What is CVI?

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Learning Emotions with CVI

In the previous section on Emotions, we explained a little about emotional development and how it is affected by CVI. In this supplementary page we aim to explain a little further, and show where difficulties lie, and simple approaches to help, in relation to those with:

  • 1. CVI from birth, profoundly affected, no language.
  • 2. CVI from birth, with language.
  • 3. Acquired CVI (including in the older population).

Emotion: Dictionary DefinitionEmotion: Dictionary Definition

Understanding emotions is key to successful human relationships.

Emotion is about how we are feeling, how we understand how others are feeling, and how that makes us feel. It includes how we react to things, including how we react to how other people react.

Think for a moment about how you express how you are feeling to others, for example, you might:

  • Smile, showing something is making you happy
  • Laugh to show something is funny
  • Cry to show you are very upset
  • Stare to show you are concentrating

This list is endless. And when you smile, laugh, cry or stare, you are not acting, these are your emotional reactions, and this is how others understand how you are feeling, and react accordingly.

This is how we learn to get along with other people, and forms the basis of all our social relationships.

Think of recent conversations, even short ones like thanking a person serving you in a shop. Think of that exchange, in terms of the information your brain was receiving and interpreting, which might include:

  • Facial expressions - e.g. smiles (slight or bold), frowning, raised eyebrow, raised cheekbones, curl or twitch of the nose, eye roll, staring, looking away etc
  • Body language - e.g. head tilts, shoulder shrug, reaching out an arm or hand, stepping closer of moving back, folding arms, pointing, turning away, hair flicks, shifting weight from one foot to another etc
  • Tone of voice - e.g. short, friendly
  • Other - e.g how much time given, patience, sincerity, the sort of questions asked e.g. are you having a nice day?

These are all non-verbal cues (or clues!), transmitting how we are feeling. The vast majority of our feelings are not transmitted through what we say, but through these non-verbal cues.

Source: Daniel Goleman, Emotional Intelligence

Send & Receive: Emotional Non-Verbal Cues

It's a bit like a bat and ball game, like ping pong, backwards and forwards, one player responding to the other.

Think of two people talking:

Each person constantly transmits and receives, and ideally correctly interprets, then reacts accordingly, and transmits further how they are feeling through their exchange.

The emotions of someone you know are is easier to interpret than those of a stranger, because your brain has had multiple repeated experiences. Let us imagine you have worked alongside the same colleague called Ben for years, and one day you 'pick-up' a sense that all is not well. Nothing too obvious, Ben is just a little quieter and the normal morning smile seemed different. From years working together you actually have little 'Ben' pathways and centres in your brain, and you can interpret what is 'typical Ben' and what is 'untypical Ben' - and if 'untypical Ben' you can make a decision as to what to do, for example offer to get him a coffee or ask if he is ok.

These interactions we take for granted, but they are far from simple.

We communicate how we feel, sending non-verbal cues, alongside whatever we are saying or doing, sort of in parallel. So, back to our colleague Ben, in a conversation, you might be telling him about a fantastic film you recently saw at the cinema. In addition to what you are saying, you are sharing how you are feeling, for example:

  • A change in voice tone showing excitement
  • Hand and arm movements (gesticulations)
  • Smiles and laugh

And you would hope that Ben was interested and enjoying your account, but how would you know that? By the same non-verbal cues.

What if Ben looked like this (below) as you were explaining how fabulous the film was...

How would that make you feel? Might you stop telling Ben about the film, maybe because he looks a bit bored? His look is received by your brain, and matched with facial expressions you know, and importantly facial expressions you know specifically in relation to Ben. You might feel offended, or hurt, or angry, or worried - and this you will show.

Ping pong, back and forth, Ben's and your feelings, shared and experienced through very complex non-verbal cues, in constant non-verbal conversation.

This diagram is a very simple cycle of how two people sending and receiving non-verbal information to each other about how they are feeling, affect each other.

To get along with people requires some degree of appreciation, understanding and application of this process. That requires two things:

  • An understanding of your own emotions and feelings
  • An understanding of emotions and feelings in others

From this understanding a person can become sympathetic, empathetic, supportive etc.

The rules are...there are no rules!

