Personality Function, Dysfunction, and the Social Domains Organisation of Mentalizing Processes

In this three-part Papers Podcast, Professor Jonathan Hill discusses his JCPP paper ‘The social domains organization of mentalizing processes in adolescents: a contribution to the conceptualization of personality function and dysfunction in young people’ (https://doi.org/10.1111/jcpp.13838).

Part One explores the controversy surrounding personality function and dysfunction.

Discussion points include:

• Definition of personality functioning and dysfunction.
• The subjective experience of personality dysfunction and impact on life choices.
• How to differentiate personality function and dysfunction.
• How to differentiate between normal adolescent changes and personality dysfunction.
• The developmental factors are associated with the emergence of personality dysfunction.

Part Two focuses on mentalizing, the mentalizing processes, and social domains.

Discussion points include:

• Definition of mentalizing and when the ability to mentalize arises developmentally.
• How the concept of mentalizing relates to personality dysfunction.
• An overview of the social domains hypothesis and how this relates to mentalising.
• The different types of social domains and what is meant by domain disorganisation.
• How do different social domains influence the function and dysfunction of the mentalizing process.

Part Three is an overview of the paper, methodology, key findings, and implications for practice.

Discussion points include:

• Why they were surprised with the results from the study.
• The implications of the study from a research perspective.
• Additional research that is exploring this topic further.
• Implications of the findings from an intervention or practitioner perspective.

The guiding principles in my work are that theoretical and empirical developments need to go hand in hand, with real, and not token, influences on each other. This is a philosophical, scientific and psychotherapeutic stance. Four main strands in my work reflect this perspective:

• First, the study of developmental processes contributing to vulnerability to mental disorders in children and adolescents, and to resilience. This has been through the UK ‘Wirral Child Health and Development Study’ (WCHADS), the Indian ‘Bangalore Child Health and Development Study’ (WCHADS), and the Colombian, La Sabana Parent-Child Study.
• Second, the development of a clinically and therapeutically practical framework for understanding and working with, parents and children, the Family Domains Framework (FDF).
• Third, conceptualization and assessment of personality functioning in adolescence and the transition to adult life.
• Fourth, identifying distinctive causal processes in biology, with a central role for normativity (correctness vs mistakes), and action, in order to inform hypothesis testing in biological and behavioural research. (Bio and image from the University of Reading)

Transcripts

Episode One
Episode Two
Episode Three

Episode One

[00:00:01.430] Mark Tebbs: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, Freelance Consultant and today’s interviewer. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances. If you’re a fan of one of our Papers Podcast series, please subscribe on your preferred platform, let us know how we do, with a rating or review, and do share with friends and colleagues.

Today, I’m delighted to be interviewing Professor Jonathan Hill. Jonathan is a Professor of Child and Adolescent Psychiatry at the University of Reading. He’s co-authored a paper with Peter Fonagy, Tiziana Osel, Isabel Dziobek and Carla Sharp. The paper’s entitled “The Social Domain Organisation of Mentalizing Processes in Adolescents: A Contribution to the Conceptualization of Personality Function and Dysfunction in Young People.”

Jonathan, thank you for joining me, I’m really looking forward to our conversation today. Let’s start with an introduction and if you could just, sort of, say who you are and a little bit about your career to date.

[00:01:20.270] Professor Jonathan Hill: Yeah, so as you said, I’m, at the moment, Professor of Child and Adolescent Psychiatry at the University of Reading. And quite a lot of my work is on development and psychopathology on childhood and even prenatal origins of mental disorders, through the “Wirral Child and Health Development Study,” which I lead, which, as the name suggests, is on the Wirral, just over the river from Liverpool, which I was previously, at the university.

My work also concerns processes in families and working with parents of adolescents with the sort of difficulties we’re going to be talking, and in that respect, I am also an Honorary Consultant in Child and Adolescent Psychiatry, in Oxford Health Foundation Trust.

As part of my interest in long-term outcomes from childhood, I’ve, for a long time, been interested in how we think about personality functioning, and that really forms the main background to this work.

[00:02:25.700] Mark Tebbs: Brilliant, I’m really looking forward to our conversation today, especially as we’ve, kind of, got an opportunity to do a little bit of a deep dive into the subject. So, we’re going to do a series of three podcasts, so we can really unpack and explore the subject. The paper brings together these three concepts: so the personality function and dysfunction, social domain organisation and mentalising. So, we’ll be able to focus this first podcast on the controversy, I guess, surrounding personality functioning and dysfunctioning, and I’m hoping that the first podcast will lay some of those foundations for the other two, where we can go into a little bit more detail on the other concept and also, onto the paper itself. So, it’s a great opportunity to be able to go a little bit deeper in the subject area.

I think it would probably be useful if we just started with a little bit of definition. So, could you describe what’s meant by the terms ‘personality functioning’ and ‘dysfunction’?

[00:03:25.680] Professor Jonathan Hill: Well, there isn’t really one unifying definition, but we can point to a number of aspects of all of our lives, which we are trying to grasp here, which is that we all have a characteristic way of seeing the world, of experiencing the world, of responding emotionally to the world and particularly to others. And we have – all have our own patterns of relating, both in close relationships and in less close relationships, for example, in work or educational settings. We have a way of viewing ourselves in the world and a more or less clear sense of what that is. And all of this, as it were, can be bundled together into what we think of as personality functioning.

And then these, sort of, various facets of who we are and how we function can be disrupted, in some ways, that make life more difficult, including making our life with others more difficult, keeping a hold of jobs, or staying in an educational setting, achieving goals in life. All of these can be affected in a set of difficulties that we refer to as ‘dysfunction.’

