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With trauma, one of the most common deficits is pragmatics. It encompasses turn taking, social language, eye gaze, reciprocity, understanding, empathizing, sympathizing. Those are all part of our social language - it doesn't have anything to do with verbalizations. It's awareness of your environment, your inferencing, your insight, so that is really a difficult area to treat.
I begin with attention. There are five different types of attention - there's sustaining attention, alternating attention, divided attention, visual attention, all attentions that we take for granted and use during daily activities. Normal human attention is seven minutes. If i have a patient who’s had trauma and they only sustain 30 seconds of attention, we can't advance to other treatment.
To work on attention, if I’m working with someone with low sustaining attention we could have sorting activities. For example, we could have knives and forks and safely separate the two from a pile. Connect Four is another way to work on attention. Taking turns in playing red and black tokens - that entails reciprocity, turn taking, and sustaining attention. For visual attention we would have a sheet of paper with numbers, and I would ask the patient to cross out every number three.
Once attention is there, we can progress to some sort of activity where we have reciprocal conversations. Topic maintenance - let's see how much we can make those conversation turns, to see if we're engaged, if we're together on a topic. So that encompasses a real conversation what we are used to in daily life.