Asian Journal of Psychiatry 31 (2018) 36–40

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Social cognition intervention in schizophrenia: Description of the training of T

affect recognition program – Indian version
⁎
Umesh Thonsea, Rishikesh V. Beherea, , Nicole Frommannb, PSVN Sharmaa
a
Department of Psychiatry, Kasturba Medical College, Manipal 576104, India
b
Department of Psychiatry and Psychotherapy, Heinrich Heine University, Dusseldorf 40629, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: Social cognition refers to mental operations involved in processing of social cues and includes the domains of
Social cognition emotion processing, Theory of Mind (ToM), social perception, social knowledge and attributional bias.
Schizophrenia Significant deficits in ToM, emotion perception and social perception have been demonstrated in schizophrenia
Training which can have an impact on socio-occupational functioning. Intervention modules for social cognition have
Affect recognition
demonstrated moderate effect sizes for improving emotion identification and discrimination. We describe the
Indian version of the Training of Affect Recognition (TAR) program and a pilot study to demonstrate the fea-
sibility of administering this intervention program in the Indian population. We also discuss the cultural sen-
sibilities in adopting an intervention program for the Indian setting. To the best of our knowledge this is the first
intervention program for social cognition for use in persons with schizophrenia in India.

1. Introduction
Social cognition refers to mental operations involved in processing
of social cues and producing an appropriate response to them. The
ability to recognize emotions is a specialized ability, highly evolved in
human beings (Herrmann et al., 2007). Seminal work by Ekman &
Friesen (1971) demonstrated the universality of emotions and they
described six basic emotions (happy, sad, fear, anger, surprise, disgust)
which can be recognized across different cultures. The NIMH consensus
definition of social cognition has identified 5 important domains of
social cognition. These include: emotion processing, Theory of Mind
(ToM), social perception, social knowledge and attributional bias
(Green et al., 2008). Social cognition research in schizophrenia focuses
on two primary areas. First is the relation of social cognition deficits to
symptomatology in schizophrenia, and second is the role of social
cognition deficits in socio-occupational functioning and psychosocial
rehabilitation.
2. Clinical importance of social cognition deficits in schizophrenia
2.1. Relation to symptomatology
Evidence from Meta analytical studies supports that patients with
schizophrenia have significant deficits in social cognition as compared
to healthy controls with large effect sizes for ToM, emotion perception
and social perception (Chan et al., 2010; Savla et al., 2013). These
deficits are associated with positive symptoms such as persecutory de-
lusions and poor insight (Bental et al., 2001; An et al., 2010). An
aberrant emotional salience mediated by dopaminergic dysfunction has
been described in paranoid subtype of schizophrenia and may be re-
lated to psychopathology (Philips et al., 1999; Behere et al., 2011;
Kapur., 2003; Behere., 2015). Other studies on chronic negative schi-
zophrenia suggest that these deficits may be independent of psycho-
pathology and are stable over the course of the illness indicating that
they may be trait markers for the illness. (Kucharska-Pieturaa et al.,
2005; McCleery et al., 2016) These negative symptoms may also med-
iate the relationship between second order theory of mind and func-
tioning in schizophrenia (Mehta et al., 2014).
2.2. Relation to socio-occupational functioning
Functional impairment in schizophrenia is determined by a multi-
tude of factors. Neurocognitive performance in schizophrenia on do-
mains of executive functions, attention, learning and memory, are
closely associated with their vocational rehabilitation and employment
(McGurk and Meltzer., 2000; Bryson and Bell., 2003; Evans et al., 2004;
McGurk and Mueser., 2006; McGurk et al., 2007). However, neuro-
cognitive abilities have been described to explain only 20% to 40% of
variance in functional outcomes (Horan et al., 2008). Social cognition is
a significant factor mediating the effect of neurocognition on

⁎
Corresponding author at: KEM Hospital Research Center, 489, Rasta Peth, Sardar Moodaliar Road, Pune 411011, India.
E-mail address: rvbehere@kemdiabetes.org (R.V. Behere).

