COMMUNICATION CHANGES
COMMUNICATION IS MORE THAN WORDS
Eye contact, gestures, words, physical touch, listening, reading, writing, facial expressions, loudness and speed of speech are all ways in which we communicate with others.
His speech was always clear, and he could understand what he heard and read and could write but his communication was completely different – does that make sense?
He would just go quiet in a group of people. He doesn’t seem able to come up with new topics.
Wife of a 55-year old man with right hemisphere stroke.
It is often friends and family members who will notice changes in communication first as we get to know the unique way that the people in our lives communicate.
WHAT MIGHT BE DIFFERENT AFTER A RIGHT HEMISPHERE STROKE?
There are many parts of communication that can change of a right hemisphere stroke. For some people communication appears relatively unchanged except when they are in particular situations, such as a noisy restaurant where many people are talking at the same time. Other people might have more noticeable changes to their communication.
Most often changes happen in prosody (paralinguistic domain of communication), gesture and facial expression (extralinguistic domain of communication), discourse and more complex reading and writing (linguistic domain of communication). The result is that someone’s way of communicating might not match the expectation based on the topic of conversation or who they are speaking to. This mismatch is known as apragmatism or an impairment in pragmatics. These terms are described below and in the downloadable summary document.
DISCOURSE: TALKING MORE, TALKING LESS
Discourse is a word used to describe communication that involves stringing words and sentences together. Telling a story, having a conversation or instructing someone on the steps to follow to service a lawnmower are all examples of discourse.
A right hemisphere stroke can change how we tell stories and have conversations. Some people talk less than what they used to in the past, while other people talk a lot more after a right hemisphere stroke. In both of these cases, the person with a right hemisphere stroke might not be aware of how their story telling and conversations have changed. Others might know that there is something different about the way in which they chat, but find it hard to go back to their typical way of talking.
When someone says much less during a conversation than what people have become accustomed to, it might be misinterpreted. Common misinterpretations are that the person is depressed, or just not interested in the conversation. Similarly, when someone talks a lot more, it might seem rude, especially if they do not give the other person a chance to speak.
Friends who used to have a lot to say to each other might suddenly feel at a loss as to how to keep the conversation going. Spouses might feel frustrated if they are not given a chance to share their stories and news.
I used to yell my orders and make sure things got done at work. Since the stroke I just sit down and shut up in groups of people.
54-year-old man with a right hemisphere stroke
He seems to go well with old friends as long as it is just one or two mates but add their partners to the mix with unfamiliar topics and he is lost – he then tends to just change the topic and can say embarrassing things.
Wife of a 67-year-old man with right hemisphere stroke
APROSODIA: HOW WE SPEAK
When we speak, we do not only say words, we also decide how we want to say those words and sentences.
We can change the way in which we say words by speaking faster, slower, pausing, saying a word louder or softer or using a higher or lower tone of voice (pitch). If we want to emphasise (stress) a particular word, we might pause before we say it, stretch it out, or say it louder.
Think for example of how an angry parent might speak when trying to get an unruly toddler’s attention in a busy store. We do not need to hear the words that are being said, we only need to hear the tone of voice to know that there is trouble.
When someone we know well speaks faster than their typical way of speaking then we might interpret it as them being excited or worried about something. If they speak slowly and softly then it might mean that they are not feeling well or that they are sad.
The way in which we change our speech is called prosody. When someone has a right hemisphere stroke, they might find it difficult to change how they speak. We say that they have difficulty using prosody (aprosodia). This means that they cannot give people clues about what they are thinking or feeling based on the way they use their speech.
We all have our own unique way of speaking. Our friends and family become very familiar with the way we speak and may know what we are thinking or feeling purely by the way we sound.
When someone has aprosodia, they might lose the ability to change their speech pattern. If we say everything using the same speed, and without changing stress or pitch, then we can sound monotone. This could be misinterpreted as the person being bored or disinterested in the conversation.
Often the person who has had a stroke is not aware that their speech has become monotone, or they might find it difficult to change the way they speak.
Having aprosodia might also make it difficult to notice someone else’s speech. Aprosodia might make it hard to realise when someone else is worried, excited, or sad, purely based on how their speech sounds. This can be difficult for friends and family members to understand as the person with aprosodia might come across as insensitive when in fact, they just could not pick up on speech clues.
If you have aprosodia, then it will help to start a habit where you tell people what you are thinking or feeling and explaining that your speech is different because of the stroke.
