R E H A B I L I TAT I O N A RT I C L E

Social Cognition Interventions

in Neuro-Rehabilitation:
An Overview
neuro-rehabilitation literature over two decades
Summary ago.2,3 More recently, both simple instructions and
• Social cognition difficulties include multi-media packages (using audio-visual interactive
problems with understanding the mental computer software stimuli) have been used to target
perspectives and intentions of others specific social cognitive functions such as emotion
(mentalising), emotion recognition, recognition from face and/or voice, across a range of
affective responses to social cues, affect clinical groups, including psychosis4 and acquired
regulation and social problem-solving and
brain injury.5-8 Other interventions have focused on
decision making.
multiple social receptive and behavioural functions,
• The assessment and rehabilitation of social including emotion recognition and mentalising abil-
cognition difficulties is a relatively
ities.9,10 Elsewhere, clinical and experimental studies
embryonic and underdeveloped field in
have reported gains from training cognitive control
Dr Giles Yeates neuro-rehabilitation, despite the
is a clinical neuropsychologist and widespread prevalence of such difficulties operations adjunctive to mentalising and emotion
couples therapist. His clinical and across neurological conditions. recognition, such as focusing attention to certain
research activity focuses on parts of the face11-12 and social problem-solving.13
relationships following acquired brain • The currently small range of interventions
offered have diverged from initial social These approaches are indirectly informed by theo-
injury. He is co-author of “A
Relational Approach to skills training approaches to include the retical frameworks that emphasise the intentional
Rehabilitation: Thinking about specific training of component social elements of social cognition functions,14 such as
Relationships after Brain Injury” cognitive abilities, approaches that use the mentalising and emotion recognition. Skills in accu-
(Karnac), co-editor of the Karnac body to aid in the comprehension of rately inferring/comprehending the perspectives of
Books Brain Injury book series, and is
social information and approaches that use others (from visual, auditory and contextual aspects
editor of the journal “Neuro-
Disability & Psychotherapy”. live interactions in social relationships as a of communication) or identifying essential facial
core focus of the intervention. features (e.g., eyes, mouth) and matching with intact
Correspondence to: or relearned knowledge of differing emotional
Dr Giles Yeates,
Community Head Injury Service,
expressions. While some of the social cognitive abili-
Buckinghamshire Healthcare NHS Abstract ties supported in this way have become more diverse
Trust, Camborne Centre, This article provides an overview of interventions over time, they may not have a significant impact on
Jansel Square, Bedgrove, Aylesbury developed and trialled in the embryonic field of the spontaneous, intense and changing nature of real-
Bucks, UK. HP21 7ET.
Email: [email protected]
social cognition neuro-rehabilitation. Interventions world social interactions. In addition the studies
are categories under the headings of explicit skills above report mixed results in terms of intervention
Conflict of interest statement: training, embodied/relational interventions, and efficacy. However, some aspects of neuro-rehabilita-
None declared. relational approaches. tion would clearly benefit from incorporating such
Provenance and peer review:
The assessment and treatment of social neuropsy- approaches. An example would be vocational reha-
Submitted and externally reviewed. chological impairments has received comparably bilitation, where post-injury work performance
less attention and development than other domains involving formalised or scripted sets of narrowly
To cite: of cognition. These include difficulties in repre- defined social interactions with customers would be
Yeates G, ACNR2014;V14:2:12-13
senting the intentions and perspectives of others amenable to these social cognition rehabilitation
(mentalising), recognising emotions, inferring packages.
nuanced social communications such as sarcasm
and deceit, accessing social knowledge and Embodied & affective interventions
emotion-based decision-making. Founded on New theories and paradigms gaining prominence in
distributed neuroanatomical substrates, impair- social neuroscience, particularly following the
ments of these functions have been found to be discovery of neural mirroring systems, are accounts
present and enduring across major sub-groups of of embodied simulation, contagion and resonance.15
acquired brain injury (for review see ¹). The theoret- These collectively emphasise the body-based affec-
ical richness of the social neuroscience revolution tive/emotional and non-intentional dimensions of
has not been matched by translation of concepts social cognition, such as the involuntary mimicry of
and findings into rehabilitation practice. This article facial musculature in response to the emotional
will review the embryonic field of social cognition expressions of others. In some scenarios, such as the
rehabilitation, categorised into three intervention experience of intense love for another, there is a
clusters: a) explicit skills training, b) embodied and deactivation of brain areas associated with inten-
affective interventions and c) relational approaches. tional mentalising systems alongside an activation of
these automatic, affective processes.
Explicit skills training These theoretical emphases have begun to influ-
Social skills training for various clinical groups ence innovations in the rehabilitation of emotion
predates neuro-rehabilitation of social functioning. recognition. Skye McDonald and colleagues in
These were initially focused on teaching and role Australia11 have evaluated a protocol where survivors
playing social and communicative behaviours of traumatic brain injury first approximate their facial
without an underlying neuropsychological rationale, expression to a task stimulus (e.g., an angry face)
and examples of these approaches did feature in the prior to identifying that emotion. Jacoba Spikman

