Ashwini 00:00:23 - 00:00:38
We're delighted to be joined today by Catherine Davies from SLT for Life. Catherine is a speech and language therapist and I'm going to hand over to you really, to explain to our audience what it is you do and what speech and language therapy actually is.
Catherine 00:00:38 - 00:01:22
Yeah, thank you, Ashwini. I'm really pleased as well that you've invited me today.
So a speech and language therapist works with a variety of communication and swallowing difficulties with clients following a brain injury. Regarding the swallowing difficulties that can be broken down into different levels of difficulty, and there's all sorts of different consistencies of diet and fluid that somebody may be recommended to have, depending on the nature of the delay and the difficulties with the different stages of swallowing, and this is difficulties again have occurred following damage to certain areas of the brain and the cranial nerves involved in eating and drinking.
Sometimes people are oral fed via a peg and they may have some taste.
Ashwini 00:01:22 - 00:01:24
Can we just explain what a peg is for those who don't know?
Catherine 00:01:24 - 00:01:54
Yeah, so a peg is a tube that goes into the stomach and provides all the nutrition and hydration. And sometimes if the swallowing difficulties are too severe, somebody will be consistently peg fed.
However, sometimes people are combination fed and introduction of oral trials. There's a lot of therapy techniques, strategies and manoeuvres to support encouraging the muscles to regain strength and a speech and language therapist would be the main person involved within the rehab of the swallow.
Ashwini 00:01:54 - 00:02:07
And why is swallowing important? I know it's something that we all do instinctively without even thinking about it. But what is it about swallowing, in particular? What are the risks involved if somebody has an impairment with their swallow?
Catherine 00:02:07 - 00:02:52
Yeah, there's significant risk because when... none of us actually actively think about swallowing. It's just something automatic every day. We're all swallowing our saliva hundreds of times a day. If there's difficulty with swallowing, as soon as the swallow is triggered, nobody can control the speed or where the food or fluid goes. So if the muscles aren't ready to close the airway, then there's a significant risk of food or fluid entering the airway. The airway then may become, you get infections, because it's a foreign body into the lungs and that can lead to pneumonia, which is obviously life threatening.
So it's a really... An area that there's a lot of risk assessments around and a lot of caution and a speech and language therapist is heavily involved and asked to review swallow and the mechanisms involved.
Brooke 00:02:52 - 00:02:59
Is that something that everybody with a brain injury suffers with? Because I don't think I had an issue with swallowing.
Catherine 00:02:59 - 00:03:28
Yeah, no, it's not. I think there can be sometimes issues following if somebody's intubated because you will struggle to swallow then, but post intubation - so the tracheostomy. Sometimes people don't have any difficulty or they may have a very slight assessment and progression to normal diet and fluid, but it's very minimal, so that area is often kind of forgotten, well not forgotten, but not a big picture of your rehab journey. So it really can vary depending on the difficulty.
Brooke 00:03:28 - 00:04:06
I think I remember when a speech and language therapist was going to get involved, I remember thinking that I didn't have any problems with speech and language. But then again, I think that reminds me of the fact that I didn't really know what my difficulties were and it was a lot of other people told me.
Somebody actually told me early on that I should have videoed myself and I really wish I had have done because I always thought I was fine, but my parents and my support worker told me that I used to speak really low, really quiet and I had no intonation in my voice. Is that common as well?
Catherine 00:04:06 - 00:04:38
Yeah, that's very common and relates to the communication difficulties. And I think again, there's the fine line between having insight and videoing and the right time for that. I think sometimes if videoing... Speech and language therapists use videoing and recording quite a lot, especially within the dysarthria, which is the area you've had work on, which I'll describe in a minute, to gain insight. But if it's done too soon, it can affect somebody's confidence. And I think that can then be a little bit detrimental to mood and confidence.
Brooke 00:04:29 – 00:04:33
Yeah, yeah, I was going to say confidence.
Catherine 00:04:38 - 00:04:48
So it is a fine line and the therapist, will use it, it is a good measure to look at where you were and where you are now, especially when it's subtle changes as you're progressing.
Brooke 00:04:48 - 00:05:04
My family and friends and stuff, people that I saw everyday, they wouldn't, and myself, I wouldn't really notice any difference because it was day on day, but if I didn't see somebody for like 6 weeks or something they would like always make a big remark about how much I’d improved.
Catherine 00:05:04 - 00:05:07
Yeah. And that's the thing I think, it's the subtle changes day-to-day that people don't see. You don't see yourself...
