Agreeing the Task

This session concentrates on the top quadrant of the AMBIT Wheel which is Working with your CLIENT. The goal is to provide an opportunity for the team to share, learn and practice how Mentalization, and particularly the The Therapist's Mentalizing Stance can support the work that team members do face-to-face with young people and their families.
In addition, it seeks to make clear the basic tension between two particular elements of AMBIT's principled stance (see Core Features of AMBIT) - which are Scaffolding existing relationships and Managing Risk.

Explaining the issue

(1) Talk about Scaffolding existing relationships - having an approach that focuses on identifying existing StrengthsResiliencies that might be built upon - elements of a young person's existing relationship to their self (pride in some skill, an existing capacity to be reflective, etc), to family members, friends, other professionals that it would be important that we do not damage in our well-intentioned work.

• It is important that a worker does not seek to replace these relationships with a "perfect alternative"
• Remember that as a worker, I will be leaving, and many of these other relationships will remain.
• Avoid making myself indispensible, and help develop Self-efficacy in the young person.

(2) Talk about the risks that prioritising and scaffolding these relationships entails. Many existing relationships will be far from "therapeutic", and the need for Managing Risk can sometimes get lost in a kind of "therapeutic omnipotence".

• Workers can become over-identified with their clients
• They can "up-regulate" their risk thresholds:
• convincing themselves that they shouldn't be a "worrier", or that they need to "keep up with the times" and accept that "this is how the world is..."
• convincing themselves that preserving their therapeutic relationship is more important than "calling time" on a risky situation.

(3) Talk about how AMBIT assumes that workers will ALWAYS be slightly out of balance in one direction, or the other, when they are treading this tightrope between Scaffolding existing relationships and Managing Risk. The point of attention to the SupervisoryStructures in Working with your TEAM is to get help in constantly correcting these inevitable imbalances, before they get dangerously large.
(4) Watch the video at The Therapist's Mentalizing Stance together.

• The point of the "four-legged stance" is for it to be SIMPLE, so practitioners can "hold onto it" in the hurly-burly of the face-to-face encounter, when our own mentalizing is likely to be challenged.
• The assumption of a worker should be that "I WILL lose my own mentalizing at points in this work... I just don't know when... I don't WANT to do this, I just know that it happens..." and the skill is then to be able to notice my own misunderstanding, and become curious (with the client) about how I came to get it so wrong. This is where we are modelling the fragility of our own mentalizing, to teach the client about theirs. It requires a sort of "confident humility" in the worker to do this.
• Go through the four elements ("legs") and watch video examples of the techniques used to uphold these (remind people the video is NOT a "masterclass" but just a talking point, and an approach that they will need to find their own way of doing (more) authentically - mentalizing work is not about pretending to be a mentalizing therapist!)

STANCE	STRUCTURE & TECHNIQUES
1. The Inquisitive Stance 2. Holding the Balance 3. Terminating non-mentalizing interactions 4. Highlighting and reinforcing Positive Mentalizing	Holding this stance, helped by the structure of the Mentalizing Loop workers use a wide range of Mentalizing manoeuvres to create conditions in which the client can begin to think about their own (or other people's) thinking/intentions, rather than remaining caught "inside" their own (non-mentalizing) thoughts

• Emphasise that it is a STANCE because the worker is always trying to "keep all four legs on the ground" - noticing what I am NOT doing, is as important as knowing what I AM doing.

Practice

See Advice about Role Playing before going into this.
See Training Exercises for Mentalization to select an exercise, or try these role-playing options below:

PREPARATION:
Break into groups of THREE (or 4 with the 4th person as an observer, or "tag worker" ready to step in if the first worker "dries up".
EITHER (A):

• Get one person in the three to talk about a recent conflict they found themselves in (from clinical work, or their personal life if they are happy to discuss this).
• The second person acts as "therapist" and tries to apply The Therapist's Mentalizing Stance as they draw out the story, and work with their "client".
• The third person acts as an "anti-therapist" and (without being too obviously blunt!) deliberately intervenes on a few occasions trying to talk about it without applying any elements of the stance
• talking with certainty about the "client's" feelings and intentions
• ignoring any reflective/mentalizing that they do
• emphasising ONLY the feelings, without any of the beliefs/cognitions
• allowing the "client" to continue in "non-mentalizing" ways of thinking without interrupting/pausing/inviting them into a more mentalizing approach to the issue.

OR (B):

• Use the structure above but agree on a specific client in a particular scenario to role play
• Remember that once the role play starts, the client is the person in the room, not the "real person" they are modelled on "out there" - it is not helpful to practicing if one of the trainees keeps interrupting to say "no, X would never say that!"

Reflect

Allow time for the team to reflect on:

• The extent to which they may already use a mentalizing stance - or may adopt it at times. Remember that all effective therapeutic approaches appear to have found different ways to help clients mentalize - the difference (if there is any) in mentalizing approaches is the explicit focus on this, and the fact that (with or without using the word "mentalizing" there is an effort explicitly to teach the client to recognise that they think in different ways at different times, and to "home in" on mentalizing in the here-and-now of the session.
• Where mentalizing may not be helpful (when the priority is Managing Risk is the most obvious - it is no use mentalizing a tiger as it walks towards you, its jaws dripping with saliva...)
• How might this approach augment the skilled work that they are already doing?

Manualize

Go to + Manualize our work and create a page of reflections from the team on:

• Key learning points that make sense in OUR local context
• Plans for how we are going to try out this material in practice
• A review date for when we will check back with each other
• (For the gold star:) Outcomes measures by which we could tell if this is having a positive effect on our practice. This might be very simple - a clinician-rated scale of 0 - 5 for "how much I applied (or tried to apply) a mentlaizing stance in this case" and another 0 - 5 for "how helpful was applying the mentalizing stance in this case?"

A more formal training plan for a 3 hour session: