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Why should I trust you? AMBIT: helps where it’s hard to help

Teachers to nurses, youth workers to psychiatrists, psychotherapists to social workers—you name it, we are legion; the “helping professions”. We’ve made progress over the past century, finding effective ways to help many – perhaps most – of the difficulties our clients face, but we shouldn’t be complacent. Even the most “evidence-based” of our interventions are only effective for 50-60% of the cases that they are used with. When we do offer help, the more concurrent problems a client has, the more likely it is that they won’t improve. So despite being referred to as the helping professions, we don’t always help; accepting this is not as easy as it sounds.

Who wouldn’t want to badge their work as “helpful”? No one (well, not that I’ve met) comes to work with the intent of being unhelpful, yet if we are honest, the experience of being told robustly “This isn’t helpful!” is something most of us who try to help are familiar with. Ironically, though perhaps unsurprisingly, it is often the clients that we most worry about who react in this way.

What about these people, those not helped by the standard approaches that help so many others so well? They get labelled as “complex”, with “multiple comorbidities”, “treatment resistant” or “hard to reach”; everything we know suggests that their “problem” is not captured by the nature or degree of a specific diagnosis. Alongside the professional tasks of delivering, coordinating, or integrating help, at least as important is the fact that, for many clients, the ordinary channels for accepting help are blocked.

‘The first “key” to epistemic trust consists of “ostensive cues”, wake-up signs that alert us to the fact that the person in front is about to say something of specific significance to me.’

“Epistemic Trust”, and research into this, is a helpful window onto this conundrum. Want to open a door that is locked fast? You’ll need a key. Through some elegant experiments, researchers have looked for and begun convincingly to identify a range of keys that allow clients to “open up” to help.

The first “key” to epistemic trust consists of “ostensive cues”, wake-up signs that alert us to the fact that the person in front is about to say something of specific significance to me. This includes things like eye contact, the to-and-fro of well-timed reciprocal turn-taking in conversation, and gently exaggerated tones of voice (mothers speak to their babies in that sing-song tone known as “motherese”).

Second, having got my attention, the most powerful key of all is the offer of contingency—a fit between my experience (what it’s like to be me, here, right now) and what I see reflected back in this helper’s face, their voice, the content of what they say, their physical responses. When a potential helper gets this right about me, I feel recognised (think about that word: re-cognised) as though the other person has ‘got’ me; my specific here-and-now predicament is reflected back, compassionately. I feel understood in such moments, and thus perhaps understandable, or validated. This is a good feeling, of course, but it is also the key, par excellence, for unlocking the door to help, for opening the “epistemic superhighway”.

Experiencing this sense of being-understood, epistemic trust grows in me towards the person showing that understanding. Epistemic trust is a specific form of trust, not just in that person generally, but in the social value of what they seem to understand about the ways of the world.

With epistemic trust, I’m prepared to take in advice/information/help on offer, and even more importantly, try it out elsewhere in the social world. In the mind of the person helped, the belief arises that “if this person is that good at ‘getting’ me, then what they say must have value beyond just their mind.” Believing that, I’m more likely to try out new ways of being, behaving, or responding in other areas of my life, with other people. Assuming that what I learn is actually helpful, and critically that my social world is benign enough, then I just may get positive feedback from these new attempts at solving old problems. And that is learning.

Now that “skill” of making sense of my behaviour is what we refer to as mentalizing. Applying this framework for understanding human communication in therapy has already proven helpful and effective with a wide range of difficulties, starting with the Borderline Personality Disorder, using the therapeutic approach known as mentalization-based treatment (MBT).

Image by Bevington, Fuggle, Cracknell and Fonagy. Used with permission.

AMBIT (adaptive mentalization-based integrative treatment), developed for the most complex, risky, and commonly non-help-seeking populations, has grown out of the MBT family of treatments that have developed mentalizing approaches for individuals, families, groups, children, and adults. AMBIT uses the same theoretical framework of mentalizing, but does so with a whole-systems emphasis, considering the wider context in which systems of care are situated.

A typical client of an AMBIT-influenced team might be a 19-year-old with a long history of neglect and undisclosed trauma in his early life, who has been known to child services because of questions about ADHD and conduct problems, whose offending behaviour and homelessness now brings him to the attention of services. He rejects the local authority’s offer of a hostel bed, because it insists on no alcohol and attends the hospital later that day, having taken an overdose, revealing multiple scars to his forearms.

AMBIT does not only encourage workers to use mentalizing techniques with their clients, but insists that they balance their application in three additional directions. The purpose is to support workers to maintain their balance sustainably – in a field of work that often leaves them feeling out of balance. If you think you always know exactly what is going on and what to do in this line of work, then you are probably dangerously out of touch with the complex, murky, risky reality of your role as a helper.

In addition to working with your client, the extra three areas where mentalizing can enrich and stabilise practice are working with your team, with your wider networks, and learning at work.

AMBIT is an approach that has itself developed as a ‘learning organisation’, building and broadcasting its learning as it goes in a flexible online ‘wiki’, rather than limiting itself to static print publications. AMBIT is co-produced by academics, clinicians, and more than 2000 trained field workers who have been able iteratively to feed back their own experiences—refining, pruning, and enriching the model, which continues to adapt and grow: street level experience is balanced with research evidence. AMBIT has described itself as an ‘open source’ approach to the development of effective practice for clients whose complex, multiple, difficulties (and low epistemic trust) renders them less able to benefit from conventional, often rigid, albeit evidence-based forms of treatment.

Featured image credit: Helping hands by InsidePhotography. CC0 Public Domain via Pixabay.

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