Pragmatics and Social Cognition: Clinical Considerations for Adults

Editor's Note: This text is a transcript of the course Pragmatics and Social Cognition: Clinical Considerations for Adults, presented by Katy Magee, MHS, CCC-SLP, L-CBIS.

Learning Outcomes

After this course, participants will be able to:

• Define apragmatism and social cognition.
• Describe appropriate assessments and interventions for pragmatics and social cognition.
• Describe the implications of deficits in pragmatics and social cognition on interpersonal relationships.

Introduction

I am a speech pathologist at the Shirley-Ryan AbilityLab, specializing as the cognitive communication lab therapist. It's a referral service, and I exclusively work with patients with cognitive-communication deficits, mainly those with right hemisphere dysfunction (RHD) or bifrontal involvement. Additionally, I mentor and support fellow speech-language pathologists, engaging in teaching and training. I hold certification as a brain injury specialist, enabling me to treat a broad spectrum of conditions, including traumatic brain injuries, strokes, and neurodegenerative diagnoses.

My career has taken diverse paths, from starting in schools within an autism classroom and providing pediatric home therapy to venturing into the medical field. I began in the neuro ICU and participated in a day rehabilitation program. In 2017, I joined Shirley-Ryan AbilityLab DayRehab centers, initially as the cognitive-communication lab therapist and later transitioning into a role as a research scientist in the neuroscience lab.

While I have appreciated my clinical experiences, I am excited to dive deeper into literature and research. In my new position, I focus on social cognition, reward sensitivity, and emotion recognition following right hemisphere dysfunction.

Overview of Right Hemisphere Disorder

An overview of right hemisphere dysfunction (RHD) emphasizes the significance of the right hemisphere in various cognitive processes, particularly its critical role in communication, especially pragmatics. Generally, damage to the right cerebellar hemisphere can lead to a collection of symptoms affecting attention, memory, executive functions, awareness, discourse comprehension and production, as well as pragmatics and prosody. 

Ramsey and Blake's 2020 survey, a cornerstone in understanding RHD, provides valuable insights into the perspectives of speech-language pathologists (SLPs) in this field. Throughout this section, I will frequently refer to their findings as a point of reference.

Pragmatic involvement, a key aspect influenced by RHD, is often observed in the frontal lobes, specifically the right frontal lobe. Extensive research consistently indicates that lesions in the right hemisphere contribute to pragmatic breakdown. Robertson and Gallagher's study highlighted that individuals with right hemisphere lesions encounter challenges in processing more complex language, particularly within the area of pragmatic language. This encompasses the prosodic part of language, figurative language, idiomatic expressions, and various discourse aspects. Moreover, heightened right hemisphere activity has been documented during comprehensive discourse analysis, further underscoring its role in language processing.

SLP Practice

Let's consider the prevalence and our role as SLPs. According to the 2020 Ramsey and Blake article, cognitive-communication disorders are prevalent in traumatic brain injuries, affecting over 70% of individuals post-injury. Another noteworthy statistic reveals that 50% of patients with right-sided strokes exhibit cognitive-communication impairments. This prevalence escalates to 80% when surveying right hemisphere strokes in rehabilitation programs. These high prevalence rates suggest a substantial portion of our time as SLPs is likely dedicated to cognitive-communication interventions.

Despite these significant prevalence figures, research indicates that a majority of surveyed SLPs—approximately 76%—rely primarily on observation and informal dynamic assessments before incorporating standardized assessments into their evaluations.

RHD Gaps?

Historically, our practice has centered around assessing attention, memory, and executive functions, areas well-supported by literature and standardized assessments. Even today, these domains continue to receive more attention than pragmatics. Research substantiates this trend, revealing that a substantial 94 to 98% of SLPs routinely screen for attention, memory, and executive functions. In contrast, the screening rates for pragmatics dip to 80%, and nonverbal communication lags further behind, with only 55% of responders indicating routine screening. So it appears that if SLPs aren't confident in those areas, then they are not addressed. 

What if we leave these symptoms untouched and untreated? Can they undergo spontaneous recovery? While there may be some limited natural healing, the persistence of these symptoms raises the question of their significance. This issue came to the forefront when a patient's family questioned the value of addressing seemingly minor concerns like eye contact, greetings, and question-asking. The patient, though functional in speech and on a level seven diet, presented cognitive-communication challenges. The family's primary focus was on memory and executive functions to facilitate the patient's return to work.

In response, I had to emphasize the importance of seemingly subtle elements such as eye contact. Eye contact is not only a crucial aspect of cognition, integral to attention, but it also plays a role in memory processes. Furthermore, the ability to make eye contact is essential for locating sounds, ensuring safety, and engaging in social greetings and conversations. I stressed that the absence of eye contact during conversations could convey disinterest or inattentiveness, potentially impacting relationships both personally and professionally.

I emphasized that eye contact contributes to social etiquette and interpersonal relationships with family, friends, and coworkers. It's also a safety measure, aiding in situations where someone needs to alert you to potential dangers. When working on eye contact with a patient, I prioritize the initiation of eye contact in response to stimuli, such as hearing their name or a knock on the door. This initiation serves as a critical first step toward reestablishing comfortable engagement with eye contact, setting the stage for addressing its duration.

In both research and real-time clinical discussions, it becomes evident that there are gaps not only in the treatment provided by speech pathologists but also in educating families about the broader impact of seemingly minor cognitive-communication challenges.  The surveys in the articles looked at discourse, pragmatics, and aprosodia, which are missing in our screenings, assessments, and interventions. 

Returning to the question of why this matters and why we are discussing it, a survey was conducted on stroke survivors and caregivers, specifically 22 months post-stroke. The survey delineated various areas of participants, including caregivers and stroke survivors, and indicated the difficulties they still experienced in those areas. Notably, attention is drawn to the right hemisphere caregiver and left hemisphere caregiver sections, particularly focusing on prosody, empathy, personality, and behavior.

Observing the significantly high numbers for right hemisphere caregivers, even 22 months post-stroke, prompts a reconsideration of our earlier question - do these challenges diminish in a naturalistic environment or gradually heal in a more familiar setting? While there may be some improvement, it does not appear to be an inherent aspect of spontaneous recovery. Consequently, this emphasizes the importance of addressing these issues early in rehabilitation.

