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. Professor Jonathan Hill Hello, again. 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? 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. Mark Tebbs So, when does the ability to mentalize arise, or develop mentally? 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. Mark Tebbs Okay, and how does the concept of mentalizing relate to personality dysfunction? So, what happens with mentalizing in somebody with personality disorder? 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. 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…? Professor Jonathan Hill Yeah, yeah, yeah, yeah, I think so, yeah. 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? 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. 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? 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. Mark Tebbs Could you just explain what those different social domains are? 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. Mark Tebbs So, how does the different social domains, the social situations, how does that influence the functioning or dysfunction of the mentalizing process? 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. 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? 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. 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? 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. 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? 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. Mark Tebbs Thank you very much. For more on Professor Jonathan Hill, please visit the ACAMH website at www.acamh.org, and Twitter @ACAMH. 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