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108
Towards
the
neuropsychological
foundations
of
couples
therapy
following
acquired
brain
injury
(ABI):
a
review
of
empirical
evidence
and
relevant
concepts
Giles Yeates*
Abstract
The professional support of intimate relationships following acquired brain injury
(ABI) is required to respond to their social, psychological, and neuropsychologi-
cal dimensions. In relation to the latter, while the unique contribution of the
brain injury itself on the couples’ relationship has long been recognised, a neuro-
psychological component of couples’ interventions has remained outstanding.
The advent of social neuroscience has provided bridging concepts and stimu-
lated focused studies of specific social neuropsychological impairments post-
injury. Social cognition rehabilitation strategies are now emerging, but have been
developed in parallel to family and couples psychotherapeutic work. This narra-
tive, unsystematic review explores the potential for cross-fertilization of these
traditions by covering: i) a summary of couples outcomes post-injury; ii) the
range of neuropsychological impairments post-injury that may impact on the
couples’ relationship; and iii) neuro-rehabilitation interventions to date that aim
to specifically address the interpersonal dimension of some of these impairments.
The literature review concludes with a suggested framework for conceptualising
the impact of altered neuropsychological functioning on couples’ relationships
as differing forms of socio-emotional misattunement. Necessary components of a
neuropsychologically-informed couples intervention are provisionally outlined.
Key words
: brain injury, stroke, social cognition, couples, relationships, couples
therapy.
Introduction
and
overview
A frequent issue brought to brain injury services is a profound sense of
disconnection between romantic partners when one is a survivor of
acquired brain injury (ABI). This disconnection is most easily charac-
terised by a loss of felt closeness in the relationship and familiarity
Neuro-Disability & Psychotherapy
1(1)
108–150 (2013)
*Correspondence to: Dr Giles Yeates, Community Head Injury Service, Buckinghamshire
Healthcare NHS Trust, Camborne Centre, Jansel Square, Bedgrove, Aylesbury, Bucks,
HP21 7ET, UK. E-mail: Giles.Yeates@buckspct.nhs.uk
Q1
5-Yeates.qxp 04/01/2013 14:18 Page 108
between partners. However it is often the “elephant in the room” in sub-
sequent points of therapeutic contact. Other rehabilitation foci can take
prominence, such as maximising the functional independence and facil-
itating the emotional management of the survivor (Yeates, 2011). Where
couples and families are the focus of professional involvement, relatives’
understanding of ABI sequelae and assistance in survivor rehabilitation
feature heavily. This is in contrast to the rarity of goals for
inter
-depen-
dence, increasing closeness, intimacy, and connection in the romantic
relationship.
A relational perspective on brain injury and neuro-rehabilitation has
developed over several decades and has intensified in the literature
within recent years (Bowen, Yeates, & Palmer, 2010). This movement
has included the application of systemic and family therapy ideas to con-
ceptualise social contextual influences (e.g., socio-economic factors,
culture, gender, socially-negotiated meanings) on ABI and the trajectory
of subsequent relationships. Supportive strategies for conversation and
communication between partners have developed within this tradition
(e.g., Bowen, Yeates, & Palmer, 2010; Watzlawick & Coyne, 1980). The
links between subjective psychological distress in intimate relationships
post-injury and enduring mental health outcomes for both survivors and
their partners have been noted (Perlesz, Kinsella, & Crowe, 2000). A dis-
juncture exists however, between the acknowledged contribution of
neuropathology on altered intimate relationships (e.g., Gosling & Oddy,
1999; Rosenbaum & Najenson, 1976) and the absence of neuropsycho-
logical formulation or intervention in professional support for couples.
This review aims to establish the conceptual foundations of how to
remedy this disjuncture. Several sources of literature are comprehen-
sively gathered together: i) a summary of couples’ outcomes post-injury,
ii) demonstrated links between differing neuropsychological impairments
and interpersonal outcomes, including; iii) those impairments conceptu-
alised within contemporary social neuroscience frameworks, and iv)
social cognition rehabilitation efforts. It is based on both the empirical
and theoretical literature currently available, as such focusing on hetero-
sexual couple relationships initiated both prior to and subsequent to the
index injury, where children may be present.
The core fundamental neuropsychological threats to intimacy and
attachment described in this paper are considered broadly applicable
across sexual orientations in couples, while a specific consideration of
sexuality difference is explored by Bowen, Yeates, and Palmer (2010).
The decision to review across ABI subgroups is based on comparable
findings for the presence of relevant neuropsychological impairments
and relationship outcomes across these groups (the reader will see that
findings relating to differing forms of ABI are represented in the study of
COUPLES THERAPY FOLLOWING ACQUIRED BRAIN INJURY
109
Short-
ened
run-
ning
head-
er
OK?
5-Yeates.qxp 04/01/2013 14:18 Page 109
each impairment category). Where a specific finding only relates to one
ABI subgroup, this will be mentioned exclusively (e.g., traumatic brain
injury, TBI). As there are insufficient studies in the current literature that
directly address the link between neuropsychological impairments and
couples’ relationships, studies that have explored related psychosocial
outcomes have also been included, and both conceptual and empirical
perspectives have been incorporated. A systematic or quantitative review
is not currently possible given the infancy of the dedicated literature on
this topic. As such, a narrative, unsystematic review format is presented
below, chosen to maximise a comprehensive survey of the literature that
does not prematurely reject studies of relevance, but where a statistical
or more tightly-defined categorical synthesis is not possible due to study
heterogeneity (Popay et al., 2006).
Unique
couple
relationship
outcomes
after
neurological
injury
In a seminal study, Rosenbaum and Najenson (1976) highlighted the
unique quality and increased challenges for couples’ relationships fol-
lowing brain injury in comparison with orthopaedic controls. Follow-up
studies using this comparative sample methodology (using spinal cord
injury and orthopaedic groups) have both confirmed (Peters, Stambrook,
Moore, & Esses, 1990) and failed to find (Bracy & Douglas, 2005; Frank,
Haut, Smick, Haut, &Chaney, 1990; Kreuter, Dahllöff, Gudjonsson,
Sullivan,& Siösteen, 1998; Testa, Malec, Moessner, & Browt, 2006) a
trend for worse relationship outcomes in couples and families following
ABI. However the dimension of time post-injury has not been sufficiently
matched in these studies.
Other studies within the literature have used a range of relationship
indicators within ABI samples. These have usefully been reviewed by
Godwin, Kreutzer, Arango-Lasprilla, and Lehan (2011), who note the
marked variability of post-injury separation and divorce rates across even
large sample studies, ranging from fifteen to seventy-eight per cent. This
review critiques the gross nature of marriage outcome as an index of the
relationship, and highlights qualitatively distinct problems experienced
by couples post-injury who do remain together. These include high lev-
els of marital dissatisfaction, dyadic maladjustment, sexual dysfunction,
and progressive social isolation for both partners. Outcomes for non-
injured partners include increased burden, strain, stress, and clinical
anxiety and depression. Many of these outcomes have been shown to
increase over time post-injury (for specific studies see Bowen, Yeates, &
Palmer, 2010; Godwin, Kreutzer, Arango-Lasprilla, & Lehan, 2011).
Subjective experiences of partners themselves, where studied, indicate
the quality of disconnection and distress that may not fully be captured
110 G. YEATES
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in the aforementioned literature. Non-injured partners (predominantly
female) describe such as “living with a monster”, or living with “Jekyll
and Hyde” (Wood, 2005). Others describe being “married to a stranger”
(Wood, 2005), “married without a husband” (Mauss & Ryan, 1981), or
wanting their real husband back (Wood, 2005). Intimacy “feels wrong”
to some partners (Gosling & Oddy, 1999), with the emotional aspect of
the relationship side feeling “badly damaged” (Oddy, 2001). Some part-
ners report a dislike for physical contact (Rosenbaum & Najenson, 1976).
Two recent qualitative studies of intimacy following ABI reported the
accounts of both survivors and their partners. Gill, Sander, Robins,
Mazzei, and Struchen (2011) used a thematic analysis to identify both
barriers to intimacy in couples’ relationships following traumatic brain
injury (physical, cognitive, and emotional changes, emotional reactions
to changes, altered personhood of the survivor, sexual strains and incom-
patibilities, role changes/conflicts, communication difficulties, family
factors, isolation) and dimensions of relationship strength that supported
the quality and longevity of the relationship post-injury (unconditional,
unselfish love, being there, commitment to staying and working on the
relationship, being understanding, pre-injury relationship foundation,
gratitude for survival, spending time together/friendship, social support,
family bonds, spirituality, prior experience, coping skills).
Yeates, Whitehouse-Hart, and Balfour (in press) focused on elements
that were disturbing and hard for respondents (twenty couples) to articu-
late. Post-injury changes in survivor interpersonal functioning were
experienced as intrusive for both partners and survivors, who also
reported themes of lost familiarity, distance, and alienation within the
relationship. Judgements of personality change in the other partner were
made both by relatives and survivors within these experiences, highlight-
ing disrupted affective recognition of the other as a critical factor in rela-
tionships post-injury. The non-injured partner’s experiences were
private: the disturbing extent of these changes post-injury were not wit-
nessed to the same degree by friends or other family members. In addi-
tion to pre-injury vulnerabilities in the relationship, disturbances to
emotional and intentional attunement between the couples were associ-
ated with these interpersonal experiences, suggesting a role for injury-
specific neuropsychological factors. Indeed, all of the survivor
participants of this study demonstrated at least one form of social cogni-
tion impairment on testing.
