The Importance of Cognitive Communication in Vocational Rehab

Cognitive communication is a complex skill which includes language, attention, memory and problem-solving as well as the social part of communication or pragmatics. Many parts of the brain, including the frontal, temporal and parietal lobes, interact to ensure the correct functioning of this essential social and work-related skill.

Due to the interconnected nature of brain functioning, impairment of cognitive communication is a frequent consequence of brain injury, affecting an individual’s ability to communicate successfully and limiting their capacity to return to work post injury.

In this article we look at the role of the Speech and Language Therapist (SLT) in vocational rehab and how, amongst the many areas of support provided by SLTs in neurorehabilitation, they assess the speech, language, and communication functioning of each individual and the possibility of returning to and remaining in work.


The Importance of Cognitive Communication in Vocational Rehab


Vocational rehabilitation at Badby Park


Badby Park is a specialist neurological care home in Daventry providing rehabilitation, long-term care, respite and palliative care for people with progressive neurological illnesses, acquired brain injuries and spinal injuries.

Candida Ellis is a SLT at Badby Park, and has a particular interest in cognitive communication function, and its role in a person’s functioning across all aspects of daily life.

As part of a multi-disciplinary team (MDT), which also includes psychologists, occupational therapists, physiotherapists, amongst other care professionals, Candida provides vocational rehabilitation programmes for individuals who have suffered a brain injury and are considering a return to work.

Vocational rehab is a broad term that encompasses a variety of assessments, advice, therapies and additional resources that enable someone to return and remain at work. The specialist MDT at Badby Park, offer a range of clinical and therapeutic support that ranges from executive function and communication assessments, practising of practical workplace skills, to communicating with employers and travelling to work reviews.


The Importance of Cognitive Communication in Vocational Rehab

Communication and a MDT approach


Clear and effective communication is vital to the success of a MDT as it enables a holistic and personalised approach to vocational rehab. Team members draw upon others expertise and share best practice, they work together on goal setting and ensure the individual has access to specialist knowledge at the most appropriate junctures of the rehabilitation programme.

In addition, facilitating effective communication between clinicians and individuals participating in the rehabilitation programme, who are likely to have impaired cognitive communication, is fundamental to the real life impact of the rehab.

The better the individual can communicate his or her wishes, and the more effectively they can respond and interact during therapy sessions then the greater understanding the MDT will have of the barriers for returning to work. Measures to address these issues can then be implemented and the individual can receive holistic support tailored to their bespoke needs.

SLTs play a central role in enabling the individual to establish good communication with the team and support them to express what they want to achieve in terms of vocational rehab. As Candida explains, ensuring that the individual can navigate the multitude of physical, cognitive and emotional issues that arise during rehab programmes is vital.


The Importance of Cognitive Communication in Vocational Rehab


Candida says:

“Our work focuses on understanding any barriers that an individual may face in returning to work, all the while increasing their independence and their ability to perform the requirements of their employment.

For individuals who have suffered a brain injury the possibility of returning to work, whilst very fulfilling and empowering, can also seem daunting, with multiple hurdles to cross.

We always try to consider their emotional and social needs, as well as physical – and we can’t do that without clear and effective communication. In my role as a SLT, I prioritise assessment with lots of reassurance so individuals do not see it as a test that they will pass or fail. It is important that individuals understand we are trying to identify areas that can be targeted to make their discharge and/or return to work successful.

Our assessments look at verbal reasoning and executive function and pragmatics. It is possible to have cognitive communication disorder alongside dysarthria (speech impairment) or dysphasia (language impairment) so if present these will be assessed too.

Once there is a full picture of the individual’s communication the next priority is to explain any deficits to family or those closest to the client (with permission from the individual first). The importance of this is to maintain the individual’s relationships and enable their visitors to understand why the person may present as “different” post injury.

The MDT will also be given feedback and a care plan will be created for all colleagues to guide them in how best to communicate with the person to maximise and support their communication skills throughout their day.”

The Importance of Cognitive Communication in Vocational Rehab


Communication builds trust


Often the impact of a brain injury can go unnoticed by those who are not aware of what has happened because the injury is hidden, but that doesn’t mean its impact is any less. Brain injury can affect many aspects of daily life, and SLTs work with each individual to understand the extent of the impact and how best to manage it.

Candida says:

“This group of individuals are often referred to by Therapists as ‘the walking wounded’. The individual may be able to function physically but there’s a hidden area of cognitive impairment that can hinder functioning across a wide spectrum of tasks.

This is made harder when individuals return to their day-to-day life as others are unlikely to see any physical impairments and therefore have little or no understanding of the difficulties this individual faces. One simple example would be an individual who has poor listening skills can be interpreted as rude, annoying or unlikeable. Something as simple as this can damage relationships; both personal and professional.

And that, like any hidden disability or non-visible area of injury, comes with its own bespoke needs. The impact on daily life can be far reaching, and it is only when you have worked with an individual over an extended period that you can start to understand the full extent of their cognitive impairments and the impact that it will have on their attempts to return to work.

It is difficult for a person to accept that they have impairments in areas such as communication that everyone takes for granted. Initially there will be lack of insight and then denial is common. So developing a relationship of trust, where the individual feels safe and relaxed working with you, and is willing to listen and explore different interventions, is very important.”