https://doi.org/10.1016/j.ajp.2017.12.015
Received 5 May 2017; Received in revised form 8 December 2017; Accepted 26 December 2017
1876-2018/ © 2017 Elsevier B.V. All rights reserved.
U. Thonse et al.
functioning and these can directly influence work outcomes (Bell et al.,
2009; Fett et al., 2011; Horan et al., 2012; Bhagyavathi et al., 2015).
2.3. Implications for psychosocial rehabilitation program
Interventions in schizophrenia are now focused on improving real
world functional outcomes. The ability to understand social cues in the
environment and to respond to them in an appropriate manner has a
direct bearing on interpersonal relationships and hence on socio-occu-
pational functioning. While traditional psychosocial rehabilitation
programs such as sheltered workshops can achieve a better outcome in
less socially demanding situations, reintegrating people with schizo-
phrenia into the society may pose real life challenges. The trait nature
of social cognitive deficits suggests that these deficits could be a hurdle
in achieving the desired results of functional recovery in schizophrenia
as they may persist throughout the course of the illness (Gessler et al.,
1989).
Hence supplementing conventional cognitive remediation programs
with skills training and social cognition training may be necessary for
tangible effects on functional competence and real-world behaviour
(Roncone et al., 2002; Fett et al., 2011; Bowie et al., 2012). We describe
the Indian version of the Training of Affect Recognition (TAR) program
and a pilot study to demonstrate the feasibility of administering this
intervention program in the Indian population. We also discuss the
cultural sensibilities in adopting an intervention program for the Indian
setting. To the best of our knowledge this is the first intervention pro-
gram for social cognition for use in persons with schizophrenia in India.
3. Description of training of affect recognition (TAR)
The Training of Affect Recognition (TAR) (Frommann et al., 2003)
is a standardized social cognition intervention program and is available
in German, English, Spanish, Norwegian and French versions and now
in a Kannada and Hindi version as well. It is a twelve - session program
typically conducted twice a week for a duration of forty five minutes to
one hour each. This intervention program follows the principles of er-
rorless learning, positive reinforcement, feature abstraction and self-
instruction. The compensatory strategies such as verbalization of the
characteristic feature of facial affect are also incorporated in this pro-
gram.
Many studies have established the efficacy of TAR in improving
performance on the social cognition domains (Wolwer and Frommann,
2011; Sachs et al., 2012; Frommann et al., 2013). A randomized con-
trolled trial found a significant improvement in facial emotion re-
cognition in persons with schizophrenia who received TAR intervention
(N = 28) in comparison to a cognitive remediation program (N = 24)
and treatment as usual (N = 25) (Wolwer et al., 2005). Another study
reported that TAR intervention group showed improvements in facial
emotion recognition, prosodic affect recognition, ToM and social
competence when compared to a group of patients with schizophrenia
who had received a cognitive remediation program alone. TAR inter-
ventions have been found to have moderate to large effect sizes in
improving facial emotion recognition in persons with schizophrenia
(Wolwer and Frommann, 2011; Sachs et al., 2012).
4. Indian version of the training of affect recognition (TAR)
This intervention program is an Indian version of the Training of
Affect Recognition (TAR) program (Frommann et al., 2003). The dif-
ferences in cultural sensibilities between Western and Indian cultures
necessitated modifications in the social contexts used in the program.
The Indian version retains the number of sessions and basic prin-
ciples of errorless learning, positive reinforcement, feature abstraction,
verbalization and self- instruction. The Caucasian faces used to present
emotion stimuli are retained in the Indian version.
The cultural biases in perception of emotions has been a matter of
37
Asian Journal of Psychiatry 31 (2018) 36–40
debate. Ekman and Friesen (1971) described that identification of basic
emotions is universal in nature. However some other studies argue for
an in group advantage in recognition of emotion belonging to the same
culture (Elfenbein and Ambady 2002a; Beaupre and Ursula, 2016,
Wickline et al., 2009). A study examining cross cultural variations in
emotion recognition in the Indian population found happy, sad and fear
expressions to be identified equally and a weak effect for ethnicity on
facial stimuli for anger and surprise (Habel et al., 2000). A meta-ana-
lysis of cultural specificity of emotion recognition described that emo-
tions are universally recognized at better than chance levels and the
cultural differences in response bias are least for posed expressions than
spontaneous expressions (Elfenbein and Ambady, 2002b, 2002c). We
examined effect of culture on emotional recognition in our population
in a pilot study. 25 healthy subjects from native population were pre-
sented with an emotion recognition task consisting of 40 emotion sti-
muli (5 basic emotions – anger, fear, neutral, happy, sad from 4 eth-
nicities – Indian, negroid, mongoloid and Caucasian) and their
performance on emotion recognition accuracy was assessed. There was
no significant effect of ethnicity of emotion stimuli on accuracy of
emotion recognition [Emotion recognition accuracy score for: Indian
stimuli 7.5 ± 1.1, Caucasian stimuli 7.2 ± 0.9, Mongoloid stimuli
7.5 ± 1.1, Negroid stimuli 7.7 ± 1.7, F = 0.64, p = 0.6]. This sug-
gests that subjects from our native population were able to adequately
identify the basic emotions irrespective of ethnicity of facial stimuli.
4.1. Description of the intervention program
This training program consists of three blocks of four sessions each.
Block – 1 (sessions 1–4): The focus of intervention is on identifying,
discriminating and verbalizing facial features of six basic emotions
(happy, sad, fear, anger, surprise, disgust) and neutral emotions. This
block includes two computerized tasks. In the ‘Facial parts’ task subjects
are taught to identify specific facial features associated with various
emotions. In the ‘Selection task’ subjects are taught to recognize emo-
tions from whole face stimuli.
Block – 2 (sessions 5–8): The second block focuses on promoting
judgment confidence by training subjects to identify emotions on de-
graded images or stimuli depicting lower intensity of emotions. Subjects
are also trained on a ‘Matching task’ to group similar emotions from a
set of various emotional stimuli presented together.
Block – 3 (sessions 9–12): The third block focuses on skills of
identifying and interpreting emotions in social situations, social cues
and attribution bias. In the anchor task subjects are presented with si-
tuational contexts and are asked to match the contexts with the ap-
propriate facial emotion stimuli. The task involves social cues from real
life situational contexts with progressively increasing complexity.
In this version, all task instructions in English were translated into
Kannada, which is the vernacular language of Karnataka state in India;
and back translated. In the Indian version of the TAR, the following
cultural sensibilities had to be considered 1) Translating instructions
and anchor points into vernacular language 2) Use of social contexts
and situations that the subjects could identify with 3) Methods used in
administration of the tasks and conduct of sessions.
4.1.1. Challenges in translation
One of the major challenges faced was in performing literal trans-
lations of English instructions or questions to Kannada. It was observed
that literal translations changed the forms of the sentences. For eg: for
the “Selection task of emotions” – both male and female faces are
presented and a literal translation of the instruction “Which person
looks sad?” gave a clue to the gender of the presented stimuli hence
inducing a bias. To overcome this thematic translations were adopted
and all instructions were converted into gender neutral forms. All
translations were made by the first author (UT), a native Kannada
speaker of the vernacular language and back translated by two lan-
guage experts.
U. Thonse et al. Asian Journal of Psychiatry 31 (2018) 36–40

