To define communication clearly and completely seems to be impossible and, probably, a never-ending endeavor1. The existence of various conceptualizations should be recognized as inevitable and natural, though it should not be considered inconsequential. The adoption of distinctive points of view will guide clinicians towards different directions, emphasizing certain aspects of communication in detriment of others2. Whilst intervening in the field of communication, professionals may adopt one of the three main “theoretical categories” through which the process of human communication may be analyzed3:
-
communication as a unidirectional process from sender to receiver;
-
communication as a two-way process of meaning construction between communicators;
-
communication as an omnidirectional and diachronic meaning negotiation between partners.
Following the first perspective is the Linear Model of communication, according to which the sender creates and encodes a message, sending it through a channel to a receiver. This entity decodes the information, while competing with distractions that disrupt transmission, in this model identified as noise4. Noise within the process interferes with the success of communication, impacting the way messages are sent and received, and potentially creating failure5. Below, in Fig. 1, the Linear Model of Communication is graphically illustrated.
Theories understanding communication as a two-way process are framed within the Interactional Model of Communication, valuing how actors engage in conversations and converge while sharing information3. Here, communication is conceptualized as an ongoing flow in two directions – from sender to receiver and from receiver to sender. A communicator can perform the role of either sender or receiver in the interaction, but never simultaneously. Another element that is crucial to the interactional conceptualization is the feedback, the response to a message, which takes place after a message is received. One additional feature of this model is that each actor in communication presents with an individual field of experience, the person’s culture, experiences, and heredity, that influences the ability to communicate with others. Noise is present in the interactional context and may inhibit the effectiveness of communication5. Figure 2 represents the interactional understanding of the communicative exchange.
Lastly, the Transactional Model assumes the perspective of communication as an omnidirectional and diachronic process of meaning negotiation. Interaction between partners plays a fundamental role in this multidirectional process of meaning co-creation3; according to this lens, participants send and receive messages and feedback simultaneously and not in a unidirectional or back-and-forth modality4. In cooperation, all participants are responsible for the effectiveness of the interaction and, not only do the communicators influence each other, it is assumed that messages are interdependent and sequential, with the influence of one message over the others5. As partners communicate, their separate fields of experience tend to merge, in an active effort for mutual understanding and co-construction of shared meaning5. A broad notion of noise embraces the existence of different types of distorting variables in the exchange4 and misunderstandings are seen as more than the interference of noise in the chain of messages/feedbacks; individuals have to incorporate where the other in the relationship is coming from in order to build shared meaning and misunderstandings often rise when the partners have difficulty in doing so5. One last feature of the transactional archetype should be highlighted: transactional communication is considered diachronic. Instead of focusing on the transmission of messages/feedback, in a linear or circular way, the transactional paradigm brings the attention to growing interaction between communicators, developing over time3. The relevance of time is anchored in Dance’s Helical Model of Communication7, which explains that communicators improve their messages/feedback with several trials over time; whenever one communicates, the subject expands his abilities and the circles of communication grow and grow, similarly to the geometry of a helix, with increasingly wider circles. A visual representation of the Transactional Model of communication is presented in Fig. 3.
Karen Bunning’s definition of communication goes along with the Transactional Model of Communication. The author defines communication as a process between two or more persons, who are “working together”, coordinating their actions and reactions in response to each other and to the context8. Interestingly, Pearson, Nelson, Titsworth and Hosek9 embrace the idea of communication as a “project”, stating that “communication is considered a process because it is an activity, an exchange or a set of behaviours - not an immutable product” (p.8–9). Embedded in the Dialogical philosophy, Linell10 asserts that communication ought to be acknowledged in the form of communicative projects, described as “other-oriented and jointly accomplished communicative actions, typically but not necessarily carried out in external interpersonal interaction” (p. 178). These projects assume the form of two or more communicators interacting over sequences of acts, looking to establish a communicative fact that is mutually understood. Inherently, the three viewpoints emphasize the co-constructive nature of the communicative process, and the first8 argues that its success depends on both sides – the “speaker” and the “listener” – and highlights the importance of the context in communication; part of the meaning comes from within the context.
Having defined communication, in the context of interpersonal exchanges, it matters to investigate the other dimension of this process: communication disorders or miscommunication. Communication disorders are broadly defined by the American-Speech-Language-Hearing Association (ASHA) as impairments in “the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems”, ranging in severity from mild to profound. A communication disorder may be developmental or acquired and may result in a primary disability or be secondary to other disabling condition11. From a dialogical point of view, difficulties in communication may be understood in a broader perspective, regarded as miscommunication. In this case, difficulties in communication are collectively and reciprocally generated, frequently because of misinterpretations of the partners’ intentions and related to different fields of experience12. Pondering the adoption of a transactional understanding of interpersonal communication, the expression Complex Communication Needs (CCN) may bring a more comprehensive understanding of this phenomenon, meaning that some individuals may not demonstrate all the communication skills required to fulfill their needs in different contexts13. This may happen because they do not use speech to communicate functionally, as a result of some kind of disability, relying on alternative forms of communication, such as gestures or graphic symbols14. It may also be the case that some of these people may be unintelligible to unfamiliar partners and/or they may struggle understanding the way others communicate13.