So, I think the thing to bring out is that we are talking about the majority of the things that matter to all of us, that fit together in a rather complicated way, both individually and interpersonally. And when they are not going as smoothly as they might, they can be a major challenge for the individual and for those who are close to them and less close, but also aiming to help them.

[00:05:27.480] Mark Tebbs: Thank you for that. So if we were thinking about the subjective experience of personality dysfunction, what would that feel like for an individual? Is there a way of describing what some of that subjective experience feels like?

[00:05:40.449] Professor Jonathan Hill: Well, that’s a good question and we probably don’t know as much about that as we need to, and also, there’s not going to be one answer to that. So, I think for some people, the experience is that even the simplest – apparently, simplest things in life can be difficult for the majority of young people, being in school, responding to the academic and institutional requirements of being in school, relating to other young people in school. And these sorts of things that are relatively straightforward for a – for the majority are experienced as difficult. Now, the experience then can vary. For some, it is an experience, that, in an important respect, other people and institutions don’t understand what it’s like to be in their situation.

For others, it’s probably more an experience of failing to find a way, of disappointment, of feeling that they can’t proceed in the way that they would like to. So, you’ve got elements of feelings of personal failure and also of the world around not understanding, not meeting needs, and so on.

That’s one aspect, but for others, it can be more to do with a sense of not quite knowing who they are, what their place is and where they belong, or even if they belong. Not feeling confident of the commitment and love of others. Of finding themselves easily feeling let down in the particular, sort of, arena that we’re talking about, which we’re referring to in terms of borderline difficulties. The experience of being at the mercy of emotional shifts is a common experience. Young people could describe themselves as finding their emotions suddenly activated, very intensely, in a way that they often don’t understand and are difficult to regulate.

But there are other patterns of personality dysfunction, which are really much more characterised by aggression and violence towards others. And that experience can be sometimes linked to an ex – a feeling that the world is a threatening place and a place where one needs to be on guard and quick to respond, perhaps meeting perceived aggression with actual aggression. So, in summary, it’s not easy to give one answer to that, and there are different patterns of personality dysfunction in which one or other of these sort of experiences seem to predominate.

[00:08:44.510] Mark Tebbs: And I’m just wondering, do we see personality functioning and dysfunction on a continuum? But how do we, kind of, differentiate one from the other?

[00:08:52.320] Professor Jonathan Hill: Well, this is a really important question because historically, the concept comes out of what we refer to as a categorical framework. That is, of a person either having a disorder or not having a disorder, as if there was a sharp boundary. But all the evidence is that’s not the case, that young people and adults vary in the extent of their dysfunction, and that can vary not only in how severe it is, but, for example, which aspects of their lives it affects. So, some people find some aspects of their lives more difficult than others, and then an even quite narrow area of difficulty can then have broader effects on a person’s life. So, we refer to it as dimensional both in terms of the kind of difficulty, the severity of difficulty, and where it’s encountered.

Increasingly, we’re aware that people may have a degree of personality difficulty or dysfunction that doesn’t go above the traditional thresholds, but still makes a difference. We have, for example, published on this in relation to parenting, where we find that difficulties of the borderline personality disorder type that are well below any threshold for a disorder seem to make a difference, or to make it more difficult for parents to provide for their children in certain ways.

[00:10:33.220] Mark Tebbs: Yeah, so – and at that more severe end, I’m wondering about what the, kind of, research suggests about, like, life chances and the impact of that on people’s opportunities and, I guess, probably psychopathology.

[00:10:46.970] Professor Jonathan Hill: Yes, I mean, once a person has these sorts of difficulties, there is quite a likelihood that it will affect all aspects of their life in such a way that they then have more to cope with and experience a closing of life opportunities, which then makes things more difficult. So, I mean, this is one of the reasons that I, and many of us, would argue that it’s so important to understand this problem in adolescence, which is the key time at which opportunities open up or close down, in which a young person may, by virtue of the way they are coping and managing, find themselves in supportive environments or less supportive environments.

That makes adolescence such a key time in terms of opening and closing of life opportunities. And clearly, if the young person, of the sort that we’re talking about, let’s say a 15-year-old, among the difficulties they have is being in school, completing schoolwork, coping with the interpersonal demands of being in school, they quite often miss time from school or find themselves in a setting that is not so likely to open opportunities for them. They may then struggle, for example, in going into an apprenticeship where they would – if they could succeed, where they would acquire key skills for the future.

A key issue for many young people is making good choices about romantic partners, and one of the key problems that can arise for young people with personality difficulties is that they are not good at spotting where there is potential for romantic relationships to become a source of adversity or even violence, as opposed to sources of crucial support. So, these, sort of, sets of difficulties in adolescents can impact in all these sorts of ways hugely. Not only on how a young person is now, but how they will be and what their opportunities and supports will be over many years.

[00:13:15.899] Mark Tebbs: You’ve mentioned adolescence, and obviously adolescence is often a time of huge change and turbulence. So, how do we differentiate between that normal adolescent changes with the personality dysfunction?

[00:13:27.670] Professor Jonathan Hill: As we’ve said, we are talking about a continuum, but if we take the young people who are suffering quite a lot, the difficulties with their emotions, with their relationships, including sometimes relationships with parents, are at a level where they’re adversely affecting how they function. And what we’ve just referred to in terms of their opportunities and the extent to which they find themselves in a supportive setting, or a less supportive setting. So, the key is, to what extent are these difficulties in regulating emotions and relating behaving, to what extent are they impacting on the young person’s life?