Brooke 00:05:07 - 00:05:15
Hmm yeah. Especially at that early stage when your recovery is quite rapid.
Catherine 00:05:15 - 00:05:31
And I think everybody's self-monitoring and awareness of themselves is different. You know, I think when we all hear our voice recordings, we think 'do I sound like that?’ So it's, we hear ourselves differently in our head as well, everybody does.
Brooke 00:05:31 - 00:05:39
There's also that element of denial as well. There's denial that you have anything wrong with you and you're trying to prove that you're fine, stuff like that.
Catherine 00:05:39 - 00:05:53
Yeah, yeah. And that's a massive area that I'll discuss around kind of cognitive communication difficulties and the overlap between speech and language therapy and OT, occupational therapy and psychology.
Brooke 00:05:53 - 00:06:17
I remember the first thing I’d had done was an assessment. I was told to name as many words as I could beginning with the letters F and S and C. And all I could think about was words beginning with F, S and C which weren’t particularly... which you shouldn't say in a professional place! And that was kind of like blocking my thought process. So I...
Catherine 00:06:17 - 00:06:19
Brooke 00:06:19 - 00:06:21
Actually ended up saying them just to get them out of my head.
Catherine 00:06:21 - 00:06:55
Yeah. And I think listening to you, it's really nice, you're almost explaining the things that speech therapists would say - words that are not always appropriate are the ones that are stored and accessed much easier. You know, I've known people with very, very severe aphasia, which again I'll explain in a minute ,and they've had no speech, not able to form words, find words, but swear words have come out.
I think it's because we're very conscious not to use them in day-to-day life. They are almost stored separately, so they're easily accessed.
Ashwini 0:06:55 - 00:06:59
I wonder if that also plays into things like lack of inhibition following a brain injury.
Catherine 00:06:59 - 00:07:05
Yeah, because kind of the cognition, the behaviour, again plays a large part in the communication skills.
Brooke 00:07:05 - 00:07:49
I remember being surprised at how much speech and language therapy has to do with the brain and the process of thinking. So I was thinking at first that my speech was fine. You know, I can speak, I can say words. I didn't realise how bad they sounded, that's where the video would come in. But I just remember I these exercises to do and it was like we had to name as many things... it started with nouns, adjectives and so as many nouns you could do connected to a bathroom. So say, toothpaste, bath, shower, whatever - they were the easy ones. And then it was like adjectives, which was like brushing, scrubbing, cleaning. But I think the hardest one was like emotions. Yeah, yeah.
Catherine 00:07:49 - 00:08:01
Yeah, because they’re more abstract, emotions. They’re not very, kind of, the words that we use less frequently. And not related to objects, are they? So the emotions are hard.
Brooke 00:08:01 - 00:08:27
And I remember thinking this is really, really hard and I that's when I first got into it because I could feel... being able to access words more clearly and it was making me think. And try and think like how on Earth do I think of an emotion connected with a bathroom and stuff like that. And I was really, really thinking hard. And I remember after the exercises I was totally exhausted and thinking it was, you know, some good had been done there, whatever ti was.
Catherine 00:08:27 - 00:09:52
Yeah and that and that's the cognitive fatigue, so the fatigue of the brain, which I'm sure the occupational therapist and psychologist has covered as well. And this is again that multidisciplinary working. So I think what you've done there is really nicely shown the differences in the role of speech therapists. So you've talked there about the dysarthria side, as in what your speech sounds like to people. So if I just go into a bit of detail around dysarthria.
So dysarthria is a difficultly or a weakness with the strength and speed of oral muscles. So when we talk our tongue and lips are moving several times just for one word, because every single sound we say the mouth needs to do something differently. So following a brain injury, if the cranial nerves have been affected that affect the strength and speed of the oral muscles. If things slow down, in our head we want to say things as quickly, but the muscles can't quite get there. So it either... some people naturally slow down, which you may have done or sometimes sounds are missed because people are trying to speak as quickly, so then it will massively change the intelligibility of speech.
So for example, if I was going to say stairs, but I miss out the S or the T, it would be tairs or sairs, which is completely different words.