These subjective experiences are incongruous with many of the essen-
tial overlapping factors that have been shown over decades of research
to constitute romantic love: passion, intimacy and commitment, sexual
desire, attachment, and mate selection/focused attention on one specific
individual (Aron, Fisher, & Strong, 2006; Fisher, 2004; Yovell, 2008). In
COUPLES THERAPY FOLLOWING ACQUIRED BRAIN INJURY
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making closer links between unique injury-related factors and couples
relationships, certain cautions must be headed. Outcome studies high-
light the complex relationship between injury-related variables and out-
comes in the social domain, noting for example that psychological or
social variables often mediate injury-related factors or predict greater
variance in the outcome of interest than injury related variables (see
Bowen, Yeates, & Palmer, 2010, for full review). With this orientation to
psychosocial complexity then, it is now possible to proceed and review
empirical and conceptual studies that highlight the unique contribution
of ABI to the couple relationship through the identification of neuro-
psychological deficits post-injury that impact on interpersonal and social
relationships. Evidence will be considered within each major domain of
cognitive functioning in turn.
Neuropsychological factors of influence: traditional constructs
Executive functioning
Executive dysfunction has long been associated with negative outcomes
for those close to the survivor. Early authors identified problems in-
cluding aspontaneity, stubbornness, difficulty responding to changes in
routine, and disinhibition as the greatest predictors of partner burden or
stress (Brooks, Campsie, Symington, Beattie, & McKinlay, 1987;
Weddell, Oddy, & Jenkins, 1980). More recently, executive difficulties
demonstrated through neuropsychological assessment have been shown
to be associated with reduced social participation (Nybo, Sainio, &
Müller, 2004; Villki et al., 1994), strained social relationships and inter-
personal difficulties (Mazaux et al., 1997; Yeates et al., 2008), increased
likelihood of domestic violence within the couple relationship (Marsh &
Martinovich, 2006), and other psychosocial outcomes such as unem-
ployment and poor community integration (Martzke, Swan & Varney,
1991; Ownsworth & Fleming, 2005; Tate, 1999; Villki et al, 1994).
Furthermore, the executive functions of cognitive flexibility and inhibi-
tion of self-orientated perspectives have been shown to be critical
adjuncts to social cognitive processes discussed below (Grattan,
Bloomer, Archambault, & Eslinger, 1994; Henry, Phillips, Crawford,
Ietswaart, & Summers, 2006; Samson, Apperly, & Humphreys, 2007;
Shamay-Tsoory, Tomer, Goldsher, Berger, & Aharon-Peretz, 2004).
Memory
Memory problems for the survivor have been linked, among other
factors, to judgements of personality change by relatives (Weddell &
112 G. YEATES
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Leggett, 2006), a core phenomenological dimension in partner’s dis-
tress around closeness, intimacy, and the couple relationship (Yeates,
Whitehouse-Hart, & Balfour, in press). The use of an electronic com-
pensatory memory device was shown to reduce carer strain in a group
of partners and parents of injury survivors (Teasdale et al., 2009), sug-
gesting that unmanaged memory difficulties may contribute to relative
distress.
Attention
Other strands of neuroscientific research have focused on the social
specialisation for at least one form of attention, shared social attention,
and orientating to the eye-gaze direction of others. This has been linked
to the superior temporal sulcus (STS) (see Langton, Watt, & Bruce, 2000;
Perrett et al., 1985), and the orbito-frontal cortex (Baron-Cohen, 1997;
Vecera & Rizzo, 2006) and has been identified as a necessary precursor
for more sophisticated mentalising abilities (Baron-Cohen, 1997). In ABI,
difficulties have been reported in both shared attention (Campbell,
Haywood, Cowey, Regard, & Landis, 1990) and voluntary shifting of
attention triggered by social contextual cues such as words or eye gaze
direction (Langton, Watt, & Bruce, 2000; Perrett et al., 1985). No author
has to date studied associations between such deficits and couple func-
tioning quantitatively, but a qualitative study identified the barrier that
problems alternating attention pose for spontaneous and responsive
gestures of intimacy and connection (Gill, Sander, Robins, Mazzei, &
Struchen, 2011). This function seems to be theoretically relevant and
such associations plausible. Finally, McDonald and colleagues
(McDonald, Bornhofen, & Hunt, 2009; McDonald et al., 2011) speculate
on the auxiliary role of focused attention for socio-emotional communi-
cation processes.
Language
The interplay of language disorders and relationships has been both
acknowledged (e.g., McDonald, 2000) and neglected. The interrelated
concepts of pragmatic communication, nonverbal communication, and
social communication have been operationalised in this literature, over-
lapping with contemporary social neuroscience concepts discussed
below. In addition there are studies focusing on overt aphasia and cou-
ples’ relationships. An association between the presence of aphasia post-
stroke and reduced marital satisfaction has been demonstrated by
authors, but findings on the relationship between aphasia severity and
marital satisfaction have been mixed across studies (Williams, 1993;
COUPLES THERAPY FOLLOWING ACQUIRED BRAIN INJURY
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Williams & Freer, 1986). Buxbaum (1967) found that wives’ degree of
affective nurturance towards their husbands was related to their per-
ception of the severity of their husband’s aphasia and also positively
correlated with their (wives’) own marital satisfaction post-stroke, but
unrelated to their actual interactions and shared activities with their hus-
bands. L
//
apkiewicz, Grochmal-Bach, Pufal, and Tl
//
okin´ ski (2008) used a
non-aphasic stroke control group to demonstrate decreased marital
coherence, quality of life, and received support in partners of stroke
survivors with aphasia.
Neuropsychological
factors
of
influence:
socio-eemotional
communication
Early psychosocial outcome studies identified emotional, personality,
and behavioural changes as greater predictors of partner burden or
stress in comparison with cognitive or physical changes (Brooks,
Campsie, Symington, Beattie, & McKinlay, 1987; McKinlay, Brooks,
Bond, Martinage, & Marshall, 1981; Oddy, Humphrey, & Uttley, 1978;
Thomsen, 1974, 1992). These categories of personality and emotional
change require greater specificity and neuropsychological formulation
(Yeates, Gracey, & McGrath, 2008). Descriptions of childishness, irri-
tability, emotional lability, and poor impulse control were included in
these broad categories, as were referents to social interactional problems
(losing track of social conversation, withdrawing from social interaction,
behaving in a socially embarrassing way). Contemporary social neuro-
science has arguably brought a greater level of conceptual specificity to
these presentations, indeed the proposed
DSM-V
will include “distur-
bances in social cognition” in the diagnostic criteria for traumatic brain
injury (APA, in preparation).
In contrast to previous frameworks that have described impairments at
the level of social inputs and outputs for individuals (e.g., Tonks,
Williams, Frampton, & Yates, 2007), this review will draw on concepts
from social neuroscience focused on the communicative processes and
actions between people. These processes are commonly comprised of
shared representations and responses between people (“intersubjective
space”), emerging from social interaction involving interacting neuropsy-
chological functions in multiple brains. These processes can be distin-
guished by distinct qualities and functions, that Frith and Wolpert (2004)
and Gallese (2006) differentially describe as a) perspectival space—men-
talising and intentional decoding, b) “we-centric” space—emotion
recognition and affective attunement, and c) closing the loop—socially-
appropriate decision-making and behaviour.
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Perspectival space—mentalising and intentional decoding
Traditionally referred to as theory of mind, this is a neuropsychological
process where the intentions, goals, beliefs, and perspectives of another
are inferred, using a range of behavioural and situational information that
may be available.
Neuro-anatomical substrate and conceptual framework
A range of studies have identified the following neuro-anatomical
structures to be involved in mentalising operations i) tempero-parietal
junction (TPJ), ii) temporal poles, and iii) medial frontal cortex (for
reviews see Frith & Frith, 2003, 2006). The first component involves the
socially-shared attention function described earlier, involving the pos-
terior end of the superior temporal sulcus and the adjacent TPJ. This sup-
ports the following of others’ eye gaze direction to determine a shared
point of focus (Langton, Watt, & Bruce, 2000; Perrett et al., 1985). This
area also supports the ability to represent the world from different visual
perspectives, allowing the observer to know what is different about
another’s view or position. Impairments on mentalising tasks have been
demonstrated in patients with TPJ damage by a group of researchers
(Apperly, Samson, Chiavarino, & Humphreys, 2004; Samson, Apperly,
Chiavarino, & Humphreys, 2004; Samson, Apperly, & Humphreys,
2007), who conclude that the TPJ is necessary for the ability to infer
someone else’s perspective. This works in parallel with the right inferior
frontal gyrus, the latter recruited to inhibit one’s own perspective during
these operations.