As you say, there are some commonalities. For example, experiencing intense negative emotions, either low mood or irritability or anger, is common is adolescence. Some degree of conflict in relationships is pretty common. But for the majority, this doesn’t affect their ability to stay in school, to make relationships, to acquire skills, and to maintain their course into adult life.

[00:14:46.300] Mark Tebbs: Yeah, that’s really helpful. You’ve mentioned borderline personality disorder, I’m just wondering, is borderline personality disorder and personality dysfunction, is it the same thing? Are those terms interchangeable, or is there some sort of difference that would be useful to unpack?

[00:15:02.980] Professor Jonathan Hill: Well, you are asking a question, which is a topic of great controversy and debate. Certainly, if you take this general characterisation of personality dysfunction that we’ve been taking about, there are a number of ways in which people can run into difficulties in functioning. So, the borderline idea is really – the focus is on the intensity of emotional reactivity, the maintaining of relationships, and common feature is self-harm and suicidal behaviours. And those sorts of difficulties seem to go together, even though they are, in many ways, very different, and they go together to adversely affect a young person’s life.

Now, a number of other patterns have been described. Probably the other best research one is antisocial personality disorder, and here we’re talking about a pattern of offending, of aggression, of violence, of causing difficulty to others. And in this case, this is a pattern that’s commonly started much earlier in life and has been seen in behaviour problems in early childhood, which seems to be, to a certain degree, also the case for the borderline pattern, but much less strikingly than in the antisocial.

The common feature across those two patterns is the disruption of the ability to stay in education, to maintain a job, to get into supportive and rewarding relationships. So, you’ve got different characterisations, but some commonalities in terms of this social and interpersonal dysfunction.

But there are several other patterns that have been described, including the narcissistic pattern, schizoid pattern, and avoidant pattern. I mean, the classification systems have, until recently, included several personality disorders, each with claims to being distinct. But that is the area of debate now.

So, there isn’t really a clear answer to your question, except to say that when it comes to what the clinical practice – if you take adolescent services in general in the UK and internationally, then, this borderline pattern is one of the commonest, and perhaps the most common. And is the one that is particularly demanding in terms of working out ways of helping for child and adolescent services.

[00:17:53.990] Mark Tebbs: We haven’t talked that much about this from a developmental perspective, so I’m just wondering what are the developmental factors that are associated with the emergence of personality dysfunction?

[00:18:04.190] Professor Jonathan Hill: In the case of the antisocial pattern, of repeated aggression, offending, we know a lot about the developmental origins of that. We know that this pattern commonly starts early, and we know that it affects many aspects even of young children’s lives, and we also know a lot about variations in the way these arise. So, there are patterns within the children who develop these difficulties early where their functioning seems to be mainly linked to a lack of empathy or concern for other’s feelings or the affect of their behaviours on others. That’s referred to in terms of callous unemotional traits. While other patterns seem to be more related to emotional reactivity. A bit like the borderline, sort of, example in adolescence, but here really reacting aggressively to minor challenges.

So, these are large literature and a very sophisticated literature on the developmental origins of the antisocial pattern. Now, the literature on the origins of this borderline pattern, and just important to say here that even these are not discreet and easily differentiated. So young people and adults commonly show features of more than one of these patterns. So, the fact that you predominantly – your problems are of self-harm, of interpersonal sensitivity, of emotional reactivity, that can also be accompanied by problems of aggression and law-breaking.

But if we take the, sort of, somewhat more straightforward instance of borderline difficulties, we do know that there are associations between early emotional reactivity and behaviour problems early in life, like there are for the antisocial. But that is almost certainly not the whole picture.

We then – once we’ve left those sorts of antecedence, we get into areas more of speculation. We know there’s a strong heritable component for all of these difficulties, so – which basically tells us the young people, from early on, almost certainly had some characteristics that created a vulnerability or maybe a vulnerability when, in some family contexts, but not others. Now, there’s a big debate on the extent to which developmental origins of borderline difficulties includes child maltreatment, and that is also a area of some debate because it’s commonly difficult to separate out the genetic and the environmental effects.

Another strand, which suggests something like that the young people with borderline difficulties, they were more likely early on to be emotionally reactive, to be highly emotional children, and we refer to that as temperamental emotional reactivity, either easily angered or easily frightened, or both. And one idea, which actually turns out to be quite difficult to study, is that particular patterns of parenting, not maltreating parenting, not trauma, but parenting that has not quite latched onto the particular needs of the young person, or where parents have not, for example, found a way of helping an emotionally reactive child to regulate. And so, we’re talking about a child who would be challenging to a lot of parents, or maybe most parents, and where the critical issue is, well, were the parents able to find a solution for that child?

So, if I was putting money on the story, it would be something like that, an interplay between the particular vulnerabilities or needs of the child and the particular responses of the family, which obviously starts with the parents in the first years of life. But it wouldn’t be surprising if that then, as it were, ramified outwards, for example, to responses of Teachers or peers. And if we generalise from the antisocial story, we know that all those factors are very important.

We know that kids with early aggressive behaviours are commonly not popular with other kids. They make relationships with those other children who have the same sort of difficulties, so the peer interactions tend to make things more problematic. So, we have much less evidence on what I’ll call the borderline story, but that seems to be the sort of thing that may be the case.

[00:23:13.380] Mark Tebbs: We’re coming to the end of this podcast, so there’s just a couple of things I think would be useful. So, like, we set out the ambition to lay the foundations for the further two podcasts, and I’m just wondering is there anything else we need to do? And then, could you also just give us a little bit of a link into the second podcast and the areas that we’ll start to discuss in that?

