Local Session 07: Working with your Client pt.2 (Hard to reach)

11th June 2015

Agreeing the Task

This is the second training session on Working with your CLIENT. The previous session on this subject (Local Session 06: Working with your Client pt. 1 (Mentalizing stance)) focused on a stance, a structure, and techniques, which aim to support a young person (and their family) to mentalize about themselves and others. This second session focuses mainly on working with a young person who does not necessarily want to work with you and may be described as "Hard to reach". The aim of the session is to provide workers with a wide range of ideas to help them with this difficult problem which is often at the heart of the work.

Explaining the issue

As a starting point, we would want to emphasise that being Hard to reach and not seeking help for severe and major difficulties is not an indication that the young person is doing something wrong. "Under-served" is a less judgmental way of describing this population. The key challenge is for the worker to develop an authentic understanding in which it makes some sense that the young person in front of them would not have sufficient trust and confidence in others to come asking for help. In our experience it is often quite understandable.
  • Creating an experience in a young person that their predicament here-and-now is accepted as real, and is somewhat understood ("That's it! You've finally got it!") is at the heart of the theory of how Epistemic Trust is formed - which opens the door to learning.
  • Acknowledging the fact that our intentions in our work are broadly positive (to help) may be far from clear to our clients whose ability to mentalize us may be limited. Our AMBIT (sphere of influence) in this work only extends to the areas where there is an explicit overlap between our intentions, and those of our clients (hence the importance of Broadcasting Intentions).
  • The benefits of a team culture of Active Planning:
    • It is better to have a plan and shared goals than to "wing it" - all outcomes studies support this.
    • But mentalizing theory also stresses how important it is to maintain attunement and engagement
    • Active Planning implies sensitivity and adaptation of what is offered in keeping with "where we are" (see Active Planning and the therapeutic journey).
    • The difference between a plan (like a map) and your observation of the actual landscape you are traversing
    • Collaborative goal setting - see Active Planning: a core process with clients and the Active Planning Map as a tool to help broadcast the worker's intentions, to foster a non-expert mentalizing stance, and arrive at a shared plan.

Practice

(A) Thinking about the dilemma of the hard to reach
  • Break into pairs and on flip chart paper list out all the reasons why it might make good sense in a young person's mind NOT to want to trust the worker/team that is offering help.
  • Discuss in the large group - consider the Therapeutic Bargain.
(B) Thinking about what to do with our clients
  • If you have time, discuss in small groups/pairs "How do we decide what to do at present?" - then have a large group discussion (perhaps use the Fishbowl discussion technique).
    • Above all, we would emphasise that local teams generally have a lot of skills in assessment already, but are these shared explicitly between all team members? Are there some team members who are known to have special abilities in engaging and learning about specific problem areas? how do these get shared among other team members?
    • Look at the material in What's the problem?
    • Look at the AIM (AMBIT Adolescent Integrative Measure) in the AIM Form, which can help by suggesting and ranking possible interventions. Offering the interventions that the situation calls for, rather than "the ones I like doing".
  • See Learning about Active Planning and Team training session: deciding on the intervention, to practice using the Active Planning Map.
  • Discuss how Managing Risk will influence your planning and choice of interventions.

Reflect

  • Facilitate team discussion about the content of the session
    • How might any of this material augment or improve existing practice?
    • What elements are worth trying, and how would this take place (try to be specific about the how and the when in any shared intentions revealed).
    • What elements of existing team practice should be preserved, or shared, and how can this be done?

Manualize

Go to + Manualize our work and create a page of reflections from the team on:
  • Key learning points that we agree 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) Active Planning and The Therapist's Mentalizing Stance in this case" and another 0 - 5 for "how helpful was applying these tings were in this case?"