A second component of mentalising is mediated through the temporal
poles (TPs), where a convergence of differing modality inputs produces
sophisticated contextually-based social knowledge, often based on nar-
ratives or scripts (Olson, Plotzker, & Ezzyat, 2007). This is flexible and
responsive, allowing the application of both general and moment-to-
moment knowledge of specific individuals in specific contexts during the
process of mentalising. This process also seems to be guided by an affec-
tive, visceral responsivity. Damage to TPs has been shown to impair the
access to and use of this information (Funnell, 2001). The TPs and their
interconnections with the amygdala have been conceptualised as one
homogenous socio-affective component of mentalising (Olson, Plotzker,
& Ezzyat, 2007). Some authors (Adolphs, Damasio, & Tranel, 2002;
Shaw et al., 2004; 2005; Stone, Baron-Cohen, Calder, Keane, & Young,
2003) have drawn attention to the amygdala’s role in representing the
mental states of others, and acquired damage to the amygdala has been
shown by these investigators to be associated with failures on mentalis-
ing tasks for both affective and epistemic (belief content) perspectives of
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others (Stone, Baron-Cohen, Calder, Keane, & Young, 2003; but chal-
lenged by findings from Shaw et al., 2004).
The third neuropsychological and neuroanatomical component of the
mentalising trinity is perhaps the hardest to define and has been sub-
jected to the most scrutiny. Certain investigators (Amodio & Frith, 2006)
have drawn attention to the key role of the medial frontal cortex (MFC)
and the adjacent paracingulate cortex, contributing to mentalising in dif-
ferent ways. The overall function is claimed to be the anticipation of
future mental states in others, but with more dorsal and rostral areas of
the MFC involved in a) understanding perspectives likely to be different
from one’s own, b) inferring what people are thinking, c) inferring pri-
vate, non-communicative intentions and actions of others, and d) initiat-
ing instances of shared communication of intention. In contrast an area
ventral to this is involved in a) quick “like me” processing to rapidly infer
others’ mental states similar/in harmony with one’s own, and b) inferring
communicative intentions in others. The most ventral area of the MFC
involving orbital cortices is considered to be involved in the inferring of
others’ emotions.
Mentalising has been shown to functionally and neuropathologically
dissociate from executive functioning (Fine, Lumsden, & Blair, 2001;
Havet-Thomassin, Allain, Etcharry-Bouyx, & Le Gall, 2006; Rowe,
Bullock, Polkey, & Morris, 2001). However difficulties in cognitive flexi-
bility (Channon & Crawford, 2000; Grattan, Bloomer, Archambault, &
Eslinger, 1994; Henry, Phillips, Crawford, Ietswaart, & Summers, 2006;
Shamay-Tsoory, Tomer, Goldsher, Berger, & Aharon-Peretz, 2004) and
problems in the inhibition of self-perspective (Samson, Apperly, Kathir-
gamanathan, & Humphreys, 2005; Samson, Apperly, & Humphreys,
2007) have been shown to be associated with mentalising performance
in brain injury groups in complex and heterogeneous ways. Bibby and
McDonald (2005) showed that while general inferential, working mem-
ory and implicit language abilities may influence performance of people
with TBI on mentalising tasks, they are not sufficient to account for this
performance completely, nor discount the possibility of an indepen-
dently-existing mentalising deficit in its own right.
Mentalising and ABI
Within studies on acquired brain injury, mentalising has been shown to
be impaired in survivors of TBI. This includes, and in some studies is
restricted to, frontal damage (Bibby & McDonald, 2005; Channon,
Pellijeff, & Rule, 2005; Havet-Thomassin, Allain, Etcharry-Bouyx, & Le
Gall, 2006; McDonald & Flanagan, 2004; Milders, Fuchs, & Crawford,
2003; Milders, Ietswaart, Crawford, & Currie, 2008; Muller et al., 2009;
Santoro & Spears, 1994; Stuss, Gallup, & Alexander, 2001), bilateral but
116 G. YEATES
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not unilateral damage to anterior cingulate from mixed neuropathology
(Baird et al., 2006), a patient that underwent stereotactic anterior capsu-
lotomy (Happé, Mahli, & Checkley, 2001), post-operative lesions from
space-occupying masses in frontal cortical areas (Channon et al., 2007),
mixed frontal aetiologies (Channon & Crawford, 2000; Grattan,
Bloomer, Archambault, & Eslinger, 1994; Rowe, Bullock, Polkey, &
Morris, 2001; Shamay-Tsoory, Tomer, Berger, &Aharon-Peretz, 2003),
and varied right hemisphere pathology following cerebrovascular acci-
dent (CVA), including anterior damage (Happé, Brownell, & Winnder,
1999).
Failures to find mentalising deficits following frontal lesions are also
reported, including participants with MFC (Bird, Castelli, Malik, Frith, &
Husain, 2004) and orbital frontal cortex (OFC) (Bach, Happe, Fleminger,
& Powell, 2000; Blair & Cipolotti, 2000) damage. Mentalising deficits
have been found for the latter group when using more affective material
(Stone, Baron-Cohen, & Knight, 1998). A meta-analysis (Martín-
Rodríguez & León-Carrión, 2010) notes the highest effect size of demon-
strating mentalising impairments has been achieved in the presence of
frontal damage. An important observation is that in TBI at least, the pres-
ence of mentalising impairments is unrelated to time post-injury (Bibby &
McDonald, 2005) and has been shown to remain stable across repeated
assessments over time (Milders, Ietswaart, Currie, & Crawford, 2006).
Mentalising as inference or intentional attunement?
Current debate in this literature differentially emphasises the role of auto-
matic processes within mentalising. Mirror neuron theorists have high-
lighted a different neuroanatomical network to suggest that the inference
of others’ intentions can be achieved through automatic process of
attunement (e.g., Gallese, Keysers, & Rizzolatti, 2004). Subjectively,
intentional attunement involves quick reflexive awareness of another’s
goal pursuit (Gallese, 2006), described by Merleau-Ponty (1962): “It is as
if the other person’s intentions inhabited my body and mine his” (p. 185),
or by Gallese (2006): “the collapse of the other’s intentions into the
observer’s ones” (p. 21). The ability to inhibit unintentional motor mim-
icry has been shown to be associated with the ability to attribute others’
mental statistics in frontal injury participants, and also associated with
visual and cognitive perspective taking in participants with damage to
the TPJ (Spengler, von Cramon, & Brass, 2010), indicting a common
underlying mechanism of embodied and higher-level social cognition,
which the authors suggest is involved in the inhibition of self-perspective
when interacting with others.
While mentalising theorists now emphasise automaticity, they note
that mentalising offers a unique contribution to social communication:
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the inference of more stable mental attributes, the conceptualisation of
difference in others’ perspectives, causal explanations of quick socio-
emotional exchanges, and inhibition of self-perspectives to avoid the
confusion with the inferred intentions of another (Frith & Frith, 2006).
Those emphasising automatic attunement in turn acknowledge the need
for a deliberate inferential approach within a socially ambiguous
scenario, where others’ intentions are not immediately clear or commu-
nicable (Rizzolatti, Fabbri-Destro, & Cattaneo, 2009).
“We-centric” space—emotion recognition and affective
attunement
Mirror neuron theorists consider certain neuroanatomical networks to
support a “simulation” process of social communication (for review see
Gallese, Keysers, & Rizzolatti, 2004; Rizzolatti, Fabbri-Destro, &
Cattaneo, 2009), automatic and embodied, not inferential. Examples in
the social domain include contagious laughter, picking up on a tense
atmosphere in a room, and involuntary mirroring of others’ facial ges-
tures or postures. From individuals in social interaction there is an emer-
gence of a “shared manifold” (Gallese, Keysers. & Rizzolatti, 2004) or
we-centric space (Gallese, 2006): those connected in exchanging socio-
affective information are connected on the basis of similar subjective
experience and bodily responses rather than differences in perspective.
These researchers focused initially on neurons within the inferior parietal
lobe and the caudal part of the inferior frontal gyrus, found to simultane-
ously fire for observed-other and self-generated hand and mouth motor
actions. A similar mechanism has since been described in the observa-
tion and experience of pain, emotion, and affective empathy, a proposed
process of simulation involving anterior aspects of the cingulate and
insula, together with the amygdala (reviewed in Gallese, Keysers. &
Rizzolatti, 2004). Others have described this as a
contagion
of emotion
(Hatfield, Cacioppo, & Rapson, 1994; Watt, 2007), emphasising an
unconscious, automatic quality (with empirical support from Dimberg &
Thunberg, 1998).