Table 1
Summary of changes made in TAR − Indian Version.

Changes made Task Modified TAR(Training of Affect Recognition) – English version Training of Affect Recognition-Indian Version

Translation All tasks were translated and Language: English Language: Kannada
back translated into the
Kannada language
Use of culturally Immediate Positive feedback In original TAR (English version) uses the word “well The word “Shahabaas” is used which is a culturally
appropriate in all tasks done” appropriate term to denote immediate positive feedback
equivalent terms Anchor tasks In a particular situation, the word “Bummer” is used. The word “bummer” does not have an exact equivalent in
Kannada. The culturally equivalent term “kirkiri’
meaning ‘Irritating’ was incorporated.
Use of gender neutral Selection task of emotions The task involves presentation of male and female When literally translated to Kannada, the form of the
forms emotional stimuli and the subject is instructed to match sentence gives a clue to the gender of the face and this
the emotion to the face. For eg: the subject is asked − can serve as a bias to the subject.
Which person looks sad?
To overcome this all instructions in this task were
translated into gender neutral forms.
Modifying situational Anchor tasks Situational cues: Which person smells that the stew is bad The situational cue here was changed from ‘stew’ to ‘meat
cues in social contexts and thinks: this is disgusting!”? Which person looks at the curry’. The situational cue here was changed from ‘vase’
broken vase and thinks: “I’ll never get such a nice piece to ‘clay cooking pot.’ The situational cue here was given
again!”? Which person notices the neighbor driving a new as ‘car’ instead of ‘sports car’. The situational cue here
sports car and thinks: “Is this Peter’s car?”? Which person was changed from ‘tram’ to ‘bus’.
watches the tram’s emergency stop and thinks: “Oh my
god, it’ll crash!”

