Co-Constructing Mentalizing Contexts in Therapeutic Work with Adolescents-Exploring Resilience in Social Support Networks

ABSTRACT

Adolescence, a transformative phase of human development, is marked by a growing need for social support. During this pivotal period, young individuals grapple with the challenges of identity formation, emotional regulation, and forging meaningful relationships. Research has underscored the significance of a robust social network in fostering resilience and promoting mental well-being. In this exploration, we consider the evolving landscape of adolescent support, drawing insights from the concept of Mentalization-Based Therapy (MBT), especially from the specialized treatment model explicitly designed for adolescents, known as Mentalization-Based Treatment for Adolescents (MBT-A). MBT-A is an approach that emphasizes establishing a therapeutic alliance, epistemic trust, and mentalizing within an adolescents’ therapy and social context. This approach includes forming a dynamic external support network to help the young person remain connected with their social environment. Through two case examples, we illuminate how this approach aims to strengthen mentalizing within peer groups and the wider social contexts adolescents live within. This paper will consider the various ways in which therapists might step outside the activity of individual therapeutic sessions to address mentalizing barriers preventing the adolescent from accessing everyday social support. In this process, we encourage creativity and multiple participant involvement, challenging the boundaries of perceived therapeutic practice.

Introduction

Adolescence, a complex phase of human development, brings forth numerous challenges (Freud, 1958). This period is marked by renegotiating attachment dynamics within the immediate family and initiating fresh, emotional bonds with peers (Gee et al., 2014; Malberg et al., 2023; Scheuplein & Van Harmelen, 2022). One crucial developmental milestone during adolescence is creating a solid social support system beyond the family unit, a pivotal step in fostering resilience and minimizing maladjustment (Eisenberger et al., 2007; Masten et al., 2012; Orben et al., 2020; Steiner et al., 2019).

Consequently, in the adolescent’s gradual shift toward independent world navigation, peers assume a central role in offering social and emotional comfort. Hence, this phase presents an opportunity for alternate attachment figures to assume the stress-relieving function of social support (Orben et al., 2020; Savin-Williams & Berndt, 1990). Throughout childhood, caregivers play a crucial role in alleviating stress responses. However, as children enter adolescence, the capacity of parental support to regulate stress-related cortisol responses notably declines. This trend is consistently documented across various studies, including those by Gee et al. (2014) and Scheuplein and Van Harmelen (2022), alongside Hostinar et al. (2015), who specifically highlight the diminishing impact of such support during this critical developmental transition.Therefore, peers play an amplified role in providing both social and emotional sustenance (Scheuplein & Van Harmelen, 2022).

While the mechanisms through which friendship support contributes to resilience are not entirely clear, emerging evidence suggests that friendships may confer positive effects on adolescents’ coping aptitudes, self-esteem, and threat appraisals, potentially through companionship and experiences characterized by minimal conflict (Goodyer et al., 1990; Lakey & Cohen, 2000). Further research indicates that friendships bolster adolescents’ confidence in their own abilities to engage with others, manage interpersonal emotions, and effectively navigate conflicts, which, in turn, has been associated with lower levels of depressive symptoms in both boys and girls (Fitzpatrick & Bussey, 2014). Ultimately, these findings converge to illustrate that friendships can enhance an individual’s resilience by positively influencing their self-perceptions. Positive friendships encourage the development of a more confident self-view, thereby equipping individuals to better handle and overcome life’s challenges (Masten et al., 2012). While friendships offer substantial developmental benefits, their fullest potential is realized through the lens of mentalizing – the ability to understand oneself and others from an internal perspective.

Mentalizing and adolescence

Mentalizing, the ability to understand misunderstandings or to see oneself from the outside and someone else from the inside, is a uniquely human capacity underlying our ability to make sense of our relational and emotional world (Bateman & Fonagy, 2016). Adolescence, represents a profoundly transformative period in human existence. It is a specific developmental juncture that gives rise to a spectrum of alterations across various domains, encompassing cognitive, identity, social, psychological, neurobiological, and hormonal dimensions (Pfeifer & Blakemore, 2012), which in turn create challenges in terms of mentalizing. Empirical studies confirm there to be distinct neurobiological features intrinsic to adolescent development and playing a part in the adolescent’s mentalizing capacity (Pfeifer & Blakemore, 2012; Sharp & Wall, 2021).