Emotion recognition and responsivity in ABI
These ideas have been considered in relation to the acquired neuro-
pathological evidence by Goldman and Sripada (2005). ABI participants
with damage to the anterior insula who can no longer experience disgust
or recognise facial expressions of disgust in others (Adolphs, Tranel, &
Damasio, 2003; Calder, Keane, Manes, Antoun, & Young, 2000). The
same has been found for the recognition and experience of both anger
and fear following amygdala damage (Adolphs, Tranel, Damasio, &
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Damasio, 1994; Sprengelmeyer et al., 1999). Gu and colleagues (2012)
found that participants with unilateral damage to the anterior insular cor-
tices were impaired in both explicit and implicit recognition of another’s
pain (from a first person viewpoint directed at limbs in painful situations),
when compared to both controls and participants with dorsal anterior
cingulate, dorsolateral prefrontal and temporal pole lesions. Goldman
and Sripada (2005) concur that core emotional states are passed between
individuals in an automatic, non-inferential way. They suggest either
reverse simulation (facial mirroring of emotional expressions leading to
the generation of that affective state in the observer), or a process of
shared resonance (the “tuning fork” model, Jacob, 2009) where the
embodied state is activated internally in all privy parties.
Other studies have not explored the simultaneous experience and
recognition of specific core emotions following neurological damage,
but have studied one of these dimensions in isolation. TBI, stroke, and
OFC/anterior cingulate cortex (ACC) neurosurgical samples have been
found to display deficits in recognising many emotional expressions from
static face stimuli (Adolphs, Damasio, Tranel, & Damasio, 1996;
Babbage et al., 2011; Borgaro, Prigatano, Kwasnica, Alcott, & Cutter,
2004; Croker & McDonald, 2005; DeKosky, Heilman, Bowers, &
Valensteine, 1980; Green, Turner, & Thompson, 2004; Hopkins, Dywan,
& Segalowitz, 2002; Hornak, Rolls, & Wade, 1996; Hornak, et al., 2003;
Jackson & Moffat, 1987; Kemp et al., 2012; Mandal et al., 1999;
McDonald & Saunders, 2005; Milders, Fuchs, & Crawford, 2003;
Milders, Ietswaart, Crawford, & Currie, 2008; Prigatano & Pribram,
1982; Soussigan, Ehrle, Henry, Schaal, & Bakchined, 2005; Spell &
Frank, 2000), particularly negative emotions (Blair & Cipolotti, 2000;
Croker & McDonald, 2005; Hopkins, Dywan, & Segalowitz, 2002;
Jackson & Moffat, 1987). It is claimed by one group that recognition of
fear/anxiety is most commonly problematic following injury (Braun,
Lussier, Baribeau, & Ethier, 1989). In a recent study emotion recognition
difficulties in a TBI sample were associated with the presence of dysos-
mia (impairments in olfaction) on formal testing (Neumann et al., 2012).
Emotion recognition deficits have been found for speech without facial
information, the recognition of prosody and emotional tone (Dimoska,
McDonald, Pell, Tate, James, 2010; Hornak, Rolls & Wade, 1996;
Hornak et al., 2003; McDonald & Pearce, 1996; McDonald & Saunders,
2005; Marquardt, Rios-Brown, Richburg, Seibert, & Cannito, 2001;
Milders, Fuchs, & Crawford, 2003; Milders, Ietswaart, Crawford, &
Currie, 2008; Paulmann, Seifert, & Kotz, 2010; Pell, 2007; Ross, 1981;
Spell & Frank, 2000; Williams, & Wood, 2010), and from postural cues
(Jackson & Moffat, 1987). Deficits in emotion recognition have been
demonstrated in video stimuli combining both visual and audio elements
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(McDonald & Flanagan, 2004; McDonald & Saunders, 2005). Emotion
recognition impairments in TBI have been shown to be independent of
other aspects of cognition, but related to injury severity (Spikman,
Timmerman, Milders, Veentra, & van der Naalt, 2012). They have been
demonstrated to be stable post-injury and enduring across time
(Ietswaart, Milders, Crawford, Currie, & Scott, 2008; Knox & Douglas,
2009).
Altered subjective experience of emotion alongside these receptive
deficits has been noted (Croker & McDonald, 2005; Hornak, Rolls, &
Wade, 1996; Hornak et al., 2003; Saunders, McDonald & Richardson,
2006), but the variability of this dimension within TBI samples and the
lack of a direct relationship between recognition and experience within a
specific emotion has been highlighted (Croker & McDonald, 2005;
Hornak et al., 2003). Certain authors (de Sousa, McDonald, & Rushby,
2012; de Sousa et al., 2010, 2011; McDonald et al., 2010) found impair-
ments in automatic facial mimicry in response to displays (static and
dynamic) of facial expressions of unpleasant emotions in their TBI sam-
ples, found to be related to autonomic responsivity and self-report of
empathic skill (de Sousa, 2010, 2011) but unrelated to emotion iden-
tification (McDonald et al., 2010). More consistently, there has been a
reliable demonstration of deficits in autonomic arousal and visceral emo-
tional responsiveness (muted galvanic skin response, and/or a felt sense
of compassion, sorrow, or being moved emotionally) in relation to socio-
emotional cues following TBI (Blair & Cipolotti, 2000; Buchanan, Tranel,
& Adolphs, 2004; de Sousa, McDonald, & Rushby, 2012; de Sousa et al.,
2010, 2011; Hopkins, Dywan, & Segalowitz, 2002; McDonald et al.,
2011), particularly expressions of negative emotions (Saunders,
McDonald & Richardson, 2006; but see also Turner et al., 2007). These
deficits are framed by some authors as absolute and enduring, while
others hypothesise a continuum model of autonomic responsivity, damp-
ened but not completely absent following injury, and open to experi-
mental manipulation (Bowen, Yeates, & Palmer, 2010; Evans, Bowman,
& Turnbull, 2005).
Affective attunement as heterogeneous process?
While it is beyond doubt that the facial and spoken transmission of affect
can be a direct and viscerally-potent experience, its naturalistic occur-
rence often manifests within a tapestry of other multi-modal, dynamic
information. Studies of ABI attempting to capture this complexity have
reported mixed results, depending on the variables operationalised.
Some authors have demonstrated a relatively preserved or improved
ability for individuals with ABI to recognise emotions within a dynamic
display (Atkinson, Heberlein, & Adolphs, 2007), sometimes alongside an
120 G. YEATES
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impairment in the recognition of static facial emotional expression
(Adolphs, Tranel, & Danasio, 2003; Humphreys, Donnelly, & Riddoch,
1993; McDonald & Saunders, 2005; Saunders, McDonald, & Richard-
son, 2006; Williams & Wood, 2010). In contrast, superior performance
on static
vs.
dynamic displays has been found by Knox and Douglas
(2009) and deficits in affect recognition from dynamic displays were
noted when both visual and audio (speech content) elements were
included (Saunders & McDonald, 2005). Authors in these latter studies
consider dynamic displays to be more cognitively demanding and so
exploit a greater range of deficits (attention, working memory, visual
tracking, etc.) for TBI participants. A specific combination of deficits was
noted in a case of amygdala damage, where emotion recognition deficits
were shown to co-occur alongside a tendency for the participant to spon-
taneously fixate less on eye regions of the facial stimuli (Adolphs, Tranel,
Damasio, & Damasio, 1994; Adolphs et al., 2005).
The understanding of complex socio-emotional communications such
as sarcasm and irony seem to require both cognitive perspective-taking
and the registration of affective, prosodic tone, with these elements and
their acquired neuropathology differentially emphasised across differ-
ing testing paradigms (Channon, Pellijeff, & Rule, 2005; Martin &
McDonald, 2005; Shamay-Tsoory, Tomer, & Aharon-Peretz, 2005).
Emotion recognition deficits have been shown to extend into the seman-
tic domain, when tested (Croker & McDonald, 2005; Milders, Fuchs,
& Crawford, 2003; Milders, Ietswaart, Crawford, & Currie, 2008; Park
et al., 2001), although dissociations have been reported for impaired
prosodic
vs.
intact semantic processing (Dimoska, McDonald, Pell, Tate,
& James, 2010) and intact semantic affect recognition
vs.
impaired facial
affect recognition in (Braun, Lussier, Baribeau, & Ethier, 1989) in TBI
samples. Many aspects of socio-emotional communication may there-
fore be emergent, composite phenomena, prone to pathological fraction-
ation. In turn, there is evidence that the neuropsychological systems that
such phenomena depend on are distinct in themselves. In TBI at least,
difficulties in emotion recognition have been shown to be neuropatho-
logically and functionally independent from mentalising (Henry, Phillips,
Crawford, Ietswaart, & Summers, 2006).
Closing the loop—socially appropriate decision-making and
behaviour
The decoding of other’s perspectives, or the sharing of an experienced
affect, lead within normal social encounters to an action tendency—a
response that is elicited and expected by others involved in the
encounter. A congruent, functional, and satisfactory response within
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121
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Q5
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both a given set of culturally-relative norms (Brothers, 1997) and univer-
sal, cross-cultural attachment patterns (Watt, 2007) can be seen to close
a communication loop. This seems to essentially involve the responsive
application of relevant social knowledge during social encounters, vis-
ceral arousal guiding cognitive operations, and the regulation of affect
and behaviour.