12 > ACNR > VOLUME 14 NUMBER 1 > MARCH/APRIL 2014

 R E H A B I L I TAT I O N A RT I C L E

and colleagues in the Netherlands recently In mental health psychotherapy literature, these findings tentatively support the ‘raised
reported details of their multi-modal ‘T-ScEmo’ an approach known as mentalization-based threshold for autonomic responsivity’ hypoth-
intervention.10 This includes emotion recogni- therapy (MBT18) has been developed in use esis mentioned above. In this case, both
tion training involving instructed facial with clinical groups who also demonstrate survivor bodily responses and the socio-
mimicry, together with additional cues to asso- varied social cognition impairments, such as emotional cuing of the partner is amplified to
ciate the proprioceptive feeling of the survivor’s those with a Borderline Personality Disorder maximise affective empathic survivor
facial expression with previous memories of diagnosis. In MBT the therapeutic relationship responses and adaptive relationship func-
similar sensations. with the clinician is used as the main vehicle tioning.
However these studies have reported mixed to identify breaks in accurate mentalising,
findings across participants and weak group together with the characterising features of Conclusions
effects. This may be related to sample charac- mentalising errors. MBT is practiced both as an This is an area of rehabilitation in its very
teristics, but also these approaches are neces- individual and family therapy, and while yet to infancy, with a significantly limited evidence
sarily making a process intentional (e.g., the be formally evaluated within neuro-rehabilita- base. On the one hand, trials of social skills,
experimenter instructing a survivor to mimic tion, offers significant face validity as a poten- emotion recognition and mentalising inter-
their face to a stimulus) that in natural occur- tial intervention. ventions have not used sufficiently ecologi-
rence, in healthy populations, is considered to Togher and colleagues19 reported an RCT of cally-valid or meaningful outcomes. On the
happen involuntarily. The question is raised as the provision of communication partners to other hand, approaches informed by contem-
to whether the same underlying process is train survivor social communication skills porary social neuroscience theories that aim
being exploited in both healthy functioning through live interactions and a stable social to support a natural embodied process have
and clinical rehabilitation. relationship. Finally, Yeates and colleagues20 reported mixed group findings or case study
Experimental studies of survivors’ autonomic report the use of a couples therapy interven- data, limited in its generalisability. However the
nervous system, bodily-mediated responses to tion for survivors with both executive and range of approaches and conceptual frame-
both social cues (e.g., displays of distress) and social cognition impairments and their part- works being developed in this young field is
during emotion-based decision making tasks ners (who have been shown in previous notably diverse, at last in dialogue with current
have highlighted blunted responsivity (see 16 for research to emotionally withdraw and so exciting developments in social neuroscience.
review). Some authors have explored the provide fewer cues for survivors). Using case These approaches, represented in the figure 1
hypothesis of a raised threshold for a triggered study quantitative evaluations of changes in below, signpost the range of possible direc-
autonomic response conducive to adaptive measures of psychological distress and rela- tions for future innovation in social cognition
social cognitive functioning, rather than a tionship functioning in survivors and partners, rehabilitation. l
complete absence of such.1 Evans, Bowman
and Turnbull17 have reported improvements on
an emotion-based decision making task if clin-
ical participants are directed to amplify their Explicit Skills Training Embodied/Affective
internal monitoring of bodily feelings (intero- Mimicry
Social skills training T-ScEmo
ception) during task performance. training
Mentalising & emotion recognition Associations to mimicry
training
Relational approaches Mentalisation-
Cuing selective/focused Interoceptive cuing
The few approaches described thus far have attention based therapy during emotion-based
(MBT) decision making
focused on the individual survivor, conceptual- Social problem-
ising isolated social inputs and outputs, and solving training Social
Emotionally-
communication
their remediation/compensation. Fewer focused couples
partner
therapy (EFT)
approaches still have actively used the rela- intervention

tionships and presence of significant others

themselves within social cognition rehabilita- Interventions targeting
tion. There is some evidence that this may be social-interactional processes Figure 1: Visual overview
using relationships of social cognition
an important new direction for rehabilitation rehabilitation
innovation, truly social cognitive interventions. interventions.