Considering these symptoms from the perspective of traumatic brain injury (TBI), it becomes evident that these challenges are not exclusive to right hemisphere strokes; they are frequently reported in our TBI population. The implications of impairments in pragmatics and social cognition extend beyond individual struggles and potentially strain interpersonal relationships. Heightened vulnerability may lead to exploitation, violence, and criminal behavior.

Confidence as a Cognitive-Communication Specialist

We discussed the prevalence, symptoms, and the importance of these aspects. But do you feel confident in assessing and treating them appropriately? As SLPs, it is our responsibility to target these areas. However, based on this research, our collective comfort level in addressing these issues appears to be lacking.

Maro Turkstra and Duff's 2021 report proposed changes in graduate programs, focusing on TBIs with the inclusion of RHD. The findings revealed that only 61.5% of respondents considered themselves the most knowledgeable team member on an interdisciplinary team regarding cognitive communication. 

Reflecting on my own educational experience in 2010, during graduate school, there was no class dedicated to pragmatics, and there was limited discussion on the topic. This educational gap is important to acknowledge. Furthermore, it's worth noting that among allied health professionals and therapists, their scope of practice doesn't encompass all these aspects either.

While psychologists and social workers may address some aspects, especially in pediatric cases, SLPs are regarded as specialists in this domain. It's essential to recognize that evidence supports SLP interventions to enhance attention, memory, social communication, reading comprehension, executive function, and metacognition.

Recent INCOG articles introduced a new pillar of social cognition, indicating its growing importance. Notably, pragmatics and social cognition are relatively recent additions to our scope of practice, placing them as emerging domains within the broader field of cognitive communication.

Dysphagia and aphasia have a wealth of evidence in the literature, with recent years witnessing a surge in research in these areas. However, it wasn't until the 1980s that attention turned to areas such as turn-taking pragmatics and discourse. The field is continuously evolving, with ongoing research efforts to establish evidence-based protocols.

Apragmatism

Pragmatics

Now that we've identified the gaps and highlighted the importance of addressing these areas, let's break them down. Starting with pragmatics, it's important to understand its foundational principles before exploring what constitutes an impairment in pragmatics. Pragmatics connects linguistic knowledge with communicative proficiency. It involves the appropriate use of language across various social contexts to ensure the accurate interpretation of intentions and references.

To simplify this concept, let's consider an analogy—pragmatics as the makeup of communication. Analogies are a helpful tool for grasping complex ideas, and they aid in patient and family education. In this analogy, think of communication without pragmatics as a robotic exchange of messages—a back-and-forth on a blank canvas. Pragmatics, on the other hand, adds color to the message, similar to putting on makeup.

The makeup analogy draws parallels between choosing makeup based on the occasion and adapting communication based on the context. Pragmatics is like the color of the message. You can dress up your message to give it all the information you want to convey. Emotion, intention, assumptions, excitement. These make our messages less robotic and more human. Just as you decide how much makeup to wear and which colors to choose depending on the day or night, communication is similarly influenced by factors such as the audience, location, and the message you aim to convey.

Consider the phrase, "Hey, what's up?" In a high school classroom, it might be accompanied by a head nod, a quick eye glance, and a small smile. In a sports setting, it could involve a loud voice, high fives, and an excited facial expression. Contrastingly, in a library, a simple head nod and a smile might convey the same message without verbalizing it. The point is that the same three words can elicit very different responses based on the environment, demonstrating the role of pragmatics in shaping communication.

Just like selecting makeup based on the occasion, the context determines how you "dress up" or "dress down" your language, making pragmatics a vital aspect of human communication in diverse social settings.

Apragmatism

To understand what constitutes an impairment in pragmatics, let's explore "apragmatism." Apragmatism is a disorder characterized by difficulties in conveying or comprehending meaning or intent through various modes of context-dependent communication. These modes encompass linguistic, paralinguistic, and extra-linguistic elements, including but not limited to discourse production and comprehension, prosody, facial expressions, gesture, and body language.

This term has been officially recognized by the American Neurogenic Communication Disorders Association (ANCDS) and serves as somewhat of an umbrella term. ANCDS breaks down apragmatism into subcomponents. According to Blake's work in 2021, apragmatism is specifically defined as a disorder affecting the conveyance or comprehension of meaning or intent through linguistic, paralinguistic, and extra-linguistic modes of communication.

As we proceed, we will explore each of these subcomponents in detail, providing a comprehensive understanding of the challenges associated with apragmatism. Toward the end, we'll tie it all together to emphasize the broader implications of this condition within the context of communication disorders.

Linguistics. I like to use visuals and analogies to help with understanding concepts, so let's consider linguistics. Linguistics involves the processes occurring inside your brain—what you think about, use, and comprehend during communication. 

This can be categorized into comprehension and production. Comprehension involves interpreting non-literal language, employing sarcasm, grasping jokes or humor, and understanding pronoun usage. If you struggle to understand something, using it becomes challenging. Therefore, comprehending and interpreting these elements is crucial.

Here are a couple of examples. Pronoun interpretation and usage have always been integral to pragmatics. However, it wasn't until two years ago, actually, that I encountered a situation illustrating this concept. I had a patient, and if you're familiar with the movie "Rush Hour," there's a scene in China where the characters' names are Ju (J U) and Mi (M I), pronounced as "you" and "me." The main character in the movie is struggling to ask for Ju, and the other guy insists, "No, I'm Mi." This confusion leads to a breakdown in understanding who's who, emphasizing the complexity of pronoun usage.

Similarly, a few years ago, I encountered a lady in therapy who was having difficulty following directions and was providing unusual responses when asked about her feelings or well-being. Upon investigation, I discovered that her challenges stemmed from an inability to interpret pronouns in the correct context during interactions.