Brooke 00:09:52- 00:10:40
Do you know what I can really strangely relate to that at the moment because I've got a girlfriend who's Spanish speaking and I'm learning Spanish and she's helping me with my Spanish homework and rather than just getting her to do it for me (which is quite tempting!), she's really good. Like we we're doing it for two and a half hours last night. I'm saying something, I'm saying a word like abblah and I think I'm saying it fine and she's like ‘no, no’. And she's making me do it again. She's making me go through the vowels, and I'm going ‘ah’ and she's going ‘ah’ and it just sounds like absolute craziness if you overheard our conversation last night! ‘Ooo, ooo’ and she’s like ‘no, no’.
Catherine 00:10:40 - 00:11:29
So yeah, that's another level, isn't it? And again that's a great link because you know I wouldn't be able to teach somebody Spanish so...
But in my role, again, if the mouth has changed shape, can't form the sounds, vowels can be completely different. And if we look at accents, people's accents, they're all, if you break them down, it's the vowels that often change the accent of speech and sometimes people can almost have a different accent as well. So within dysarthria, as you're saying, there's the forming of all the individual sounds. There's the breath support as well. So sometimes breath supports is reduced so somebody can’t say as much on one breath, they may be breathing kind of from upper chest and we teach diaphragmatic breathing.
Brooke 00:11:29 - 00:11:30
Catherine 00:11:30 - 00:12:02
And there's looking at pacing, so there's a lot involved and I would say with the dysarthria, that's where insight is really needed. So I've worked with people and if they've got really, really significant and severe cognitive, so thinking difficulties, really, really poor attention. It's going to be incredibly difficult to be as successful with the dysarthria because you do have to have that awareness to be able to carry over. It's always a carryover of skills into conversation that's difficult.
Brooke 00:12:02 - 00:12:49
I had that big time, lack of concentration. At first, everybody's like, really sympathetic with you and everybody’s, you know, really enthusiastic. And I just used to be as friendly as possible and really enthusiastic and I was used to people saying, ohh yeah, you know you're doing great, you're doing fantastic and you do, lap that up! And I remember this endocrinology nurse, I remember her saying to me ‘your concentration is not very good is it’. And if I saw like a CCTV camera or something, you know I would’ve probably realise that, yeah, I was changing subjects and not staying on the same subject or anything. Sometime, like, it’s tough love, isn’t. I remember that was really, really useful for me because yeah, not everything's sunshine.
Ashwhini 00:12:49 - 00:12:53
Yeah and obviously people want to kind of highlight the positives inyour recoveries, but...
Brooke 00:12:53 - 00:12:54
Ashwini 00:12:54 - 00:12:58
Sometimes you also need the reality check that there's still some way to go.
Catherine 00:12:58 - 00:13:12
And again, there's a fine balance between that because I've also worked with some clients that don't lap up the praise, you know, and that's quite difficult for therapists to deal with, because we really naturally praise people because we are really pleased with progress that people are doing.
Brooke 00:13:12 - 00:13:16
Because you’ve done well, you've done all your work.
Catherine 00:13:16 - 00:13:35
Well, it's yourselves that are doing the work, we're just guiding.
And this one particular client really didn't like praise and would then criticise more, you know that they still had difficulties. So that was kind of liaising with psychology and what phrases to use to support that person without, you know, over praising.
Ashwini 00:13:35 - 00:13:51
So coming back to dysarthria, you've talked about what it is and the difficulties that can follow. So as a speech and language therapist, what kind of exercises do you do, what other sort of rehabilitative methods do you employ to improve that?
Catherine 00:13:51 - 00:14:37
Yeah, so we would do an in-depth assessment where we would look at certain movements for the tongue, lips, the palette, breath support. And we also look at the voice box - as in, you know, can somebody change pitch, can they change volume? And then we analyse where the deficits are and have very specific exercises we would do for the areas. So for example, if somebody’s struggling to lift the tongue up, there's a lot of sounds like ‘t’, ‘l’, from the top of the tongue. So we will be doing repetitive exercises.
So with dysarthria, it is very repetitive the therapy, it's quite intense, it's recommended regularly. So as you said, a support worker, somebody being able to support that on a daily basis.
Brooke 00:14:37 - 00:14:47
Yeah because the speech and language therapist I had, Lucy, she like set homework, if you like, to do. And then I used to do it with support worker.
Catherine 00:14:47 - 00:15:32
Yeah and it's quite a set hierarchy we would work through within the difficulty. So we would look at strengthening the muscles in isolation. So that's just lifting the tongue up and down, strengthening lip seal with certain specific exercise.