[00:23:34.780] Professor Jonathan Hill: Yes, well, I think that the areas that we have been looking at in this study, and that need – can be brought out early on, are to do, first of all, with the way we all interpret the world, interpret what other people do, the way we understand what motivates other people, and this is this broad area of mentalising that we’re going to talk about. And so, the question is, well, to what extent do young people and adults, who have personality difficulties, have differences in the way they experience others that contribute to this?

And then, the other area that, again, we haven’t really got onto yet, but is going to be a focus for the next podcast is, it seems that we all have this remarkable ability to vary the way that we behave, depending on the way we perceive the opportunities and the resources of different kinds of relationship. And this is this, what we’re going to talk about in terms of social domain. So, that’s an, as it were, additional layer to the idea that personality functioning and dysfunction has to do with social relating. This is the idea that is has to do with varying the way we relate, depending on who we’re with and what our role is with them and what their role is with us, and what the tasks are that we share.

[00:25:09.380] Mark Tebbs: Thank you so much, Jonathan. I’m really looking forward to doing that second and third podcasts. For more details on Professor Jonathan Hill, please visit the ACAMH website at www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.

Episode Two

[00:00:01.360] Mark Tebbs: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, Freelance Consultant and today’s interviewer. Today, I’m delighted to be interviewing Professor Jonathan Hill. Jonathan is a Professor of Child and Adolescent Psychiatry, at the University of Reading. He’s co-authored a paper with Peter Fonagy, Tiziana Osel, Isabel Dziobek and Carla Sharp. The paper’s entitled “The Social Domain Organisation of Mentalizing Processes in Adolescents: A Contribution to the Conceptualization of Personality Function and Dysfunction in Young People.”

So, welcome, again, Jonathan. Lovely to be speaking to you, again.

[00:00:49.360] Professor Jonathan Hill: Hello, again.

[00:00:51.399] Mark Tebbs: So, in the first podcast, we tried to lay some of those foundations, so really focusing on the broad topic of personality dysfunction. Today, we’re going to focus more on mentalizing and social domains. I think it’s probably best to start with some terms and definitions. So, could you explain what is meant by the term mentalizing?

[00:01:12.080] Professor Jonathan Hill: Yes, the idea of mentalizing came out of studies into what’s been referred to, or is referred to as “theory of mind,” which is the idea that even young children can understand that the way another person views events can be different from the way the person themselves views them. So, there can be more than one perspective on the same events. This, then, was extended from fairly cognitive studies in which children were shown events among doll characters and asked what these doll characters believed had happened, to a more general idea that in all relationships, there is a need for the participants to understand that the way they see things might not be shared with another.

Now, once you get to the idea that there can be more than one perspective on the same events, you also get to the idea that the way I am seeing events now might, on reflection, look different if I was to see them from another perspective.

So, the idea of mentalizing includes both the idea that things may not look the same to others, and also that it is possible for me to view things in a different way. And obviously that – the relevance of that is that it suggests a way forward, therapeutically. If I am, as it were, stuck in my view of things, the mentalizing possibility is that if I could see them in a different way, new opportunities might arise. Or, if I could see the possibility that my view of how another person is motivated. Let’s say if I were to take the view that another person was not caring in the way they treated me, but I could see an alternative in terms of, for example, the other person being under stress and having other things on their mind, and so what I’m interpreting as uncaring actually is a function of what they are having to deal with. Then, by mentalizing in this way, I open up new possibilities for interpreting others and reflecting on my own way of seeing the world.

[00:03:40.060] Mark Tebbs: So, when does the ability to mentalize arise, or develop mentally?

[00:03:44.520] Professor Jonathan Hill: Good question. I mean, children pass theory of mind tasks, which are these relatively simp – straightforward ones using dolls, at around ages three or four. Once you go beyond those relatively constrained experimental approaches, it’s much harder to study, but, for example, you can show that four-year-olds respond empathically to other’s distress. So, we infer from that that they are not only able cognitively to put themselves in another person’s place, but also emotionally.

Now, you know, at that sort of age, the capacity to describe that is limited, but we can see children behaving in ways that convey that.

So, I think the short answer is that this capacity appears pretty early in childhood and then becomes elaborated, more complex, more sophisticated, as children get older.

[00:04:47.000] Mark Tebbs: Okay, and how does the concept of mentalizing relate to personality dysfunction? So, what happens with mentalizing in somebody with personality disorder?

[00:04:58.070] Professor Jonathan Hill: Well, as we are probably going to talk about at some length, we’ve got two sorts of idea in play here. One is that problems can arise from not mentalizing enough, and another is that problems can arise from over-mentalizing. And I do think it’s important to say that once we get into this arena, there are a lot of aspects of what we’re referring to as mentalizing that we don’t really understand very well.

So, for example, we don’t know how much to think about this in terms of the amount of mentalizing someone does, or the way in which a person identifies which aspects of what another person is doing to focus on. ‘Cause obviously we’re all processing information at a huge rate about what other people are doing, and it may be that what we mean by, let’s call it over-mentalizing for the moment, is focusing on more aspects of another person’s behaviour than most people would. So, we don’t know whether it’s to do with how much we process, how we think about what we process, simply how much of our mental space we’re devoting to mentalizing. So, there’s a lot to be said about what we don’t know.

But going back to your question, the core idea is that on the one hand, if I don’t mentalize enough then I don’t have a good enough theory of what is motivating another person. So, I may go to a rather simplified view, for example, based on what I think. So, based on my preoccupations, because I haven’t appreciated enough of the possibilities of what the other person is doing or saying, I, as it were, default to my own view. And of course, you know, it’s very easy, let’s say – I mean, we’re talking about people with personality difficulties, for example, feeling a strong emotion, such an anger, to go from that emotion to the interpretation that a person is being unfair on them or something like that, or neglectful. So, as it were, reading off my emotional state to infer another person’s motives, in part because I’m, what you might call, under-mentalizing. I’m not reflecting on the possibilities for the other person. So, that would be one line of thought.