4.1.2. Modifying social contexts and cues
In the section on ‘anchor tasks’, certain social cues were not in
keeping with the local cultural background and necessitated modifica-
tions. The modifications in keeping with the Indian cultural context
(summarized in Table 1) were suggested by the language experts. The
situational cues and their modifications were presented to 2 native
Kannada speakers who were asked to identify the emotion associated
with these situational cues to establish concordance.
4.1.3. Method of administration and conduct of sessions
The first author of this study (UT) received supervised training in
task administration from the developer of the original TAR program
(NF). Majority of the patients were not computer literate and were not
capable of performing the computerized tasks independently and re-
quired assistance. Hence a modification in task administration was
made where in patients were asked to indicate their responses which
were then recorded by the therapist. The intervention was administered
in groups of two, over 12 sessions at a frequency of 2–3 session per
week. The administrator encouraged active group discussions and in-
teraction between the subjects and provided constant feedback.
All changes were discussed with and approved by the author of the
original TAR (NF). By incorporating the same changes a Hindi version
of the TAR is also available.
A pilot study was conducted using this TAR-Indian Version to assess
the feasibility of administering this program in our patient population.
5. Methods
5.1. Sample and design
The study was conducted at ‘Hombelaku’, the Psychiatric re-
habilitation centre, of Department of Psychiatry, Kasturba Medical
College, Manipal University, Karnataka, India. Inclusion criteria in-
cluded 1) Diagnosis of schizophrenia (ICD-10) 2) age range of 18 to 55
years and minimum education of at least 7th standard 3) Clinical Global
Impression (CGI) score ≤3 and Positive and negative syndrome scale
(PANSS) score ≤70 4) On stable dose of antipsychotics for more than 4
weeks 5) Willing to provide written informed consent. Patients with
history of seizure disorder or head injury or intellectual disabilities,
obsessive compulsive disorder and patients meeting the criteria of
substance disorder other than nicotine dependence in the last 6 weeks
were excluded. This study was approved by the institutional ethics
committee and was carried out from February 2016 to December 2016.
5.2. Participants
13 patients were assessed of whom, 11 consented for participating
in the study. One patient was discharged from the rehabilitation centre
after 9 sessions and did not complete the training program. Hence final
analysis included 10 subjects who had completed training on the TAR-
Indian Version.
5.3. Assessment
Patients’ socio-demographic and clinical information such as pa-
tient’s age, gender, educational background, occupation, diagnosis,
course of the illness, current medications data were collected by using
semi structured interview. Patients’ psychopathology was assessed
using Positive and Negative Syndrome Scale (PANSS) (Kay et al., 1987).
5.3.1. Emotion recognition assessment
Performance of facial emotion recognition was assessed by the Tool
for Recognition of Emotions in Neuropsychiatric Disorders (TRENDS)
(Behere et al., 2008), which is a culturally sensitive tool and has been
validated in the Indian population. It consists of 52 static (still) and 28
dynamic (video clips) images of six basic emotions (happy, sad, fear,
anger, surprise, disgust and a neutral facial emotion expressed by four
actors (one young man and one young women, one older man, and one
older women). The actors displayed the emotions at high and low in-
tensities. This study utilised the 52 static (still) images for assessing the
emotion recognition abilities in persons with schizophrenia. Patients
were assessed at the baseline and after the TAR intervention.
5.4. Procedure for administration of TAR – indian version
Two subjects were paired together for the entire duration of 12
sessions. Sessions were conducted at a frequency of 2–3 per week with
each session lasting for forty-five minutes. Post intervention assess-
ments were completed within one week after the 12th session. All the
intervention sessions were administered by the first author (UT). Study
participants did not receive any monetary benefits for their participa-
tion in the current study.