For instance, let's consider a hypothetical scenario with a made-up name, Diane. In a conversation between Diane and me (Katy), I asked Diane, "How are you?" However, Diane, in her thought process, interpreted the "you" as referring to Katy, not herself. This lack of inference meant that she didn't connect the pronoun "you" with Diane because it was coming from me. If this seems confusing, it underscores the point—pronouns only make sense if our brains recognize the two communication partners and their respective positions in the interaction. This principle applies similarly to pronouns like "he" and "she."

In her responses to inquiries about herself, Diane would inadvertently answer in relation to me. For example, she might say, "You look nice today," or "It looks like you didn't sleep last night," providing answers that were about how she viewed me, not herself.

Our interventions focused on improving her understanding of pronouns, including distinctions between male and female and the nuanced dynamics of "you" and "me." Additionally, we worked on referencing and following gestures of pointing to someone. The gesture "point" proved to be a fascinating and effective method for helping her identify the person being referred to in a conversation.

Currently, I am actively involved in a research project centered on emotion identification. The task involves assessing individuals' ability to comprehend humor, recognize sarcasm, and, more specifically, determine the emotional tone of sentences and pictures. In one task, participants are presented with a sentence and asked to categorize it as positive, negative, or neutral, aiming to evoke an emotional response from the words. The same approach is applied to pictures.

During this research, I encountered a notable example. I presented a sentence, "The barn is red," to a participant, and her response was categorized as positive. While I initially perceived this statement as neutral, considering it a factual observation without emotional ties, her interpretation differed. She labeled it as positive because red is her favorite color. This instance highlights how personal preferences and associations can influence emotional categorizations.

This trend continued throughout the assessment. For instance, when presented with the sentence "The cancer is back," the same participant labeled it as positive. Her reasoning was rooted in the fact that she had successfully overcome cancer twice before, framing the recurrence as a positive outcome. This stark contrast in emotional interpretations emphasizes the subjective nature of emotions and the impact of personal experiences on individuals' perceptions.

Leading into the production aspect, individuals with linguistic impairments under the apragmatism umbrella may exhibit traits such as being tangential, verbose, lacking expression, and leaning towards a personalized or egocentric style. This was evident in "Diane's" behavior.

Our activities consistently revolved around her – her experiences, thoughts, and mindset. Encouraging her to recognize alternative perspectives or different ways of interpreting information was challenging. Additionally, conveying main ideas posed difficulties for her, as she tended to be disorganized in speech, struggling to articulate the intended message. 

From a production discourse perspective, resembling linguistic impairment, the analogy of a salad comes to mind. In a formal setting, like a plate with neatly arranged components such as meat, potatoes, and vegetables, everything is distinct. Conversely, a salad features various elements thrown together without organization. Comprehending the individual's thought process is like trying to assemble a cohesive structure from the scattered pieces of a salad. It becomes challenging to grasp a coherent line of thought as if one is attempting to process multiple ideas simultaneously.

Paralinguistics. Transitioning to the paralinguistic aspect, which can be seen as the second step or outer layer, this is how communication sounds. Building on the linguistic dimension discussed earlier, this phase involves three key areas: grammatical, pragmatic, and emotional or affective elements. These facets play a crucial role in conveying thoughts and feelings.

Starting with the grammatical aspect, it involves the syntactic structure of sentences, distinguishing between statements and questions. A simple alteration in intonation or pitch can transform a statement into a question, highlighting the significance of prosody in speech.

Moving on to the pragmatic aspect, emphasis is key. Placing stress on specific words can convey excitement, fear, or other emotions, while also guiding the listener to discern the crucial elements in a narrative. What stands out in a story can significantly impact the listener's takeaway.

Finally, the emotional component is in all of our communications. The speed and pitch of speech serve as indicators of emotional states. A faster rate and higher pitch may signify happiness, engagement, or excitement, while a slower pace and lower pitch might suggest sadness, fatigue, or disinterest. It's similar to applying makeup to words, shaping how they are perceived. In essence, the paralinguistic layer paints verbal communication with a palette of tones and nuances.

This paralinguistic layer is dual in nature and is both receptive and expressive in nature.  Individuals must not only comprehend paralinguistic cues from others but also use these cues effectively when communicating with others. Returning to the earlier discussion about the challenges faced by the woman when navigating positive and negative interactions, this aspect is closely linked to the next section, where we will look at the analysis of emotions and try to understand why someone may be experiencing a particular emotion. 

Extralinguistic. The final layer or step, the extralinguistic layer, can be thought of as the body of communication. It encompasses nonverbal elements such as body language, eye contact, gestures, and emotional facial recognition and expression. Similar to the previous layers, impairments in this area can manifest as both receptive and expressive challenges.

As mentioned earlier, individuals with difficulties in comprehending these nonverbal cues may also struggle with using them appropriately. An example is the misinterpretation of facial expressions. In such cases, a person might react based on their interpretation rather than to the communication partner's underlying intention. While miscommunication occurs with individuals without brain injuries, it tends to be more consistent within this specific population.

Interestingly, facial recognition of emotion is noted to be a huge impairment in right hemisphere dysfunction and bilateral involvement. Research suggests that patients who have difficulty interpreting emotions are also showing difficulty using them. 

Breaking down this complex interplay, consider a scenario where a patient can accurately identify the emotion displayed by a boy in a picture, recognizing it as sadness. However, when asked to explain why the boy appears sad, they struggle to connect it to the surrounding context—the room's contents or the recent conversation with the mother. This difficulty in linking emotion to language or context highlights a challenge in integrating linguistic, paralinguistic, and extra-linguistic elements. 

To revisit the layers: the linguistic aspect represents what's happening internally—the cognitive processing of language; the paralinguistic dimension is the transition from internal thought to actual speech, including intonation and emphasis; and finally, the extralinguistic layer involves the nonverbal aspects, such as facial expressions and gestures. The extralinguistic layer involves all the external elements—your body language, facial expressions, and gestures.

I see it as a bit of a process. When addressing apragmatism, I focus on specific areas to improve linguistic impairments or pragmatic components. I break it down to identify the specific areas we're working on. Individuals may have impairments in one, two, or all three dimensions—linguistic, paralinguistic, and extra-linguistic. It's not necessary for the impairments to be isolated or follow a specific order.