And then the other, which links to the hyper-mentalizing, which was the focus of our study, there the idea is that I run a risk by over-interpreting other people’s behaviour. So, someone being late, for example, for an appointment, can have explanations all the way from heavy traffic and needed to do something else, to not being interested, not being bothered, not thinking the person was worthwhile to meet up with.

I could, potentially, have a very wide range of hypotheses or theories, sort of, representing a broad range of mentalizing. In which case, I may select from those alternatives ones that are wrong or misleading, or perhaps not securely enough based on the evidence. And that’s one of the core, sort of, ideas about hyper-mentalizing is that it’s mentalizing that’s not secured sufficiently, or not sufficiently linked to, as it were, what most people would perceive if they were in that situation. So, at the moment we have ideas that, as it were, run both ways.

I think another point to bring out, which is one that I know Peter Fonagy would make clearly, is that one can run into difficulties by having too fixed a devotion or commitment to one way of seeing things. So, it’s not just to do with whether – how much I’m mentalizing, but the extent to which I appreciate whatever I’m view I’m taking is just a point of view. It may be that it’s one that needs to be relinquished in favour of another one.

[00:09:02.610] Mark Tebbs: Okay, so the way you described it – so, I may be getting this wrong, but – so it was almost – so, is there a sense that both under and over-mentalizing can be problematic and that there’s, like, a range in the middle of healthy mentalizing? Is that…?

[00:09:18.290] Professor Jonathan Hill: Yeah, yeah, yeah, yeah, I think so, yeah.

[00:09:20.130] Mark Tebbs: That’s really helpful, and the last point that you made around the fixed perspective, is that about the quality of mentalizing rather than the amount?

[00:09:29.570] Professor Jonathan Hill: Yes, it is. Yes, it’s the – yes, exactly, exactly. And that, again, is difficult to evaluate it, but, for example, there are interviews such as the “Adult Attachment Interview,” in which one can assess the extent to which a person seems to be entertaining more than one way of seeing what’s happened in their lives. So, that is – as you say, it’s not to do with the amount, it’s to do with the quality, and particularly that quality of understanding or experiencing this as a mental event rather than an attribute of the physical world.

[00:10:06.620] Mark Tebbs: Brilliant, and I’d just like to move us onto a little bit more about the social domains hypotheses. Can you give us a little bit of an overview around social domains hypotheses and then how that relates to the concept of mentalizing?

[00:10:19.750] Professor Jonathan Hill: Well, one of, probably, the best ways to come at this is to think about what children achieve early in development. So, if you take the, say, six-month infant, six-month infant is pretty indiscriminate in who they smile at and gurgle with and go to. Whereas the one year is already very discriminating between parents and other caregivers and strangers. So, by one, the child is beginning to demarcate their social world, in terms of who they approach, who they look to, who they look to when they’re distressed, who they share a reserve with. And that then becomes elaborated through childhood to a quite remarkable degree.

So, if you take the five-year-old going to school, most five-year-olds already understand that what they can expect from a Teacher is different from what they can expect from a parent and, in turn, different perhaps from what they can expect from the parent of a friend. And of course, for this to work it has to be reciprocated. So, if you take the example of the five-year-old who’s running across the playground and falls over and cuts their knee and starts crying, they will generally look for a degree of comfort from a Teacher, and the Teacher, in turn, will offer a degree of comfort. But if the child isn’t comforted quickly, will ask something like, “Do you know if your mum or dad’s at home?” or go to call a parent. And the child will typically show a much more wholehearted, full-blooded turning to a parent when they come into the school for comfort.

So, this is really what we’re talking about, is capacity, that seems to come in very early, to understand different kinds of relationships serve different functions, that they have different resources, that problems are solved differently in these different kinds of relationships, and that there are characteristic behaviours that are expected, acceptable, and supported. And that then becomes elaborated into what we see through adolescence and in adult life, when most of us manage to make that demarcation relatively clearly, going from the very intense dramas of family life to the task-oriented, much simplified environments, let’s say, of work and probably, one might characterise friendships as intermediate between those. So, that is the idea.

Now, the notion of domains, there was a Developmentalist, Daphne Bugental, who referred to domains as the algorithms of social life, which I think’s a very nice expression. And basically, what we use are unwritten rules that use in guiding how we think, how we behave, what we look for, in different social contexts or domains.

[00:13:39.550] Mark Tebbs: Could you just explain what those different social domains are?

[00:13:43.740] Professor Jonathan Hill: Well, the way that I’ve conceptualised it in – there was an interview measure that I devised a long time ago called the “Adult Personality Functioning Assessment,” in which we identified five domains, which are – this is in adults, romantic relationships, friendships, work interactions, broader social interactions, so those are the sort of interactions where you don’t have a lot to guide you as to how to behave, for example, parent meeting another parent at a school gates who they don’t know well. And negotiations, such as with someone in a shop. So, we basically, in that measure, describe five domains. Now, whether that’s the right number, I don’t know. But we can – in terms of writing the rules for interviewing in those five, we have been able to describe distinctive characteristics of what we’re looking for. So, that probably covers a lot of the ground anyway.

[00:14:47.370] Mark Tebbs: So, how does the different social domains, the social situations, how does that influence the functioning or dysfunction of the mentalizing process?

