Autism, empathy, and the Sally Anne Test

I remember thinking that people's worlds must all be slightly different from each other, depending on who they were and where they were. I remember thinking that each person had their own separate world, and it almost made me dizzy.

Source Lisa Daxer in her blog, 'Reports from a Resident Alien'

Lisa Daxer, who writes about her experience of autism, talks about the moment when she suddenly realised that everyone has a different perspective, known as Theory of Mind. 

What is Theory of Mind?

There are quite a few theories of mind, but in this case it refers to the intuitive leap that children make when they are between 2  and 4 years old. It is the ability to imagine yourself from another person's perspective, and work out what they can know, and therefore how they will feel and behave.

Autistic people are believed to miss out this key developmental step, or at least that was what I was taught. The truth as always is more complicated.  

The Sally Anne Test

Was developed by Baron-Cohen, Leslie, and Frith, to see whether autistic children have Theory of Mind. In the test, a story is played out with dolls in front of the child, which goes like this,

One doll is called Sally and the other is called Anne,

Sally has a basket, and Anne has a box,

Sally puts a marble inside her basket,

Sally leaves and goes outside where she can no longer see her basket,

While Sally is away, Anne takes the marble from Sally's basket, and...

... puts it inside her box.

Sally comes back in from outside. 

​The researchers after checking the child understands what has happened, asks them this question,

Where will Sally look for her marble?

Educate Autism has an excellent and clear infographic of the Sally Anne Test

If you have Theory of Mind, you will in all likelihood have an almost instantaneous intuitive answer of where Sally will look. The basket of course!

However, you might then have the same experience myself and my colleagues had when the trainer asked us why we thought that. It was immediately followed by an awkward silence. While everyone was sure the answer was basket, people were initially unsure as to why they thought it was the basket. The trainer had to tease out the answer, "because that's where I would look, if I was Sally."  

In the experiment, Baron-Cohen and team chose two groups of people. One had Down's Syndrome and the other had Autism. When they asked them the question, 16 out of 20 of the autistic children said Anne's box, while for the people with Down's Syndrome, only 2 out of 14 said the box.

Those who chose Anne's box were said to lack a Theory of Mind, because they were believed to be unable to imagine what Sally could know and so didn't realise she could not know the marble had been switched

Does this mean autistic people lack a Theory of Mind ?

 As Ben Goldacre says, it's a bit more complicated than that, 

From the experiment we do not know why the children chose the way they did. Some of the children may have identified with the puppeteer rather than the dolls, and the person moving the dolls clearly knew where the marble was. Also there are other interpretations, which still allow for a Theory of Mind, such as having Sally find the marble in Anne's box, because otherwise she would be sad if she lost it. 

Some autistic people can and do develop a Theory of Mind, and so can 'pass'  the test. However most of the studies on this have been done on children, and very few on adults. People, such as Lisa Daxer, tend to develop it later, and tend to have a more cognitive, less intuitive understanding. As Lisa says in her blog, "it's a difficult puzzle for us to learn. It takes us longer, like it takes a dyslexic person longer to learn to read."

How can knowing about Theory of Mind help?

Theory of Mind is so intuitive we often just take it for granted that everyone has this same understanding. Often when we're trying to explain social interactions to autistic people we will use Theory of Mind formulations. They are often tricky for them to make use of.

It is usually better to offer a rule-based guide that works in most situations. So it is better to say, "If you want to have friends, you have to say yes sometimes when your friends ask you out to play," rather than saying "How do you feel when you ask your friend to do something and they say no?" 

The first approach can lead to working out how often 'sometimes' is, while the second approach is only useful if the person is also able to imagine being their friend when they are saying no to them. 

​Building empathy with dolls and toys

I find them very useful in the counselling room. By speaking through a doll or a toy, people can find a voice, which would otherwise not be present if they were talking face-to-face. 

In addition, by telling the story through dolls or toys, the person can play out difficult encounters. As narrator of the story, looking down from above grants them a unique vantage point.

The process of naming others as toys or dolls in a story, also allows us a greater connection to them. So, when a toy, we have named, experiences another toy saying "no," we also get a sense of what this feels like, and because the toy is representing someone we know, we also have a connection to them. 
 
This dual connection - how I am feeling, while holding a toy which represents someone else - is Theory of Mind in action. And in my practice as a counsellor, I have witnessed autistic people making sense of social interactions that would otherwise have been mysterious and incomprehensible.  

---

title image by ​Daniela Corno