Autism & the double empathy problem

We reference the double empathy problem in many of our other articles, and we have briefly explained the concept whenever we mention it. But in this article, I will cover the double empathy more comprehensively, and examine how it impacts autistics.

What is double empathy?

In general terms, empathy refers to the ability to understand the mindset of another person. To learn more, you can read our article about the different types of empathy. However, our empathic ability is not the same across all situations. This can be explained using double empathy.

Double empathy refers to how:

• It is easier to understand the mindset of people who are similar to you
• It is more difficult to understand the mindset of those who are different from you

This concept was specifically developed by the autistic autism researcher Damian Milton to explain how autistics and neurotypicals empathize with each other. It explains how allistics (non-autistics) struggle to understand the lived experiences of autistics and autistics struggle to understand the lived experiences of allistics^[1]Double Empathy, Milton et al. (2020)^[2]On the ontological status of autism: the ‘double empathy problem’, Milton (2012) Likewise, autistics are better at understanding other autistics and allistics are better at understanding other allistics.^[3]Autistic peer-to-peer information transfer is highly effective (Crompton et al., 2020)^[4]Neurodivergent intersubjectivity: Distinctive features of how autistic people create shared understanding (Heasman & Gillespie, 2019)

Double empathy & theory of mind

The double empathy problem relates to theory of mind (ToM), or cognitive empathy. In older research on autism and in many stereotypical views of what autism looks like, it is believed that autistic individuals have poor ToM. That is to say that autistics are unable to empathize with others because we do not have the ability to understand others’ mindsets. But, this isn’t entirely true…

Viewed through the lens of double empathy, more recent and autism-affirming research has found that allistics also struggle to empathize with others. The catch is that these struggles appear when one neurotype (autistic or allistic) is trying to understand the mindset of the opposite/other neurotype.^[5]Can Neurotypical Individuals Read Autistic Facial Expressions? Atypical Production of Emotional Facial Expressions in Autism Spectrum Disorders, Brewer et al. (2016) Since research has historically been designed and conducted by neurotypicals, it is often biased. Due to double empathy, if research is based on comparing against neurotypical norms and expectations, autistics will always look “deficient” and neurotypicals will always look “capable”. Thankfully, more and more research has recognized the biases involved in conducting cross-neurotype research and have made adjustments. For example, researchers are finally asking the autistic community about what types of studies would be beneficial.^[6]Research priorities of the autism community: A systematic review of key stakeholder perspectives (Roche et al., 2020)

Overall, double empathy teaches us that autistics are just as capable of empathy and understanding as neurotypicals and the cross-neurotype struggles go both ways!

How does the double empathy problem impact autistics?

Double empathy becomes a “problem” when allistics and autistics interact with each other and are unaware of the limits of cross-neurotype understanding. In the section about ToM, I shared how this can lead to pathologizing and biased conclusions in research.

Day-to-day, the double empathy problem impacts how autistics are perceived and treated by others. For example, a study measuring social interaction satisfaction and first impressions found that when allistics were conversing with autistics for the first time, they rated the interaction as less favourable than when they were conversing with other allistics.^[7]Outcomes of real-world social interaction for autistic adults paired with autistic compared to typically developing partners, Morrison et al. (2019) They also expressed that in the future, they would prefer to interact with their allistic conversation partners rather than their autistic conversation partners. Since individuals were unaware of their conversation partners’ diagnoses, their first impressions were based on their experiences during the social interaction. This suggests that a communication mismatch is enough to negatively impact how we are perceived by neurotypicals.

A recent study even showed that a communication mismatch can influence the perception of those who are not taking part in the interaction but who are observing the interaction.^[8]Non-autistic observers both detect and demonstrate the double empathy problem when evaluating interactions between autistic and non-autistic adults, Jones et al. (2023) Observers rated conversations between autistics and allistics to be awkward, whereas conversations between two autistics or two allistics were rated as more enjoyable and smooth. This once again highlights that it is primarily the mismatch across neurotypes that leads to the double empathy problem.