Imagine, for a moment, piloting a soapbox car outfitted with the roaring might of a Ferrari V8 engine, complete with twin turbochargers and boasting around 660 horsepower. This display of horsepower is unquestionably impressive, yet the diminutive homemade vehicle’s capability to harness and control this force is limited. This scenario can be seen as an analogy to the adolescent journey. A disparity emerges between the potency of horsepower and the finesse of tapping the brake pedal. Neuroscientific investigations have unveiled that the cerebral regions responsible for enabling engagement with the frontal lobes (representing the brake) to manage emotional responses (symbolizing horsepower) are still in the process of constitutional development during adolescence (Blakemore & Robbins, 2012; Casey et al., 2008). Certain studies grounded in neuroscience and psychodynamics suggest that the swift provocation of emotional reactivity hinges upon a mentalizing capacity yet to reach full maturity (Luyten & Fonagy, 2018; Sebastian et al., 2010). Relatedly developmental, attachment and psychodynamic-oriented scholars emphasize mentalization as a fundamental concept for comprehending the establishment of identity and self-organization (Benzi et al., 2023; Fonagy & Luyten, 2018; Lind et al., 2020; Schore, 2001).

When listening to young people and their struggles, it becomes apparent that many of their challenges revolve around their interactions with peers. Often, difficulties in comprehending misunderstandings (mentalizing) lead to increased vulnerabilities. These vulnerabilities leave the adolescent in a state of psychic equivalence, wherein they cannot verify their mental perceptions against reality (what I feel is how it is). This state projects their self-perception onto others, causing them to believe that nobody cares about them or that everyone rejects them. Psychic equivalence hinders alternative perspectives, trapping them in this cycle.

If young people perceive themselves as a burden to their social environment, they become convinced that others would be better off without them (Buitron et al., 2016). Alternatively, they might enter a pretend mode, wherein their self-perception and perceptions of others lack grounding in reality. This results in a mental state devoid of objective reality, leaving them disconnected from others’ minds and feeling isolated.

Social connectedness and the we-mode

Referencing the work of philosopher Tuomela (2005), Fonagy et al. (2022) discuss mentalizing as a shared social cognition, forming the basis of our humanity. This collective framework of thoughts, feelings, assumptions, and mental states shared with others is integral for fostering a sense of connection. Fonagy and colleagues term this phenomenon the “we-mode” (Fonagy et al., 2022). As humans, we can relate to emotions like heartbreak, pride, and grief, and we naturally seek to share these experiences with others to alleviate the pain. When we lose the ability to calibrate our emotions, we often seek a trusted individual to recalibrate and anchor our experiences in reality through their perspective.

Loss of this social connectedness or the anchoring to collective social cognition can lead to feelings of isolation and loneliness. During adolescence, it becomes paramount to maintain a connection to collective mentalizing. Trusting in the availability of someone to turn to during times of misunderstandings and relational challenges is vital. The adolescent phase, being developmental, offers a chance to hone these capacities within the peer group in preparation for adulthood.

Mentalization-Based Treatment (MBT)

Mentalization-Based Therapy (MBT) provides a framework for understanding and enhancing mentalizing abilities within the therapeutic context (Bateman & Fonagy, 2004). In this article, our approach draws inspiration from MBT but specifically focuses on adolescents and their social context. MBT strongly emphasizes alliance and epistemic trust, the belief in the relevance of transmitting socially relevant information in the context of relationships, which aligns with our goal of strengthening mentalizing within peer groups.

Within the scope of MBT treatments is a specialized treatment model explicitly designed for adolescents, known as Mentalization-Based Treatment for Adolescents (MBT-A) (Rossouw & Fonagy, 2012; Rossouw et al., 2021). MBT-A adopts key principles from Mentalization-Based Therapy (MBT) strongly emphasizes cultivating a therapeutic alliance, fostering epistemic trust, and nurturing mentalization within the unique developmental context of adolescents. The structure of MBT-A is centered around the development of mentalization, with a particular focus on its impact within peer relationships and the external network around the young person.

MBT-A is a structured treatment program comprising weekly individual sessions with adolescents, supplemented by mentalization-based family therapy every third week. Additionally, group MBT therapy sessions with adolescents undergoing treatment play a significant role in the therapeutic process. While discussing the various MBT treatment variations exceeds the scope of this article, it is worth mentioning that MBT has a rich history of group work, such as MBT-Group (MBT-G) (Karterud, 2015), and MBT-Introductory (MBT-I) (Bateman & Fonagy, 2016). Recent developments have also seen MBT groups’ effectiveness for adolescents with emerging borderline personality disorder (BPD) (Beck et al., 2020; Chanen et al., 2021; Jørgensen et al., 2021). Group work is a fundamental aspect of MBT, enabling patients to understand the thoughts and feelings of others while also being transparent about their own mental processes and reactions (Malberg, 2013).