Then we would move to a sound, maybe a sound with a vowel, then it would be single words. This is probably everything you went through, reading paragraphs and the real difficulty is that carry over into conversation because as we're all talking, we're just subconsciously thinking of words and how we're formulating the message we want to get across rather than, how am I breathing? What's my tongue and lips doing? So it's kind of almost got to become automatic. So that's why it's such repetitive practice.
Brooke 00:15:32 - 00:16:30
You’ve just reminded me of something there. Like, I remember thinking like when I started speaking to people I remember like in your normal life you have like an auto cue of what you're going to say next. It was as if somebody used to just rub it out all the time. So I was, like, dealing with that as well as dealing with trying to sound normal and stuff. And I just remember having this, must have been like a lack of confidence, or whatever, but I remember thinking I'm just really boring. People must want to get away from me and I'll do this person a favour and get away from them because what would you want to speak to me for if I've got nothing to say? I don't do anything interesting, especially when I had... I suppose it happened to me at the time when my friends were like progressing in their careers and moving down to London, I had ones you know, applying for different jobs, my friend became a teacher. Just all these exciting things happening in people’s lives. And I was learning to say ‘ooo, ooo’ and then you know, I just thought why would anybody want to speak to me.
Catherine 00:16:30 - 00:16:32
Yes, because your life had dramatically changed, hadn’t it.
Brooke 00:16:32 - 00:16:32
Yeah, yeah. Massively slowed down, yeah.
Catherine 00:16:32 - 00:16:55
You were on a path the same as your friends, and then everything, as you say. But you were obviously very motivated to engage. But you know, I think all of us professionals who work with people with brain injury, we advise and we have the knowledge to support, but we will never fully understand what somebody's been through because you know, that's a unique experience, isn't it?
Brooke 00:16:55 - 00:17:21
I had this like amazing story to tell, but after that was told I hadn't done anything or what I thought was not anything of note. And your life was just so different from everybody else’s. Everybody else had got, like, you know, people getting like, you know, applying for jobs or for their first mortgage, people have kids and like, I was doing things like speech and language therapy, just making different noises and stuff. And I just thought why would anyone be interested in me from that.
Catherine 00:17:21 - 00:17:48
Yeah, and you engaged. Some people, you know, may not have engaged, you know, with, you know. When I've worked in the NHS in more of acute phase, it can sometimes be really difficult getting people to engage because your life has completely changed, you know, what are these things I'm now being asked to do when last week I was doing such things. So that's a real credit to yourself that, you know, that you were motivated. You engaged really well and that's, you know, how you've then significantly improved.
Brooke 00:17:48 - 00:18:07
Yeah, I still do now. I still have massive confidence knocks. I just feel like I'm so far behind people, you know everybody else, and I just think you're paranoid that people think because you know, because I only work part time and stuff. I just think people must have such a low opinion of me. When I know for a fact that they don't. But it's difficult – it’s one thing knowing and one thing believing.
Ashwini 00:18:07 - 00:18:12
Yeah, I think this is a bit like the episode we had where we were about not comparing yourself to others.
Brooke 00:18:12 - 00:18:15
Yeah. Yeah, absolutely. Yeah. And I still do that, and I know you shouldn't.
Catherine 00:18:15 - 00:18:43
And you shouldn’t really, yeah. And I think, you know, it's probably easy for people to say that, but it's believing that. And I'm sure if that's something that neuropsychology are able to support because this is something that I'm sure we do hear all the time, and can only imagine that, you know. And actually, you've got a lot more resilience than people who haven't had to go through a journey like that. And it's the social norms, isn't it? If you're saying I only work part, that's because you in your head, you think your social norm is to work full time.
Ashwini 00:18:43 - 00:18:51
But then you know, who else goes out doing public speaking and running, you know, crazy marathons and whatever, learning Spanish…
Brooke 00:18:51 - 00:19:00
Well, the belly would tell different! My priorities have changed, but I will get back tomorrow to running hopefully!
Catherne 00:19:00 - 00:19:16
And I think with, you know, like with you saying you're… you have to think about things, that's a completely valid point. You know, as I said, even with the dysarthria, it's with all areas of communication.
Following a brain injury, everything has to be thought about, which must be incredibly tiring.
Brooke 00:19:16 - 00:19:30
And your brain is, it's got to do the most work that it's ever had to do but it's the least capable of doing it. So everything just takes so much longer than it would and by the time you've thought of it, you’ve forgotten what you're talking about anyway!
