One of my former patients, a man I’ll call Josh, knew exactly what he wanted to say.  He also knew exactly how he wanted to say things—using as many words as possible.  Why?  Well, after his traumatic brain injury (TBI), Josh was unable to speak more than a few words so he used a DynaVox communication device.  He was also unable to walk, use his arms and hands functionally, and even eat.  Because so many things had changed, Josh wanted his communication partners to know that he was still the same intelligent man he always had been.  So, rather than saying one or two words in response to a statement like “We are getting ready to put in our garden,” Josh would type something like “Before you plant you should make sure you prepare the soil.  Do you want to borrow our rototiller?”  He typed letter-by-letter, only using word prediction on occasion.  Since Josh needed to operate his communication device using two switches (rather than touching the screen), this process was not quick.

Multiple times, Josh told me how his caregivers, family members, and friends didn’t seem to take the time to listen to him.  They would become distracted as he typed and might answer the phone, leave the room, or start talking themselves.  This was very frustrating for Josh and frequently made him upset.  He just didn’t understand why his communication partners didn’t wait for him.  He didn’t get why they couldn’t just listen to him.

For their part, the communication partners did really want to talk with Josh.  They just didn’t understand why everything he said had to take so long.  By the time he created a sentence or two, any visit or time to chat was over.  They were very frustrated as well.

When you aren’t in the situation, it is easy to see that Josh’s need to be seen as intelligent was interfering with the success of his conversations.  His desire to use complete and correct sentences was preventing him from getting very far into an interaction before his communication partners needed to move on.

While there are probably a lot of things that could have helped Josh, one thing we worked on was pre-planning communicative opportunities.  Basically, pre-planning means thinking ahead to an event, activity, or interaction and trying to identify possible messages to communicate.  For example, if Josh knew that a friend was coming over that week, he might think of several questions or stories he wanted to tell that person.  Before his friend came, he would program them into his device.  Then, when the friend was there, Josh could ask his question or tell his story in a fraction of the time he would have otherwise.  That way, he and his friends could talk about more things or talk more deeply about one thing.  Pre-planning didn’t prevent Josh from spelling out new messages during an interaction, but it kept him from needing to spell out EVERY message.  It took a little explaining, support, and practice for Josh to accept this idea.  But once he saw how the quality of his conversations improved, he was sold.

Some individuals with TBI or aphasia are able to do this planning and programming on their own.  Others need support from a therapist, family member, or caregiver to help them with various aspects.  Either way, the end result is well worth the time and effort involved.  To learn more on this topic, read this article from the Implementation Toolkit.