Can you see what I mean? by Laorag Hunter

My definition of successful communication is broad. For me, successful communication is communication that works. Simply put, a message “works” when the person I am communicating with gets the meaning I intended. When you hear, read or see something and communication “works” you have a confidence that I call the “I see what you mean” feeling.

My closing the office routine includes checking the answering machine. On Friday I am glad there is only one message, thinking that it won’t take up much time. The message is from a female asking me to call her on a specific number. Perhaps she’s also in a rush to start the weekend as her message is delivered at high speed.

The message starts well enough, “Please can Mrs Hunter call…..” but then I am not sure if she says Liz, Louise, Lois or perhaps even Lesley on “01382……” I can only think it is numbers something, something, something and something as she reels the figures off so fast that there is no way I can remember them (especially while I am still trying to work out the Louise/Liz/Lois part). I don’t recognise the voice.

Three listenings later I have finally got the number by writing each digit down as quickly as I can, but the name still eludes me. I am left feeling irritated at the time this has taken and mildly concerned that without knowing the name I have no clue as to what it is about.image However, at least I think I have got the phone number and that might be sufficient to respond. Having got part of the message reminds me that understanding is not all or nothing, and that it comes in degrees or shades of grey.

My machinery for understanding is, as far as I know, only mildly impaired. I have some reduction of visual acuity (correctable by glasses). My hearing is good and my knowledge of word meanings is reasonable, above average in some topics (such as knitting) and poor in others (such as musical terminology). My speed of understanding is variable and I notice that I like radio presenters with a slightly slower speed of delivery (for example, Eleanor Bradford, the BBC health correspondent goes at a comfy speed for me). If I am tired, then I really don’t cope well with words coming thick and fast. It’s a double whammy if the subject matter is a difficult or unfamiliar one and causes the disturbing “in the dark“ feeling. And, I know that when I have something on my mind or my anxiety is raised I also can’t process messages so efficiently.

My capacity to understand is robust in comparison to the people with aphasia who I work with everyday. Aphasia describes difficulties using and understanding language and is a common consequence of stroke, head injury or brain illness. Recent mainstream publications have done much to improve recognition and understanding of aphasia. I recommend Grace Maxwell’s account of her husband Edwin Collin’s brain haemorrhage and rehabilitation, and neurologist Jill Bolte-Taylor’s personal account of her own stroke and aphasia. Jill Bolte-Taylor’s TED Talk has had 16 million views (please do watch this fascinating talk if you are not one of the 16M). Difficulty using language is the most obvious feature of aphasia. Communication partners can see and hear any struggle for words; mis-pronunciations; word substitutions such as saying “tiger” when meaning “cat” or replacing words with nods, sounds, gesture and pointing. Understanding cannot be seen; it is a private matter and the tendency for communication partners to over-estimate understanding leads to problems.

Some examples from patients who have recovered enough expressive speech to describe their problems with understanding help to illustrate this.

  • “Judy said to me put on your armani. armani? What on earth is my armani? I don’t know what she means.”
  • Jim puzzles over the word grapefruit. “Grapefruit? That word seems remote to me as if it is somewhere out there on a headland.”
  • Susan is shocked when the waiter brings her a plate piled with various seafood (she hates fish). When Susan chose “fisherman’s platter”, in her mind she saw a plate of cheeses, breads and pickles. In her mental store of word meanings, she has connected Fisherman’s platter onto her entry for Ploughman’s lunch.
  • Martin doesn’t understand the instructions the consultant has given him verbally at his recent consultations to increase one epilepsy medication and reduce another. The consultant is frustrated with what he wrongly perceives to be a lack of compliance.

Some people with aphasia are able to indicate they have difficulty understanding. One gentleman, Eddie, makes a sweeping gesture backwards above his head to express an idea along the lines of “the words are going over my head.” Not all people with aphasia are able or willing to admit they don’t understand. Jill Bolte-Taylor cautions partners to “be aware that I may want you to think I understand more than I do.” For any individual, with or without aphasia, admitting to being somewhere in “shades of grey” of understanding might be avoided in order to save face. Admission of comprehension failure can provoke feelings of shame and associations with lack of competence. Eddie has got it sussed. He recognises that the incompetence rests with an environment that doesn’t provide the support he needs for his communication, both his understanding and expression, to be the best it can be.

There is much you can do to increase the likelihood that the receiver “sees what you mean.” Another analogy from a patient likens this to cleaning a dirty window, “suddenly it cleans and I can see it.” Here are just 10 tips on how to clean up your communication so that more people get more meaning from your messages. You may notice these are all things that assist your own understanding.

  1. Be unhurried. Communicate that you have plenty of time, give the individual your full attention, be friendly and behave in a way that puts people at ease.
  2. If you are not sure, ask the individual if they need any special help with communication.
  3. Say things more than once and chunk information into bits to avoid information overload.
  4. Make the topic clear, perhaps even writing it down. Give a little extra information to help make sure the topic is understood, for example Judy quoted above could have said “wear your Armani, it smells wonderful.”
  5. Write down key words while you speak or write down important information for people to take away and re-read. Even if reading is compromised a combination of hearing and seeing words helps many people with aphasia.
  6. Use technology to assist, for example, make documents so that computers and digital devices can speak the text; use sub-titles on TV and YouTube videos. Record your instructions or messages into the person’s phone so they can listen to it as often as they need.
  7. Add an illustration to your communication, a drawing, diagram, symbol, photograph or map. Use cameras in mobile devices to give people images they can take away to help them understand, such as an exercise sequence.
  8. Show as well as tell when possible. Maybe you have an image on your phone of the event or place you are talking about? Can you mix up a thickened drink while you talk through the instructions?
  9. Speak clearly and write legibly (have you ever been unable to read your own writing?).
  10. Use clear signs in departments with symbols that are commonly recognised.

More detail with signposts to useful resources can be found at the Talk for Scotland Toolkit and the Stroke Association Accessible Information Guidelines.

There isn’t one solution and it is unrealistic to believe that strategies like those above guarantee understanding. The goal is to provide the support that best helps that individual to understand at the highest level of clarity they can.

Finally, if you do leave a message on my phone, especially if it is a phone number, a name or a CHI please speak Notlikethis But like this.

Laorag Hunter is a Speech and Language Therapist at NHS Tayside’s Centre for Brain Injury Rehabilitation.  You can follow her on Twitter @LaoragHunter

June is “Speak about Aphasia month”. If you would like to learn more about aphasia these are the books Laorag mentions in her blog.

Maxwell, Grace (2010). Falling and Laughing: the Restoration of Edwin Collins. Ebury Press.

Bolte Taylor, Jill (2009). My Stroke of Insight. Hodder Paperbacks.

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7 Responses to Can you see what I mean? by Laorag Hunter

  1. Robin Ion says:

    One of the most useful reads I’ve come across in a long time. Please read this excellent blog


  2. Merryn Anderson says:

    Great insights into understanding and supporting those with communication difficulties.


  3. Laorag Hunter says:

    Thank you for your comment.


  4. gem says:

    I’ve never come across Aphasia in my work that I have been aware of, but I’m sure I will in general life at some point. The tips are useful for any clinical staff when thinking about communicating . Really interesting read, glad you shared this post! x


    • Laorag Hunter says:

      Thanks for your comment Gem. If you have time to follow up the references they are both good reads as well as being informative.


  5. Sarah McFarlane says:

    I am so glad I took the time to read this. Your insights are very helpful and hopefully I will become a better communicator because of it. I will definitely look up the references that you suggest.


  6. Laorag Hunter says:

    Thanks for your comment Sarah.


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