It is tricky, and there are so many rules that understanding emotions is pretty much without rules, because:

  • Facial expressions are not always reliable, a smile can be cruel and crying can be happy or overwhelmed, not just distressed.
  • Body language can be equally unreliable, and tones of voice can be tricky to interpret and also variable.
  • The feelings we are showing might not be about what we are experiencing at all - Ben (above) who looks bored might be feeling very worried thinking about someone who is sick, but it looks like he is bored with your account of the film.
  • All of these are different for everyone, and...
  • All of these we apply differently to different people - think of someone you know really well, and how differently your behaviour is around them compared to someone you know less well, and...
  • We all think the emotions we experience are the same, so happy for me is the same as happy for you, but are they?

It is difficult, there are few rules, and some people are clearly better at this game of pong-pong emotions than others, because none of us are mind readers - those who are better are more able to effectively express their emotions and interpret the emotions of another and act accordingly.

That is the case for us all.

What about those affected by CVI?

All of the above still applies, but it is more difficult, for many different reasons (explaining in more detail in the Emotions page), including:

  • The visual clues are inconsistent and difficult to interpret
  • Focusing on interpreting the non-verbal messages, whilst listening to a person involves both looking and listening at the same time, which many with CVI struggle to do, (example here).
  • If CVI from birth, the person may not correctly match the experience they are feeling with the same emotion as understood by others, leading to behaviour that might seem inappropriate or odd, as they try to fit in, for example they might think they are being funny when they are being offensive.
  • CVI can make a person feel alert, anxious or frightened (see CVI Frights), where the 'feelings' the person is expressing are actually non-conscious reactions due to brain processes they have no control over, for example looking startled as someone approaches to walk past them - a companion might think they are worried, unhappy, not enjoying their company, when actually their brain has incorrectly calculated a likely collision, and for protection activated their fight or flight reflex releasing a shot of adrenalin into their system that they have to try to manage. Does this sound extreme? From accounts we have heard it seems extremely common.
  • Where CVI is acquired, for example following a stroke or due to dementia, there is a before and after that no longer add up, which can make emotional actions and reactions very difficult, unsettling and upsetting.

Language: An Important Common Thread

Think back over the last few days to something that created a strong emotional reaction. It could be something you watched on television, maybe the news, or something that you witnessed or something someone said to you. How did you feel? Maybe:

  • Vulnerable
  • Angry
  • Stupid
  • Appreciative
  • Overwhelmed
  • Depressed
  • Frightened
  • Optimistic

Add how you felt to this list.

Thousands of different emotions have been identified, and whoever you are, wherever you are, whatever you added to our list, there is one thing all of these emotions, including yours have in common...

They have a name.

They are understood as a label - a word.

In our Access section we explain how the brain learns as a simple repeated process of experience, memory and recognition (explained in more detail in Lessons Level 2), for example in relation to sadness in another:

  • you experience the sadness by seeing it, maybe a person is crying or looks unhappy
  • your brain looks in your memory of emotions and finds a match
  • and that match goes to look for the label where it is correctly identified as sadness, and then...
  • feeds your frontal lobes and you can decide what you want to do, e.g. offer comfort.

CVI & Learning Emotions

CVI presents particular challenges around learning to identify the different emotions, here's one reason why...

Looking at the images below, what labels would you give each emotion?

Here's what we thought (below) - you may disagree, that's part of our point, different people identify different emotions, there are no fixed rules.

CVI can affect the image in many different ways as we have explained throughout this website. One of the most common ways an image is affected due to CVI, particularly affecting children, is because their visual attention is reduced (due to simultanagnostic vision).

How might these emotions look for them?

This is how such vision has been described to us, where there is much less to see, and faces in particular are particularly challenging to see as a whole. How easy is it to identify the emotions now?

Primary / Basic Emotions & Affective Blindsight

The academic debates around everything related to emotions are full of disagreement, even around what an emotion is:

Although extensively studied, an unequivocal definition of emotions is still lacking and the subject of contentions.

Alessa Celeghin (source at end of page)

One of the areas of disagreement is about whether our brain comes sort of pre-programmed with an understanding of certain primary or basic emotions, or whether we learn them.

We are not planning to add to this debate, but there is an area we find interesting around CVI and learning emotions, and that is around affective blindsight.

With blindsight, if a person's brain does not create a picture due to damage in the occipital lobes, movement can create a reflex which we know can evolve to produce an image. Affective blindsight it like this, but with key facial expressions.