Discourse

Discourse encompasses all the previously mentioned areas, primarily focusing on linguistic aspects. According to Steel, deficits in spoken discourse emerge as a hallmark in communication impairments associated with RHD. Individuals with RHD often exhibit impaired discourse, characterized by various challenges, including egocentric or overly personalized thoughts, tangential or hyper-verbose speech, a deficiency in emotional and affective expressions, and a lack of informativeness resembling a disjointed "salad" rather than a structured narrative with meat and potatoes.

Discourse among those with right hemisphere strokes tends to be less relevant, deviating from the main idea. There's a tendency for discourse to become confabulatory, rooted in personal opinions, leading to an overall impaired global coherence when we analyze language samples.

Recently, a modified version of the cookie theft picture has been introduced. While many of you are likely familiar with the traditional cookie theft task from the Boston Diagnostic Aphasia Examination (BDAE), this new assessment tool has emerged in research as a valuable resource for objectively measuring discourse.

This modified tool provides insights into how individuals describe a scene. We can assess the number of content units provided, analyze the usage of words with more than one syllable, and observe the spatial orientation, whether they are looking more toward the right or left side of the picture.

In general, individuals with RHD tend to produce fewer content units, use words with fewer syllables, and often direct their attention more towards the right side, possibly due to left neglect. This tool offers a concrete way to conceptualize and measure discourse objectively.

Social Cognition

Let's discuss social cognition. To be candid, during my time in school and early work experiences, social cognition was rarely included in my writings or training materials. Everything seemed to fall under the pragmatic umbrella. However, in recent years, as literature began to focus on social cognition and communication, it began intertwining with pragmatics. Let's explore and dissect how they complement each other.

What is social cognition, and how does it differ from pragmatics? First, let's define it. Social cognition involves understanding other people, predicting their behaviors, sharing experiences, and effective communication—essentially grasping others' thoughts and feelings. It encompasses both cognitive and affective aspects, including theory of mind, general emotion, perception, and empathy. Similar to apragmatism, social cognition is a broad term that can be divided into cognitive and affective components.

One helpful framework that aids in my understanding of social cognition is the distinction between hot social cognition and cold social cognition. Hot cognition pertains to the emotional and affective aspects, encompassing elements such as emotional empathy, emotional recognition, motivational significance, and visceral changes. These components are deeply rooted in emotion and effectiveness. On the other hand, cold cognition involves components like theory of mind, cognitive empathy, and pragmatics within the realm of social cognition.

Hot Social Cognition

Let's look at the components of hot social cognition. Emotional empathy is the capacity to resonate with others' feelings. This is particularly relevant for patients or individuals with brain injuries, enabling them not only to comprehend but also to express empathy towards others' feelings, even when they don't share the same emotional experience. Additionally, emotional recognition involves understanding both dynamic and static emotional facial expressions, as well as interpreting emotions conveyed through vocals.

Motivational significance plays a role, which is the inclination to engage in communication with others. This includes the desire or "get up and go" motivation to connect with others. Autonomic changes, on the other hand, refer to physiological responses to stimulation. Assessing factors such as motivation, the presence of a reward sensitivity network, and the inclination to be social and integrate with others.

Cold Social Cognition

The cold aspect involves theory of mind, which encompasses recognizing and understanding other people's perspectives, acknowledging the existence of diverse opinions, points of view, and perceptions beyond one's own.

Inferencing, or reading between the lines, entails grasping the intended meaning when people express themselves indirectly, such as through metaphors like "it's raining cats and dogs." While it's understood that literal cats and dogs aren't falling from the sky, you are inferring that and interpreting that metaphorical statement that it's advisable to bring an umbrella due to heavy rain.

Cognitive empathy involves mental perspective-taking, fostering an awareness of flexibility, and recognizing multiple approaches to interpreting situations based on others' perspectives. 

General pragmatics encompasses language use within social constructs and how linguistic knowledge is conveyed in communication.

I find myself relying on theory of mind within social cognition more frequently than the other components. This tendency stems from the observation that individuals, particularly those recovering from a brain injury, often need to focus on understanding diverse perspectives. In the initial stages of recovery, the emphasis is typically on them as they heal, leading to a potential over-personalization of their thought processes. Consequently, these individuals may develop rigid thinking patterns, making it challenging for them to integrate and communicate with others who hold differing points of view. Thus, theory of mind becomes a key element in my approach to describing and addressing social cognition in such cases.

Here's an example from my training sessions with caregivers and patients in the areas of social cognition and pragmatics, a scenario commonly encountered in hospital settings. It's not uncommon to hear the perspective that individuals appear sad or exhibit limited facial expressions solely because they are in a hospital environment, and the assumption is that things will improve once they return home. While I appreciate this viewpoint, my knowledge and experience suggest that the challenges don't necessarily get better immediately upon leaving the hospital.

The concern arises when these individuals, who may be somewhat happier at home, continue to display a lack of complete facial expressions, especially in situations requiring humor, such as interactions with their children online or making phone calls to family. It's essential to emphasize the importance of maintaining at least some level of facial expressions and an understanding of how others perceive them, even if the improvement in mood occurs with the change of environment.

An example I often use with both patients and caregivers to explain these concepts involves an apple, specifically choosing one that isn't identical on both sides. Holding the apple between the patient and the caregiver, I prompt them to describe what they see. The patient identifies it as an apple, while the caregiver describes it as a rotting apple with a wormhole. I point out the difference in their perspectives and inquire if they are looking at the same apple. Both agree, but when I ask the patient if they see on their side what the caregiver sees on theirs, the response is "no," although they still acknowledge it as an apple.

I emphasize that while it's undeniably still an apple, the caregiver's perspective differs from the patient's. When asked if the caregiver is wrong, the patient responds with a "no," but adds that she could have simply said it's an apple because that's all it is. I acknowledge this possibility but clarify that my question wasn't about the object IS; it was about what each person SEES. This explanation underscores the idea that even if the central topic or object is the same, individual perspectives may vary based on different points of view. I stress the importance of linguistic awareness and theory of mind in comprehending that multiple perspectives coexist in communication.

