Dawn Neumann, PhD • Barbra Zupan, PhD Barry Willer, PhD

Communication of emotion is integral to human interactions but people don’t often convey their feelings to others through words. Instead, people are expected to recognize others’ feelings through facial expressions, tone of voice, and other nonverbal cues. 1,2 One’s ability to recognize emotion in others is an important compass for guiding social behaviors3 because it facilitates better understanding of others and strengthens interpersonal connections.

Research shows a high prevalence of emotion recognition deficits in people who have had a moderate to severe traumatic brain injury (TBI).4,5 These deficits are likely due to a disruption in optimal functioning of the brain regions and networks typically engaged in processing emotional information.6,7 Recognizing emotion via facial affect is particularly difficult, impacting 39%4 of the TBI population. Studies suggest that men and women with TBI are equally impaired at recognizing emotions from faces 8 and that negatively valenced emotions are more challenging to identify than positively valenced ones.5 This means someone with a TBI is likely to misinterpret or fail to recognize their loved ones’ sad or anxious emotions. As such, impaired emotion recognition may have serious implications for psychosocial outcomes for people with TBI and their family members.

It is widely known that individuals with TBI and their family members often report poorer relationship quality, fewer social interactions, and increased isolation after their injury.9-11 A growing body of evidence supports an association between emotion recognition abilities and social behavior and outcomes after TBI .12-15 It is possible that the inability to recognize how a family member or friend is feeling hinders appropriate responses to emotional situations, including empathic ones. Notably, up to 70% of individuals with TBI have low empathy16-18, and poor emotion recognition may be partly to blame. Indeed, one study found that when participants with TBI accurately identified emotions portrayed by actors in a video clip, they had an empathic response 71% of the time. In other words, if they perceived the actor as sad, they also felt sad.19 In contrast, when participants did not recognize the emotion, empathic responses only occurred about a third of the time.

Social functioning is also reported to be associated with facial emotion recognition following TBI. This has been indicated in studies that have shown an increase in inappropriate behavior, poorer interpersonal communication, and less successful social integration in participants with TBI who had trouble recognizing facial affect14,15,12,13,20,21 A literature review published in 2019 identified that 60% of studies in this area reported a significant association between emotion perception and social functioning after TBI.15

While the author of the literature review acknowledged that there are likely several factors contributing to poor social and behavioral outcomes after TBI, he also stated that it was clear that impaired affect recognition is an important relevant factor that should be addressed when trying to improve social outcomes for individuals with TBI.12,22-25

A couple of studies offer strong evidence to indicate that impaired facial affect recognition after TBI can be remediated with treatment.26

The first study to provide Level 1 evidence came from a randomized controlled trial (RCT), which compared a facial affect recognition intervention (FAR) to an active control intervention (Control) training basic cognitive skills. This multisite study conducted in the USA, Canada and New Zealand, examined outcomes a week after treatment ended and then also three and six months later. Twenty-four participants were randomized to the FAR intervention (described below) and 24 to the Control intervention. Participants were an average of 10.3 years post-injury. Both interventions were computer-based programs delivered individually by a clinical research assistant over nine sessions.26 Study results indicated that participants who received the FAR intervention significantly improved at recognizing emotions in facial expressions, and that their outcomes at posttest exceeded those participants who received the pure cognitive skills training. Moreover, participants retained the improvement in their facial affect recognition skills for six months after the treatment ended. A recent systematic review of evidence-based cognitive rehabilitation designated the FAR intervention a Practice Standard for treating facial affect recognition deficits in people with acquired neurocognitive impairments and disability.27

The FAR intervention should be perceived as an important foundation from which more advanced social skills could be trained. Notably, researchers in the Netherlands did exactly that. They added modules to the existing FAR intervention aimed at teaching empathy and related social skills and included caregivers in several of the treatment sessions.

Findings from their RCT indicated significant improvements in emotion recognition in participants with TBI, and importantly, caregivers reported significantly more empathic behaviors and perceived improvement in relationship quality.28

FAR Intervention: The 9-session treatment was a computer-based program led by a clinical research assistant over two to three weeks.

