listen can manifest itself in frowning that makes a person appear angry. The person is trying to concentrate. The conversation is apparently demanding.
• Little eye contact is made. It may then seem as if there is no interest in what is being said. It can arise from various causes: looking away to reduce visual overstimulation, wanting to concentrate on what is being said, difficulty following the story, paralysis, fatigue and, in the case of more serious cognitive defects or confusion, many other causes. Healthy people will also look to the upper right when asked to remember something as it looked, and to the upper left to remember what it sounded like. That is a natural thing. This is amplified in people with brain damage.
• Taking language literally which may cause misunderstandings. Think of not understanding puns, humor, proverbs. Difficulty with indirect meanings and double meanings or not realizing that something is intended to be ambiguous or even obscene.
• Word meanings are spread throughout the brain. A word with two meanings can be misunderstood at first.
• Difficulty understanding the gist or essence of the story.
• More easily distracted, which means less attention is paid to the conversation.
• Difficulty remembering what is said.
• A person may keep repeating topics, words or entire sentences, as happens with perseveration.
• Slow responses to questions or no responses.
• Reduced initiative in speaking. Loss of initiative/apathy can occur after brain injury
• A person may be too tired. Talking is tiring but listening is even more tiring.
• Someone can make unqualified or inappropriate statements. This may be due to the area of the brain that is affected, but it may also be because someone wants to take 'the shortest route' to quickly say what he or she wants. That way it takes the least effort. That can seem very rude. It is not always intended that way.
• Straying from the subject.
• There seems to be no structure in telling a story. Someone may lack an overview and find out for themselves what was important while talking.
• Not getting to the point, providing seemingly irrelevant information.
• Wordiness.
• Problems speaking, reading or writing.
• Word-finding problems: difficulty finding the right words.
• Word confusion: mixing up words or exchanging letters in a word.

Do you have a brain injury yourself?

Please take a look at our download page whether there is a credit card card that can quickly explain something about your situation. Maybe you can laminate yourself, or maybe someone in your circle of acquaintances has a laminating machine.

Tips for the conversation partner without brain damage

Tips for communicating with someone with a brain injury
(Tips for professionals, partners, informal caregivers)

1. It is good to realize that several areas of the brain must be active during a conversation. It has been proven that someone with a brain injury shows more brain activity and uses more brain energy than a healthy person. The stimuli from hearing, listening, feeling, thinking, etc. must enter the damaged (dead) part of the brain. The brain areas of the emotions, the memory of the emotions, expressing the emotions, thinking, overseeing and controlling the emotion and the double control over what is said make communication very complex. It takes time. It certainly takes effort and it causes fatigue. Seven to eight brain areas are active during an emotion alone.
2. Every person with a brain injury is different from another person with a brain injury. Try to find out what communication difficulties exist and try to adapt to them.
3. If you know what caused a communication problem, or where behavior comes from, you can begin to understand it. There are opportunities to influence communication or behaviour.
   Personality, Biography, Health, Neurological damage, Social and environmental factors, together provide a cause for behavioural and communication problems.
4. Slow down (give and take your time). If, as a care provider, you appear in a hurry to do something quickly or finish it (task-oriented), then you do not slow down. The result may be that the other person blocks.
   Connect (get in touch) and provide predictability. Make sure the other person understands what is coming. That, together with familiarity, means safety. Don't forget a friendly facial expression. Your facial expressions influence the entire communication. If someone hears half of something or something goes too fast, the facial expression will be decisive.
5. Make sure there are no distracting factors (background noise, too bright light, children, pets, app messages or phone calls) and ask if the person you are talking to is in pain. Pain is a huge internal distractor.
6. Do not let your conversation partner look into the light or make sure that the background behind you is quiet (no busy road traffic or moving people).
7. Make sure you wear calm-looking clothing, without busy patterns or colors.
8. Make sure your phone is on silent and there are no other interruptions during the conversation.
9. Don't talk too much with your hands. These can be distracting movements that someone unintentionally follows with their eyes.
10. First ask if the person with brain injury wants to tell important things or talk about something important. This gives the person with brain injury peace of mind because he or she does not have to remember it.
11. Use short sentences, without subordinate clauses.
12. Ask the person with a brain injury how long a conversation can be sustained and protect her or him by stopping it in time. Monitor the time. Does the person have a reduced sense of time? Then that person may not be able to determine whether fifteen minutes or an hour will be good. Then pay extra attention to whether someone is blocking in his or her thinking. Or, for example, that someone is less able to express her- or himself properly. These are signals of an overloaded brain and then stop! Give rest!
13. Agree on a signal for when it becomes too much. Also observe.
14. If it is a very important conversation, explain that you will provide a summary and main points on paper.
15. Wrap up topics. Return to a topic that you wanted to address but have deviated from.
16. Bring a short line into your story. State the message you want to convey without elaborating.
17. Avoid puns, double meanings or proverbs. Or explain them. Be unambiguous (open to one interpretation) and direct.
18. Name your own emotions. I am sad, I feel....
19. Ask about feelings. Don't interpret what you see based on too little body language or facial expressions. Don't simply interpret behavior. There is often an inability resulting from an invisible consequence of the brain injury. It's not unwillingness.
20. Make eye contact yourself while listening and talking, understand that it can be sometimes intensive for someone with a brain injury to make eye contact again. Try to use your facial expressions in a friendly manner.
21. State that you are asking a question. If necessary, repeat the question calmly.
22. Avoid interrupting and filling in words.
23. Take turns talking.
24. Ask one question at a time. Do not give multiple choices: "Do you want something to drink, cola, orange, water or a ....." These are four subjects that have to be remembered.
25. Always check whether the person with brain injury can still follow you. A 'yes' is not always a 'yes'. Sometimes subtly giving a short summary is useful.
26. Realize that pain, a full bladder, an awkward sitting position and other physical discomforts are disruptive factors for someone with a brain injury to focus and maintain attention. Just like for healthy people.
27. Speak calmly but naturally.
28. Feel free to use body language such as thumbs up and thumbs down if necessary. Only do this if you know that someone does not normally follow your hands with their eyes. People with a form of aphasia often also use thumbs up and down communication. Then you can join in.
29. Make sure you understand what the person is saying.
30. Be careful with apps, chats, messenger messages with someone with a brain injury. A message can be misunderstood very quickly because someone does not hear the intonation or see your friendly facial expression. Language can once again be taken too literally, no matter how well you mean it.
31. Be respectful.
32. Every person is different. Every brain injury is different. One person has one item from this list of difficulties with communication, the other has several.