Social Cognition and Apragmatism

Is social cognition the same as apragmatism, or are they different? The straightforward answer is no, they are not the same. Let's break it down in a couple of ways. Social cognition empowers us to predict others' behaviors, share experiences, and communicate effectively, providing a foundational understanding for effective communication. In contrast, pragmatics focuses on external expressions, encompassing how one portrays, communicates, and receives information from the outside.

Impairments can manifest in either domain independently or affect both simultaneously. For instance, a patient might exhibit an impairment in eye contact, which falls within the pragmatic domain and can be addressed accordingly. Conversely, someone experiencing a breakdown in social cognition, particularly in theory of mind related to interpreting others' body language, may respond atypically due to a lack of perspective and theory of mind skills.

Moreover, isolated impairments in body language could occur. It is critical to dive into the specifics and understand the underlying reasons. This approach involves asking questions such as: Why does a person behave a certain way? What is their intention? Understanding these aspects helps streamline the plan of care and allows for a targeted intervention to address the specific breakdown in either social cognition or pragmatics.

I think of social cognition as the soil, and pragmatics as what grows from it. When social cognition has the right ingredients, nutrients, and suitable conditions, it becomes fertile ground for beautiful flowers to blossom. Conversely, malnourished and dry soil may result in atypical pragmatics, manifesting as breakdowns or lack of growth. From a metaphorical standpoint, flat affect and limited facial expressions, along with a lack of social reciprocity, can be attributed to deficient social cognition. The absence of motivation, cognitive empathy, and visceral changes contributes to a barren landscape, similar to dry soil yielding weeds.

Assessments

I'd like to provide a brief overview of assessments, bearing in mind that this list is not exhaustive. The choice of assessments may vary depending on factors such as the population you're working with, age groups, geographic location, and the level of care. However, here is a compilation of some of the most commonly reported assessments identified in both research and clinical practice.

• Discourse Comprehension Test
• The Pragmatic Protocol
• Profile of Communicative Appropriateness Communicative Abilities in Daily Living
• Functional Communication Profile
• The Awareness of Social Inference Test
• Assessment of Pragmatic Abilities and Cognitive Substrates
• RIC Evaluation of Communication Problems in Right Hemisphere Dysfunction
• Cookie Theft Discourse Analysis

Selecting the most suitable assessments for your specific population is essential. Personally, I find the Cookie Theft Discourse Analysis and the RIC Evaluation of Communication Problems particularly valuable.

Additionally, there's an older Social Inferencing Test that is similar to the Awareness of Social Test. However, the stimuli in this test are outdated, diminishing its utility. I'm hoping that an updated version will become available, making it more applicable to contemporary contexts. This test involves a CD where participants listen to intonation, prosody, and the reading of a story, requiring them to read between the lines—an intriguing aspect. Ultimately, the choice of assessments should align with the unique needs and characteristics of the population you work with.

Interventions

Having covered prevalence, the significance of assessment and treatment, as well as definitions and assessment options, let's look at interventions. Once it's established that an individual has pragmatism or social cognition concerns, determining the appropriate interventions becomes imperative.

Interventions involve a strategic combination of behavior shaping, feedback, modeling, and the use of multiple examples to encourage generalization. Creating opportunities for high-dose practice is another critical element in social communication interventions.

A common question I encounter is whether one-to-one training or group training is more effective. The answer is a combination of both, and it depends on the specific goals and outcomes you want to achieve. The literature can provide some guidance in making these decisions, but it's important to consider the nature of the intervention.

When working in a social group, the emphasis is often on generalization and implementing strategies collaboratively. On the other hand, if the goal is to build awareness and lay a foundational understanding, a more targeted approach in a one-to-one setting may be beneficial.

In my personal approach, I find a balance by combining both methods. One-to-one sessions allow for focused attention, rapport building, and targeted interventions such as feedback, modeling, and education. As the individual progresses, I facilitate the transition to social settings, encouraging the generalization of skills and strategies within a group context. This comprehensive approach helps address individual needs while fostering broader social communication abilities.

Let's look at some interventions. There are partner-based interventions and those that involve familiar social groups. Here are a few, with some derived from evidence-based literature and standardized protocols, while others are practical clinical insights that have proven helpful.

Firstly, we have PragmaCom, a well-established intervention. Another is Cognitive Pragmatics Theory or Training, which focuses on the cognitive aspects of pragmatics. The ARCS Treatment involves an approach that combines education and cognitive therapy.

It's important to note that this is not an exhaustive list, and the literature may recommend some more strongly than others. The choice of intervention may also depend on your personal preferences and the specific needs of the individual or group you are working with.

PragmaCom (Meta-pragmatic model)

The first intervention is the PragmaCom. If you work on pragmatics, you might already be using this model without realizing it. PragmaCom is considered a meta-pragmatic model, emphasizing the concept of training the "thinking about thinking" concept of using pragmatics.

Think of this as a training program or a workout regimen. Participants or clients are guided to reflect on what happened, define their goals, identify areas for improvement, create a plan, and determine the next steps. This process actively engages the metacognitive component. Drawing a parallel, you might recall the Cognitive Rehabilitation Manual's emphasis on metacognitive training through the goal-plan-do-review cycle. It involves establishing the goal of an activity, outlining the steps to ensure successful completion, executing the task, and then reviewing the outcomes.

Applying the PragmaCom model involves a process similar to the goal-plan-do-review cycle but tailored to pragmatics. In a communication exchange, the individual is guided to identify any breakdowns or issues. Was the interaction successful, or were there misinterpretations? Reflecting on these aspects, you can determine what went wrong or, conversely, what contributed to a successful interaction.

If a miscommunication occurred, figure out specifically what happened. Was it a misunderstanding, a breakdown in non-verbal cues, or an issue with perspective-taking? On the other hand, if the communication was successful, what factors contributed to its success?

Following this reflection, the next step is to address the breakdown. This may involve fixing the issue or adopting a more flexible thinking approach. Create new ways of thinking and practice the revised approach, either by rehearsing the breakdown scenario or developing a different perspective for future occurrences. 

