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One Floor Up

Mary KennedyMary Kennedy is taking research on traumatic brain injury to the next level by studying how we think about how we think.
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by Danny Lachance
Mary Kennedy
Most people know the unwritten rule. When you sit down next to a stranger on a bus, you might say hello and, if you are feeling particularly bold, make light conversation—an inncous comment or two about the weather or the recent performance of a local sports team.

But for someone recovering from a traumatic brain injury, or TBI, interactions with strangers can be different. “People with TBI might start with the light chit-chat and then suddenly find themselves telling a stranger about their injury and about the personal problems they’re having," says associate professor Mary Kennedy.

Whereas a normally functioning adult would size up the situation on the spot and say, “Gee, this isn’t appropriate," Kennedy says, a person with a TBI will sometimes self disclose past the point of her discussion partner’s comfort.

Or the opposite can happen. Following a TBI, those who used to recount their days to loved ones in intricate detail over dinner start giving one-word answers to questions. Just as details, elaboration, and extended reflections—the stuff of intimacy—can inappropriately appear in some injured people’s conversations with strangers, for others they can evaporate from interactions with loved ones.

The importance of self-regulation

While they are quite different, both problems reveal an impairment in a person’s ability to self-regulate. When we speak, learn, study, and interact, Kennedy says, we typically operate at two levels. At one level, our brains are attending to the obvious: selecting words and forming sentences, recognizing a pattern, storing a fact in memory, deciding what we want to say.

But at another level that has only recently gained much attention from those who study brain injuries, our brains are engaged in the act of self-regulating. We’re not just selecting words; we’re thinking about whether the words are the most accurate and whether they’ve been understood by our listener. We’re not just storing a fact in memory; we’re thinking about how good our memory is and what strategies we need to use to make sure the memory sticks. We’re not just deciding what we want to say; we’re thinking about whether what we’re saying is appropriate for the social context.

To emphasize the element of self-awareness involved, researchers refer to these as “meta" processes. So, for instance, we each have a memory that stores and retrieves our experiences. But we each also have a metamemory, an awareness of the act of storing and retrieving experiences.

These “meta" abilities are attributed to activity in the frontal lobes, the part of the brain most typically injured in a TBI. The consequences of injury to this self-regulating part of the brain are serious. If you don’t remember how you remember, you’re likely to keep forgetting; likewise, if you don’t think about how you’re speaking, you’re likely to remain incomprehensible, Kennedy says. It’s like driving a car without a dashboard. Without a speedometer or warning lights, you’re likely to go too fast or too slow or to drive when smoke is coming out of your engine.

Jogging your metamemory

By zeroing in on our meta-abilities, Kennedy has developed strategies that clinicians can use with the injured to help get them back on track.

Peer feedback can be invaluable, she says. “Group therapy is really helpful for people with TBI because they get feedback from their peers about how they did in a particular situation, and the feedback is sometimes more effective when they hear it from someone who isn’t their therapist, someone they see in a different role," she explains. In therapy sessions, then, peers take over the role once played by metamemory or metalanguage, helping clients with TBI to evaluate their own faculties on a moment-by-moment basis.

“Errorless environments" are also beneficial, Kennedy says. For people struggling to monitor the clarity of their speech, coaching that is immediate is likely to improve self-awareness. “Rather than having clients do a trial-and-error approach," in which the clients might stumble while reading an entire passage aloud before getting feedback from the clinician, “we set up a situation in which they can be error-free or nearly error-free by giving them prompts, cues, written support, whatever it takes to make sure that they’re completing the task error-free," she says.

Kennedy points to a client who had been taught by numerous therapists in the past how to speak loudly and slowly. Both her speech and her short-term memory were severely impaired. She was aware of her speech and memory problems but did not know when or how to use compensatory strategies for either problem. Her problem wasn’t with her ability to speak loudly and slowly, but with her meta-ability, her ability to keep in mind the imperatives to speak slowly and loudly and to use these strategies at the right times.

“She was reading sentences." Kenndy says. “We wrote ‘Talk slower and louder’ on a card that we placed in front of her. And then, as she indeed talked louder and slower, as she remained errorless, we removed the card and substituted more subtle forms of feedback."

An emotional future

Looking to the future, Kennedy hopes to find out more about the role that emotion plays in self-regulation and self-awareness. Indeed, the significant percentage of clients with TBI who suffer from anger management problems may indicate that brain injuries inhibit self-regulation by upsetting the equilibrium in the brain between reason and emotion.

An imbalance of emotion may work against self-regulation. “It’s almost like our mind gets hijacked by our emotion." Kennedy says. “There’s lots of evidence in the neuroscience literature that shows that when the emotional component of the frontal lobes is being activated, the cognitive part of the brain is not activated."

It's still an untested theory, but Kennedy is hoping to design studies that will help clinicians and researchers better understand just how emotion affects self-regulation in tasks like remembering and speaking and what clinicians can do to maximize its benefits and minimize its liabilities.

A former clinician herself, Kennedy knows how important effective research can be for clients. "When I was a clinician, I was struck by an absence of research findings that I could apply in therapy for individuals with brain injury. Now as a researcher, I understand the challenges of designing a sound study that also answers clinically relevant questions. It's when those two goals are met that we can really figure out what kinds of strategies and feedback will enhance the cognitive, memory, and communication abilities of those with brain injury."