Some adults who have lost vision due to lack of blood getting to their visual brain, can appreciate the emotions that others are expressing through their facial expressions. This difficult to believe feeling, is thought to be due to the non-conscious visual brain which is not affected, sending the emotional message to consciousness.

We've heard from some parents of children with CVI, who have told us that their child seems to respond appropriately to their facial expressions.

So a baby, who has occipital lobe damage meaning their brain creates no image from the information received and processed through their eyes, may see, understand and respond to their mothers smile.

Both blindsight and affective blindsight are processed in the thalamus and superior colliculi. The vision we are aware of is, called conscious vision, is processed in the cerebral cortex (the cortex is the 'grey matter' outer layer or the cerebrum). Blindsight is non-conscious reflex vision, and the thalamus (indicated on the diagram below) is deep in the centre of the brain and not part of the cerebrum.

The visual information goes through the babies eyes which can be working typically, but do not create a picture in the brain, we know that bit is not working. Separately, the same visual information travels along a different path in a different way to go to the thalamus, where the information is processed and a match is found that the baby not only understands but responds to - by smiling back! How can they do that? One suggestion is that primitive parts of our brains, developed to keep us safe going back to stone-age times, are pre-programmed with an understanding of very basic visual facial emotions through expressions, indicating safe and not safe.

Why is this relevant to CVI?

What this might suggest is that the brain and its relationship with faces and facial expressions is both very primitive and very complex. Complex is important, because people with CVI struggle with visually complex images to process. But for most a face is a similar shade of the same skin tone, there are features, but not so many - is a face really that complex?

Imagine you are out and about, and separately meet the girl pictured on the left, and later shopping for apples (picture on the right). In terms of colour and detail, the picture on the right is far more complex visually, but there is something about processing a real human face that seems to make it much greater than the sum of its parts - your brain is calculating:

Face Processing

  • What is it - it's a face (found in your right temporal lobe store of memories)
  • Who is it - is it someone you know - more right temporal lobe searches - maybe a match, maybe not?
  • If a match - an enormous trail in your mind connecting the person and your history together activates, and this will feed your frontal lobes, so you can decide if it is someone you want to engage with or not, and if so, the tone, which is determined by
  • How are they - reading the subtle signs (non-verbal cues) - is she calm, upset, angry, do I need to ask?

The brain processes needed to pick apples, even though visually more complex in terms of colourful and detail, are not as demanding as the brain processing required when interacting with people.

Parallel Processing

The issue is one of parallel processing, which we know is affected by CVI. Look at the film of these two brains (below)

Laboratory for Visual Neuroplasticity, Massachusetts Eye and Ear Infirmary, Harvard Medical SchoolVideo Link: https://vimeo.com/221750541

The brain on the right has CVI, and a significantly reduced number of pathways and connections (explained in more detail here). It may be that many with CVI, due to incredible complexity making enormous demands on their brain, can only ever see one small part of a face at a time. We explained the major problems all with CVI face in relation to how they experience things affecting learning in Access and Lessons Level 2.

If emotions are not experienced, they are more difficult or impossible to learn and therefore more difficult or impossible to recognise.

Understanding emotions in ourselves and others is key to developing theory of mind. Theory of mind is key to happy successful long-lasting social relationships. We are a gregarious race, loneliness and solitude are not a choice anyone makes unless the alternatives are worse - which they can be for people with CVI, including leading to depression and suicidal feelings - so this is really important to understand - because there is so much you can do to help.

1. CVI from birth, profoundly affected, no language.

For this group, they would have felt a range of emotions, but not necessarily been able to match them with others. This can give a sense that they are unaware or unresponsive to the feelings of others. This is almost certainly not the case. Like everyone, they will have known people in their lives they like best, and others they like less.

Even where there is no language, we think the easiest way to learn is to start consistently giving key emotions a name, like happy or scary, and have a consistent reaction to match the emotion and their reaction, for example if happy (ideally you are somewhere relatively clutter free), be still, and with a big smile, slowly say happy, let them look at you - find the different parts of your face and a bit at a time learn to build the picture of what your face looks like, with what they are feeling under the name happy.

It may seem pointless to use a word with a child who has no language. Yet even if the child is unable to say the word, if you clearly repeat the same word next to the same experience, from children we know, their brain will slowly start to make the connections. This takes time and patience is required. The word gives the experience a label in the mind to help connect what is happening to what is known, and then make sense of things. For more information please see our section Language (for non-verbal children with CVI).