However, recognizing that not all clinics and adolescents align neatly with the original MBT-A model, it is essential to raise a fundamental question: Why do barriers persist that hinder us from broadening our therapeutic approach beyond the confines of individual sessions within the consulting room? To address this challenge, we consider the prospect of expanding our efforts to establish a supportive environment for peer mentalizing. Collaborating with the adolescent to co-create mentalizing spaces offers the potential to empower them and enhance their sense of agency within the therapeutic process. When working with adolescents, the emphasis shifts toward the external support network rather than intrapsychic interpretations. When working with young individuals in one-on-one sessions, a central objective is to enhance the patient’s openness and ability to engage socially recognizing its crucial significance in resilience and development. As practitioners of Mentalization-Based Therapy (MBT), we employ interventions rooted in the multifaceted concept of mentalizing, as delineated by Frith and Frith (2006). Mentalizing encompasses four distinct dimensions: automatic versus controlled, affective versus cognitive, self versus other, and inner versus outer, as elucidated by Fonagy and Luyten (2009). This mentalizing process is intricately tied to our attachment systems, which can become disrupted when emotional responses are triggered in our relationships (Fonagy et al., 2010). In the therapeutic process, the therapist’s task is to balance these dimensions while also attending to the young person’s attachment system, thereby facilitating the development of a more grounded and empathetic perception of themselves and their social environment. It is important to note that mentalizing is not an all-or-nothing phenomenon; rather, it exists on a spectrum, contingent upon the individual’s level of arousal and the external pressures they experience (Bateman & Fonagy, 2016).

Consequently, we all experience fluctuations in our capacity to mentalize; at times, we possess it, and at other times, it eludes us. During adolescence, when young individuals are navigating a period marked by heightened demands and substantial changes, they appear to be particularly susceptible to experiencing lapses in their mentalizing abilities, particularly in situations characterized by interpersonal misunderstandings (Bleiberg et al., 2012). A noteworthy aspect of a well-developed mentalizing capacity is the ability to comprehend and navigate misunderstandings effectively. This skill constitutes a higher-order cognitive achievement, necessitating the acknowledgment of one’s own emotional reactions and thoughts in response to the misunderstanding (Debbané et al., 2016).

Yet, as clinicians, we occasionally encounter situations where these interventions practiced alone in the one-to-one process may not suffice. In such cases, our goal is to reconnect young individuals with their peer groups through creating contexts where collective mentalizing can be practiced and flourish. To achieve this, we need to step outside the traditional treatment frame and engage with the realities of their lives with the central focus shifting to supporting mentalizing within the actual social context of adolescents.

These approaches differ from the social contexts created in MBT-I and MBT-G therapy components in that it places a strong emphasis on active engagement with the adolescents existing social support network or addressing barriers in the adolescent accessing typical social contexts.

The clinical descriptions presented herein are constructed from amalgamated cases, reflecting the authors’ clinical insights rather than real adolescents or families. These fictitious scenarios underscore how therapists specializing in mentalization-based treatment for adolescents (MBT-A) are expanding their practice beyond traditional settings to create adaptable strategies that cater to the distinct requirements of adolescents in therapy.

The integration of peer support in Mentalization-Based-Treatment for Adolescents (MBT-A) therapy engaging Joseph’s journey

In the treatment of Joseph, a 17-year-old facing challenges with self-harm and borderline personality disorder, a shift toward peer involvement marked a significant evolution in therapeutic strategy. Previously, his therapy focused on individual and family sessions. However, after five months of therapy, which resulted in stabilized symptoms and improved school attendance, the therapist proposed a novel idea: incorporating Joseph’s friends into his treatment plan. This marked a deviation from standard Mentalization-Based Treatment for groups (MBT-G) and individuals (MBT-I), as it placed a strong emphasis on mentalizing within Joseph’s natural social framework.

Joseph’s response was unexpectedly positive, prompting the therapist to consider his genuine interest and readiness for this step. The therapist, in consultation with colleagues, had determined that the therapeutic alliance was sufficiently strong to support this expansion. The introduction of his real-life friends, rather than fellow patients, into the treatment was a paradigm shift, emphasizing authenticity in the social context of therapy.