The Importance of Cognitive Communication in Vocational Rehab


Developing acceptance and insight


An open, trusting relationship also allows the individual to develop insight into how their conditions might present externally – often they are not aware of how their impairments shape their behaviour or communication. In particular, engaging in social interactions and developing relationships, which are a fundamental aspect of workplace culture, can be overtly impacted.

Part of Candida’s work with the MDT at Badby Park is to help individuals understand what has happened to them and how it is now impacting their functioning and interactions with others. It’s a gradual process that must always prioritise the emotional wellbeing of the person being supported. The Psychology team are integral to this.

Candida says:

“Developing insight into how a brain injury impacts social function can be quite unsettling for the individual. We need to work gradually with them to help them accept and address what is happening.

For example I was recently working with an individual who had a traumatic brain injury, and was unable to take turns interacting with others in a conversation. If permitted he would talk continuously for 15 mins and not be aware that the other person had not spoken.”


The Importance of Cognitive Communication in Vocational Rehab


“When we discussed this issue he was not conscious that it was happening. So we began a gentle process of supporting him to understand what was taking place and then working towards becoming more self-aware during conversations. This was a collaborative effort with the psychologist, occupational therapist and physiotherapist so that at every treatment session his communication impairment was addressed.

We talked through the behaviour, explained it in gradual steps and we actually recorded a conversation, with his permission, and played it back so that he could watch himself and look at the experience more objectively.

During this whole process, it is important to offer consistent reassurance, and to be aware of the emotional needs of the individual you are supporting. You must ensure that you are working at an appropriate level for their rehab and not put undue stress on them.

When the individual has developed insight into what is happening and is accepting of that, we can then teach methods that can support them to hold successful conversations with others, and to self-monitor better.”

The Importance of Cognitive Communication in Vocational Rehab


Working with the employer


Vocational rehabilitation programmes are different for each individual. All jobs require unique skill sets and aptitudes, include different responsibilities and tasks, and each workplace has their own special workplace culture, with preferred communication methods and behaviours.

So in order to give the individual participating in rehab the best chance of returning to and remaining in work, the team at Badby Park liaise with employers and their HR teams to ensure all scenarios are planned for.

According to Candida, communication between employer and employee is vital to ensure a smooth return to the workplace.

Candida says:

“Our rehab programmes are tailored to the person and the requirements of their job, but unless we speak directly with the employer we don’t know what they are. One of the team typically phone each person’s employer and ascertain what skills they need to do their job and also find out more information about the workplace environment and culture.

I find it is a very beneficial process for the employer too, they get to ask questions to find out more about the employee’s situation and how they can best support them from their side. Often employers are anxious about how to support their employee and have concerns about how to meet their needs. Employers have been consistently grateful for the contact and the explanations of the employee’s strengths and areas of need.”

The Importance of Cognitive Communication in Vocational Rehab


Offering practical support to return to work


As well as communication support, the MDT at Badby Park offer a wide variety of practical tools and therapeutic interventions to further independence.

Candida says:

“In terms of the scope of support we offer, we look at all the different tasks they would be required to complete if they were to return to work. For example, we rehearse practical tasks where we can assess their skill levels, like practising emails or working through spreadsheets.

All the while we make sure they are happy with everything that we are discussing, we’re conscious that the trust remains, and that they are comfortable communicating with us in this way. Often the more we rehearse, the more open they become and we can move forwards towards their rehab goals.

I have recently worked with a patient who was considering a return to her previous workplace. She had suffered a brain aneurism and the cognitive impact had been significant. One particular impairment that impacted her return to work was marked by word finding problems and a tendency to reverse pronouns, especially when she was under pressure.

For example, she had to attend a number of medical appointments and over the course of those she was asked multiple questions, covering various elements of her medical history. She reported that she wasn’t given much time to answer the questions and feeling pressured, the experience became quite difficult as it increased the cognitive load. The result of this was that she became unable to speak at all.

The patient was very conscious that upon returning to work she may be faced with similar experiences so we looked at ways to help her manage communication. We made cards that notified others of her situation so that when she was having difficulty expressing herself, she could hold them up and the other person was able to understand what was happening.

This helped the individual feel more relaxed in pressured situations and also gave her the confidence that she may be able to return to work.”

The Importance of Cognitive Communication in Vocational Rehab


As well as communication and work place practical skills, the MDT at Badby Park also support individuals with tasks in daily life that may have an impact upon returning to work, such as taking public transport and planning routes.

As Candida explains, a significant element of vocational rehab is to consider wider areas of daily life that could impact a person’s return to work.

Candida says:

“This particular individual was required to make a train journey to and from work so the Occupational Therapist accompanied her on the journey to assess whether making the journey independently was viable and what additional support was needed. As well as assessment and treatment across the board of activities needed to function independently, such as community visits to ensure road safety, ability to plan meals and buy food and home visits.  The Psychology team also provided support for memory and other cognitive strategies. It’s a collaborative approach.

If an individual does not choose to return to work. The whole team will provide assessment and treatment for whatever range of impairments the individual has. The treatment will be tailored for each individual according to what their goals and priorities are and the environment they will be discharged to.

In a similar way to returning to work, families and carers will be educated about each person and the support they will need. Prior to COVID, and where possible within COVID restrictions, we always provide opportunities to meet face-to-face, if not this is done on the phone. This will happen throughout the individual’s stay.

Rehabilitation cannot happen in isolation. The home environment is no different from the work environment. For a successful discharge and to provide as full a life as possible, our team need full information and skills and strategies to support each individual.”


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