Theory of Mind relies upon our understanding of relationships and emotions which are essential for human cooperation. There are various methods that the brain uses to enhance the cognitive functions involved in Theory of Mind and this can increase brain plasticity after there has been neuronal damage. Some of these methods involve very ancient techniques to enhance human relationships such as story-telling, art and music. In fact, it is posited by some researchers that the evolution of Theory of Mind was essential to these faculties being developed by humans, and that they still hold the key to brain development but also brain rehabilitation. This paper addresses these claims in three parts- the first part gives an explanation of Theory of Mind; the second gives research evidence as to why it can be useful in rehabilitation after acquired brain injury; and the third explains how it is used in rehabilitation therapies but suggests also that the experience of art forms as a member of an audience can be as important as practicing them.
What is theory of mind?
A basic necessity for human communication is the ability to understand another person’s perspective through the use of one’s imagination. It is a critical tool for maintaining human relationships. Through it we can guess at other people’s motivations, their beliefs, their desires, and describe them on the basis of their intentions. Imagination is the basis of Theory of Mind which is the cognitive tool necessary to create literature, art, drama, humor and music as a means of expression, communication and recognition. Theory of Mind, or folk psychology as it is sometimes known, is based upon the understanding that humans are autonomous agents that have mental states which form beliefs and desires which are the basic motivators of human actions.
Without this cognitive tool it would not be possible to create theories of how other minds might work. Because the mind is opaque, human beings need a model or simulation to understand how another person’s mind is working. Psychologists posit that children develop Theory of Mind at around four years of age. It is at this age that children become self- aware and able to infer what others might be experiencing as well, and this ability requires imagination (Leverage, 2011, p.13). Information gathered from the people we socialize with, such as their behavior and what they speak of, allows us to make inferences about them. From this information we can make a mental model of the person.
It is argued that, like grooming among primates, language developed as human society increased and conversation allowed many more relationships to emerge (ibid, p. 16-17). Using language and the ability to make mental models of others and also mental models of others’ mental models, Theory of Mind has allowed us to be more socially intelligent. The extra neural growth in the brain’s cortex allows humans to maintain several layers of these mental models for different other people. These mental models are called ‘intentional states’, or the states of beliefs, desires, and emotions (ibid, p.18).
An intentional state describes the behavior of a person based upon their knowledge, beliefs and desires. When there is a conflict between reality and a person’s belief, it is the person’s belief that will determine their behavior. The knowledge another person has may be different to my own. For example, I know that a dangerous spider lurks behind that rock and, using that knowledge, I can either warn that person if it is my friend who cannot see it or tell that person it is safe if they are my enemy. In this way I have used Theory of Mind to manipulate the other person’s behavior. The dissemination of false or true information has been predominant in human interaction (Firth & Firth, 2005).
The transmission of knowledge also involves the use of Theory of Mind and, it is contended, is the reason for enabling accumulative cultural knowledge. The maturation of the development of the faculty of Theory of Mind is thought to have coincided with the appearance of homo sapiens around 250-200 thousand years ago. This facilitated an explosion in technical, social and cultural phenomena, such as the earliest forms of fictional art and symbolic adornments during the early Paleolithic era (Livingston 2010, p.95). Theory of Mind allows cultural development faster than genetic evolution can provide. It enables individuals to ‘imagine’ their self acting as another (ibid. p.96). This can be done through sharing emotions which is a unique and crucial element of Theory of Mind (ibid. p.98).
Emotions can be described through symbolism. Symbolic representations arise out of collaborative problem solving. Individuals use these representations for dialogical interaction to produce some form of joint understanding. Symbolism, along with reflective thought, allows a thought to be produced and to be reflected upon. This has two functions: the first is to correctly transmit cultural knowledge, for example a child elicits a thought and an adult will critique it which may force the child to reexamine the thought from a new perspective; the second allows for individual skill development where a person reaches a certain level of skill at a task and is then able to reflect upon the elements that allowed them to achieve it. This allows the creator to act reflexively and hone skills and thoughts by making refinements, adjustments and progressions (ibid. p.99).
Why could Theory of Mind be useful in dealing with brain injuries?