I know that it is not apparent from my face, so I have learned to tell people what I am feeling.
59 year old man with right hemisphere stroke.
For myself, I think it’s more important for family members to understand the changes that I’m going through and how my personality can change and how I might be difficult to live with and how to cope.
71 year old man with right hemisphere stroke
I remember sitting on the couch crying one day and he just looked at me and changed the subject, as if he didn’t even realise that I was sad.
Wife of a 67-year old man with right hemisphere stroke.
Not being able to read facial expressions that show emotions can be particularly difficult in marital relationships and friendships.
FACIAL EXPRESSION, EYE CONTACT AND GESTURES
Facial expressions, eye contact and gestures are other ways in which we communicate that does not need words.
These non-verbal (no-words) ways of communicating is particularly important to show that we are interested, and to give some indication as to what we think about the conversation and what we might be feeling or planning on doing next. It is also the way in which we show the person we are speaking to that we want their opinion or are waiting for them to tell us more.
After a right hemisphere stroke these non-verbal ways of communicating can change. Some people use less eye contact while others might hold eye contact for longer than what they used to in the past – this can make people feel uncomfortable if they do not understand that it is due to a stroke.
A right hemisphere stroke can also make it hard to interpret or make sense of other people’s non-verbal communication clues. Someone might miss the non-verbal raising of eye brows to show surprise, a nod of the head to encourage contribution to the conversation, or stepping away to show that a conversation must come to an end.
If we miss all of the non-verbal clues and just continue talking then we might come across as bossy, rude, or insensitive to the other person’s needs.
PRAGMATICS
HOW WE COMMUNICATE IN DIFFERENT CONTEXTS
Pragmatics includes all the ways we change how we speak and communicate depending on who we are talking to and the location and situation we are in. Imagine three situations. In the first you are talking to a close friend in your home. In the second you are talking to that same friend in a café where the tables are close together. In the third you are talking to your boss. The topics you discuss, the language you use, the gestures and facial expressions, and the amount of humour, sarcasm or emotion probably change in each of those three scenarios.
The ability to determine what and how to communicate in different settings is pragmatics. A right hemisphere stroke can cause a disorder of pragmatics, called apragmatism.
Someone with apragmatism might bring up controversial or sensitive topics in a public space or at a work event. They may talk about the same topics and use the same language with close family members as they do with people they’ve just met.
Apragmatism can lead to uncomfortable situations in which people are misunderstood or are embarrassed by a conversation. Misunderstandings can put strain on relationships because if a friend or spouse suddenly cannot read your emotions and empathise with you, it can feel like they no longer care about you.
People with apragmatism are not intentionally being rude or uncaring. Their right hemisphere stroke may have impacted the areas of the brain that we use to judge situations and determine what is appropriate to share and how best to share the information.
Situation 1
With a close friend in a private area, you might share personal information or stories, use informal language, perhaps interrupt each other during the conversation, show emotion, and refer to “inside jokes” or information that means something to both of you.
Situation 2
With a close friend in a public area, such as a busy restaurant you might not bring up very personal topics that you do not want to be overheard by others, you might show less emotions, but you still could use inside jokes, interrupt each other, and use informal language.
Situation 3
The topics you discuss with a boss probably are related to work, may not involve a lot of emotion, and is probably not of a personal nature. Unless you are on very friendly terms with your boss your language is likely more formal, and you do not interrupt them.
READING AND WRITING
He was having trouble reading novels after the stroke. The novels weren’t making sense. The speech therapist and occupational therapist explained that he was not reading from the left hand margin. He was missing words and losing his place on the page.
Wife of a 71-year-old man with right hemisphere stroke
Reading and writing difficulties after a right hemisphere stroke can occur due to a number of reasons. Changes to attention and memory might make it hard to read for a long period of time, and to remember what has been read without needing to go back over the same passage.
Communication changes can also make it hard to understand the meaning of what is read. A right hemisphere stroke might make it difficult to understand figurative or implied meanings (e.g. life is a roller coaster) or the play on words that is often used in newspaper headlines (“tattoos – a dyeing art”), where the words could be interpreted in different ways.
Visual neglect is another reason why someone might struggle with reading and writing. The terms neglect dyslexia and neglect dysgraphia are sometimes used when the cause of a reading or writing difficulty is visual neglect. The person might loose their place on a page, miss the first few words of each sentence or start writing in the wrong place or away from the left hand margin. Often people are not aware of this happening. Occupational therapists and speech pathologists support people with reading and writing difficulties after a stroke.