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. 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. 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’? 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. 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? 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. 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? 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. 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. 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. 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? 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. 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? 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. 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? 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. 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? 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. 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.