[00:14:56.759] Professor Jonathan Hill: Well, I guess this is where we’re into the area that we’re just trying to open up. The hypothesis is that if you are going to modify what you do, in the way that – I’m talking even about the child modulating their behaviour with a Teacher, with a friend, with a parent, then one way in which they may do this is in terms of how much they interpret the intentions of the other person. So, for example, interpreting a Teacher or a work colleague’s behaviour, predominantly in terms of the task, which is the work task, or the outputs that are needed, and so limiting the extent of the mentalizing to cover a narrower range than you might with a romantic partner, for example.

So, we did a study, an imaging study, where we presented different kinds of probes to people, such as a work colleague forgets your birthday, you partner forgets a birthday. So, a work colleague who knows when your birthday is forgets it. A romantic partner who knows when your birthday is forgets it. Now, the idea would be that the range of ways in which you interpret that, depending on who the other is, will vary in a domains way. So, for the work colleague, it will be appropriate to interpret this in a fairly ordinary way, like they were busy, they had other things on their mind, and so on. For a romantic partner, it will be appropriate to at least consider the possibility that this was more personal.

So, the idea is that the scope, the range, depth, perhaps particularly the emotional implications of another’s behaviour varies, depending on the social domain. So, in effect, it may be more adaptive to, as it were, narrow or broaden the scope of mentalizing, depending on the domain, as it were, as a guide to behaviour in that domain.

[00:17:13.880] Mark Tebbs: Yeah, so I think the paper suggests that romantic relationships require more mentalizing than other social domains. I think that’s probably the example that you were just using there. So, could you just explain that a little bit more to us?

[00:17:27.900] Professor Jonathan Hill: I mean, the particular link that we were looking at was to hyper-mentalizing. This is the idea of going beyond the evidence. And this is all hypothesis now. I mean, these are – this is what drove the research, as it were. If you think about either a romantic partner, or a parent with a child, where it may not be obvious, so, for example, a romantic partner comes home from work and they’re in a bad mood. You could take a fairly narrow view of that, basically just say, “Well, I don’t – you’ve no reason to be in a bad mood,” or something like that. So, some sort of relatively narrow mentalizing stance. Or one might want to explore the possibility that things that aren’t immediately obvious are driving this, such as that they’re worried or that they’ve – they’re distressed about something.

In other words, it will be adaptive, potentially, to go beyond what’s obviously there. And this can be very important for parenting – and parenting of adolescence, where the signals may not be very clear. So, having an expanded repertoire of ideas for what might be going on could be very important. And the way that I would argue this also is that almost certainly if you have this expanded repertoire, let’s call it hyper-mentalizing, it’ll be more mistake-prone. Except you could say, the more ideas I generate about what’s driving someone else’s behaviour, the more likely I am to be wrong, almost by definition.

So, certainly in romantic relationships, provided they’re in reasonably good shape, there is an opportunity to revisit that and review how one person saw things, how another person saw things, and come to a revised view. And obviously, apologising and having the opportunity for intimacy and emotional closeness all creates the possibility for that kind of review to go on, which obviously would be not advisable in a work setting with someone one didn’t otherwise have a friendship with. And probably is intermediate in friendships.

So, I think that the idea would be that romantic relationships, and in a different way parent/child relationships, sometimes have to be transacted at the level of an attempt to understand where things are not clear, having the expanded repertoire is helpful, and because of the closeness, there’s opportunity to go back, review, reconcile, and so on.

[00:20:11.400] Mark Tebbs: Thank you, I think that’s a nice segue into the third podcast. So, I’m just wondering, is there anything else that needs to be said in this middle podcast? Is there anything that we need to say before we close this middle one down?

[00:20:26.320] Professor Jonathan Hill: Well, and maybe just to bring out that in this view, the extent of mentalizing would be seen as more or less helpful, depending on what you’re doing. So, rather than an idea that there’s too much or too little, there is an idea that that all depends. So, it’s somewhat relativised. And I think that that’s what goes into our thinking in the paper.

[00:20:50.340] Mark Tebbs: Could you tell us a little bit more about that core idea around domain disorganisation and how it relates to the more problematic side of personality disorder and personality dysfunction?

[00:21:06.340] Professor Jonathan Hill: Yes, the idea of domain disorganisation really came out of the interviews that we were doing, using the “Adult Personality Functioning Assessment,” with adults, both in mental health services and outside, where there seemed to be an issue not only of how much they were struggling in various domains, but the extent to which they seemed able to keep the demarcation clear.

So, the very striking example that came up several times in interviews with people with borderline difficulties, was that they commonly had one friend that was very intense, and which seemed to have some of the dynamics of a romantic relationship, for example, of exclusivity. They only had one and it was important to the participants that they didn’t have others. And so, this, which came up, as I say, in the interviews, seemed to be an additional component of the problems that those with the borderline difficulties had, which we then generalised and refined in the interviewing in what we’ve published as the revised “Adult Personality Functioning Assessment” as a general description of a reduced demarcation between the domains, in terms of the intensity of the relating, the resources that people seem to expect, and the behaviours that they showed.

And then we published, out of work with Paul Pilkonis, in Pittsburgh, that it seemed that domain disorganisation was particularly characteristic of borderline personality disorder. So, in those publications, we contrasted that with avoidant personality disorder. So, there were some indications that it was a distinctive feature for borderline difficulties.

[00:23:04.680] Mark Tebbs: Thank you very much. For more on Professor Jonathan Hill, please visit the ACAMH website at www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.