Following ABI there are a myriad of ways in which the interactional
loop is not closed in an attuned way or as per normal convention. With
regards to the application of social knowledge, (mostly frontal injury) sur-
vivors have been unable to access social schema knowledge during
mentalising (Channon & Crawford, 2000), detection of social norms
(Blair & Cipolotti, 2000), make accurate judgements of “approachability”
for faces expressing negative emotions (independent of emotion recogni-
tion ability, Willis, Palermo, Burke, McGrillen, & Miller, 2010), and
social problem-solving, normally used to inhibit aberrant behaviour
(Dimitrov, Grafman, & Hollnagel, 1996; Grafman, 1994; Grafman et al.,
1996). The latter has been shown to co-occur in one ABI sample with
mentalising difficulties (Channon & Crawford, 2010). Martins, Faisca,
Esteves, Muresan, and Reis (2012) found an atypical pattern of moral
judgement-making in a TBI sample (who tended more commonly than
controls to allow harm to occur to one story character for the greater
good), significantly associated with the presence of social emotion
recognition difficulties. A tendency to violate the peri-personal space of
others has been demonstrated following OFC damage (Morris, Pullen,
Kerr, Bullock, & Selway, 2006). An acquired deficit in social exchange
reasoning following OFC and anterior-medial temporal damage has
been demonstrated alongside intact non-social reasoning (Stone,
Cosmides, Tooby, Kroll, & Knight, 2002). Saver & Damasio (1991)
reported intact access to social knowledge but maladaptive social behav-
iour in a case of ventro-medial frontal damage.
This latter finding highlights the role of impaired visceral responding in
inappropriate social behaviour. Some authors have developed a model
of
somatic marker
deficits following ventro-mesial frontal, amygdala,
and insula damage, restricting a survivor’s access to visceral/emotional
signals during social decision-making. These result in minimal anticipa-
tory autonomic arousal and impaired reversal learning across differing
contingencies undisclosed in advance, assessed using a gamble task par-
adigm (Bechara, Damasio, Damasio, & Anderson, 1994; Damasio,
1994). Differing forms of impaired gamble task performance have been
repeatedly demonstrated in participants with differing profiles of ventro-
medial and insular damage (e.g., Bechara, Damasio, & Tranel; 2005;
Clark et al., 2008) and in a ventromedial frontal damage group impaired
performance has been demonstrated to endure across a six year post-
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injury retesting period (Walters-Wood, Xiao, Denberg, Hernandez, &
Bechara, 2012). Somatic markers are claimed to be necessary processes
within the ambiguity and/or complexity that characterises much of the
social dimension. The emoting areas in the ventromedial frontal cortex
are triggered by social cues (violation of social norms, others’ suffering,
social co-operation, embarrassment, guilt, and despair), in turn interact-
ing with control operations such as attentional, executive, and working
memory functions to guide social responding (Damasio, 1994; 2003).
Similarly, a review of the temporal poles (Olson, Plotzker, & Ezzyat,
2007) suggests that a core function of this structure, intimately intercon-
nected with the OFC, is to link social cues to the visceral responsiveness
of the individual. The shared core presentations of developmental,
acquired, and progressive pathologies involving the temporal poles
include significant fluctuations in mood, emotional blunting or inappro-
priate emotional responses to others, or socially-congruent prioritisation.
Other authors highlight a core difficulty in affect regulation and frustra-
tion tolerance within social situations (Burgess & Wood, 1990).
The final area of relevance within this discussion is sexual dysfunction
post-injury. To connect with another within physical intimacy also
requires mindreading, attunement, and responsiveness that fit socially-
relative conventions of a sexual encounter. Disruption to such processes
in a sexual encounter have been linked in anecdotal case reports to
attentional switching difficulties (Gill, Sander, Robins, Mazzei, &
Struchen, 2011) and interoceptive emotion-based decision making diffi-
culties (Yeates, Balfour, & Whitehouse-Hart, in press). Ponsford (2003)
and Simpson (2001) have investigated factors influencing sexual dys-
function post-injury. While many indirect factors have been implicated
in these research programs (including side-effects of medication in addi-
tion to survivor depression and self-concept), the role of hypothalamic
and fronto-limbic damage has been noted to result in loss of sexual
desire and responsiveness (internal experience of arousal, erectile dys-
function, anorgasmia), or for a minority of TBI samples, hypersexuality
and sexual disinhibition (Ponsford, 2003). This is an under-researched
area and the empirical elaboration of sexual changes post-injury and
their impact awaits future study.
Socio-emotional communication impairments and
psychosocial outcome
These social cognitive difficulties are possible candidates for a neuro-
pathology of couples’ relationships. However, few studies have empiri-
cally explored associations between these impairments and any kind of
psychosocial outcome. Some studies have explored couples’ outcome
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but have identified impairment through questionnaire ratings of such dif-
ficulties (Burridge, Williams, Yates, Harris, & Ward, 2007; Williams &
Wood, submitted; Wood, Liossi, & Wood, 2005). These methodologies
are problematic given a) the range of non-organic factors that could
result in a significant other rating someone as, for example, a poor
empathiser, and also b) the neuroanatomical complexity described
above. As such, only the studies that have explored outcome while using
neuropsychological test measures of socio-emotional communication
impairment will be reviewed in detail below.
Mentalising and outcome
Some authors have observed that failures on mentalising tasks were asso-
ciated with everyday failure to use spontaneous social behaviour such as
humour, partner-directed behaviour, and establishing of “common
ground” in linguistic social interaction (Gupta, Duff, & Tranel, 2011;
McDonald & Flanagan, 2004). In contrast Milders and co-workers
(Milders, Fuchs, & Crawford, 2003; Milders, Ietswaart, Crawford, &
Currie, 2008) have shown that in TBI samples, failures on vignette and
cartoon-based measures of mentalising do not significantly predict psy-
chosocial functioning as rated on standardised questionnaires; only the
faux pas test (Stone, Baron-Cohen, & Knight, 1998) was reasonably cor-
related with a measure of social behaviour.
Emotion recognition and outcome
One study has formally explored the relationship of emotion recogni-
tion difficulties in an ABI sample and marital relationships. Blonder,
Pettigrew, and Kryscio (2012) have demonstrated significant associations
between the level of impairments in emotion discrimination, matching,
and nonaffective prosody discrimination, and marital satisfaction in a
right hemispheric stroke sample. Milders and colleagues (Milders, Fuchs,
& Crawford, 2003; Milders, Ietswaart, Crawford, & Currie, 2008) did not
find an association between emotion recognition and social outcome
measures, despite varying both neuropsychological testing paradigms
and choice of outcome measure. In other TBI studies, inverse predictive
and correlational associations have been demonstrated between abilities
in emotion recognition and social integration (Knox & Douglas, 2009;
Struchen et al., 2008). Positive correlations were also found between
social integration and survivors’ ability in matching facial affect to social
situations (Knox & Douglas, 2009). Facial affect recognition has been
positively associated with actual social communication competence as
rated by close others (Watts & Douglas, 2006) and within a child head
injury group, inversely correlated with relatives’ ratings of socially in-
appropriate behaviour (Pettersen, 1991). Struchen, Pappadis, Sander,
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Burrows, and Myszka (2011) demonstrated that the ability in a TBI sam-
ple to comprehend mental and emotional states in video clips predicted
the degree of community integration in that sample. To date, autonomic
responsivity to emotional cues has not been explored as a correlate or
predictor of social outcome.
Social decision making, behaviour, and outcome
Damasio’s (1994) speculative link between impairments in interocep-
tive-based decision making and difficulties in social relationships post-
injury has been explored empirically in participants with specific
ventro-mesial prefrontal cortical lesions (Bar-On, Tranel, Denburg, &
Bechara, 2003; Tranel, Bechara, & Denberg, 2002) and in a general TBI
group (Levine et al., 2005). These authors found significant correlations
between gamble task performance and behavioural and emotion scales
rated by survivors, significant others, and/or ratings of social functioning
by clinicians. Struchen and colleagues (2011) found that a measure of
“sending skills” (TBI participants’ enacting in role-plays their responses
to social problems represented on video clips) predicted the degree of
social integration in that sample.
Methodological
critique
of
the
literature
In applying this literature to couples relationships post-injury, caution
must be heeded in relation to the sensitivity of both the neuropsycholog-
ical testing paradigms and outcome measures to couple relationship
processes. Some authors have failed to demonstrate associations
between executive dysfunction with psychosocial outcomes, dependent
on the choice of neuropsychological and outcome measure (e.g.,
Martzke, Swan, & Varney, 1991; Milders, Fuchs, & Crawford, 2003;
Milders, Ietswaart, Crawford, & Currie, 2008; Ownsworth & Fleming,
2005).The mentalising literature has favoured the use of written stories
and vignettes as a test of this ability (e.g., Stone, Baron-Cohen, & Knight,
1998). These seem to involve stable cognitive appraisal and perspective-
taking from a distanced reader, and are not constituted through immedi-
ate social stimuli such as eyes, facial expression, posture, and verbal
communication—arguably the stuff of interpersonal relations.
