This article was featured in the April edition of OT Today.
Six years ago I began attending Spanish evening classes. It is a journey that I am still on now, and there have been many difficulties and rewards along the way. One of the surprising outcomes of my learning is that it has made me think more deeply about the communication difficulties of some of the clients I work with, including those with dementia, acquired or progressive neurological damage, learning disabilities and mental health difficulties. It has prompted me to consider in more detail how language is constructed, and just how complicated it is. Speaking our first language is a skill that took us many years to learn, and is something that is easy to take for granted. When we speak, listen, read and write, we are using a number of different cognitive and motor skills, using many different neural pathways linking different areas of the brain, and at a very high speed. Learning a second language as an adult has put me in situations where I wasn’t able to speak or listen as instantly as I would have liked, with all of the associated frustrations, emotions and social difficulties. Without meaning to suggest that this allows me to fully understand the experience of communication difficulties associated with a health condition or disability, I feel that it has increased my empathy and understanding of some of these challenges, made me reflect more deeply on my own communication in the workplace, and has hopefully made me more patient as a clinician.
When considering the hierarchy of cognitive skills, the building blocks at the base of the triangle are attention and concentration. Without this, we are unable to focus long enough to take in information, and also therefore unable to form memories. This includes the working memory where we hold short term information during a conversation, and even within each sentence that we speak. Concentration in its
own right can be affected by neurological damage, but it is also impaired when we experience fatigue, stress and pain, which are common symptoms of many health conditions. Concentration can also be severely affected by acute anxiety and depression. When learning or practising Spanish, especially at the beginning, I would become tired quickly due to the amount of concentration and effort demanded from my brain, and my concentration would soon dwindle. If I pushed it too far and continued to demand more than was comfortable, this could easily lead to headaches and irritability. By this point, my ability to take in information even in English would start to shut down, and speech could become a background noise of sounds with no meaning. When I relate these experiences to how I communicate with clients who may be struggling to concentrate themselves, I feel that it has enhanced my awareness of this difficulty. I have been able to adapt my approach including close observation and questions to check what has been understood, not giving more information than is needed, wording things as simply as possible, and choosing the right time to present information. It has also changed my approach to communicating with colleagues, recognising that at times when others have poor concentration, whether through tiredness or information overload, that this isn’t the best time to communicate important information to them, that it will cause extra stress and may not even be heard.
Above concentration in the cognitive hierarchy is Information Processing, essential if we are to process verbal or written information and turn the sounds into meaning. This involves many areas of the brain that are far beyond my expertise, but include the association of current sensory stimuli with long term memories (including words, grammar and contextual memories), the ability to hold short term working memories, and the coordination with visual or auditory information. Difficulties with information
processing can make it difficult to interpret more than small pieces of information at a time, as time is needed to digest this. My experience of learning Spanish has led to a greater personal understanding of this, as I appreciate the need for words to be pronounced slowly and separated from each other, and ideally to have a pause after each short sentence to allow my brain to catch up. At these times I am acutely aware of how my working memory is holding words from earlier in the sentence, which I still haven’t translated into English. There forms a queue in my mind of words I have heard and remembered in Spanish, but that I am yet to translate. Moreover, if there is a grammatical structure that I am not confident in, this is a further piece of information that I need time to recognise and interpret. When, in time, I have achieved this, only then am I ready to hear the next short sentence. If I am being spoken to in Spanish by someone who doesn’t have the skill or patience to adjust their speaking in this way, after the first sentence or two I can become lost and overwhelmed and unable to focus on or process anything, even if I were to know the meanings of those individual words. This has led me to greater awareness of clients who are experiencing difficulties with this, and has improved my ability to adapt my approach accordingly. It has also led to an increased appreciation of using simple written information, if provided in a context where it can be digested without external pressures in the clients own time and pace.
Higher up in the cognitive hierarchy is Executive Function, a higher level cognitive ability. This plays a part in choosing appropriate words for the context, and also with the learned social cues, rules and expectations that are followed during conversation. These skills aren’t something that I can associate with my language learning experience, but are worth mentioning when considering the impact of loss of cognitive or language abilities on communication. Reflecting on this can lead to
greater understanding of socially inappropriate words or behaviours in clients that we may work with.
Aside from the cognitive aspects, learning a second language has also increased my personal experience of the social frustrations of communication difficulties. I emphasise that this isn’t comparable with the experiences of those who struggle with their native tongue, especially those who have lost previous fluent abilities, but has made me reflect more deeply on this. A few years ago I attended a language school for a week in Seville, and stayed with a local Spanish lady who spoke no English and who made no attempt to adapt her speech for me. Despite me often not understanding what she said, she would continue to talk intensely and at speed at me, which at times could leave me feeling exhausted, frustrated and overwhelmed. Sometimes I was able to express basic sentences to her, but other times I would search my jumbled messy mind desperately for words, my speech tripping over itself, struggling to pluck a word out of the haze. My memory was working overtime, trying to find any association such as a semantic group or a wordplay I had constructed as a memory aid for a particular word, but this took time. This would be further frustrated when instead of giving me time she would try to finish my sentences for me, often incorrectly. I had chosen to be in this situation, I knew that it was temporary, and I could pick up the phone and have an English conversation whenever I wanted. Therefore it isn’t comparable with the clients I have referred to in this article. However it did make me think that the anxiety and uselessness that I was experiencing at the time were just a fraction of how clients with communication difficulties must feel, and how terrifying, incomprehensible and confusing an added cognitive impairment on top of this must be. And of how the communication skills of healthcare professionals can enable or disable a person with these difficulties.
I would recommend taking the time to start learning a second language to any healthcare professionals who haven’t experienced this as an adult. I write from the UK, where it is very common to only speak English. It will increase your awareness of your clients communication difficulties, it will open up a different way of seeing the world, and it may even help ward off dementia.
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