The group work did not merely add to Joseph’s therapeutic process but redefined it. Joseph himself selected which friends to include, ensuring a level of comfort and preexisting trust. This approach diverged from typical peer therapies by bringing in individuals who were part of Joseph’s everyday life, not as patients, but as key figures in his social world. The decision to keep the group small, usually five to six individuals, was intentional. It allowed for a dynamic that was both intimate and conducive to in-depth discussion, striking a balance that enabled personal engagement and maintained the focus on group interaction.

During the initial session, the therapist clarified that the group’s purpose was not solely to support Joseph but to provide mutual assistance among all members as they navigated adolescence. This was to alleviate any sense of burden and to foster an equitable and collective “we-mode.” Ground rules were established, including respecting privacy and understanding the group’s objectives. The therapist also took the opportunity to dispel myths about borderline personality disorder, fostering an atmosphere of knowledge and empathy.

As the sessions progressed, mentalization – the ability to understand mental states in oneself and others – became the focal point. The group explored the often misinterpreted feelings and behaviors of both Joseph and his peers, understanding that these could lead to confusion and conflict. The therapist introduced psychoeducational material to illuminate the emotional and cognitive processes at play when feelings of threat or misunderstanding arose.

The group, meeting every three weeks over four months, engaged in collaborative “thinking together” (Fuggle et al., 2016) exercises that enhanced empathy and cohesion. Over this period, Joseph and his friends developed a shared vocabulary for discussing their emotions and challenges, which led to a richer, mutual comprehension. By the end of the intervention, the group felt confident in their ability to independently manage the complexities of their relationships, demonstrating the potential of brief, focused peer involvement in treatment.

Ultimately, Joseph’s peer group work acted as a conduit between therapeutic settings and everyday social interactions. It extended beyond mere support; it empowered Joseph and his friends to face the intricacies of adolescence with a renewed sense of understanding and empathy.

Unraveling epistemic trust and epistemic injustice: Co-constructing understanding and connection with Euan and his social networks

The therapeutic conversations with Euan took various shapes and forms throughout the 14-month MBT-A therapy process. The work began with an initial request to provide some understanding of Euan’s state of mind and if a specialist forensic assessment was required to account for his increasingly threatening behaviors. The assessment did not indicate the need for forensic input. Rather, it revealed a young man with a deep wish to be understood and connected to others and, perhaps more significantly, a need and right to have his perspective understood and validated in a world which frequently diminished his account of himself.

The following details the various ways in which mentalizing contexts were co-created with Euan, his therapist and teachers, focusing on his need and right for social connection and understanding, and recognizing and valuing difference in social interactions.

Note: The language used in this clinical account reflects “Euan’s” preferred use of person first language and/or the term neurodivergent when describing his life experiences. All identifying details have been changed to protect identities. Euan is a clinical construction based on therapeutic work with four young men seen in mental health services with a co-existing autism diagnosis. Permission to use material was obtained.

History

15-year-old Euan was well known to child and adolescent mental health services, having been diagnosed with ASD, ADHD and complex early trauma at the age of 6 years. Born a healthy boy to committed parents, he showed no early signs of developmental concern until the age of 2 years when he suddenly stopped walking and crawling, and his growing speech was replaced with indistinct babbling. Euan no longer smiled or sought eye contact with his parents, with his previous capacity for joint shared attention severely diminished.

Upon examination at hospital, Euan was found to have suffered internal bruising consistent with blunt trauma.

An extended family member who frequently cared for Euan was found guilty of inflicting this harm and subsequently received a custodial sentence. In the early aftermath of this trauma Euan and his parents were offered therapeutic support from a range of professionals. Euan recovered his ability to walk and talk, and his interest in others returned. However, significant concerns remained for his ability to control his attention, regulate his feelings and engage in social interactions. Following his being diagnosed with autistic spectrum disorder and ADHD his parents received support in understanding and managing his needs and Euan received play therapy.

He entered mainstream school without undue concern, made friends with a small but loyal group of peers and with some assistance from a classroom learning assistant managed to finds ways to focus and engage in his learning.

Fast forward to age 15, Euan was at the point of exclusion from his secondary school. He had locked a staff member and 30 students in a classroom and refused to give up the key.