Catherine 00:19:30 - 00:19:32
Yeah, that’s a great phrase that, isn't it?
Brooke 00:19:32 - 00:19:36
You were just like… so you just kind of back out of conversations and you realise you’re kind of stuttering at people and then you just…
Catherine 00:19:36 - 00:19:39
Brooke 00:19:39 - 00:20:09
And then you think this guy must… it must be just a really awkward situation, so I'll just let him go and then you run and hide. It’s something I wrote about… I remember somebody I knew, I can’t even remember who it was, I just remember the process of this happening and seeing somebody walking down towards me in the, down the Main Street. And I remember jumping into a shop just to hide from them just to excuse, wasn't particularly to excuse myself. It was, to excuse them with the awkwardness.
Catherine 00:20:09 - 00:20:17
So again, I suppose that's, that's about you perceiving how other people might think, you know, what they may think of you rather than what actually happened.
Brooke 00:20:17 - 00:20:39
I remember at the time I had this stammer - I've never ever had a stammer before in my life and it was just like, it was horrible. It was just like you tried speaking and it just doesn't come out and it's just, yeah. I've got so much more empathy for anybody with any… It just opens your eyes, doesn’t and it makes you, I guess, a kinder person, you do understand that be kind thing.
Catherine 00:20:39 - 00:22:38
And I think, you know, what you're describing there is kind of all the areas of communication. So the areas that speech and language therapists work with is initially we look at somebody's level of attention. So can somebody focus, can they maintain attention, so can they… because before, somebody needs to attend and have a certain level of attention to be able to listen to information and be able to process it.
And then we look at how much somebody's understanding. So is somebody now only understanding single words. Are they only understanding nouns and we would look at this via formal assessments. And then we kind of work on a cognitive neuropsychology model, neural linguistic model where we look at kind of input and output. So we would then look the same at written language. So what can somebody read? Can they read as they did before? Do they recognise the letters? Can they read single words? Can they read… and we do a lot of, you know, word picture matching to identify that.
Again, if somebody couldn't read prior to their injury, that's completely different. What we look at is how somebody was before and compare that.
And then we look at the word store. So which is we kind of have a word store in our head. So if I think of the word tree. So I've said the word tree, but we're all imagining what a tree is. We know what it does. Where it is, where the tree is, what it looks like, and they're all the… That's the semantic information, and that's the area where you were being asked to describe things in a bathroom. So we'll think of the bathroom. We imagine what a bathroom is, what’s in there, then, a more abstract area that is emotions linked to that, as you were saying.
So we've kind of don't looked at the input - what somebody understands both by listening and reading, what's happening in the word structure. So are they able to access words, you know, and that's where we do the categories, category naming, as in things in the bathroom, fruits, vegetables, you know, we progressively get harder.
Brooke 00:22:38 - 00:22:43
Yeah, I could see how it was like branching out and out. You could sort of see it like making new pathways my brain almost.
Catherine 00:22:43 - 00:22:52
Yes. Yeah, exactly. And I often say it's a little bit like when you went from A to B via a motorway previously, it’s now going on the A roads. So we're building…
Brooke 00:22:52 - 00:22:58
… new pathways, but it takes longer, obviously on the A roads doesn't it…
Catherine 00:22:58 - 00:25:07
Yeah. And it's just accessing and its strategies as well. So I'm sure not only did the therapy work on category naming because by doing that you are creating the pathways, but there's probably strategies involved as well, as in, you know, you were probably recommended to describe a word if you struggled to think of it, to kind of draw it. You know, there's other ways and I often, to kind of make sessions a little bit more fun as well, we'll do games as in, what am I? who am I? Where somebody will explain something and you guess who that person is. Or ask for yes or no questions - Am I an actor, am I female? And it's, you know, it's getting the brain working. You're still generating words and you're thinking of questions, and it can be quite fun.
And then from the word finding again there can be difficulties with the output. Getting the words out, forming the words. So there's the word finding which is being able to, ‘oo, tip of the tongue’, I've got the word there, I can't find it, I know it, but I just can’t get it out.
And then there’s the forming of the words, which is, you know, are they clear, is there dysarthria there?
There's also something called a dyspraxia, which is more of an incoordination of muscles. So we identify that more as a groping around for sounds. So a dysarthria is often more of a slurring, and so the word’s there, it's similar, it's sounding like it, you know, tree would sound similar to tree, it might just be, yeah, tea or slurred. With dyspraxia, it might be more, ‘click, click, clay, click…’ and they’re groping around. So that's actually trying to coordinate what the sounds are within a word.
