Early identification of "patients at risk" for not completing regular treatment or not benefitting (sufficiently) from treatment might be among the most cost-effective strategies in mental health care. The recently introduced concept of epistemic trust (ET) may have the potential value to predict patients at risk and therefore act as a marker of treatment outcome. We argue that ET may be the final common pathway through which aversive relational experiences in the past result in interpersonal dysfunctioning, which in turn result in dysfunctional therapeutic relationships, rendering it difficult for patients to trust whatever is offered to learn in therapy. Hence, the concept of ET can play an essential role in personalized medicine, allowing for a more tailored treatment assignment to specific patients' characteristics, which may improve treatment outcomes. In this brief report, we define the clinical features of ET by describing its core domains based on consensus of expert opinion on the concept. The response rate was high, and there was a high level of agreement across experts, demonstrating a strong consensus between experts on the definition and clinical features of ET and mistrust and its significance to the understanding of personality disorders.By means of having a clear definition of the clinical features of ET, we hope to make it accessible for assessment.
This chapter describes the adoption of the AMBIT framework by a team working with adults with a personality disorder diagnosis, in Utrecht, the Netherlands. The implementation of the AMBIT model in this service context is explained with reference to the four quadrants of the AMBIT wheel. In the first quadrant, Working with your Client, the challenge of establishing epistemic trust and the significance of scaffolding healthy existing relationships is explained. In Working with your Team, the importance of a well-connected team in in supporting individual workers’ mentalizing capacity is covered, and the use of daily team briefings and weekly or two-weekly intervision sessions. The AMBIT model was particularly relevant in highlighting to the service the importance of the third quadrant, Working with your Network, and building awareness of the prevalence of network dis-integration and the value of using the dis-integration grid. The fourth quadrant, Learning at Work, was implemented by creating a learning space via regular meetings to discuss progress and practice, manualizing, local trainings, and sharing practice with other mental healthcare organizations.
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