download.lww.comdownload.lww.com/.../JHTR/A/JHTR_1_1_2014_03_31_NEUMANN_… · Web viewThis section shows a mixture of eight faces from the current and previous level for review

RCT Emotion Recognition after TBI, 1

Faces Intervention

Supplemental Digital Content

I. Treatment Concepts The Faces Intervention aims to improve three main skills that are theorized to be the crux of

emotion recognition:

a. Attending to and processing characteristics of facial features indicative of an emotion, both individually (e.g., eyebrows), and globally (i.e., energy level and overall face tension).

b. Personal experiences with one’s own emotions in order to better recognize emotion in others. In other words, making associations with one’s own emotional experiences.

c. Developing a stronger conceptual understanding of emotions.

II. Learning Strategies Repetition Vanishing Cues Increasing complexity and difficulty level Feedback

III.Communicating the purpose and importance of the treatment to participants

Prior to beginning treatment activities, the therapist reviewed the following foundations of the intervention with each participant:

1. Goal of treatment: The purpose of this treatment is to try to help you better recognize how people are feeling. When this study is over, we hope that when you are talking or socializing with others, you will be better able to figure out how they are feeling.

2. Importance of recognizing others’ emotions. Help you to interact with others better (behavior) Help you develop stronger emotional bonds with others. Give you skills to be more supportive towards others. Help you to show you care about others’ feelings.

3. Importance of discussing and understanding their own emotions. During the course of this treatment, there will be times we will ask you to refer to your own emotions and to discuss some of your emotional experiences. It is expected that the more you are able to understand your own emotions, the better you will be able to recognize others’ emotions. It’s important to be in touch with your own emotions because:

It may improve your emotional self-awareness and understanding of your own emotions

Face-specific (a)

General emotion (b, c)


It is believed to be important for helping you to better relate to others’ emotions It is believed to be important in helping you identify your emotional needs, and consequently

important for finding more motivation. It is believed to be important for judgment and decision-making if you consider how

consequences of your actions will make you feel better.

III. Description of the Faces intervention and treatment administration The Faces Intervention is a computer-based treatment program with seven levels. The 40 faces

presented throughout this program are a subset of stimuli from the Pennsylvania Emotion Recognition Test (PERT; Gur RC, Sara R, Hagendoorn M, et al. A method for obtaining 3-dimensional facial expressions and its standardization for use in neurocognitive studies. Journal of Neuroscience Methods. 2002;115(2):137–143).

Earlier levels of the program include face stimuli that were standardized as expressing more “obvious” emotional expressions. Later levels include face stimuli that were standardized as expressing more “subtle” expressions.

Since the major difference between each level of the Faces Intervention is the difficulty level of the face stimuli, we only only describe Level 1 of the intervention in great detail (see below). Also below are brief descriptions of Levels 2-7 that indicate stimuli and procedural changes from Level 1.

1. Level 1 Level 1, Section 1 (Identify the emotion)

Title page and Instructions: “Recognizing Emotions from Facial Expressions: In this section you will be shown faces expressing different emotions. Your task is to identify the emotion that each face is portraying.”

A total of 9 static faces are presented one at a time on the screen to participants. Participants are asked to select from a list of 4 emotions, which emotion best describes how the person is feeling. (See Figure 1). There is no time limit.

In this level, participants are presented with visual cues (written and pictorial) encouraging the participant to look at the eyes and the mouth. (See Figure 1). Note that these cues will gradually vanish within each section and will be reintroduced as more difficult faces are introduced to the program.


Figure 1.

Correct Responses: If the correct response is selected, participants will see a popup box with feedback saying, “Yes, this person is______”. The therapist will then ask what made the participant choose that response and also to describe characteristics of eyebrows, eyes, mouth, global percept of the face. If participants are having trouble describing the features, the therapist can help by describing the features for them. Once the features have been accurately described, participants will be allowed to move to the next screen.

Incorrect Responses: If an incorrect response is selected, participants receive feedback in a popup box that says “No, this person is not______. Study the hints to the right of the picture.” (See Figure 2). These hints describe the facial characteristics, the overall look of the face, and also provides the correct answer. Participants cannot move forward until they select the correct response.

Figure 2.


Level 1, Section 2 (Identify the emotion + personal experience)Instructions: “In this section, after you identify the emotion for each face, you will be asked to discuss a time that you remember feeling that emotion yourself or an example of an event that would make you feel that emotion.”

In this Section, the same 9 faces from Section 1 are shown again, but in a different order. Note that the visual arrow cues are removed for all stimuli in Section 2 (i.e., vanishing cues).

Part I: Participants are asked to first identify the emotion using the same procedure described in Level 1, Section 1.

Part II: Participants look at the facial expression and briefly describe a time they felt that same emotion. See Figure 3. The therapist records the event described on the participant’s record sheet.

Figure 3.