And we also look at writing as well, how could somebody, you know, could somebody spell. So the physical part of writing is more the occupational therapists and the physiotherapist. But the being able to know that a B is the shape of a B, or, you know, the word cup is C-U-P, and they can write. So again, we can have a prescriptive therapy program looking at spelling.
Brooke 00:25:07 - 00:25:25
Something that's just triggered my memory then. I remember I had to, I can't remember what it was, but I think I was getting a new bank account or something, and I was asked to sign my name and I was like, I can't remember my signature. I’d forgotten my signature and I had to make a new one up… I don’t know if that’s any way linked to speech and language therapy!
Catherine 00:25:25 - 00:25:38
Yeah, yeah, absolutely. And I think you know, often being able to write your name, signature, address can come to you quicker than others. So it may have been that other areas of spelling were difficult for you initially as well.
Brooke 00:25:38 - 00:25:43
It's just so many… I think the thing is there's so many things going on at once, isn’t there?
Catherine 00:25:43 - 00:27:17
There is and I think you're giving really nice examples that are, you know, enabling me to describe the role and I think you know, that's the area… with speech and language therapy, you know, I still now sometimes have people say, I'm not sure why I've been referred to a speech therapist and I think, you know, sometimes it's very obvious and I think an area I very much specialise it... I work with people from kind of just post coma stage so you know, very severe up to a very high level, which is probably some of the areas you were working on, which is your very subtle higher level language difficulties. So, interpreting and understanding humour. So this is more of your cognitive communication difficulties. Social skills is a big one that I work on with clients. So again, how you perceive others and what you think they think about you, your emotions is a massive one. So not just naming an emotion, but actually picking up and identifying emotions in others, and I find there's often quite noticeable changes in social skills post brain injury and these are not always identified initially. So sometimes a client may be referred to me further down the line, you know, after you've had occupational therapy, physiotherapy, psychology and sometimes it may be colleagues that have worked with me previously that think oh hasn’t Catherine worked with clients with this before and I use a lot of questionnaires which sometimes highlight to people. So it'll be a social skill questionnaire. You know, do I give the same eye contact? Yes or no. You know, do I recognise…
Brooke 00:27:17 - 00:27:19
Eye contact was a big thing for me.
Catherine 00:27:19 - 00:27:33
Do I have struggle to initiate conversation? Do I struggle to stick to the point, the topic, as you were saying before. So that can combine attention and also a social communication skill.
Brooke 00:27:33 - 00:27:36
Eye contact without looking creepy!
Catherine 00:27:36 - 00:27:37
Brooke 00:27:37 - 00:28:29
You can overdo eye contact, can’t you! Yeah, where am I looking??
But on the subject of humour, I was allowed, well I nagged and nagged for a mobile phone. It was 2007 so they weren’t really as big as they are now. But I had this mobile phone and my mate Graham sent me a joke and I think the joke was something to the sound of ‘somebody just offered me some venison for £10 kilo. Do you think that's dear?’ And obviously that's the joke, isn’t it!
But I had a discussion going with everybody in my ward, there was like 6 guys in my ward, whether this price was expensive for the venison. So we decided it was good, it was OK. So I sent ‘No, that's OK’ back, mate, and that he must have been thinking, what? It was a joke!
Catherine 00:28:29 - 00:29:10
And that's a great example of literal interpretation. That's what we see. You know, I'll see it all the time. And so it's again and you might think, well, how do you therapise that? How do you work with that? But it's just by kind of exposure, explaining situations, teaching abstract language, reforming information, you know. Because I think if somebody had deficits previously, so if you know, if somebody before the brain injury, you know had autism or was on the spectrum and didn't understand humour and had significantly impaired social skills, then that would be quite difficult to work with because again, we're looking at what were their skills like previous to the brain injury? How will we restore the skills?
Brooke 00:29:10 - 00:29:14
Yeah, because you don't know the person previously to the brain injury.
Catherine 00:29:14 - 00:29:37
But we get a lot of information, so when I do questionnaires, I will also do questionnaires with family members because somebody might put no change, no change, no change to everything and the family are going, you know, lots of change, lots of change. So then that's kind of trying to subtly increase the insight and that's kind of going back to the beginning of the conversation, wasn't it as in what's you know, what’s that fine line of insight as in, you know, should we be… How much should we let somebody know initially without affecting their mood?