Another application of the PragmaCom model involves figurative language or metaphorical analysis. Consider the example: "The lawyer is a shark." Is the lawyer an actual fish in the sea? No. Does the lawyer have fins? No. Recognizing that this is a metaphorical statement becomes evident. Understanding its deeper meaning requires reading between the lines and acknowledging that it conveys a message beyond the literal interpretation.

To apply the model, individuals can begin by identifying the metaphorical statement, like "the lawyer is a shark," and then probe into potential reasons for a breakdown in understanding. For instance, someone may struggle with the metaphor, questioning its logic because lawyers are not literal sharks. You can have a conversation about that misunderstanding.  

The next step is to consider both the literal and expressive meanings. Being a "shark" could mean literally living in the ocean, or does it mean embodying assertiveness or holding a high position within an organization because they are ruthless? Again, there are numerous ways to interpret this statement. 

Have the patient reflect and discuss the elements that might help them determine if it's figurative or literal. Talk about the context in which the statement was made: "Were you at work, and you heard your boss say this about one of your colleagues? You know that your colleague's not a fish." Saying this to the patient might make it more literal.

Ask them what it means to be a shark. This is similar to the Semantic Feature Analysis (SFA) approach used in aphasia treatment.  What does it mean to be a shark? Ask them to describe what a shark is.  What are all of the actions or associations that go with a shark? Do any of those match what a lawyer might be?

Moving into phase three involves considering new contexts. After describing the attributes associated with a shark, the patient engages in logical reasoning. Does it genuinely make sense for someone to use this phrase or describe another person in this manner? The clinician guides the patient in selecting appropriate attributes and maybe has them practice using the expression in different contexts. 

This intervention often starts with a general dialogue. Whether using a paper with phrases or engaging in contextual scenarios—be it one-on-one, within a family setting, or a group—the PragmaCom model provides a structured framework. The process involves guiding individuals through the processing, interacting, and responding to figurative language.

The PragmaCom model can be used in one-on-one scenarios, particularly when addressing a breakdown in communication. Have the person follow the sequential steps of identifying the breakdown, reflecting on its causes, creating a new phrase, and then trying it again.

Cognitive Pragmatic Training

Let's discuss Cognitive Pragmatic Training. There are two primary perspectives to consider in approaching CPT. The literature commonly abbreviates it as CPT, and it typically involves group training conducted over a span of six to 12 weeks, with two to three sessions per week, depending on the specific focus. Group sizes vary, ranging from three to eight participants, depending on the targeted objectives.

CPT focuses on various expressive modalities of communication; linguistic, extralinguistic, paralinguistic, social appropriateness, and conversational abilities.  The sessions concentrate on aspects of awareness, theory of mind, planning, and role-playing in communication scenarios. Aligning with a structured approach, similar to PragmaCom, CPT proceeds through stages and attempts to deconstruct the communication act by identifying who spoke, what was said, and to whom.  Then, identifying the mental state of the person to determine the intentions and meanings behind the expressions, considering factors like the speaker's gaze, stated intentions, and anticipated responses.

The next phase explores the communicative effect, dissecting interactions between individuals. Did the response align appropriately with the initial message, or was there a breakdown? The role-play of the two individuals is examined to determine the appropriateness of reactions and responses. In other words, did I communicate my intentions of what I wanted? Did they give their intentions? Is my reaction appropriate to what they wanted? Did I match what they wanted? If not, do I need to change my reaction or my response? The idea is to take a discussion and dissect it.

In instances where family or friends are present, I incorporate Cognitive Pragmatic Training (CPT), combining elements of the PragmaCom approach. For example, if a patient seems angry because their spouse mentioned returning on Monday, leaving them alone over the weekend, I initiate a discussion to uncover why they're angry. By asking the patient why they believe the spouse is absent for the weekend, a common response might be, "She doesn't want to spend time with me." However, without directly communicating with the spouse, assumptions can lead to misunderstandings.

I encouraged the patient to ask about the spouse's perspective. Upon doing so, the spouse revealed that she needs to attend to the children, as they are not in school during the day, and she will return when they are back in school. This newfound information altered the patient's initial reaction. I  talked through how responses can be inaccurate if we don't know other perspectives and if we assume perspectives, and they're incorrect. 

This is where we dive into how responses can go sideways if we don't know other angles and jump to conclusions. It's like stepping into a spiderweb—things get tangled. In my sessions, it's often a straightforward chat. Let's break it down step by step. What were you thinking? What were they thinking? How did the conversation flow?

Attentive Reading and Constrained Summarization (ARCS)

The ARCS program, known as Attentive Reading and Constrained Summarization, is likely familiar to many of you. Traditionally used for patients with higher-level aphasia, we're increasingly seeing its application at the discourse level. The primary goal of ARCS is to improve topic maintenance and semantic specificity.

The ARCS program, known as Attentive Reading and Constrained Summarization, is likely familiar to many of you. Traditionally used for patients with higher-level aphasia, we're increasingly observing its application at the discourse level. The primary goal of ARCS is to enhance both topic maintenance and semantic specificity.

Earlier, I compared discourse in aphasia to a salad—tangential, verbose, and disorganized. The challenge arises when it's difficult to discern the main point or sustain the topic, leaving the communication partner hanging in the balance, wondering, "Where are we going from here?" ARCS specifically addresses linguistic processing at the discourse level, focusing on macrostructures.

Unlike treatments targeting language and words at the sentence level, which operate at the microstructure, ARCS dives deeper. The therapeutic approach involves reading a passage aloud, with the patient's task being to summarize it effectively. The objective is for the partner or therapist to grasp the content through a concise one to two-sentence summary.

During this process, strict rules apply to constrain the use of non-informative words. This means no "things," no "stuff," no "um," or "ah," no pronouns, and notably, no opinions are allowed in the summarization.

For individuals with significant apragmatism, a common tendency is to over-personalize their discourse. For instance, when reading about a topic like scuba diving, they might swiftly divert the conversation, expressing their disinterest or lack of intent to partake in such activities. The inclination to interject personal opinions can hinder effective discourse.