38
U. Thonse et al.
Table 2
Performance on emotion recognition tasks (TRENDS) in patients group Pre and post intervention.
Variable N Pre-intervention TRACS Mean ± SD
TRACS 10 31.30 ± 7.0
TRACS: TRENDS Accuracy Score.
Significance at *p < 0.05.
5.5. Statistical analysis
The primary outcome measure was performance on the emotion
recognition task before and after intervention. Subject’s performance on
TRENDS was assessed by calculating the total number of images that
were correctly identified out of a maximum of 52 images and termed as
the TRENDS Accuracy Score [TRACS]. Pre-and post-intervention
TRACS were compared using the paired t-test.
6. Results
The mean ± S.D age of the patients was 40.2 ± 10.7 years. Seven
patients were diagnosed with paranoid schizophrenia and three were
diagnosed with undifferentiated schizophrenia. All patients recruited
had symptoms in remission as indicated by their PANSS scores [positive
symptoms (mean ± S.D) = 5.1 ± 7.6; negative symptoms
(mean ± S.D) = 9.0 ± 7.0; general psychopathology (mean ±
S.D) = 10.9 ± 9.3]. There was no significant change in psycho-
pathology scores post intervention [post intervention positive symp-
toms (mean ± S.D) = 4.4 ± 4.9; t = 0.42, p > 0.05; post interven-
tion negative symptoms (mean ± S.D) = 7.3 ± 5.6; t = 1.40,
p > 0.05; post intervention general psychopathology 10.20 ± 7.7;
t = 0.97, p > 0.05]. At baseline the performance on emotion re-
cognition task in the schizophrenia subjects was [pre-intervention
TRACS (mean ± S.D) = 31.3 ± 7.0]. (The previously reported per-
formance on TRENDS by 45 healthy controls is 57.5 ± 7.0; Behere
et al., 2011). Post intervention a significant improvement in emotion
recognition was observed (Table 2).
7. Discussion
To the best of our knowledge this is the first description of a social
cognition intervention program applicable to the Indian setting. This
intervention was a translated version of an existing program originally
developed for the German population. This program has subsequently
been translated into French, Norwegian, Spanish, English, and Dutch.
This Indian version highlights the cultural sensibilities that need to be
taken into consideration in designing social cognition intervention
programs. It was interesting to note that the training for feature de-
tection provided on Caucasian facial stimuli was able to bring about a
significant change in emotion recognition abilities as assessed on a task
with Indian facial stimuli. This supports the theory of universality of
basic emotions.
7.1. Feasibility of administering the TAR-Indian version intervention
program
Intervention was carried out in groups of two patients at a frequency
of 2–3 sessions a week for a total of 12 sessions. The subjects were
cooperative during the tasks and were able to comprehend and com-
plete the tasks given in the sessions. The subjects also did not report any
difficulty in performing feature recognition tasks when working with
Caucasian facial stimuli. The original TAR version required subjects to
undertake computerized tasks with the computer program providing a
feedback on their responses and facilitating error less learning. In our
task administration, not all subjects were comfortable with using
computers, and the test administrator assisted in these tasks. This
39
Asian Journal of Psychiatry 31 (2018) 36–40
Post Assessment Mean ± SD t p
37.80 ± 8.1 5.48 < 0.001*
provided an additional opportunity for the subjects to receive human
feedback and facilitate discussion on the recognition of emotions. In
addition, interaction between subjects could also have facilitated peer
learning and possibly contributed to improving outcomes. It would of
interest to ascertain whether this intervention has any impact on socio-
occupational functioning in patients with schizophrenia. This pilot
study was conducted with the primary aim of assessing feasibility of
administering the modified TAR in Indian population. Further studies in
a larger sample with a case control design would be necessary to assess
the efficacy of this intervention in improving psychopathology, emotion
recognition abilities and functional outcomes.
8. Conclusion
Social cognition deficits are being recognized as one among the
important deficits in schizophrenia which can significantly impact
socio-occupational functioning. Intervention programs aimed at im-
proving these deficits could potentially play a pivotal role in improving
the outcomes. The Indian version of the TAR program is an attempt to
develop a social cognition intervention program applicable to the
Indian setting. This version has taken into consideration cultural sen-
sibilities for its applicability in our setting while at the same time de-
monstrating the universality of basic facial emotions. Feasibility of
using this program in Indian population was demonstrated in a pilot
study. The program now needs to be tested in a larger case control study
design to demonstrate its efficacy in improving emotion recognition
abilities and functioning in schizophrenia.
Funding
UT was supported by the Indian Council for Social Science Research
Doctoral Fellowship Program.
Declaration of interest
None.
Acknowledgements
We thank the study participants for their enthusiasm in partici-
pating in the training program. We thank Ms. Stefanie Specht for her
technical assistance in incorporating the kannada translations into the
TAR program.
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