In the study, sessions lasted 60 to 90 minutes and focused on teaching three core skills:

1. Attention to relevant facial features; 2. Emotion replication and experience; and 3. Conceptual associative knowledge.

The FAR intervention uses a software program to present 40 pictures of emotional faces29 via computer, over the course of the intervention. The faces vary in intensity (obvious/subtle), gender, and ethnicity.

Participants are trained to look at and interpret important features (e.g., scrunched eyebrows; wide open eyes) and to select which emotion best describes how the person is feeling from a list of four options (happy, angry, sad, and fearful). Visual cues, which gradually diminish over time, are provided to help the participant learn to attend to the relevant features. Incorrect responses are met with “pop-up messages” that describe the characteristics of the facial features of emotional face, and the correct emotion (e.g., wide eyes and fear).

In addition to recognizing facial expressions, each lesson includes exercises that require participants to replicate and experience the emotion just identified by recalling personal events that elicited that same feeling. Participants are guided through a process to help them generate the emotions (e.g., mimicking of facial expressions and generation of physiological feelings). This exercise is to help the person gain insight into the “feeling” behind the emotion, which is believed to facilitate emotion recognition. Additional exercises in the program require the person to compare visual features across different faces in order to identify similarities and differences in emotional expressions. Each lesson concludes with an in-depth discussion of their personal emotional events to tie all the lessons together and build important associative knowledge.

During this discussion, participants are asked questions about their emotions and the emotions of others also involved in the situation they identified. These questions center around how the emotions were expressed and what they felt like, why they felt those emotions, and how emotions influenced their behaviors in the context of that situation. More information about the intervention can be found at the following link http://links.lww.com/JHTR/A103. The software and treatment manual can be obtained by contacting the primary author.

Despite increasing acknowledgement of the prevalence and significance of emotion recognition deficits after TBI, it appears that the evaluation and treatment of these problems has not been an adopted into standard clinical practice.30 It is not completely clear why social cognition skills have fallen through the rehabilitation cracks.

Some realistic and challenging reasons might include time constraints, uncertainty regarding whose responsibility it is, lack of knowledge about or access to assessments and interventions, and/or lack of self-efficacy.(ref) However, we must acknowledge that to discharge people with TBI back into the community without addressing this important skill as part of their rehabilitation program, is doing them and their families a disservice. Together, we must work to identify and overcome the implementation barriers.

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Dawn Neumann, PhD, FACRM is an Associate Professor at Indiana University School of Medicine in the Department of Physical Medicine and Rehabilitation, and the Research Director at the Rehabilitation Hospital of Indiana. She has a PhD in Rehabilitation Science from SUNY Buffalo and her MA in Psychology from Rutgers. Her research advances the understanding and treatment of social cognition and emotion dysregulation deficits after traumatic brain injury. She serves on the Journal of Head Trauma Rehabilitation editorial review board, and has received several recognitions, including the ACRM Deborah Wilkerson Award, ACRM Mitchell Rosenthal Award, and the Joshua Cantor Scholar Award. Barbra Zupan is an Associate Professor and Head of Course of Speech Pathology at CQ University in Rockhampton, Queensland Australia. She received her PhD in Speech Pathology at the State University of New York at Buffalo. Her research focuses on perception and integration of facial and vocal cues of emotion, and the impact of traumatic brain injury on these processes. Her research also investigated other aspects of social cognition, including emotional inferencing and empathy. She contributed to the development of facial affect recognition and emotional inferencing treatment programs as well as the development of an assessment tool for emotional inferencing. Barry Willer received his PhD in Psychology from York University, Toronto, Canada and has been faculty at the University at Buffalo since 1976. He is a professor in the Department of Psychiatry, with a long history of research in TBI. He was director of the initial Research and Training Center on Community Integration and spearheaded the development of the Model Systems database for TBI. He was lead author of the Community Integration Questionnaire. He published widely on the psychological and social consequences of severe brain injury. He has been actively involved in research on mild traumatic brain injury and concussion.