REFERENCES

1. Yeates GN. Towards the neuropsychological foundations for 8. Radice-Neumann D, Zupan B, Tomita M & Willer B. Training 14. Frith U. & Frith CD. Development and neurophysiology of
couples therapy following acquiredbrain injury (ABI): A emotional processing in persons with brain injury. Journal of mentalizing. Philosophical Transactions of the Royal Society
review of empirical evidence and relevant concepts. Neuro- Head Trauma Rehabilitation, 2009;24(5):313-23. London B, Biological Sciences, 2003;358:459-73.
Disability & Psychotherapy, 2013;1(1):117- 50.
9. McDonald S, Tate R, Togher L, Bornhofen C, Lon, E, Gertler P, 15. Gallese V, Keysers C. & Rizzolatti G. A unifying view of the
2. Boake C. Social skills training following head injury. In J.S. & Bowen R. Social skills treatment for people with severe,
Kreutzer & P.H. Wehman (Eds.), Cognitive Rehabilitation for basis of social cognition. Trends in Cognitive Sciences,
chronic acquired brain injuries: A multi-center trial. Archives 2004;8:396-403.
Persons with Traumatic Brain Injury: A Functional Approach.
of Physical Medicine & Rehabilitation, 2008;89:1648–59.
1991. Baltimore, MD: Paul H. Brookes. 16. Damasio AR. Descartes' Error: Emotion, Reason and the
3. Brotherton FA, Thomas, LL, Wisotzek IE & Milan MA. Social 10. Spikman JM, Westerhoff-Evers M, Visser-Keizer A.
Human Brain. 1994; New York: Grosset/Putnam.
skills training in the rehabilitation of patients with traumatic Neuropsychological rehabilitation of social cognitive impair-
closed head injury. Archives of Physical Medicine and reha- ments resulting in behavioural changes. Workshop presented 17. Evans CEY, Bowman CH. & Turnbull OH. Subjective aware-
bilitation; 1988:69:826-32. at the Mid-Year Meeting of the International ness on the Iowa Gambling Task: The key role of emotional
4. Russell TA, Chu E & Phillips ML. A pilot study to investigate Neuropsychological Society, 2013. Amsterdam, experience in schizophrenia. Journal of Clinical &
the effectiveness of emotion recognition remediation in schizo- Netherlands. Experimental Neuropsychology, 2005;27:656-64.
phrenia using the micro-expression training tool. The British 11. McDonald S, Bornhofen C. & Hunt C. Enhancing emotion
Journal of Clinical Psychology, 2006;45:579–84. 18. Bateman AW. & Fonagy P. The Handbook of Mentalization-
recognition after severe traumatic brain injury: the role of
Based Therapy in Mental Health Practice. 2012; New York:
5. Bornhofen C & McDonald S. Comparing strategies for treating focused attention and mimicry. Neuropsychological
emotion perception deficits in traumatic brain injury. Journal American Psychiatric Publishing.
Rehabilitation, 2009;7:1-9.
of Head Trauma and Rehabilitation, 2008;23(2):103–15. 19. Togher L, McDonald S, Tate R, Power E. & Rietdjick R.
12. McDonald S, Rushby J, Li S, de Sousa A, Dimoska A, James
6. Guercio JM, Podolska-Schroeder H & Rehfeldt RA. Using Training communication partners for people with traumatic
C, Tate R. & Togher L. The influence of attention and arousal
stimulus equivalence technology to teach emotion recognition brain injury: Reporting the protocol for a clinical trial. Brain
on emotion perception in adults with severe traumatic brain
to adults with acquired brain injury. Brain Injury, Impairment, 2009;10(2):188-204.
2004;18(4);593-601. injury. International Journal of Psychophysiology,
2011;82(1):124–31. 20. Yeates GN, Edwards A, Murray C. & Creamer N. The use of
7. McDonald S, Togher L, Tate R, Randall, R, English, T &
Gowland, A. A randomised controlled trial evaluating a brief 13. Rath J, Hennessy JJ. & Diller L. Social problem solving and emotionally-focused couples therapy (EFT) for survivors of
intervention for deficits in recognising emotional prosody community integration in postacute rehabilitation outpatients acquired brain injury with social cognition and executive func-
following severe ABI. Neuropsychological Rehabilitation, with a traumatic brain injury. Rehabilitation Psychology, tioning impairments and their partners: A case series analysis.
2012;23(2):267-86 2003;48(3):137-44. Neuro-Disability & Psychotherapy, 2013;1(2):151-94.

ACNR > VOLUME 14 NUMBER 1 > MARCH/APRIL 2014 > 13