Episode Three

[00:00:00.310] Mark Tebbs: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, Freelance Consultant and today’s interviewer. Today, I’m delighted to be interviewing Professor Jonathan Hill. Jonathan is a Professor of Child and Adolescent Psychiatry, at the University of Reading. He’s co-authored a paper with Peter Fonagy, Tiziana Osel, Isabel Dziobek and Carla Sharp. The paper is entitled “The Social Domain Organisation of Mentalizing Processes in Adolescents: A Contribution to the Conceptualization of Personality Function and Dysfunction in Young People.” This is the third podcast in a series of three, looking at personality dysfunction, mentalizing and social domain. So, welcome again, Jonathan. Lovely to be speaking to you again.

[00:00:55.120] Professor Jonathan Hill: And you.

[00:00:56.120] Mark Tebbs: This third podcast is really going to focus on the paper itself. Could you just give us a little bit of an overview of your study?

[00:01:03.210] Professor Jonathan Hill: Well, this study came out of conversations between Carla Sharp, who has published extensively on hyper-mentalizing in adolescence, from her samples in Houston, and myself, on the possible interface between hyper-mentalizing and social domains functioning, with the hypothesis that I talked about in a previous podcast that hyper-mentalizing among young people, who are in reasonably good shape, might differ depending on the domain in which they’re functioning. And this demarcation, this difference in hyper-mentalizing might be reduced among those with borderline difficulties.

So, then the question came up, well, how we might study this? Now, it turns out that the measure that Carla and colleagues have published on, to show that hyper-mentalizing is increased in young people with borderline personality disorder or difficulties, this measure called the “Movie for the Assessment of Social Cognition,” which was developed by Isabel Dziobek and colleagues, has features that seemed to lend itself to a first examination of the domains hypothesis.

So, this is a measure in which participants view a movie, which has 45 sequences in it, involving friends and strangers getting together for a dinner. So, the early phases show two female friends and two male friends discussing plans for a dinner party. And then it shows the four of them getting together for the dinner party, in which it’s clear that the males and females either don’t know each other at all or have met once before. In other words, they are pretty much strangers. And the dinner party progresses towards flirtatious, romanticised sorts of interactions over these sequences.

What we thought on reviewing this was, well, perhaps we can see whether the level of hyper-mentalizing that an observer uses depends on three contexts within this movie. So, the first is conversations between the friends, which is the same sex friends, and there are ten sequences that show that. And then the next is the early conversations between the males and females when they get together for the dinner party. So, these, in effect, can be identified as conversations between strangers. And then final is the conversations towards the end of the sequence, the signalling looks more, as I say, flirtatious and romanticised.

So, we were really doing this opportunistically, picking up on the characteristics that this assessment had, which, as Isabel describes in her publications, was designed to assess hyper-mentalizing over a range of social contexts. But it wasn’t designed to ask whether it varies by social contexts. But that’s exactly what we looked at. And we did some work to establish that these different social contexts can be identified reliably when shown to masters students.

And so, we then took the ratings that had already been done by participants in a non-clinical sample that Carla had already published on, and we re-analysed the hyper-mentalizing data to say, can we see a difference in the levels of hyper-mentalizing in these three contexts, portrayed in the MASC? And the answer was yes, perhaps one would say rather surprisingly, given that this wasn’t a measure that had been devised to do this. But one can see in the paper, the mean hyper-mentalizing scores vary markedly across the three.

So, the way the MASC operates is that young people, participants, view each of the 45 sequences and are then asked to endorse one of several possible interpretations for what a participant – a portrayed participant in the video might have been thinking or why they said what they did. And these are designed to be hyper-mentalizing, accurate mentalizing, or under-mentalizing. So, the method generates up – scores of zero to potentially 45, if you take across the 45 sequences, on each of those dimensions.

So, what we did, having identified the ten friendship interactions, the ten early stranger, male/female interactions, and the ten later romanticised interactions, we then generated hyper-mentalizing scores for each of those. And what we found was that in line with the social domains hypothesis, the average scores for hyper-mentalizing were lowest for those ten interactions between the males and females who were strangers or acquaintances. They were intermediate for the interactions that were portrayed as between friends, and they were highest for the later interactions that were the flirtatious, romanticised ones. So, that was consistent with the idea that the – there is a social domains organisation of hyper-mentalizing.

Perhaps I should say here, the one caution we need to have is that because we’re using a pre-designed measure that wasn’t – a previously existing measure that wasn’t designed to assess these differences, it is possible that that progressive change was a function of time in the assessment. In other words, we can’t rule out that the young people tended to interpret interactions as – in hyper-mentalizing terms, the longer they went into the assessment.

Then the second question was, are these young people, and again important to emphasise this is not a clinical sample, with high borderline features, assessed using a widely used measure called the “Borderline Personality Disorder Features Scale for Children,” which has been validated against interview measures of borderline personality disorder, was this demarcation of hyper-mentalizing reduced among those with high borderline features? And the answer was yes, it is, quite strikingly.

So, in other words, the young people in this community sample with high borderline features, and in fact what we show in the paper, those above the threshold identified in interview, clinical threshold, their profile is almost flat. That is to say their levels of hyper-mentalizing are very similar across the three kinds of social context that we identified in the MASC. And there’s a stepwise progression among those with middle and low levels of borderline, to a more differentiated pattern of hyper-mentalizing.

[00:09:14.540] Mark Tebbs: You mentioned you were slightly surprised by the results. Could you tell us why that was the case?

[00:09:21.470] Professor Jonathan Hill: Well, it’s probably based on the surprise that one commonly has when one’s hypotheses turn out to be supported. I think the fact that we had to use a measure that happened to have these qual – characteristics rather than it being designed for them just made it, one could argue, more striking. And I think the key thing for us is we went from the hypothesis – I mean you wouldn’t have done this analysis if you didn’t have the hypothesis. That we could go from the hypothesis to a really quite clear-cut set of findings, both in terms of this variation in hyper-mentalizing and the way in which that variation was altered in the presence of borderline personality disorder.