Level 1, Section 3 (Identify the emotion + imitate the emotion) Instructions: “In this section, after you identify the emotion for each face, you will be given a mirror and asked to imitate that emotion.”

Section 3 also uses the same 9 faces as Sections 1 and 2, but the faces again appear in a different order. Vanishing cues are again applied by eliminating the written cues that direct participants to look at the eyes and mouth.

Part I: As in Sections 1 and 2, participants are asked to first identify the emotion. Part II: Participants are given a mirror and asked to imitate the facial expression while

looking in the mirror (See Figure 4).. They are given instructions how to make their faces look more similar to the picture. How well they imitate the expression is rated by the therapist (good, fair, poor) and recorded.


Figure 4.

Level 1, Face Similarity (Identify similar characteristics across different faces)Instructions: “Next, you will see faces on the screen that are all expressing the same emotion. Even though they are different faces, their expressions look similar. That is how we know they are feeling the same emotion. You will be asked questions about how the features of their face look similar.”

Each Feature is addressed separately. Multiple choice options are made available (see Figure 5). Participants must select the description that best describes the common characteristics of the facial features before moving on. There are a total of 4 Similarity exercises; one for each emotion (happy, sad, angry, and fearful).

Figure 5.

Level 1, Face Selection (Distinguishing different emotions from another)


Instructions: Now you will be shown 4 faces on the computer at a time. You will be asked to find which face is expressing a particular emotion.”

There are 4 Face Selection Exercises; one for each emotion. After making their selection, participants are encouraged to describe the characteristics that made them select that face as depicting the emotion in question. See Figure 6.

Figure 6.

Level 1, Advanced Emotional Processing (Deeper understanding of own emotions)Instructions: “Now we are going to do something a little different from looking at faces on the computer. We are going to spend a little more time discussing some of the situations you brought up when we were doing the computer exercise. This part of the training is very important for helping you to understand your own emotions, which in turn is important for understanding how others are feeling. When we are discussing these things that happened, I want you to try to put yourself back into the situation. I want you to recall it as vividly as possible and try to feel what you ‘felt’ at the time of the situation. What I mean by ‘felt’ is that there are cues that our body gives us to let us know how we are feeling. For example, if we are happy our bodies feel light and relaxed. If we are fearful, our heart may race, and we may feel jittery. I want you to try to ‘feel’ these types of feelings again.”

Put Figure 7 up on the screen. Note that the top row shows more obvious emotion expressions and the bottom row shows more subtle expressions.


Figure 7.

Advanced Emotional Processing: “Earlier we discussed ….(situation listed below). Let’s spend more time talking about that.” Situation: (HAPPY) _(Write in brief description of an event the participant gave you earlier for “Happy”.) Proceed to ask participant questions next to checkmarks below.

After finishing with the questions below for “Happy” event, repeat with “Fearful” event. Only 2 emotions are discussed for each level. Each emotional event is reviewed for approximately 10-15 minutes.

(a) Describe the situation in more detail. (b) How did you feel? Please describe all emotions you felt.o Label your emotions (e.g,. angry, sad, etc.) o Please point to the face(s) on the computer that best depicts how you were feeling in

this situation. o What physiological reactions were you experiencing? Use Table 1 below for examples.o Re-enact physiological and body sensations.

(c) Why do you think you felt the emotions you did? For example, I was angry because…, but I was also sad because….. etc.

(d) What was your response to the situation?o How did you behave?o What emotion were you outwardly expressing, particularly your facial expressions?

(e) What do you think others’ perception of your emotion was at the time? Based on the participants’ response, what does the participant think others thought that he or she (the participant) was feeling?

(f) How did others in the situation respond to your behavior?o Their facial expressionso Their behavioro Other’s feelings (How do you think they were feeling based on facial expressions and

behavior); Why do you think others were feeling that way?


Happy Sad Angry Fearful

Muscles are…

Relaxed Heavy, as if a weight is on your chest.

Very tense.

Heart rate…

Low and normal May be slow (or fast if anxious too)

Speeds up. Speeds up.

Feel like… Floating in air or on water, Tingly.

Lacking in energy;

tired; weighed down

Tense and tight; hot as if temperature rises; may want to hit something or yell and scream.

Stomach has butterflies; Sweating and shaking; Feel on edge or jumpy.

Table 1. Examples of physiological responses and body states associated with emotions.

2. Level 2 Level 2, Section 1 (Identify the emotion + personal experience).

Nine new face stimuli used. Only written cues directing the participant to look at the eyes and mouth are included (no

arrows). Level 2, Section 2 (Identify the emotion + imitate the emotion)

Repeat the 9 face stimuli from Level 2, Section 1. No visual cues provided.

Review (Identify emotion only) This section shows a mixture of eight faces from the current and previous level for

review. Level 2, Face Similarity (Identify similar characteristics across different faces)

Does not differ from Level 1 except for the addition of some new face stimuli. Level 2, Face Selection (Distinguishing different emotions from another)

Does not differ from Level 1 except for the addition of some new face stimuli. Advanced Emotional Processing

In Level 2, events for “angry” and “sad” are reviewed.