Because our society is mostly neurotypical, these negative perceptions are commonplace and biased against autistics. This means that on a large scale, the double empathy problem leads to social stigma, social exclusion, mistrust, victimization, and discrimination of autistics.^[9]Non-autistic observers both detect and demonstrate the double empathy problem when evaluating interactions between autistic and non-autistic adults, Jones et al. (2023)

Importantly, it can also impact our relationships with the people in our lives. Here are some scenarios that can negatively impact autistic individuals due to the double empathy problem:

• Autistic children of allistic parents: It may have been difficult for our parents to empathize with our sensory sensitivities as a child because these experiences are completely foreign and potentially unimaginable to a neurotypical parent.^[10]Double Empathy: Why Autistic People Are Often Misunderstood, Crompton et al. (2021) Conversely, our parents may have asked us to do things that they felt were important but that we did not understand.
• Autistic–allistic relationships: We may have a hard time in friendships and romantic/intimate relationships. For example, our partners may not understand why canceling last-minute plans affects our entire day or why going to a loud restaurant means that we cannot focus on the conversation. As well, we may struggle to understand why our friends enjoy surprises and spontaneous activities.
• Teachers and autistic students: Our teachers may not have understood why we needed more specific instructions. They may have thought that we were being combative instead. Likewise, we may not have understood what the assignments were asking of us even though our allistic classmates had no issues.
• Healthcare providers: When we seek out healthcare, one study shows that we may face barriers due to a mismatch in communication with our neurotypical healthcare providers.^[11]Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study (Shaw et al., 2023) They explain how we may struggle to see our doctors’ perspectives and they may struggle to see our perspectives. For example, if our doctor tries to infer meaning instead of using direct communication, we may miss or misinterpret the message. This can have harmful impacts on our health if the message they tried to convey was the seriousness of our health concern, but we misinterpreted it as “no big deal”. Alternatively, if we are trying to convey how much pain we are in using explicit words but we do not display nonverbal signs of pain (e.g., crying), our healthcare providers may not believe how much pain we say that we are in.

The triple empathy problem

This same healthcare study even suggested that the double empathy problem may actually be a triple empathy problem.^[12]Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study (Shaw et al., 2023) With healthcare providers, autistics have to navigate the double empathy problem as described above, but we also face a third factor: cultural differences within the medical field.

These cultural differences refer to how everyone, neurotypicals included, faces barriers to healthcare due to poor doctor-patient relationships, struggling to understand all the medicalized jargon used by physicians, and having a different perspective on our health than our doctors do. In particular, the study found that healthcare providers tend to communicate with their patients based on their own medical knowledge, forgetting that their patients do not have the same medical knowledge as them. Therefore, for autistics, we have to deal with this same clinician-patient communication mismatch in addition to the autistic-allistic communication mismatch. Hence, the triple empathy problem.^[13]Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study (Shaw et al., 2023)

Here’s the diagram from the study explaining this triple empathy problem in healthcare:

Double empathy & double standards

Even though the double empathy problem is a cross-neurotype mismatch relating to both autistics and allistics, autistic individuals are the ones who experience most of the negative impacts. Not surprisingly, there is a link between autistics being misperceived by neurotypicals and being at heightened risk of poor mental health.^[14]Autism and the double empathy problem: Implications for development and mental health (Mitchell et al., 2021) The opposite does not exist for allistics.

One reason for our poor mental health is that autistics are burdened with having to develop our understanding of neurotypical norms and experiences in order to survive in the neurotypical-dominant world. Meanwhile, there is very little expectation for neurotypicals to try and understand our experiences.^[15]On the ontological status of autism: the ‘double empathy problem’, Milton (2012)^[16]A Mismatch of Salience: Explorations of the Nature of Autism from Theory to Practice (Milton, 2017) Our world is designed such that allistics do not need to understand autistics but autistics need to understand allistics. The mismatch goes both ways, but the onus is on autistics to “figure out” how to be included in society.^[17]Autism and the double empathy problem: Implications for development and mental health (Mitchell et al., 2021)

What does this all mean?

To summarize, the double empathy problem is a way for us to understand the biases that exist in our neurotypical-dominant society when it comes to cross-neurotype communication. It explains how autistics are generally good at understanding and empathizing with the experiences and mental states of other autistics but struggle when trying to understand and empathize with allistics. Importantly, it also explains that neurotypicals have the same struggles: they can easily understand and empathize with other neurotypicals, but they struggle to understand and empathize with us. This has been shown to negatively impact our mental health and relationships since we are the ones who are expected to adapt, but neurotypicals usually are not.