It is posited that the anterior paracingulate cortex along with the superior temporal sulcus, and temporal poles being supportive, are the active regions for Theory of Mind to be mediated (Leverage, 2011, p.3). Progressive enlargement of the cortex, it is argued, has occurred in the evolution of higher order primates because the brain needs to have more neural machinery to contain the extra mental models needed for a larger social group. For humans, language rather than grooming has taken over as the primary means of maintaining relationships in a group. Hominid evolution can be clearly seen through the enlargement of brain-cortex size over a 500 thousand year period. The human cortex became distinctly larger once language-based communication became the primary mode of communication in the group (ibid, p.17). It is argued that laughter and music also added to this increase, along with the functions of Theory of Mind.
Art is an externalization of metaphors and models. Before art emerged around 50 thousand years ago these areas of knowledge within the brain were marked out into plant/food; social world; navigation; toolmaking etc. When art emerged these areas began to overlap and metaphor, or the symbolic significance of an object or idea, became possible (ibid, p.19-20). As the brain used metaphor to communicate, the invention of writing enabled an externalized memory and the possibility of communicating over a distance. Stories became tools for thinking in the social world (ibid, p.20). This can be described as ‘distributed cognition’ and its purpose is increased explanatory power. The psychologist James Werscht gives the example of the story of how his daughter lost her shoes. He tried to help her remember where she left them. Werscht questioned who is doing the remembering? He could not have been, as he did not know where she had left them, and she could not have been remembering as she had forgotten. He argued it was a dyad, two people working as a single cognitive system, to solve a problem on an intermental plane. It is this function that allowed him and his daughter to find her shoes (ibid, p.29).
The strongest engine of the human imagination is this functional capacity for cognitive integration. We don’t just imagine stories or ideas that are the opposite to our immediate environment, we can also blend and connect them to make a mental array (ibid, p.41). Theory of Mind relies upon some basic functions to work such as perspective taking, empathy and generally speculating on the thoughts of others. It is fundamental to social cognition (Nguyen, 2015, p.651). Difficulties with this function can come about through brain damage to the frontal cortex and the region of the temporo-parietal junction (Firth & Firth, 2005).
How could these uses be put into action?
Two regions of the brain consistently ascribed with the abilities to maintain functions associated with Theory of Mind are the medial prefrontal cortex region (paracingulate cortex) and the tempero-parietal junction in the superior temporal sulcus (Firth & Firth, 2005). However, it is also contended that the evidence for a Theory of Mind cognitive network is limited and contentious (Shaafsma et al, 2015, p. 67). This is because it is thought not to be a monolithic process (ibid, p.65). It is proposed that Theory of Mind concepts are broken down into cognitive components which can describe more basic functions. These basic processes can then be mapped onto specific neural processes. No one process can be ascribed to Theory of Mind and every basic task will involve other tasks than those particularly ascribed to Theory of Mind. Theory of Mind emerges from these basic cognitive components because of the shared variance of these components.
Just as humans use the five senses to perceive the physical world around them, they also use several different social-cognitive processes to construct a useful mental view of the world around them and those who inhabit it. A map of such processes can be posited as modular, even though it is by no means certain that the brain is modular in construction. I suggest that a basic map of brain function can be illustrated as in Figure 1. This mind map shows that the basic functions of the brain interact with each other which enhance performance and ability. The map begins with the five senses which transfer information to the thalamus which acts as the basis of the assessment module. It directs the information to various areas of the brain. The hippocampus is the basis of memory and emotion. Interacting with the thalamus it sends messages to the cortex which then directs these messages to the two hemispheres of the brain, the right side concerned with imagination and the left side with ideas. These hemispheres direct the information to the frontal lobe, which is chiefly concerned with action and language. These faculties are all essential for the operation of mind reading skills. Therefore, although there is a good amount of evidence that Theory of Mind is a module that can be damaged, leaving a deficit of social skills, it could be argued that enough stimulus to the brain could allow Theory of Mind to exist in the brain without those particular regions ascribed to it.