Five new face stimuli Both arrows and written cues directing the participant to look at the eyes and mouth are

included. Level 3, Section 2 (Identify the emotion + personal experience).

Repeats the 5 face stimuli from Level 3, Section 1. Includes only written cues to look at eyes and mouth (no arrows).

Level 3, Section 3 (Identify the emotion + imitate the emotion) Level 3 Review


This section shows a mixture of faces from the current and previous levels for review. Level 3, Face Similarity (Identify similar characteristics across different faces)



Level 3 reviews events for “angry” and “fearful”.


Five new face stimuli Both arrows and written cues directing participant to look at the eyes and mouth are

included. Level 4, Section 2 (Identify the emotion + personal experience).

Repeat of 5 face stimuli from Level 4, Section 1. Only written cues directing participant to look at eyes and mouth are included (no

arrows). Level 4, Section 3 (Identify the emotion + imitate the emotion) Level 4 Review

This section shows a mixture of faces from the current and previous levels for review. Level 4, Face Similarity (Identify similar characteristics across different faces)



Level 4 reviews events for “sad” and “angry”.


Five new face stimuli used. Only includes written cues directing participant to look at the eyes and mouth (no

arrows). Level 5, Section 2 (Identify the emotion + imitate the emotion)

Repeat of 5 face stimuli from Level 5, Section 1. No visual cues provided.

Level 5 Review (Identify emotion only) This section shows a mixture of eight faces from the current and previous level for




Level 5 reviews events for “happy” and “fearful”.



Five new face stimuli used. Only written cues directing participant to look at eyes and mouth are included (no

arrows). . Level 6, Section 2 (Identify the emotion + imitate the emotion)

Repeat of 5 face stimuli from Level 6, Section 1. No visual cues provided.

Level 6 Review (Identify emotion only) This section shows a mixture of faces from the current and previous level for review.

Level 6, Face Similarity (Identify similar characteristics across different faces) Does not differ from Level 1 except for the addition of some new face stimuli.

Level 6, Face Selection (Distinguishing different emotions from another) Does not differ from Level 1 except for the addition of some new face stimuli.

Advanced Emotional Processing Level 6 reviews events for “sad” and “angry”.

7. Level 7 Level 7, Section 1 (Identify the emotion + personal experience + imitate the emotion)

Only 2 new faces added. No visual cues provided.

Review (Identify emotion only) This section shows a mixture of eight faces from the current and previous level for




Level 6 reviews events for “sad” and “happy”.

8. Supplemental Exercise: Emotion Comparisons

Very often, participants with TBI confuse one emotion for another, particularly sad and angry; angry and fearful; and sad and fearful. If participants made these errors several times (i.e.,. 3 or more), then we would insert the Emotions Comparisons exercise as a learning supplement. The Emotion Comparison exercise displayed two commonly confused facial expressions side by side (See Figure 8).

For each Comparison, participants were asked:o Which face is expressing which emotion?o What’s the difference in their eyebrows?o What’s the difference in their eyes?o What’s the difference in their mouth?


o What’s the difference in their face tension and/or energy?

Figure 8. Global Percept: Participants are encouraged to look at the whole face, not just individual

features. This is important for learning to distinguish the three negative emotions included in the treatment program. In order to do this, participants are asked about:

Energy level: How much energy does this person look like they have – a lot or a little. Little energy indicates Sad. If there is lots of energy, does it look like the energy will be used to attack or run away (distinguish anger and fear)

Face tension: Is there a lot or little tension in the person’s face or does the person look droopy? Lots of tension is typically associated with anger. Droopiness is often associated with sad.

IV. Logistics of Treatment Administration

Training should be one-on-one in a quiet room. A computer is needed for the software. Provide breaks to the participant as needed. Training should attempt to be administered 3 times a week for 3 weeks, with each session lasting one

hour. However, if there are transportation concerns, there is flexibility in how the 9 hours of treatment can be administered (e.g.,…..).

Participants may often finish more than one training exercise in one session. In order for participants to move on to the next training level, they must achieve 85% accuracy for that exercise. If they do not achieve 85% accuracy, they must repeat that exercise. Participants are able to attempt the 85% target only two times. If they are unable to achieve 85% the second time they complete an exercise, they move on to the next exercise. If a participant is below 85% accuracy for an exercise and there is a lot of time remaining in that session, the therapist can move on to the next training exercise for that day. However, on the following training day, the therapist must start with and repeat the activity level in which the 85% target was not reached.

Documents

download.lww.comdownload.lww.com/.../JHTR/A/JHTR_1_1_2014_03_31_NEUMANN_… · Web viewThis section shows a mixture of eight faces from the current and previous level for review