The use of verbal maps to help people with right cerebral hemisphere lesions compensate for perceptual-spatial deficits.

A problem frequently experienced by people with right cerebral hemisphere lesions is that of difficulty "finding the way around." The use of left hemisphere function to compensate for right hemisphere deficits by developing "verbal maps" is described. Detailed steps are given for the development and use of these "maps." A case example is provided.

People who have suffered lesions of the right cerebral hemisphere, either from stroke or trauma, often experience a number of non-verbal problems including difficulty "finding one's way around a building's corridors." (Vogenthaler, 1987). While this may be a relatively innocuous problem when the person is still in the sheltered environment of a rehabilitation center, it can be very restrictive when one returns home.

After a few frightening experiences with getting lost in a once familiar neighborhood, a person with this type of deficit may become a recluse, virtually trapped in her/his home. Trips to the local store for shopping, to church, to the doctor's office, or to visit friends can become formidable challenges without someone else as a "guide." Return to productive activity at work or school may seem impossible if one cannot find the way to the restroom or cafeteria in new surroundings.

One of the well-established practices in rehabilitation is to teach patients compensatory techniques for accomplishing tasks on which their performance is deficient. (Jarvis and Barth, 1984; Prigatano and Fordyce, 1987). When perceptual spatial deficits, including difficulty finding one's way around are due to a focal lesion of the right cerebral hemisphere, left hemisphere functioning may be intact; that is, language functions may remain unimpaired. Diller and Gordon (1981) pointed out that people with focal lesions of the right hemisphere often benefit substantially from "language-related cues." George Miller and Hassan (1986) pointed out in their review of spatial competence of the elderly that older people are assisted in "route-learning" by the use of sequential instructions as opposed to visual maps. This suggests that people with focal right hemisphere lesions who get lost will be able to compensate by the use of "verbal maps" to assist them in finding their way around.

The following steps may be used to help patients develop an initial "verbal map:" * Choose a common route which is troublesome for the patient, e.g., from the patient's bedroom to the dining room or occupational therapy area; * Walk through the route with the patient, identifying the starting point, all choice points such as turns, and the end point or destination; * At the starting point, all choice points and destination, ask the patient to stop, look around, and identify a visible "marker" which he/she can label (e.g., a phone booth or a fire extinguisher on the wall) and the instructions to be executed at that point (e.g., turn right); * Each time the patient is to turn have him/her pat the appropriate thigh while verbalizing the instructions. Model this, "turn right," while patting your right thigh; * Print the "verbal map" as a series of instructions which will direct the patient from one visual marker to the next until the destination is reached. "When you see x, do y." For example, A) Go to the door of your room and find the phone booth. B) Walk to the phone booth. C) When you get there, pat your left thigh and turn left. D) Walk to the Exit sign, etc.; Walk through the route behind the patient, listening to make certain that the "verbal map" is complete and accurate and that the patient vocalizes the instructions and gives the appropriate motor cues, thigh pats, at each turn correctly. (It is important for the therapist to be aware that those of us without perceptual-spatial deficits may have difficulty conceptualizing the task of getting from Point A to Point B without using perceptual-spatial cues.); * Have the patient travel the route regularly using the "verbal map" as a guide and evaluate the ability to do this accurately; * Once the patient is able to do this accurately and efficiently, begin to wean him/her from the use of the printed "verbal map" and rely on the memory of it in order to increase independence of functioning; * Teach the patient how to reverse the map to get back to the original starting point. Some patients may be able to learn this fairly easily; for others it may be necessary to repeat the first eight steps in the reverse direction. This is important to give a sense of "spatial security;" * Repeat the first nine steps to teach the patient how to travel a different, more complex route to a different destination; * After the patient has learned how to use "verbal maps" well, teach the patient and family members how to create new ones, using steps one through nine, so that the technique can be used in a variety of different situations after the patient leaves the rehabilitation center; and * Follow up with the patient and family to see whether they need any assistance in adapting the technique to their unique circumstances.

These steps should be sufficient for patients who have adequate verbal skills. For those with significant verbal deficits or learning disabilities it may be helpful to add cues from other sensory modalities. This can be done by starting with a model of the environment and taking the patient through it by touch, adding tactile cues. It may be necessary to provide alternating trials of practice with this model and the "real" route. The verbal instructions and the thigh pat cues should be exactly the same for both the model and the real route.

Case Example

Mr. D. was a 57-year-old white, right handed, divorced man who had suffered a right posterior parietal CVA. He was a college graduate with some graduate school course work. On psychological testing he had a Verbal IQ of 112, a Performance IQ of 77, and a Full Scale IQ of 95. On neuropsychological evaluation his greatest cognitive deficits were those attributed to his right hemisphere lesion: a left homonomous hemianopsia, left neglect, visual scanning deficits, and visual/perceptual deficits. Verbal skills remained quite adequate.

After the neuropsychological evaluation was completed, he was scheduled to come to the Psychology Service daily for cognitive retraining. After the therapist had accompanied him from the ward to the Psychology Service, about a five-minute walk, several times, it was clear that he would not be able to make the trip, which required only three choices regarding direction, by himself

At that point the therapist helped Mr. D. develop a "verbal map" using steps one through seven above. Within a few days he was able to keep his appointments by using this. After several weeks he spontaneously began to rely on his memory to guide himself. By the time he was discharged from the hospital several months later, he was finding his way to other locations in the hospital unaccompanied after having been assisted in developing appropriate "verbal maps."

In this case the patient was never taught explicitly how to develop new "verbal maps" independently, nor were family members available who could be taught the technique. However, about a year and a half after Mr. D.'s discharge from the hospital a follow-up phone contact with the nursing home where he was living revealed that he had been able to understand the process and use it in a new setting. He had described it to nursing home staff and had them help him develop new "verbal maps" appropriate to the new setting. He regularly uses the technique to go to nearby stores for shopping by himself.

Discussion

Difficulty in finding one's way around can lead to significant reduction in the quality of life. Some people may get lost repeatedly and even place themselves in dangerous situations as a result of it. This may lead to their placement in restrictive settings. Others may isolate themselves, rarely leaving their rooms in the rehabilitation hospital or center due to their fear of getting lost. In fact, this isolation, which is often attributed to depression or a personality disorder, may be the first clue to a problem with spatial orientation. These deficits are often associated with right hemisphere lesions which may result from a variety of brain injuries or diseases.

Any suggestion of spatial orientation problems should result in a neuropsychological evaluation to determine the basis of the problems. If they are due to a right hemisphere lesion with left hemisphere language functions intact, the basic verbal map technique described in this paper should be considered. If there are also language deficits, augmentation of the technique with tactile cues using a model of the environment at the beginning of training will probably be needed.

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PAUL E. JARVIS, Psychology Service, Fort Logan Mental Health Center, 3520 West Oxford, Denver, Colorado 80236.