Within this paradigm, there is also a frequent collapsing of differing
mentalising tasks within an overall scoring system (e.g., the ability to
know what someone else thinks,
vs.
the ability to know what someone
else thinks or intends for another’s mental states). This scoring system
potentially masks the detection of a more complex mentalising deficit,
considered to be a more common outcome for adult acquired neuro-
pathology (Happé, Brownell, & Winnder, 1999; Stone, Baron-Cohen,
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Calder, Keane, & Young, 2003) that may be pertinent for couple rela-
tional functioning. Some of the previously mentioned case study/case
series data (Bird, Castelli, Malik, Frith, & Husain, 2004; Shaw et al.,
2004) have suggested an absence of mentalising deficits following
medial frontal and temporal lesions. These results have been interpreted
by some authors as a challenge to the prevailing neuro-anatomical
models previously described (Frith & Frith, 2006; Gallese, 2006), but an
alternative reading is that such findings are a product of insensitive, het-
erogeneous scoring schemes on the mentalising measures. Indeed, Lee
and colleagues (2010) have provided a timely analysis of variation within
ABI group performance as a function of these different abilities, mea-
sured by different questions on the faux pas task (Stone, Baron-Cohen, &
Knight, 1998). They demonstrated that MFC patients could be most sen-
sitively discriminated from other injury and control groups through their
impaired performance on a question requiring the correct attribution of
an intention of one story character to another (deliberate or accidental
cause of offence to another).
A difficult task for investigators has been to approach the immediate,
complex, and multi-modal aspects of actual socio-emotional interactions
through a testing paradigm, while retaining an ability to fractionate inde-
pendent component functions of composite processes. When the former
has been neglected, interpersonal realities are not fully captured in the
investigation. Bird and colleagues (Bird, Castelli, Malik, Frith, & Husain,
2004) note that the husband of their participant with MFC damage rated
her as behaving inappropriately in social interactions, apparent within
the ever-changing and complicated social scenarios of everyday life.
However this participant passed all social cognition (mentalising) tests
administered. Knox and Douglas (2009) observed that in addition to their
emotion recognition data, TBI participants both spontaneously mirrored
the target facial expression to a much lesser degree than controls and
also exhibited much more incongruent verbal commentaries and infer-
ences in relation to the target material (e.g., in response to a visual
demonstration of a happy expression: “she’s got a smile on her face, but
actually she thinks
I hate you
”, p. 447). Callahan, Ueda, Sakata,
Plamondon, and Murai (2011) note in their TBI sample a “liberal bias”
where the valency of incorrectly-identified emotion was typically rated
at great intensity. As noted above, only a video-based mentalising task
yielded a significant association with psychosocial outcomes (McDonald
& Flanagan, 2004), further emphasising the importance of multi-modal
complexity.
Mirroring the complexity of real social interactions, some claims for
the isolation of pure social cognition deficits using certain paradigms
have in fact been challenged by authors who note the penetrability of
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other deficits into such tasks. In addition to aforementioned interrelation-
ships between mentalising and executive functions, the gamble task
paradigm and the associated concept of interoceptive-based decision
making has been subject to such critique and defence (Dunn, Dalgleish,
& Lawrence, 2006; Levine et al., 2005; Maia & McClelland, 2004;
Toplak, Sorge, Benoit, West, & Stanovich, 2010). Attempts to capture
complexity and diversity within a core function have been more or less
problematic. The mentalising literature includes diverse paradigms (story
vignettes, static and dynamic visual stimuli) which have been defended
through the demonstration of convergent validity between measures
(Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001). Elsewhere,
efforts in the emotion recognition literature to increase the complexity of
participant response to improve ecological validity have resulted in con-
tradictory findings across studies.
Finally, the failure in some cases to find associations between social
cognition impairment and psychosocial outcomes has also been attrib-
uted to the choice of outcome measure (Knox & Douglas, 2009). None of
the previous social cognition studies employing neuropsychological test
paradigms have used a measure of couple relationship quality or func-
tion, or of partner well-being, rendering possible associations purely
hypothetical at this stage.
Consequences
for
couples’
relationships
The impact of all of these impairments on the couple relationship itself,
defined by emotional closeness, potential for conflict resolution, and
adaptive communication, is considered here. This is a theoretical discus-
sion, based on associations between the author’s clinical experience and
the findings of the literature above. The absence of published studies
dedicated to empirically exploring these associations must render these
conjectures provisional at this stage, awaiting verification in future inves-
tigations. The possible impact of neuropsychological impairments is con-
ceptualised as potential and forms of misattunement within the
relationship, as summarised in Table 1.
Both shared and unique influences on attunement are noted, in terms
of content of an intended communication and valency or priority of a
focus within these gestures. Beginning with the traditional neuropsy-
chological constructs, difficulties in initiating socio-emotional commu-
nicative acts, anticipating outcomes, coordinating planning and prob-
lem-solving, abstract thinking, and responding flexibly to changes in
information can easily be seen as socially-debilitating qualities that can
put a couple out of synchrony with each other and those around them. If
important memories and communications cannot be shared between a
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128 G. YEATES
Table
1:
Neuropsychological
Impairments
following
ABI
and
misattunement
within
couples’
relationships
Neuropsychological Form of missattunement in the couple relationship
impairment
Executive Poor initiation of communicative, empathic, nurturing, and
functioning compassionate actions towards the other, poor initiation
of reconciliatory gestures as conflict escalates, perceived
as indifference and trigger for feelings of hopelessness
for the other.
Differing, contradictory, or unstable goals, intentions, and
plans, little coordination in problem-solving.
Difficulties anticipating problems or outcomes, generalising
across scenarios to avoid future conflict.
Inflexibility in responding to problems while maintaining
a partnership focus, formulating a reconciliatory or
de-escalating response during conflict.
Problems accessing or generating abstract concepts to
conceptualise the relationship.
Difficulties synthesising differing aspects of contextual
information to ascertain social meaning in the moment.
Attention No joint focus of attention.
No shared priority of attentional focus.
No sustained focus on social stimuli to aid comprehension.
Memory Reduced sharing of collective memories that signify
closeness and unity in the relationship, between partners
or in the interactions between the couple and others.
Difficulties holding on to and synthesising disparate,
complex socio-emotional information in working memory;
misunderstanding or confusion result.
Language (aphasia) Reduced sharing of conversation that signifies closeness
and unity in the relationship, between partners or in the
interactions between the couple and others.
Overt barrier to communication of intentions and
understanding to each other.
Expression of emotional connection through words limited
(but other direct embodied forms of affect expression and
comprehension possibly intact).
Mentalising Misattunement of intentions within couple communication.
Inaccurate inference of motives behind gestures (e.g.,
interpretation of neutral or positive intentions as
malevolent) and creation of confusion and conflict.
Missed early opportunities for the identification of meanings
in complex, paradoxical social communication, resulting
in conflict escalation.
Continued
5-Yeates.qxp 04/01/2013 14:18 Page 128
couple where amnesia and/or aphasia are present and the connecting
couple identities dependent on those reminiscences are undermined
(
re
newing
member
ship of the couple), distancing and exclusion will be
likely results.
A couple relationship is characterised by intense affect at times, chang-
ing interactions, and subtle and complex communications, often multi-
modal in nature. Responsivity is perhaps an ever-present requirement,
particularly in points of reconnection following conflict or when one part-
ner is in distress. As such, many of the aforementioned socio-emotional
communicative functions have a role, and their dysfunction could present
wide-ranging disruption to the relationship. The intensity of an emotional
COUPLES THERAPY FOLLOWING ACQUIRED BRAIN INJURY
129
Table
1:
Neuropsychological
Impairments
following
ABI
and
misattunement
within
couples’
relationships
((ccoonnttiinnuueedd))
Neuropsychological Form of missattunement in the couple relationship
impairment
Mentalising (continued) Confusion of self and other perspective, conflict escalation
and/or failed reconciliation.
Fewer switches from intense negative affective states/
communication to a meta-perspective with the relationship
and/or other’s experience in mind—conflict escalation.
Emotion recognition and Missed or inaccurate resonance of core affective states
autonomic responsivity (e.g., interpretation of neutral or positive emotions as
negative), conflict initiation or escalation and/or emotional
distancing as a result.
Delayed responses to critical emotional communication.
Failed resonance in autonomic responsivity within couple
communication, lack of complementary or synchronous
exchanges following emotional signalling: conflict
escalation or emotional distancing as a result.
Social decision-making Failure of, or ineffective application of socially-relevant
and behaviour knowledge to manage any given exchange within the
couple or respond to conflict.
Affect dysregulation and conflict initiation/escalation,
failed reconciliation.
Invasion of personal space and creation of tension and
conflict.
Ineffective use of gut-feeling during decision-making for
ambiguous dilemmas or choices within social communica-
tion; maladaptive influence of individual short-term
gains rather than longer-term benefits for the couple
relationship.
Sexual dysfunction, misattunement, and consequences for
broader psychological intimacy between partners.
5-Yeates.qxp 04/01/2013 14:18 Page 129
bond and moments of connection could be undermined by emotion
recognition and autonomic responsivity deficits. The survivor may be
experienced by their partner as distant, unavailable, and unresponsive, or
at the other extreme, over-responsive, dysregulated, and intrusive.
