Saturday, February 16, 2008

A pragmatic question

Speech therapists spend a lot of time thinking about pragmatics -- the metalinguistic aspects of communication that make up how we say what we say, including things like turn taking, topic maintenance, eye contact, and social cues like reading facial expressions. Pragmatics are often impaired in people who have right-hemisphere or diffuse brain damage -- I've seen people who talk about ten different subjects in one conversational turn and others who don't get the cue that the conversation is over when you walk out the door and continue chatting with you when you're no longer there.

It is difficult to know what "normal" pragmatics are, as personality certainly drives our own individual communication style, so therapists make their best guess based on experience, family member input, and the nature of the injury. Not surprisingly, there is a good study that shows that therapists often view people of other races as more impaired than the patient's family does (which is a bummer given that in my particular case 90% of our staff is young white women serving a population of a majority of older black men). These changes in the subtleties of communication are difficult to treat -- it's very uncomfortable to tell someone to stop talking, or stick to a topic, or to pay better attention to their communication partner. But it's important, because surely how we say what we say is just as important as what we say.

So what do you do when the pragmatics of someone who is not brain injured directly impacts your ability to interact with them?

There is a woman who has limited ability to adjust her communication style to an appropriate context (okay, she curses loudly in church). She does not make eye contact. She does not take turns. She over-personalizes any conversation someone else tries to have.

There is another woman who took over both a patient encounter and a related team meeting without acknowledging her piece in a larger puzzle. She does not take turns. She finishes sentences. She actually said to a patient, while I was giving a word of comfort to a family member, "I'm sorry, I didn't hear you because Brooke was talking."

I spent a grand total of 1 1/2 hours on the phone with a man who is desperate for help with his wife, who because of her own communication style is frustrating the hell out of him as she refuses to take short cuts in her markedly impaired communication to make it faster and less laborious. It was clear that his pragmatics were shifting as a result -- his love and admiration of her drove his relaying incredible amounts of background information.

The therapist in me wants to sit down with these women and talk about the ways that their pragmatics impact their successful communication. The friend in me would want someone to tell me the same if my communication style were driving someone crazy. The civilized society member in me (to quote Costanza, "we're living in a society here!") wants to ignore it. The human in me wants to scream at them to knock it off. I'm hoping that in my own internal turn taking that the friend wins out over the human.

I love this picture, which I imagine as taking place in some beautiful European seaside town. Looks like a fun conversation, but the US standard of pragmatics would prompt one of them to scoot over a little.

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