Communication Sciences and Disorders | Research | Theory of Mind

Theory of Mind

Overview of the Theory of Mind Training Program

The tasks in this training protocol are ordered to move a patient along a conceptually and empirically defined performance continuum from easier to more difficult. Also, some tasks build directly on other tasks, as detailed below. The program begins with a “Warm-Up Phase”, which is then followed by Phase I and II. On the basis of testing completed to date, we anticipate that Phase I and II will consistently be easier and should be presented first in order to engage patients. Phase III and IV require more effort and call on a number of skills (i.e. second-order beliefs) that are often at risk in brain-damaged patients. Phase III and IV are roughly comparable to each other in difficulty except that Phase IV requires a patient to recognize elements of motivation and deception in one of the characters. For this reason, Phase III precedes Phase IV. While the ordering of difficulty of Phase III and IV varied among the pilot patients who have already completed the protocol, these two tasks were the most difficult of the program.

Detailed Description of the Theory of Mind Training Program

Step-by-step Description of the Training and Scoring Procedures, Rationale, Criteria for Advancement.

Criterion For Initiating Training: Stable baseline performance (+/- 10%) must be documented in cartoon interpretation, spatial orientation, and quality of life (as measured by the SAQOL-39) before training is started. Baseline assessment is repeated 10 times (twice per week during the five week training period).

Theory of Mind Training: The training program is designed to provide multiple opportunities for a patient to practice, correct, and learn skills necessary to progress from one phase of the training program to another. Training begins with the Warm Up Phase and is followed by four distinct training phases (Phases I-IV).

Warm Up Phase Generating words.

Overview:
The patient is provided multiple items in each task (Tasks I-III) in order to practice generating associations for printed and pictured nouns. Five trials of ten items each are presented to the patient for each task.

Instructions:

Task I – Generate five associations about a printed word (typical, pictureable noun).

Task II – Generate five associations about a pictured noun (Atypical, such as a green apple or very small dog). To get the patient to shift what is most relevant about the object: that is, using the perceptual information as a basis for the associations.
Task III – Generate five associations about a pictured noun (same as used for Task II) with changes (broken vase, flat tire, spilled drink, cooked spaghetti, tipped over chair, broken window, bitten apple).

Scoring: The warm-up phase is not scored.

Phase I

Overview:
During Phase I the patient is told that they will be asked to help tell a number of stories. Each story involves two characters: Alice and Greg. The patient is told that both Alice and Greg have thoughts about what is happening in each story. Sometimes the characters’ thoughts stay the same over several turns of events, and sometimes their thoughts change. The patient is instructed to observe each situation to help decide when the characters’ thought change and when their thoughts do not. (Please refer to the image to see an example of the training materials)

Instructions:
Part A.

Task I – Alice views an object; generate 5 probable thoughts about the object.
Task II – Alice goes upstairs in the two family house and thinks about object; generate 5 probable thoughts about the object.

Part B.

Task I – Alice views an object; review response from Phase I A.
Task II – Alice goes upstairs and thinks about object; review responses from Phase I A.
Task III – Alice is back downstairs viewing an object with Greg, who has changed the object; generate 5 probable thoughts that Alice has about the changed object.
Task IV- Alice is upstairs talking on the phone about the object. Alice’s thoughts about the ______ are reviewed. Choose the response that represents what Alice says to her friend about the object (patient is given 3 possible statements in a multiple choice format).

Part C.

Task I – Alice views an object; review previous responses.
Task II – Alice goes upstairs and thinks about object; review previous responses.
Task III – Alice comes back downstairs, meets Greg, who changes object while both characters are present; review previous responses.
Task IV – Alice is upstairs talking on the phone about the object. Alice’s thoughts about the ______ are reviewed. Choose the response that represents what Alice says to her friend about the object (patient is given 3 possible statements in a multiple choice format).
Task V – Greg can either alter or not alter the object while Alice is upstairs talking on the phone. Choose the response that represents what Alice says to her friend about the object now (patient is given 3 possible statements in a multiple choice format).

Scoring: Responses to each task are scored as correct (1 point), delayed correct (.5), or incorrect (0). A patient can progress to the next task after receiving 90% accuracy on 5 trials of 10 items or 100% accuracy on 3 trials of 10 items.

Phase II Word knowledge/perceptual access for two characters

Overview:
During Phase II, the patient is told that they will be asked to help tell a number of stories. Each story involves two characters: Alice and Greg. The patient is told that both Alice and Greg have thoughts about what is happening in each story. Sometimes each character’s thoughts will stay the same over several turns of events, and sometimes their thoughts will change. In addition, in some stories one character will know something that the other character does not know. This knowledge will alter one character’s thoughts but not the other’s. The patient is instructed to observe each situation to help decide when the characters’ thoughts change and when their thoughts do not.

Instructions:
Part A.

Task I – Alice and Greg view an object; generate 5 probable thoughts about the object that will be used for both characters.
Task II – Alice goes upstairs and thinks about object and Greg remains downstairs thinking about the object; generates 5 probable thoughts for each character.
Task III – Provide the common associations between Alice and Greg’s thoughts about the object. (Using bubble transparency)

Part B.

Task I – Alice and Greg view an object; review previous responses.
Task II – Alice goes upstairs and thinks about object; review previous responses.
Task III – Alice is upstairs thinking about the object and Greg remains downstairs. The object downstairs is altered by Greg; generates 5 probable thoughts about the object for each character and identify the similarities and differences between Alice and Greg’s thoughts about the object.