[00:10:11.140] Mark Tebbs: What are the implications of this finding, and maybe from a research perspective?

[00:10:15.860] Professor Jonathan Hill: Well, the first is it needs replicating, which I guess is the answer we always have and it’s a very important thing to say. I think what does is, if it is replicable, is opens the possibility of the study of the interplay between two areas that are commonly thought of as rather separate, which is social functioning, interpersonal functioning, and social cognitions, that is the way in which people interpret what others do. So, that one might say, “Well, we can’t do one without the other.” So, rather than say, “Well, what are the ways that people view each other’s behaviours?” The implication of this would be, well, that isn’t a question you can answer without knowing who they’re with. But that would need a lot of working out, in terms of future research.

And then, and we go back to what we’ve talked about in previous podcasts, to what extent is the variation or the reduction in the domain demarcation that we identified with borderline, to what extent is that dimensional? I mean, is it that if you’ve got a lot of borderline difficulties, that’s even more marked? Is it that if you’ve got very few, it’s somewhat there, but not a lot? And then, of course, to what extent does the borderline profile have a specific link to this? Are there other mental disorders that also have this?

So, there’s a lot of further questions about the specificity and the severity of borderline difficulties. I think our hope is, and as reflected in the title, that this will help to flesh out how we think about borderline difficulties, not just at the level of behaviour, but of understanding what’s going on in the young people’s minds and in their relationships. And those are both very important topics or areas, therapeutically.

[00:12:28.949] Mark Tebbs: Are you aware of any further research that’s starting to explore this? Is there any research you have on the horizon that is going to look at this further?

[00:12:43.029] Professor Jonathan Hill: Well, one of the possibilities coming out of this study is that if one just takes the MASC scenarios, a key point to make is that what we refer to as the romantic interactions, that’s the later ones in the MASC, are not interactions in established romantic relationships. So, our hypothesis is that that is where the highest levels of hyper-mentalizing will be.

Now, one issue for future research is, can we devise similar sorts of tests that would show – portray interactions among romantic partners? But the other side of this is that perhaps what the MASC will do is show us how young people think when they’re in a situation where a romantic relationship might arise.

Now, this is almost certainly very important in terms of what we talked about in the first podcast, which is that the borderline difficulties probably, for some, closed opportunities, for example, through establishing romantic relationships that turn out to be violent or in other ways unsupportive.

So, a very important topic that’s not really very well understood is, how do young people think and experience and what are the emotions they have to manage getting into romantic relationships? And how does that vary, depending on borderline difficulties?

So, one of the plans we have, and we’re looking for funding to support this, is to use the MASC with young people as – the MASC as written, as a way of linking to how they’re establishing romantic relationships. So, using the same, sort of, interviewing approach, as we did with the “Adult Personality Functioning Assessment,” we know how to ask young people, for example, about whether they’ve taken a relationship forward even where it’s already in trouble. And then this will allow us to ask questions about what’s the thinking that’s going on in the establishment of relationships?

So, this has the potential to help, I think, clarify pathways into the kinds of relationships that are going to be supportive and a resource, and including a resilience – conferring resilience to mental disorders, and what are the pathways into relationships that are more problematic?

[00:15:22.410] Mark Tebbs: Thank you, and it might be too early, but I’m just wondering whether there are implications from an intervention or practitioner perspective of the study?

[00:15:31.839] Professor Jonathan Hill: Well, I think the findings suggest that there may be more than one way to come at the work with young people. So, for example, one approach might be what one might think of as a psychoeducational approach, which would involve conversations about what different kinds of relationships are for, what you can expect in different kinds of relationships, what kind of thoughts come up in different kinds of relationships, and how to make decisions about different kinds of relationships. I mean, in clinical work it’s common, working with young people with these difficulties, to find that the relationships they’re getting into are not helpful to them. But at the moment, we don’t have an organised way of talking about that with them.

These findings would suggest, well, one thing is one can talk about the specific relationships, but another is, you can talk about well, what are the – what is it I expect to find in the relationships? And how might I feel in those relationships, and how might I interpret what people do in them?

Equally, if one’s thinking about mentalization based approaches, which have been developed and for which there is some evidence, these findings would imply that the review of mentalizing in the young person will attend to how they do it, depending on who they’re with, and not only how they do it as a general characteristic. So, you begin to develop a social domains informed mentalization based therapy.

[00:17:15.539] Mark Tebbs: Thank you so much. We’re coming to the end of the podcast, so I’m just wondering whether there’s any final take home messages, any, kind of, things that you, kind of, want to, kind of, end on?

[00:17:29.660] Professor Jonathan Hill: Well, I think, for me, the extraordinary thing is what humans achieve in their social relationships, which are really at the core of everyone’s lives, in terms of making these adaptations and modulations, depending on who they’re with. It is an incredible capability, which clearly develops early and is – seems to be very important to the extent to which our lives are fulfilling, enjoyable, productive, and so on.

So, I think one of the take home messages from me is an admiration for what it is that humans are able to do and how complex that is. And then an appreciation of what it’s like for that not to be quite working and the importance of that and the implication of that. And hopefully then a set of ideas about how one can support people in maintaining this very demanding, sophisticated, remarkable capability.

[00:18:42.620] Mark Tebbs: Thank you so much, it’s been so interesting speaking to you over these three podcasts and just a privilege really to go into the depths we have, so thank you so much. If you would like to have more details about Professor Jonathan Hill, then please visit the ACAMH website at www.acamh.org, and at Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.