Although CCN tend to be linked to an individuals’ developmental or acquired disability13, the skills, sensitivity, patience, and honesty of their partners may have an enormous impact in the success or failure of the communicative exchanges15. According to Iacono16 (p.83), “as the complexity of the disability increases, so does the complexity of communication needs and of finding an alternative system” for the person to be an active participant in communication. The author goes further, explaining that “people with disabilities must also rely on the skills of others to help them to be a part of a conversation”, reinforcing the idea that communication is a two-way process, and, for the same reason, it should be seen as a two-way effort. As Dias17 concludes from a Grounded Theory study with caregivers of persons with complex disability, CCN may be present, but communication may certainly be successful, rich and diverse, depending on how supportive the communication context will be. There are, however, descriptions from persons with disability explaining that frequently partners without disability tend to dominate communication exchanges and limit the participation of the partner with CCN, by asking too many questions, occupying the majority of the conversational turns, providing few opportunities for the use of alternative systems of communication, interrupting frequently, and not always confirming the content of shared messages18.
Considering how impactful a disability may be in the person’s communication profile, one should not be surprised that many persons with complex disabilities are at risk of being socially isolated. In 2008, Sheridan Forster19 stated that the scarce research available on the topic indicated some of these people would only benefit from few minutes of social interaction daily, at the school or day service they would spend their time in. Recent investigation20 reinforces this finding, reporting that adults with disability experience social isolation and loneliness at significantly higher rates than those without disability, with damaging impact to their well-being. Looking at the situation of children with Neurodevelomental Disorders (NDD) in specific, it was found that loneliness was related to negative consequences in terms of mental health, behavior, and emotional development, with long-term effect in their adult life21. According to the same authors, the lack of research on the topic of loneliness and children with NDD reveals that this issue is not yet considered to be a significant matter. There is, nonetheless, research22 reinforcing how critical it is to address the communication needs of persons with disabilities at an early age, considering the negative impact that may exist not only for their social participation, but also in terms of language, cognitive and literacy development, access to education, and, most of all, overall quality of life.
In a research project23 aiming to make information available to support improvements in best practices in communication with people with the most complex needs, several approaches to improve communication exchanges were highlighted, namely:
- Capturing and sharing fundamental information, using Communication Passports;
- Implementing formal approaches such as Intensive Interaction, Music Therapy, use of symbols, narrative approaches …;
- Implementing informal strategies; and
- Staff training.
Bearing in mind the relevance of communication partners in the success (or failure) of communicative exchanges, it matters to explore training approaches that enhance the skills of caregivers as communication agents. In a study about partners of adults with profound disability, Hanley, Dalton, Martin and Lehane24 concluded that the attitude, personal characteristics, familiarity with the other person and knowledge about alternative forms of communication were factors that could enhance or hinder communication exchanges. Their review provided important insights on the need to clarify the role and responsibilities of communication partners of persons with severe disability, reinforced the role of specialized professionals – i.e., Speech and Language Therapists (SLT’s) – and made evident the professionals’ need of additional training to better support the partners of communicators with the more complex needs. Bortoli and collaborators25 explore the perception of SLT’s regarding the implementation of communication intervention with students with multiple and severe disability, receiving feedback from research participants about the high level of expertise required for this kind of work. The required level of skill appears to develop over time, with ongoing professional development and opportunities to access formal education to update skills and knowledge and ensure evidence-based practices.
Research25 (p. 66) points in the direction of complexity when it comes to understanding communication processes and intervention with pupils with severe disability. According to the Complexity Theory, communication may be explained as “a complex dynamic process that is embedded within not only individuals’ characteristics but also broader and equally complex contexts or systems such as institutions and cultures”. Even though the research refers to other studies in the field of Speech and Language Therapy where the complexity paradigm was approached, to date it had not been applied to the understanding of communication intervention with students with multiple and severe disabilities. This finding is in line with Simmons and Watson’s work26, who have concluded that the dominant conceptual frameworks utilized to comprehend persons with the most complex disability are tendentially simplistic, reductive, and objectifying, overlooking how complex and dynamic the lifeworld of this population may be. On the other hand, embracing the complexity of communication with persons with the more complex disabilities, following theoretical views that flow in that direction, may have beneficial results in how clinicians perceive this phenomenon and positive impact on the intervention procedures. In her essay on the topic, Nafstad27 concludes: “communication as viewed in terms of dialogical theory can help professional carers overcome the mainstream idea that it takes conventional linguistic skills to overcome the pain of the isolation”.
Reflecting upon all the previous information, the authors developed the present research with the goals of:
- Creating and validating a theoretical model to illustrate and explain the complex process of interpersonal communication with individuals with CCN;
- Creating and validating an intervention program, informed by the newly established theoretical model, to support professionals in their work with communication partners of persons with complex communication needs.
By doing so, the expectation is to create resources to support communication specialists in their interventions and having a positive impact in the lives of persons with CCN.