With ARCS, there are no opinions. This program is similar to the ORLA but for summarization. You can tweak it a bit. Have them write down their summary before reading it aloud. Once they're done, have them cross out any non-informative words and opinions. You can incorporate a metacognitive approach at the end, giving them a chance to reflect on how they're summarizing.

General Cognitive Therapy

Attention, working memory, the auditory moving window paradigm, and executive functions are innate elements that can support foundational pragmatic skills.

In conversations, strong working memory is crucial because it allows you to understand what the person just said while formulating your response. Additionally, sustaining attention throughout a conversation is essential for active participation. Therefore, engaging in cognitive therapy, in general, will contribute to the reinforcement of these skills.

I don't use the auditory moving window paradigm much, but it involves dividing discourse passages into multi-word units, essentially chunking the information. These segmented pieces are presented to individuals with right hemisphere damage (RHD), and at the end, listeners are prompted to recall the content of these passages.

Introducing pauses between each segment tests the client's ability to infer what might come next. It parallels auditory processing and reading, where individuals read a paragraph, take notes, or answer questions later. However, in this paradigm, the emphasis is on chunking the information to enhance the overall coherence of the discourse or language sample.

Education/Caregiver Training

Education is crucial, and while therapists often prioritize evidence-based protocols, we sometimes overlook the fundamental need for education alone. Not everyone requires structured protocols; some individuals simply need information. Take, for instance, the scenario I shared earlier, where a mom questioned the focus on eye contact—a valid question. However, once I explained its importance, full buy-in was achieved, leading to consistent practice even beyond therapy sessions.

Establishing a rule in the therapy room, such as not answering questions until the patient engages in eye contact, can foster daily, high-dose practice. Caregivers can be effectively trained to continue these practices outside speech therapy. Education is accessible and straightforward, ranging from casual conversations to role-playing sessions. Providing general brain education is essential and can address the common expectation that individuals will automatically improve when they return home. Despite the anticipated positive changes, it's critical to acknowledge specific brain injury details, such as damage to the right frontal lobe, which is a pivotal area for personality and pragmatics. General brain education, coupled with specific discussions on pragmatics, emphasizes that laughter and humor, seemingly automatic, require deliberate training and processing after an injury or impairment.

Regarding interpretations and intentions, know what the person's intentions are, rather than hearing a word or sentence and having an immediate emotional response to it. Take a minute and pause. Ask yourself what the person's intention was before you react.  Once you determine the intention, you can determine if it is logical. What would your response be to that? We want to educate and walk through each one of those steps. How should I sound? How should I look? What should I do for gestures? Does that match your intention? Did you convey what you wanted to convey? 

Analogies

Reciprocity. The last section is analogies which I often use to educate patients and their families.  When discussing reciprocity, especially in the context of RHD, reciprocity is the evident pragmatic impairment, particularly in the acute stages. In these initial phases, there is a lack of back-and-forth interaction, similar to throwing a ball or playing catch. While some may compare throwing a ball and catching it to a question-and-answer dynamic, I prefer the analogy of tennis because it isolates the different movements and the different parts of the reciprocal exchange.

In tennis, when I hit a ball to you, it serves as a question. As the ball lands on your side of the court, your subsequent action of hitting it back is equivalent to answering my question. If there is no further engagement after your response, the ball rolls off the court, concluding the match and ending the conversation abruptly. However, if, after the initial bounce, you return the ball with a question, reciprocity occurs. The ball is now back in my court, and as it hits the ground, I provide an answer. The same principle applies if I allow the ball to roll off the court without responding; the conversation ends.

It doesn't always have to be a question when you're hitting the ball; it can be a statement or a shift in the conversation. But somebody always has to give it back, and provide reciprocity, if you want the conversation to continue.

Eye Contact. I use feedback to address eye contact regularly. Simply put, consider how I might feel when talking to you if you're focused on my ear or the top of my head. What does that convey? It suggests a lack of care, right? Do you care? Yes, I want to engage with you. Okay, how can you demonstrate that? What impact does it have on me? I even mix it up; I might talk to them while looking at the floor to gauge their reaction.

Now, not everyone excels at maintaining eye contact. I fully support that. I struggle with it too, preferring check-ins, brief gazes, and occasional breaks. It's about initiating eye contact when your name is called, signaling your attention, and then taking a pause. These analogies help convey how it feels and what the feedback entails.

Theory of Mind.  The theory of mind analogy is the apple I mentioned earlier. You can apply it to viewpoints, perspectives, and interpretations of what people say.

Perspectives/Intentions.  If I ask you, "What is one and one?" and you interpret the "and" as a plus sign (as seen on the slide), you'll likely say the answer is two. This interpretation aligns with our learned understanding that one plus one equals two. However, consider if my initial statement was not about addition but about combining things. In this case, "and" takes on a linguistic perspective, meaning the act of placing two things together. Now, the result could be seen as 11. The key here is that interpretations, perspectives, and intentions play a significant role in shaping our understanding. I often discuss these types of breakdowns in communication. You might perceive the conversation as a two, while someone else sees it as an 11. Explore why the person interpreted it that way. What was happening? 

Culturally and Linguistically Diverse Patients

We are all aware that within speech and rehabilitation in general, we must consider the cultural and linguistic diversity of our patients and the impact that it has on speech, particularly pragmatics.  Awareness of cultural variations in areas like eye contact, turn-taking, and nonverbal cues is essential. Additionally, when working with patients from diverse backgrounds, be aware of the use and understanding of idioms and metaphorical language. Patients who speak different languages or come from different cultures may not be familiar with certain idioms, and you might need to identify equivalents that resonate with them.

Consider modifications in the assessments. For example, one of the assessments in my toolkit is a lengthy list of metaphorical and figurative language. I've collaborated with Spanish interpreters who provided me with a list of Spanish expressions and, similarly, with Arabic counterparts. Since these translations aren't an exact match to the original test, I can't generate a standard score. However, I will highlight that in my report, noting that the individual faced challenges with aspects that should be culturally relevant to them, especially in the area of metaphorical language. Offering explanations is necessary, but it's equally important to approach the results with caution. 