Part C.

Task I – Alice and Greg view an object; review previous responses.
Task II – Alice goes upstairs and thinks about object, review previous responses.
Task III – Alice is upstairs thinking about the object and Greg remains downstairs. The object downstairs is altered by Greg, and the patient generates 5 probable thoughts about the object for each character and identify the similarities and differences between Alice and Greg’s thoughts about the object; review previous responses.
Task IV – Alice is talking to her friend on the phone about the object . Chose the response that represents what Alice says to her friend about the object (patient is given 3 possible statements in a multiple choice format).
Task V – Alice is talking on the phone about the object .The patient is asked what does Alice say to her friend about the object Greg can either alter the object or keep it the same as Alice talks to her friend. Chose the response that represents what Alice says to her friend about the object (patient is given 3 possible statements in a multiple choice format).

Phase III Second Order Belief

Overview:
During Phase III, the patient is told that they will be asked to help tell a number of stories. Each story involves two characters: Alice and Greg. The patient is told that both Alice and Greg have thoughts about what is happening in each story. Sometimes each character’s thoughts will stay the same over several turns of events, and sometimes their thoughts will change. In addition, in some stories one character will know something that the other character does not know, and in some stories one of the characters will lie to the other character. This knowledge or lack of knowledge will alter one character’s thoughts but not the others. The patient is instructed to observe each situation to help decide when the characters’ thoughts change and when their thoughts do not.

Instructions:

Task I – Alice and Greg view an object; generate 5 probable thoughts about the object for the 2 characters.
Task II – Alice goes upstairs and thinks about object, generates 5 probable thoughts about the object for each character.
Task III – Alice is upstairs thinking about the object and Greg remains downstairs. The object downstairs is altered by Greg; generate 5 probable thoughts about the object for each character and provide one common association and one difference between Alice and Greg’s thoughts about the object.
Task IV – Alice is upstairs talking on the phone to Greg about object. The patient is reminded that these are accurate beliefs about the object. The patient is told that Greg says——about the object (patient is asked whether the statement is accurate or inaccurate according to Greg’s beliefs/knowledge).
Task V – Alice is upstairs talking on the phone to Greg about object. Greg lies about the object and says—— (choose the correct multiple choice response).

Scoring: Responses to this task are scored as correct (1 point), delayed correct (.5), or incorrect (0). A patient can progress to the next task after receiving 90% accuracy on 5 trials of 10 items or 100% accuracy on 3 trials of 10 items.

Phase IV Second Order Belief (motivation/deception)

Overview:
During Phase IV, the patient is told that they will be asked to help tell a number of stories. Each story involves two characters: Alice and Greg. The patient is told that both Alice and Greg have thoughts about what is happening in each story. Sometimes each character’s thoughts will stay the same over several turns of events, and sometimes their thoughts will change. In addition, in some stories one character will know something that the other character does not know, and in some stories one of the characters will play a joke on the other character. This knowledge or lack of knowledge will alter one character’s thoughts but not the others. The patient is instructed to observe each situation to help decide when the characters’ thoughts change and when their thoughts do not.

Instructions:

Task I – Alice and Greg view an object as Greg is altering the object; generate 5 probable thoughts about the object for the 2 characters.
Task II – Alice goes upstairs and thinks about object; generate 5 probable thoughts about the object for each character.
Task III – Alice is upstairs thinking about the object and Greg remains downstairs. Have their thoughts changed? (Y/N)
Task IV – Greg is downstairs with the ________. Alice is upstairs on the phone to Greg. He remembers that Alice said, “Please do not alter the______ again while I am upstairs”. Greg alters the________just as the phone rings. It is Alice and she is checking on the ________________. Greg does not want Alice to know that he touched the ________________Greg tells Alice___________ ; Choose the best multiple choice response.
Task IV – Greg is downstairs with the ________. Alice is upstairs on the phone to Greg. Greg follows Alice’s instructions and does not alter the ______. Greg wants to play a joke on Alice to make her think he changed the ______. Greg tells Alice________________ ; Choose the best multiple choice response.

Scores (i.e., percent of possible points obtained and time to completion) should be recorded for individual task. Performance on tasks, and progression from one task to the next, should be matched with performance on the cartoon assessments administered each session.

Scoring Cartoon Interpretation

We have developed criteria for scoring patients’ cartoon interpretations. The scale extends from 0-5 for first order belief cartoons and 0-6 for second order belief cartoons.

6: Complete and appropriate, identifies the second-order belief/mental state of the character
5: Complete and appropriate, identifies the first-order belief/mental state of one or more characters.
4: Complete and appropriate, identifies the mental state of one or more characters but (a) delayed (longer than 5 seconds required for response initiation), (b) may contain self corrections, or false starts but eventually gets to the correct response, or (c) may include some tangential comments and/or personalization.
3: Provides a mental state term relevant to the cartoon but inaccurate (i.e. wrong mental state, mental state of self rather than the character/wrong character) identification of the mental state.
2: Mention of oddness, incongruity of elements.
1: Interpretation has some clear elements of understanding the incongruous nature of the critical elements of the cartoon, may describe the physical details in the picture, does not identify the mental state of the character(s)
0: No response. I don’t know. Completely off topic comments unrelated/personalized association, tangential to cartoon.

The scale can be used reliably (independent inter-rater reliability reached 90%, based on 100% of the pilot subject responses during this pilot training).