Responsivity and action orientated to a partner’s changing communi-
cations is often an indicator to that partner of how they are understood,
thought about, and the degree of closeness in the relationship (Johnson,
2004). As such, these dimensions of couples’ interactions may be both
the most critical and complex arenas for potential synthesis of socio-
emotional information (affect, representation, context) and flexible appli-
cations of such within ever-changing sequences. This flexibility and
responsivity could plausibly involve both the suggested interplay of
executive, attention, working memory, and social cognition functions
discussed above, and also the primacy of visceral responsivity: intero-
ception and emotion in guiding quick cognitive operations, as prioritised
by Damasio (1994).
These conjectures describe immediate processes of attunement within
couple interactions. At the same time, a couple organised only by the
immediacies of spoken and/or emotional communication may be prone
to conflict escalation and will miss opportunities for reconciliation. It can
be important for one or both partners to step out of the “hot” immediate
emotion and use a cognitive, inferential mentalising process to understand
the cause of another’s grievance or hurt, especially if this is in response to
an accusatory communication. Otherwise, inferences of malevolent
intent in close others may come to organise the relationship. This could
be considered to be a less direct, but equally valuable form of attunement.
Beyond content-based attunement there is the need to share priorities
and foci within communication. Both partners can understand the epis-
temic (e.g., beliefs, goals, perspectives, intentions) and affective content
of the other, but be misattuned in the valency each accord to such con-
tent. Non-injured partners often complain about “falling off the radar”
and no longer feel important enough to the survivor as they juggle com-
peting life priorities in any given moment. Given the impairments noted
above, there is a role for both executive/attentional and autonomic
arousal deficits to promote a mismatch in such priorities (which foci
make it to the centre of each person’s awareness at any one time) and the
subsequent drifting of a prioritised focus if it is initially established.
While the dimensions of communicative attunement and responsivity
can unite all of the above impairments, certain neuropsychological
impairments seem to have the potential for greater disruption to intimate
connection between the couple. As an example, aphasia is an overt
barrier to sharing perspectives through language, an obvious source of
frustration and distancing for a couple. However, the recognition and
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intention towards the other partner can still be visible in a survivor with
aphasia through other communicative gestures. These interpersonal
capacities may be undermined or absent following socio-emotional
impairments while language remains intact, with more disturbing results
for the couple. Further research is required to generate empirical distinc-
tions between the differential impact of each impairment on relationship
outcomes.
At this point it is important to return to a social contextual focus as a
warning against neuropsychological reductionism dominating our view
of brain injury and the couple. These impairments are also going to have
an impact on the couple’s relations with the wider social network, the
material roles and power-bases (employment, financial management,
community participation) available to each partner. All of these will
recursively impact on the couple relationship itself, as will the mental
distress of each partner in response to these impairments (e.g., Ponsford,
2003). A closer analysis of the couple highlights further interactional
complexity. Byom and Turkestra (2012) demonstrate that an adult TBI
sample did not increase the use of mental-state terms to the same degree
with a conversational partner when the conversational topic became
more intimate in nature, in comparison to controls. However Godfrey,
Knight, and Bishara (1991) showed partners’ responses to survivors with
social skills difficulties can be more facilitative and demonstrate more
positive affect than partners of survivors with superior social functioning.
Using couples therapy theory and data from both quantitative and quali-
tative studies, a case has been made for the presence of negative interac-
tional cycles too. These involve a hurt partner’s emotional withdrawal
and/or criticism in response to the social cognition deficits providing
fewer cues for the survivor to use to attune, creating further hurt and
withdrawal (Bowen, Yeates & Palmer, 2010; Yeates, 2011; Yeates et al.,
2012; Yeates, Whitehouse-Hart, & Balfour, in press). In non-ABI sam-
ples, emotional difficulties have been shown to compromise social cog-
nition, including trauma and depression (Fonagy, Target, Gergerly,
Allen, & Bateman, 2003; Phillips & Allen, 2004). Demographic differ-
ences may result in particular trajectories for negative cycles, with gen-
der and age discriminating socio-emotional function under varying
conditions (Knox & Douglas, 2009; Phillips & Allen, 2004), including
provisional evidence for a gender difference of mentalising ability under
stress in the general population (Smeats, Dziobek, & Wolf, 2009).
Existing
and
proposed
interventions
Following the synthesis of the literature and couples’ relationships pre-
sented here, interventions that target the attunement of goals, attentional
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foci, memories, intentions, affects, and responses between partners are
candidates for a neuropsychologically-based couples intervention. As
noted above, pager memory aids have been shown to reduce care-giver
burden (Teasdale at al., 2009), and family based attentional and execu-
tive rehabilitation strategies have been suggested by Bowen, Yeates, and
Palmer (2010). The promise of a social neuroscience application into
neuro-rehabilitation has yielded few intervention strategies to date.
Social skills training has been suggested by Boake (1991) and an ran-
domised controlled trial (RCT) of a multi-modal social skills training pro-
gramme (teaching mentalising and emotion recognition skills) has shown
promising results (McDonald et al., 2008).
These approaches are arguably cold and mechanistic, appropriate for
social interactions in fixed formal environments but it is unclear if such
interventions would result in change meaningful in the context of oscil-
lating, affectively-charged relationships. Mirror neuron theory, with its
focus on embodied simulation, has yielded three intervention studies to
date. Buccino, Solodkin, and Small (2006) have applied these ideas
within physical rehabilitation while Skye McDonald’s group have
focused on social cognition interventions. McDonald, Bornhofen, and
Hunt (2009) used the reverse simulation mechanism concept proposed
by Goldman and Sripada (2005) to try and improve survivors’ ability to
recognise the emotions of others by first approximating the facial muscu-
lature of the target expression. Unfortunately, this did not prove to be
effective, nor did a parallel intervention to focus attention on target facial
features. More recently, this group noted that increased attention to emo-
tional stimuli did affect autonomic arousal of survivors, but all of this was
independent from emotion recognition ability (McDonald et al., 2011).
This may be a result of the intentional, deliberate quality of the mimicry
or focused attention strategies, not fully exploiting an automatic, reso-
nance/contagion model of affective attunement. Based on the literature
above, and in keeping with aspects of couples’ relationships, a relevant
social cognition intervention may need to target autonomic arousal con-
ducive to an empathic response in a more potent manner, to yield an
affectively charged response to social cues (e.g., the distress of a partner).
It is worth noting here that a neuro-imaging study of intense states of
romantic love indicated an activation of mid-brain and paralimbic areas
associated with automatic affective, attachment-related experience and a
deactivation
of cortical areas underlying intentional mentalising (Bartels
& Zeki, 2000).
At other times, the need is to deliberately, flexibly, and creatively men-
talise during exchanges of high emotion to reduce escalating conflict and
step out of the heat of the moment. The inhibition of self-perspectives
and approximation of another’s perspective may be a crucial precursor
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Q7
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to reconciliation. In gathering together neuropsychologically-informed
components of a couple intervention for intimacy then, the need for clar-
ification and attunement of each partner’s intentions, plans, perspectives,
and affective states is clear. The regulation of interpersonal affect is a fur-
ther component, both its amplification and down-regulation through
mentalising. Building on both tentative experimental evidence (Evans,
Bowman, & Turnbull, 2005) and clinical experience, a large group of
ABI survivors will not lack the potential for empathic connection but may
have a higher threshold post-injury for an induced, emoting response in
relation to a social cue. If this hypothesis is valid, this is open to manipu-
lation and intervention, with a more potent external, social cue.
At the same time, the emotional distress of both partners locked into,
and organised by, patterns of relating that are influenced at least in part
by acquired neuropsychological impairments is a clear factor to con-
sider. In states of attachment distress and insecurity (Bowlby, 1969) each
partner’s response is likely to be unconducive to sharing and aligning of
affective states and perspectives in a manner that will open up empathic
connection—the negative interactional cycles highlighted in the work by
Yeates and colleagues above. A couples-based social cognition interven-
tion cannot ignore these dynamics, and as such, application of social
neuroscience ideas may need to be couched within the sophistication of
a couples psychotherapy intervention.
Bringing these threads together, it is suggested here that a neuro-
psychologically-informed couples therapy intervention should contain
the following elements:
i) Elucidation and clarification of each partner’s intentional perspec-
tives and affective states in relation to the other within a safe thera-
peutic environment (a “secure base” in attachment terms). This
allows the effective communication and orchestration of such states
to facilitate attunement and alignment of socio-emotional communi-
cation between partners.
ii) As the survivor will require clear and possibly increased potent social
cues from the non-injured partner to signal their emotional and rela-
tional needs and evoke a response, the criticism and withdrawal of
the non-injured partner needs to be a clear target for intervention. A
withdrawn or hostile partner needs to be moved to a position to sig-
nal strongly but accommodatingly and invitation to connect.
iii) At other times, a role for deliberate mentalising by both partners to
break the heat of escalating negative emotions is also clear.
