Patients with severe traumatic brain injuries can relearn social communication skills

Nov 25 2008

According to new research from Australia patients who have suffered traumatic brain injuries can benefit from being re-educated in important social communication skills.

Many who suffer severe brain injuries lose the vital ability to interpret emotions which are crucial for successful social communication, but new research has found that these skills can be retrieved by means of a re-education process on how to read body-language, facial expressions and voice tone in others.

The research by psychologists at the Liverpool Hospital Brain Injury Rehabilitation Unit, in Sydney, has revealed that appropriate training can result in significant gains in "emotional perception", which is crucial for successful social communication.

The research involved 18 participants recruited from an outpatient service, who had all experienced a severe traumatic brain injury at least six months earlier and had significantly impaired ability to interpret emotions in others.

Doctors, patients and family members had identified chronic social difficulties including isolation, an apparent disregard or a lack of awareness of social cues, or inappropriate social responding.

The study's lead author, clinical psychologist, Dr. Cristina Bornhofen says someone who has suffered traumatic brain injury - commonly due to a blow to the skull - can lose the ability to accurately read other people's emotional cues, which may make their social behaviour awkward, badly timed or miscalculated.

Dr. Bornhofen says they find it difficult to integrate the cluster of non-verbal cues that accompany speech and their inability to interpret emotional expression causes significant frustration because it impairs their social competence.

This may result in difficulty interpreting an emotion such as sarcasm, for example, in which a positive verbal message is paired with a voice tone and facial expression intended to convey a meaning opposite to the verbal message.

Dr. Bornhofen says traditional treatments have emphasised training in positive social behaviours, such as turn-taking, giving compliments, and reducing undesirable behaviours, such as excessive talking and inappropriate conversation topics, however, these programs have had limited success.

Dr. Bornhofen says good social communication is possible only if people can effectively use feedback, such as that provided by the emotional responses of others and behaviourally-oriented programs have tended to neglect this critical aspect of social skills.

By using photographs and videos, the participants were tested before and after the program on an array of outcomes: independent living skills, psycho-social health, and emotional discrimination tasks requiring them to identify emotions such as happiness, sadness, anger, anxiety, disgust and surprise.

The suggestion from earlier research was that the accurate perception of emotional cues requires a variety of cognitive skills, involving several brain regions and pathways, which are yet to be clearly defined and led the researchers to compare two different treatment regimes.

Dr. Bornhofen and her co-researcher, Professor Skye McDonald randomly assigned the participants to one of the two treatments - the first, known as "self-instruction training", taught patients to answer questions by using a set of strategic questions to guide them through emotion discrimination tasks, using questions such as: What is it am I deciding about? What do I already know about it? What do I need to look or listen for?

The second regime, called "errorless learning", began with extremely easy discriminations, providing extensive practice at each stage and strongly discouraged learners from guessing when unsure - for example, repeated practice of identifying patterns associated with basic emotions (such as wide eyes and raised eyebrows in surprise) was carried out using line drawings of basic expressions laid out on a table alongside a card with the words "not sure" - participants were encouraged to point to "not sure" rather than guess the answer, and were positively acknowledged whenever they did so.

Both regimes were carefully designed to ensure that participants received comparable levels of positive feedback and therapeutic attention in each.

Dr. Bornhofen says the results suggested that self-instruction training was slightly better at improving the participants' ability to judge facial expressions from photographs, and deciding whether someone was speaking sarcastically, on the basis of a speaker's emotional demeanour.

Informal subjective reports from treatment group members and their relatives revealed improvements in the participants' ability to understand the emotional state of others during day-to-day interactions and an increased confidence in their ability to successfully engage in social contexts.

Dr. Bornhofen says the results offer hope to people who have suffered traumatic brain injuries that they can be retrained to identify emotions in others, and to begin functioning normally again and overall, self-instruction training appears to be the most beneficial strategy for teaching emotion perception skills to most traumatically brain injured patients.

The researchers are continuing research in this direction, and are preparing to publish the treatment program in manual form so that clinicians can utilise the best of the materials and techniques in their work with patients.

Dr. Bornhofen says as there are currently no other evidence-based treatment materials available for this kind of rehabilitation with people who have brain injuries, they believe the research will be of great assistance - numerous requests for the program have already been received, especially from the U.S., where the growing number of returning armed service personnel with head injuries is raising awareness in this area.

The research is published in the Journal of Head Trauma Rehabilitation.