Previous to this, there had been multiple incidents of verbal and physical outbursts with Euan abruptly leaving school premises, threatening pupils and staff, “I’ll find you, I’ll get you, then you’ll know what it means to be scared.” Euan’s intense interest in far-right politics had also garnered the attention of those around him. There was concern that he was at risk of being radicalized for engagement in terrorist activities. School staff described feeling intimidated by him, citing his often intense fixed eye contact or his absolute refusal to make eye contact.

This being in their minds indicates his lack of empathy and pathology.

Two views of Euan predominated in the larger community. One focused on his diagnosis of autistic spectrum disorder, “he’s autistic, he doesn’t mean any harm, he’s doesn’t get feelings”, the other suggesting he had a personality disorder, “he lacks empathy”, “he’s anti-social.” It was evident how hard it was to find room in these polarized narratives to get to know Euan, to be genuinely curious about him. At this point, thoughts surfaced about the potential difficulty Euan might face in getting to know himself better while surrounded by rigid interpretations of his behaviors. In the wider social context was a high profile case of a teenager with emerging personality disorder and co-existing autism having significantly harmed a child as well as there being a national anxiety for the potential radicalization of young, lone men to terrorism.

Euan’s parents worried he was increasingly anxious and becoming depressed.

His grades, formerly high and a point of pride, had plummeted, impacting on Euan’s sense of himself as competent and able. They thought he was overwhelmed with the pressures of secondary school and the increasing complexity of social relationships; they felt he was operating in “flight-fight mode.” They feared he was withdrawing into himself, which evoked strong feelings in them related to his early trauma. Euan, desperate to not be permanently excluded from school, took matters into his own hands, not attending but completing all homework sent home to an exceptionally high standard.

“Jesus Christ, you ask a lot of questions!” Establishing epistemic trust and agreeing with the way forward

Meeting Euan, it became understandable how some might feel threatened or, at the very least, confused by him. He produced a cool, uninterested exterior which suggested indifference and mild hostility. Nevertheless, there were also the quick and fleeting moments of eye contact or questions about the therapist’s country of origin, experienced as signals for communication and a search for some certainty and safety.

From the get-go, the therapist was incredibly up front with Euan, explaining her understanding of why they were meeting, her intentions and how she hoped they might work together to understand what was happening for him. In keeping with a mentalizing stance, the therapist was active, asking questions to clarify understanding whilst attempting to work within Euan’s window of tolerance for anxiety. This was greatly helped by the “impressive Lego collection” in the therapy room which gave them a physical playful object for shared joint attention whilst collectively focusing on Euan’s mental states.

Toward the end of the six assessment sessions, Euan exclaimed, “Jesus Christ, you ask a lot of questions! I thought you were a therapist aren’t supposed to know these things!” This, making the therapist laugh and then looking earnestly at Euan offering, “well, I know some things but I can’t know what it’s like for you Euan, I can guess, I can imagine but I need you to help me understand, once I think I know, well that’s probably no good for you.” This seemed to touch Euan in some way, “yeah, I get it you’re interested in my perspective, well that’s something that doesn’t happen often.” Euan added that it was hard work all the talking and thinking together but maybe it could be helpful.

Over the next few sessions, an agreement was established that there was scope for the therapist and Euan to work on developing his understanding of himself and himself in relationships with others. In particular, helping Euan to notice, name and distinguish what he might be feeling and to process or modulate and refine his affects, developing an ability to outwardly and inwardly express these (Jurist, 2005).

As therapy progressed Euan made a gradual return to school and was reengaging with friends he had known since primary school. He was also described as venturing into the larger common areas and had been seen talking with peers he had not socialized with previously. The head teacher commented, “there is less lurking in the quiet corners of the school”. This was helped by Euan having access to a classroom assistant who met with him a few times a day to check in, see how he was coping. Euan liked Miss White and although she was “a no nonsense person”, he felt she listened to him.

“I wish you could explain me to my teachers.” addressing epistemic injustice and reinforcing epistemic trust in the wider social system

Roughly six months into therapy Euan arrived for a session looking thoroughly exhausted, “can I open the window, it’s hot.” “Of course” the therapist offered “but be warned there’s construction going on, little” “Hmm, don’t mind” Euan said “it’s a kind of back ground noise, I like it.” “If it helps you, then go ahead.” Euan opened the window, then offered, “I wish you could explain me to my teachers”. When asked what he meant by this, Euan described how he was finding it difficult to be in the busy common area at school. One day he was getting agitated but the teachers would not let him go into the hallway, it was “off limits”, to students. He explained his agitation to them and that he understood it was a rule, but on this one occasion, he “really needed to get out”. “But they didn’t believe me” Euan explained and they thought the hallway was “just as noisy”, they “said I was making it up” and would “probably make trouble”.

