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. Professor Jonathan Hill And you. 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? 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. Mark Tebbs You mentioned you were slightly surprised by the results. Could you tell us why that was the case? 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. Mark Tebbs What are the implications of this finding, and maybe from a research perspective? 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. 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? 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? 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? 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. 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? 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. 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. 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