There is a large amount of credible evidence to show that the brain is plastic and able to transfer function from certain areas to others when there is a necessity to do so. The plasticity of the brain is posited as ‘the ability to make adaptive changes related to the structure and function of the nervous system’ (Zilles, 1992, p.383). The brain can make alterations in neuronal networks which include changes in neuronal connectivity as well as neuronal genesis, and also neurobiochemical changes (Fuchs & Flugge, 2014). Brain training is controversial and experimental studies show that, while effects on trained tasks are consistently reported, there is little evidence for long term effects. However, this area of neuroscience is in great need of larger and more thoroughly designed studies (von Heugten et al, 2016). And it is to this area which this paper seeks to use the basis of Theory of Mind as a rehabilitation design for people with acquired brain injuries.
Tomasello contends that Theory of Mind acts to bring together domain and non-domain specific faculties in the creation of music as it does for language. The motivation of art is the desire to communicate effectively with others; to understand and share the emotions is a crucial aspect of Theory of Mind. Affective engagement can be experienced in a variety of forms, storytelling, music, art, dance and theatre. All of these art forms rely upon cross domain channels of expression (Livingston, 2010, pp.85-6). In particular, the ability of music to change consciousness through engendering affect in individuals can be seen with its universal application in ritual and the marking of large social events, as well as its essential use in contemporary times in art forms such as film. It promotes conjoinment through coordinating the emotions of participants (ibid, 2010, p. 87).
Music therapy is one aspect of rehabilitation that can facilitate the interaction of complex patterns in the brain (Bengtsson, et al 2009; Jennata et al, 2002; Patel, 2003). For example, Broca’s area is used both in the processing of language and music, and also the sequencing of physical movement. Neuroscientists consider that this is because Broca’s area is essential to the sequencing, timing and ‘grammar’ of physical movement, language and music skills (Schlaug, 2008). Research clearly shows that learning music changes the brain with auditory and motor areas growing larger. Therefore, music drives brain plasticity (Pascual Leone, 2001) and can be beneficial for rehabilitation exercises in those with brain injuries.
Art therapy has also been found to be effective in brain rehabilitation practice. Various case studies have looked at people with severe brain damage and its associated functional impairment. A comparison was made before and after the art therapy was undertaken and there appeared improvements in memory, concentration, attention and organization (David, 1999). This was also found in a case study of a chronic stroke patient who had ten weeks of art therapy undertaken twice a week (Kim et al, 2008). The Royal Talbot Rehabilitation Hospital in Melbourne, Australia, uses art therapy as well as more traditional rehabilitation exercises in patients whose speech, attention, problem solving and memory has been affected by an acquired brain injury. It involves the use of various art forms in order to assist expression, trauma, emotions and relationships and differs from traditional art by focusing on process rather than outcome. It also assists in brain plasticity by activating twenty one different components of brain function, thereby exercising neurological pathways that have not been damaged (Harris and Hanson, 2016).
However, most importantly, such therapy cannot sit in a vacuum if it is to be truly successful. Experience is the foundation of brain stimulation and that comes through the senses. To engage in art therapy, one should experience art by visits to galleries, and it is the same for other art forms. To engage in music therapy, the experience of seeing music performed uses all of the senses and stimulates patients’ engagement with their own imagination and ideas. And so it is for theatre and books; going to the theatre is a profound experience which engages both the sensuous and tactile to found and activate ideas, imagination, actions and language for use in therapy outcomes. Therefore, part of ongoing rehabilitation for people who have brain damage should also include the experience of these art forms as well as the opportunity to engage in them.
Imagination is the basis of Theory of Mind in humans. Through its use, executive faculties within the brain are activated, such as intentional states, or our beliefs, desires and emotions. We also use it to attribute such states to others. It can be activated through symbolism and sound, such as in story-telling, plays, art and music. Because the process of Theory of Mind activates neural regions across the brain it is a good contender to promote brain plasticity after damage has occurred, particularly after an acquired brain injury. By appealing to the concept of a modular brain that interacts, the process of stimulating Theory of Mind activity within the brain could be a basis on which to design cognitive therapy for brain injuries. It has been shown that music and art therapy have good outcomes for people with brain injuries. This could be extended, especially with regard to severe brain injury, to include passive as well as active therapy. Therefore, story-telling, music and art are essential to assisting patients with brain injury. Therapy that includes being an audience member for theatre, music, and art are as important for stimulating the brain as participation in these imaginative processes to engage and stimulate the senses fully in experience.
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