This would foster the conditions for a positive interaction cycle where the
survivor can respond, tune in and the non-injured partner feel connected
and emotionally secure. In developing therapeutic gains into long-lasting
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couples’ connection, it is likely, however, that the non injured partner will
always have to take responsibility in signalling their emotional needs in a
clear, potent manner to evoke the desired response.
If these therapeutic ingredients are indeed valid suggestions, then the
future for couples work in brain injury is promising. The clarification,
coordination, and amplification of emotional states can be provided by
emotionally-focused couples therapy (EFT) (Johnson, 2004). Specifically
the EFT therapist evokes and expands the expression and emotional ex-
perience of one partner while orchestrating the response of the other. Both
anecodatal and single case evaluative evidence of this approach follow-
ing ABI is encouraging, including specific applications in response to
aphasia and social cognition difficulties (Chawla, & Kafescioglu, 2012;
Steill & Gailey, 2011; Steill, Naaman, & Lee, 2007; Yeates, Edwards,
Murray, & Creamer, submitted). The role of deliberate identification and
flexible thinking of others’ mental states to down-regulate negative affect
and restore attachment security is articulated in mentalisation-based fam-
ily therapy (Asen & Fonagy, 2012). It is clear that psychosexual therapy is
also a necessary component of a rehabilitation response to intimacy, and
suggestions have been articulated by Bowen, Yeates, and Palmer (2010).
However an attachment perspective would caution that emotional and
relational safety within psychological intimacy needs to be re-established
as a foundation for physical closeness. The case study described below
provides an example of how these ideas can be used in a couples in-
tervention within a brain injury service. The reader should consult the ref-
erences above for details on specific models.
Case
study:
an
example
of
neuropsychologically-iinformed
couples
therapy
in
an
ABI
service
Peter and Ailsa approached a community head injury service for
couples therapy following previous unsuccessful sessions of generic
couples counselling, uninformed by a brain injury perspective. They
were married for seven years and had two children (aged three and
five). Peter sustained a haemorrhage from a burst anterior communi-
cating artery aneurysm six years previously. Neuropsychological
assessment identified difficulties in response inhibition, mentalising,
and emotion recognition for anxiety and disgust only. His performance
on a gamble task indicated the presence of interoceptive-based deci-
sion-making but at a slower rate of learning across trials than control
group data. In addition, planning and organising impairments were
evident, notably the implantation of plans in relation to multiple goals
and responsive planning following changes to routine or expected
patterns of information.
134 G. YEATES
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In their seven year relationship verbal and occasional physical vio-
lence had developed post-injury and increased in frequency. In
moments of conflict Peter would shout verbal insults to Ailsa, and on
three occasions had pinned her down to the ground, snarling over her.
Triggers for this eruption of anger and violence on his part were most
frequently moments when he either felt criticised or judged by some-
thing that Ailsa had said, or when Ailsa walked away from him during
an escalating interaction between them. Initial sessions of couples
work assessed and established the level of safety for the couple and
their children at that moment in time, and as a result of exploring
issues further in couples work. With these concerns satisfied, the
couple attended fortnightly sessions to identify the nature of their neg-
ative interactive cycle and the influence of both Peter’s brain injury
and each partner’s respective pre-injury attachment history.
A repeating cycle was discerned from both their stories of between-
session arguments and from their presentation in the room during
therapy. When Ailsa would complain about some aspect of Peter’s
behaviour Peter would feel judged and criticised. In addition, when
Ailsa tried to share her feelings about their shared financial hardship,
or being treated badly by a work colleague, Peter would also become
irritable and frustrated. Requests by her to solve problems or organise
an activity spontaneously or in the spur of the moment would gener-
ate similar responses from Peter. Deeper exploration of this repeat-
ing position for Peter highlighted a common response to all of these
triggers. He would feel confused, overwhelmed, unable to plan or
problem-solve a way forward (a clear neuropsychological influence
here), and felt powerless and not “good enough” in the eyes of a close
other. A core attachment fear here was an imminent danger of being
abandoned by a close other (influenced by early childhood experi-
ences with critical parents and siblings, who were subsequently criti-
cal and demeaning of his cognitive difficulties in the pst-acute phase
post-injury). These feelings would lead him to explode and try and
control the situation, often trying to stop Ailsa from moving away
from him or leaving. Ailsa would retreat and withdraw in these
moments, and spend subsequent days and even weeks silent and in-
communicative, like a statue. This would at times be a state of fear in
response to the violence, but also during times free of conflict Ailsa
would remain uncertain as to how to share her needs and feelings
with Peter. She was weary of both his unpredictable responses but
this was also a product of her childhood in an emotionally-neglectful
and dismissive family environment, where the expression of perspec-
tives and needs was prohibited. She felt deeply alone and hopeless
in this withdrawn position. This silence confused Peter, who often
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misread Ailsa’s state of mind during these moments, or her intentions
when she tried to talk about some of the aforementioned topics. His
default interpretation was that Ailsa was criticising him once again and
the day she finally left him was getting closer and closer. As such this
perpetuated the cycle between them.
The negative cycle was outlined with the couple, with reference to
their experiences at home, but also catching the cycle as it occurred in
the therapy sessions, and expanding both partner’s fears within the
activation of the cycle and their individual attempts to regulate this
emotion in ways that further fed the cycle. The sessions were video-
recorded and the couple would watch themselves on the recordings,
supported to take an observing, reflecting position while not being in
the heat of the emotions. A diagram of the cycle was given to both
partners, that was used as a reference point during the sessions along-
side an experiential focus, but also used by the couple at home, who
pinned it up on the wall as a reminder. Mobile phone alerts were pro-
grammed to deliver key words (“explode”; “statue”) at common times
of conflict during the week. This was a key executive functioning com-
pensatory support, alongside their shared decision to avoid the instiga-
tion of unplanned complex activities or changes of plans where
possible. This initial phase of therapy (characteristic of the first stage of
emotionally focused couples therapy (EFT) Johnson, 2004) successfully
de-esclated the cycle and violence in their life.
The subsequent middle stage involved the in-session expansion
and communication of vulnerable aspects of self and attachment
fears to each other, to invite supportive responses from the other and
the co-creation of a positive, nurturing attachment cycle. In practice
this involved the use of mentalisation-based family therapy (Asen &
Fonagy, 2012) techniques to unpack Peter’s felt certainty about Ailsa’s
private thoughts and feelings during her quiet moments, his inter-
pretation of her facial expressions, and checking these interpretations
and assumptions out with Ailsa. In addition, his self-reflection of his
mental processes at these times was expanded and supported, using
in part the social cognition assessment results (e.g., therapist: “Peter
would you agree that when you do not get the right inputs when Ailsa
expresses feelings of unease and discomfort in her face and tone
of voice, it seems that you become
certain
that it she is angry and
judgemental”). In parallel EFT techniques were use to re-engage Ailsa,
expanding her expression of her vulnerability and needs in an emo-
tionally-poignant way in the session (e.g.,
tearfully
, “I really need
you to be alongside me Peter when I get overwhelmed by money
worries or when I feel hopeless about the relationship, because feeling
136 G. YEATES
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alone is the worse part”). This was successfully orchestrated with
supporting Peter to resist going into a defensive response, instead
sharing his wish to be there for her and support his wife, while also
sharing his confusion about how best to do this and fear that he will
get things wrong. The embodied, emotional potency of these
exchanges were understood by the therapists as the driver of subse-
quent change in the couples relational patterns, evoking a com-
passionate response from Peter where more intellectual-based conver-
sations would not impact on him at all. The increased transparency of
Peter’s wish to be there for Ailsa, even as confused and uncertain as it
was, made her feel “on the radar”, cared-about, and responded to
when she took the risk to express her feelings (contrary to her own
attachment fears). Her hope for the relationship increased and she felt
“let in” to support Peter’s confusion and work out a way to be closer,
together. The final stage of this twenty-five session therapy focused on
the consolidation of therapeutic gains through Peter’s ongoing online
awareness of his explosive reactions and the triggers and thought-
processes that were precursors of these, while Ailsa continued to take
more frequent risks in signalling her emotional needs in a clear way
to Peter, accepting the responsibility that it will most often be her
now post-injury, who will need to put herself back on Peter’s radar,
rather than wait for him to get it right and attune to her without assis-
tance. For her, the experience of increased closeness as a result was
worth it.
Summary
and
conclusions
The literature reviewed above collectively outlines a range of possible
threats to the couple relationship from neuropsychological impairments:
problems in executive functioning, attention, memory, language, mental-
ising, emotion recognition, affective attunement, and visceral responsiv-
ity, and difficulties that compromise the survivors ability to socially
respond within a given encounter. Despite the face validity of these con-
ceptual associations, more empirical work is required using both neu-
ropsychological measures of component functions (as opposed to
questionnaires) and measures of couple relationship functioning, to sub-
stantiate these relationships. Psychosocial complexity is a critical dimen-
sion when formulating these interrelationships, but couples therapy
interventions orientated to attunement and arousal may establish a new
chapter of neuropsychologically-informed rehabilitation to improve
inter
-dependence and intimacy.
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5-Yeates.qxp 04/01/2013 14:18 Page 137
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