For a lot of people, it seems that autism is often considered a “disorder of empathy.” However, until we can all agree what a “disorder of empathy” is or means, this is a very problematic statement, and one could even say it is just plain wrong. The main issue with this assertion is the fact that the one word, empathy, is used to cover at least two very different concepts that can be more precisely defined as cognitive empathy and affective empathy.
Cognitive empathy is the capacity to take someone else’s perspective, to “put ourselves in their shoes.” It is a cognitive ability that typically develops in childhood, emerging around age 4-5. It requests that we override our point of view, our knowledge, in order to see the world from another perspective. Some also call it theory of mind. Being able to infer other people’s mental states is important in order to understand and predict their behavior. Brain areas mostly involved in cognitive empathy consist of the medial prefrontal cortex, the right temporo-parietal junction, and superior temporal sulcus.
One of the typical tests that has been used to evaluate this capacity is the famous false-belief task, where one presents a short story involving two characters: Sally and Ann. At the beginning, both are in the room where Sally has a basket and Anne has a box. Sally has a marble and puts it in her basket and then leaves the room. Left alone, Anne takes the marble out of the basket and puts it into a box. The question asked to the participant is then: when Sally comes back, where is she going to look for her marble? Without a theory of mind, the response is going to be “in the box,” because the participant cannot put themselves in Sally’s shoes, that is, cannot understand that Sally does not know that Anne moved it to the basket. Whereas with a theory of mind, the answer will be that because Sally did not see Anne move the marble, she will look for the marble where she left it, which is in the basket.
There are many things that can be critiqued about this task, including its validity to test theory of mind in autism, but here is the gist of this test: can you override what you know to put yourself in someone else position, and also, do you have the capacity to quickly evaluate whether another person doesn’t know something that you do know?
But cognitive empathy goes beyond these simple capacities, and includes being aware that other people can be hiding their emotions, or that they can display fake ones. This is where some autistic individuals can sometimes struggle a lot, with the risk, especially for women, to be abused and become the victims of manipulative individuals. Everyone should read Liane Holliday Willey’s excellent book “Safety Skills for Asperger Women,” where she relates how she fell prey to abusers simply because she trusted them to be telling the truth. For example, her bowling professor offered to show her how the bowling machinery that collects and retracts pins and balls works, but instead took advantage of the situation to try to abuse her (p. 35). In fact, the entire book is a guide of how to develop these awareness skills and think beyond what is being said or shown. Conversely, autistic individuals are known for not lying easily, which is something to appreciate in our troubled times. At the opposite end of these abilities, one should not forget that a well-developed cognitive empathy is what enables psychopaths and liars to be so successful at manipulating others, knowing precisely what to tell to whom in order to obtain what they need.
Affective empathy, on the other hand, is what makes you share the feelings of the person you interact with or observe. It is an innate capacity, also called emotional empathy, that has been conserved through evolution. It can be observed not only in humans or in primates, but even in rodents. It is the process by which you wince in pain when you hear the story of someone getting their fingers snapped in a doorway, or when you see a person getting a syringe planted in their arm. Brain imaging studies have demonstrated, for example, that all the areas that are activated when you experience pain (also known as the pain matrix) are also activated to a certain extent when you observe or think about these painful events.
This capacity to “suffer with” is intact in individuals with autism, who are as sensitive as neurotypicals to the perception of people expressing pain. In fact, they may be even more sensitive than neurotypicals, as it is difficult for them to take distance, and not feel overwhelmed by witnessing pain. The only reason they may not display the caring, consoling behavior that one would expect, is that they experience personal distress and therefore have the need to take distance in order to not feel overwhelmed. Here again I will cite Liane Holliday Willey who writes “Like many women on the spectrum, I am very sensitive to the untouchable feelings of others. I can walk in a room of strangers and within moments be drawn to the person in the most psychological pain (…) And when I sense these things, I absorb their troubles like a sponge. “(p. 65)
This imbalance between not being able to detect lies easily and over-reacting to other people’s pain is extremely difficult to negotiate, and can probably partly explain why social relationships can feel so taxing for autistic individuals.
As long as we use one single word to express two very different realities, we will have difficulties understanding each other and communicating. We need to recognize that autism is not a disorder of empathy, but rather a condition in which cognitive empathy may be reduced, but affective empathy is heightened, which can lead to very stressful situations in daily life.
Nouchine Hadjikhani, MD, PhD, is Associate Professor in Radiology at Harvard Medical School, where she directs the Neurolimbic Research Laboratory, and Professor in Experimental Child and Adolescent Psychiatry at the Sahlgrenska Academy, Gothenburg University, Sweden. She is an author of 120 peer-review articles and 14 books, book chapters, and other publications. One publication of Dr. Hadjikhani’s research on the topic of autism and empathy can be found here.
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