Start very simple and slow, and use the word and your lovely smiling face to build the meaning - golden rules of CVI!

Parents & Carers of Young Children (with and without language)
Describe your child's emotions to your child, as early during development as you can. Be consistent and repetitive, and help build up their pathways. Your early descriptions, labelling their matching experiences will form the building blocks of the understanding needed to build successful future friendships and relationships upon.

2. CVI from birth, those with language.

Language is key. Even though some with CVI are more able than others, many will struggle processing a whole face including the emotions needed to understand how the other person may be feeling.

There is no easy-fix, this is a complicated problem, and the best way to develop understanding is to talk about your emotions. Within a safe nurturing environment, like the home, where a person is hopefully less likely to feel vulnerable and more open, explain how you are feeling, how they made you feel, how others made you feel, and use the names of the emotions, and describe it.

Reading emotions through facial expressions, gestures and other indications is always going to be difficult, so another way might be needed, including embracing your CVI, and explaining that you don't always pick up on things, or even see people let alone their expressions, but that it is not being rude, and how you would prefer people deal with that.

It is very easy to come across as rude or indifferent to the feelings of others.

3. Acquired CVI

This is really tricky, because you have a before and after brain, which are different, apart from the 'after brain' often is not aware anything has changed. Things that were easy before, like having a conversation with someone, somehow are no longer so easy, or no longer make sense. Through her series of blogs Nicola McDowell chronicles her journey of life after a brain injury, with a brain stubbornly resisting accepting that anything is different! Nicola's writing is warm and humorous, whilst her experiences are extremely relevant and show how quickly her social confidence was severely affected.

Assuming the person was socially confident before their brain injury, what do you imagine happens after just a few unexplained incidents of upsetting or offending people, without understanding why. Maybe it is just easier not to go out?

There are many different approaches to try to teach reading and understanding emotions, but most try to teach interpreting the non-verbal cues. The problem for those with CVI is the non-verbal cues are not simply misinterpreted, they are often completely missed.

With both these two groups where there is language and CVI is present, every experience involving another person can be challenging. Rather than hide and struggle, we suggest owning your CVI, let people know how it affects you, and that you can miss things, and if you seem emotionally unresponsive, it maybe because you did not pick up on the emotion.

Alternatives to Face to Face

So, clearly face to face is always going to present processing challenges for some with CVI. Hopefully some of our suggestions will help clear up misunderstandings and in turn help social communications. Separately, there are of course other ways to communicate, including communicating how we are feeling, without involving the challenges of face to face processing. These suggestions should be in addition to face to face, not an alternative.

Writing
Email, text, message, social media are all ways to communicate without the complexity of facial processing, and sometimes explaining how you are feeling, or asking about the feeling of another through writing can be effective - but people need people, and an alternative is, although quite old fashioned now...

Telephone
...telephone calls. NOT video, this is an alternative where facial processing demands are given a break. A telephone call, where you are somewhere calm and uncluttered, relaxed, means your brain has far less to do, the only cues are in the tone of voice, so much easier to pick up on now the brain is not overwhelmed. The language used on a telephone call appreciates that both parties can't see what is being discussed, so both parties become radio communicators (see Gordon Dutton's Blog 6).

Summary
Returning to our ping-pong send and receive analogy of emotional communications, needed to learn about our emotions and the emotions in others, with CVI, with the send and receive:

  • Sending emotional messages - not so difficult
  • Receiving emotional messages - much more difficult, and easy to misinterpret or miss altogether.

Quote Reference: Basic Emotions in Human Neuroscience: Neuroimaging and Beyond, Alessia Celeghin, Matteo Diano, Arianna Bagnis, Marco Viola, Marco Tamietto, Frontiers in Psychology, 24 August 2017 (Open Access)

Further information
Professor John Ravenscroft from the University of Edinburgh gave an excellent presentation of CVI and Theory of Mind, click here for free access to the full presentation slides.

Nicola McDowell, on reading this page, wrote an excellent blog explaining her experiences.

Nicola McDowell's Blog 23: Becoming a social outcast overnight.

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At CVI Scotland we are devoted to helping people understand cerebral visual impairments, and together working towards developing the understanding of this complex condition.