It can be difficult to know what to do with clients who have right hemisphere brain damage (RHD): how to assess them, what to treat, how to treat, etc. It’s not surprising, because (a) there is less collective knowledge within the field and (b) there are limited opportunities to acquire the knowledge that does exist. As for the amount of knowledge, aphasia was “discovered” and named the 1860s. In contrast, the impact of RHD specifically on communication and language has only been recognized since the 1960s, so we are behind by a century! As for the opportunities to acquire the knowledge, the problem starts in graduate school. While a majority of graduate programs have stand-alone courses on aphasia, RHD is typically covered as one of several topics/etiologies in a cognitive disorders course. I would venture that a majority of graduate programs have an expert in aphasia on faculty, while only a minority of programs have anyone interested in RHD. It is equally difficult to find continuing education about RHD after graduate school. In the past three years at the ASHA Convention there have been only between 6 to 9 presentations on RHD each year. In contrast, the number of presentations about aphasia has ranged from 177 to 269.
There is not enough room here to provide tips and advice for how to tackle all of the disorders associated with RHD, so I’ll just mention the one that I think is the most critical: talk to families. While SLPs likely talk to families of all of their patients/clients, it is especially important when working with someone with RHD. The purpose is two-fold: first to get information about how the patient has changed following the stroke, and second to provide information and resources to the families.
Getting information from the families about how (and if) the patient is different is essential. When it comes to pragmatics, there is no clear cut-off between being “normal” and being “a bit odd” as a result of brain damage. Add to that cultural differences in how people communicate (both verbally and non-verbally), and it may be nearly impossible in some cases to determine if someone has a pragmatic deficit or not. For example, just the other day I was assessing a man with RHD for a research project. In the small talk at the beginning of the session, I found out that he was originally from Wisconsin, so I asked him what brought him to Texas. He replied, “a 1972 Chevy truck”. If the exchange ended there, and I had no information about his personality from his family, I could have thought, “Aha! Typical RHD, he’s overly literal in his interpretations” and decide that I might want to target pragmatics in therapy. But the exchange did not end, and he followed up that response with an appropriate explanation of a change in jobs. Additional information from his family regarding whether or not that kind of response was a typical pre-stroke behavior would allow me to make a more appropriate decision about therapy goals.
The second part of talking with families is to provide education. They need education about the variety of problems that may occur and who they can contact for help. While families may get information about unilateral neglect from neurologists, SLPs are the ones who can educate families about pragmatics and communication. SLPs are the ones who can explain how RHD can affect theory of mind, cause a person to no longer accurately interpret another person’s intended meaning, understand their point of view, or become more egocentric and self-focused. SLPs are the ones who can explain that changes in theory of mind and emotional processing may result in changes in empathy. SLPs are the ones who can explain that appreciation and use of humor might change after RHD. SLPs are the ones who can explain that deficits in problem-solving and reasoning can affect communication, such that a person may not be able to notice or fix a communication breakdown, or figure out that the breakdown was mostly their fault. SLPs are the ones who can explain how prosody, facial expression, and body language are critical to communication, and that all can be affected after RHD. And most importantly, SLPs are the ones who can explain that they can treat these deficits.
Educating families about RHD is especially important because some deficits may not become apparent until the patient goes home. For example, an egocentric perspective and limited empathy for others might be considered normal for anyone in the hospital after a life-changing event such as a stroke, so it may not be identified as a deficit until the patient goes home and his spouse observes a lack of empathy in everyday situations. A patient also may seem to have a blunted sense of humor that in acute care may not seem unusual given the situation, but it may become really obvious when she goes home and her husband can’t joke with her like he used to, or conversations just aren’t “normal”.
When these kinds of changes become apparent, most families won’t think, “I should ask for a referral to a speech therapist”, because the person’s speech generally is fine. SLPs need to provide that link for them when they have the chance, so that when the deficits become apparent, the families will know where to go for help.
Despite the limited number of evidence-based treatments, I believe that SLPs can provide effective treatments to adults with RHD. Our knowledge about pragmatics and cognition can go a long way in addressing the deficits that limit participation in activities important to our clients. We just might increase interest in RHD, which would lead to more research, more experts in the field and more opportunities to learn about the problems, which in turn would spark more interest, lead to more research, and on and on.