Following ASHA's guidelines in the assessment and treatment of right hemisphere disorders, it's imperative to underscore and take into account this diversity. Several books and online resources address the intersection of cultural diversity and social communication skills. These materials provide valuable insights and lists of variations found in each type of culture.

Role Playing

The most important takeaway from this course is embracing role play and getting comfortable with being uncomfortable.  Pragmatics can be challenging and may involve navigating uncomfortable situations, especially when dealing with personality nuances and providing feedback. Education in these areas might push you out of your comfort zone. However, the more you engage in it, the more adept you'll become. Personally, I strongly advocate for this approach. As a mentor to new SLPs at work, I often hear them express hesitation and fear about what to say — and that's completely understandable. But with consistent practice, you'll gradually become more at ease.

Keep in mind that some people might not be aware of what they're missing or the changes happening, so you need to feel at ease providing that education. It's essential to comfortably communicate to a patient if they're speaking excessively, perhaps for 17 minutes straight – chances are they might not realize it. Without your intervention, how much longer might they have spoken, and how frequently is this happening with their family members? Establish rapport early on, and initiate these conversations as soon as possible. 

Consider involving psychologists or social workers in these discussions if it helps with your comfort level, given their expertise in the field. However, a word of caution: avoid becoming overly persistent or critical. You don't want to be perceived as constantly nitpicking every statement, as this can cause trust and rapport to deteriorate quickly. Instead, collaborate, initiate conversations together, and practice as a team.

Many times, I deliberately schedule patients during doctors' rounds, particularly when I'm aware they struggle with interacting with medical staff due to social cognition challenges. This way, I can observe the dynamics and, when needed, approach the doctors to discuss and address these issues. I take the opportunity to apply various models and facilitate constructive feedback and awareness in the process.

It's perfectly acceptable to stage interactions or work in real-time, leveraging friends, family, students, patients, or medical staff to create diverse social scenarios. One-on-one sessions are valuable for practicing planning and providing direct feedback, ultimately helping individuals improve their social interactions in the future.

A significant part of my teaching philosophy emphasizes the importance of providing feedback, even when it might feel uncomfortable or disheartening. Whether it's pointing out that a statement came across as rude or that a facial expression conveyed disinterest, the key question is whether that was the intended message. If it was, great – fantastic job. If not, it's crucial to address and rectify because delivering such unintended messages to someone who cares about you can hurt the relationship.

Consider the ripple effect: without providing this feedback and knowledge, when these patients return home, their interpersonal relationships might become strained. So, despite the discomfort it may bring to us, it's essential to acknowledge the potential difficulty for them if we fail to guide and provide this necessary feedback.

Summary

My goal with this course was to share as much information as possible without overwhelming you with two complex concepts. I hope that I've encouraged you to approach things from a different perspective and sparked an interest in exploring pragmatics and social cognition with greater familiarity and curiosity. I strongly recommend looking into the growing literature in these areas, as new research is continually emerging.

Questions and Answers

Can you provide an in-depth definition of theory of mind?

In essence, theory of mind involves your ability to comprehend and perceive another person's beliefs or emotions. It's the skill of recognizing, for example, when someone appears sad and being able to infer or acknowledge their feelings or beliefs based on your knowledge of them within the current context. Imagine it as when you're conversing with your friends, and you exchange a look across the room. In such instances, you can intuitively understand what that person might be thinking or feeling because, firstly, you're familiar with that friend and are aware of their beliefs.

Secondly, you recognize that your response or interaction could influence their thoughts or emotions. It's about grasping the behind-the-scenes feelings without the need for explicit communication.

Can you restate the percentage of right-sided stroke patients with cognitive-communication deficits?

Fifty percent of right hemisphere strokes have cognitive communication impairments in relation to the pragmatic area. Then, it jumps to 80% when they surveyed people specifically in a rehabilitation program. So not just in general because not everybody goes to a rehab program. 

How do we give feedback to patients if language comprehension is also impaired?

Depending on the severity, I assume you're referring to comprehension issues from an aphasic standpoint. There are several approaches to address this, such as modeling facial expressions and utilizing social scenarios presented through pictures. Similar to using picture supports for general comprehension, you can use visuals like a picture of a happy face with the corresponding word "happy" matched alongside an image of a boy at a birthday party. Transitioning from this, I've used a similar approach with patients who are not necessarily aphasic, but those dealing with language overstimulation, making it challenging to give them a lot of feedback.

In such cases, I've taken them to a quieter space or in front of a mirror. When practicing emotions, prosody, or response types, I might hold up a picture and ask them to give their response or demonstrate a matching facial expression. Using images in this manner provides an alternative and effective way to work on these different aspects.

I understand that a lot of this input is assuming prior competence. But what about if the patient has a neurodiversity, such as ADHD, autism, et cetera, that is now unmasked or more impactful since the new injury?

I'm not sure I have the perfect answer, but my initial instinct would be to consider premorbid deficits or impairments and assess how they may influence their overall pragmatics. This is important to evaluate during the educational phase. Following that, discuss the goals the individual wants to achieve and recognize that these goals might differ from what's considered typical.

It might involve a conversation about working towards specific objectives and acknowledging that the target might not align with neurotypical expectations. The next step would be to explore creative supports and interventions tailored to the individual. While working with children with autism or ADHD, for instance, offering feedback may still be possible but might require a different approach, perhaps emphasizing modeling behaviors to effectively shape communication patterns.

You discussed a lot of therapy strategies involving role-playing and discussions. Do you know what strategies are considered EBP?

PragmaCom, Cognitive Pragmatic Training (CPT), and ARCS are all evidence-based practices with ample journal articles available. From an educational standpoint, the INCGO (I N C O G) provides EBP-related articles, particularly focusing on TBIs but offering a substantial section on social cognition. This is an excellent starting point for education-based EBP. 

Concerning analogies and role-playing, the use of analogies is more of a clinical preference on my part, representing how I've learned to educate and break down complex concepts. The evidence-based practices for these analogies and training fall under the umbrella of CPT, especially in the context of role-playing within social groups. Even if you don't follow a set treatment plan spanning weeks with a specific number of participants, you can apply the same framework within a family context for effective family training.