Euan explained further, “it’s not just as noisy, it’s a different noise, like the construction, it’s background. “Euan expressed how’no one was interested, no one trusted or believed him”, so why should he trust them, “it goes both ways”. He then described how he felt so “furious”, “trapped like an animal” that he just stared at one of the teachers for the next 20 minutes. He worried that he might do something “stupid like before” but the staring helped him to focus, “channeled my feelings out of me.” The next day Euan didn’t attend school, missing an opportunity to hang out with newly found friends in the debating club. He was worried about getting “agitated again”.

Euan’s description of this incident conveyed something of his growing capacity for establishing epistemic trust. What was being stimulated in his individual therapy was being generalized outside of the therapy room. He had approached the teachers with some belief they would be helpful and “tried to explain” what he was experiencing. He had also imagined something of their perspective, the conflict they might experience in needing to uphold a “rule.” However, his testimony and knowledge of himself, what he was feeling and what he understood himself to need, was being dismissed by those around him. This was not an isolated incident and was typical of many tough moments in school for Euan.

Malberg (Malberg, MBT Congress Barcelona, 2023) using Fricker’s concept of epistemic injustice (Fricker, 2007), has described the various ways in which neurodivergent people and people with autism are denied “status as epistemic agents”, their position as knowers, interpreters and providers of information and knowledge is diminished due to unjustified prejudice. This being a kind of Testimonial Injustice (Fricker, 2007) when one’s testimony or knowledge is judged to be less credible. Euan’s descriptions of his “agitation” and the teachers inability to understand or be curious about this, seemed to convey something of his differing sensory processing needs (Ashburner et al., 2013) and the lack of a shared language for understanding these. This is indicative of a Hermeneutical Injustice (Fricker, 2007), occuring when society as a whole lacks an interpretative framework to understand particular experiences.

Here, “shared vocabularies have been structured in a way that unfairly distorts, or stifles understanding for, and of, a minority group” (Malberg, 2023).

Mentalizing the discomfort she felt both during the session and after, the therapist felt it unfair and inaccurate to locate the difficulties in interpersonal relating solely within Euan. Rather, there was a need to address the epistemic injustices being enacted on Euan, as these generated a non-mentalizing system closed to social learning from Euan, a young man with autism. The lack of curiosity on the part of those around him had an identifiable impact on reciprocity, leading Euan to wonder, “why should I trust them, it goes both ways.”

It would have been easy to respond to Euan’s request to “explain him” to his teachers by writing a letter detailing his needs as understood by the therapist or calling a “professionals meeting” to share understanding. Would this not perpetuate the undermining of Euan’s agency, further diminishing his status as an epistemic agent?

In the next session, the therapist explained to Euan that she felt uncomfortable “explaining him” to his teachers and that getting to know more about him had been something they were doing together. Euan responded quickly, “yes but you’re an adult, they will listen to you.”

“Well, I was thinking we might explain together what you feel they need to know.” Euan characteristically responded with a smile, “so what, are you suggesting we do some power point presentation together?” By now aware of his sense humor, his therapist suggested, “yes, but only if you’re volunteering to do it!”

Over the next two sessions therapy focused on what might helpfully be conveyed and to whom within the school. This also involved managing expectations, exploring how it can be hard to change and maybe things might not be immediately different, and Euan needed to continue to play his part in communicating.

Meeting Euan’s teachers was an enlightening experience. It was clear that some of them were very much afraid of Euan and had felt worried for their and other pupils’ safety, and despite his recent improvement, they continued to hold a fixed view of him. Others were fond of him feeling less intimidated by his exterior of indifference, saying hello, making eye contact and sharing a joke or two.

Miss White joined Euan, the therapist and three other teachers selected by Euan for a conversation followed by a walk through the school. Euan explained something about his experiences in being in such a busy, noisy and socially intense setting. Interestingly, one of his teachers shared this feeling, commenting, “I often have a banging headache after an hour in the common.” Euan identified areas which he felt less overwhelming for him. Later, Miss White and Euan drew out these areas on a map, and so long as he let a staff member know, Euan could freely go to these areas in the school to “de-compress”. From time to time, Euan looked to his therapist, sometimes asking for help to explain further what he was trying to say, but for the most part, he explained it all himself. Including “if you see me staring and looking really pissed off, something’s got me agitated and I might know or maybe not, but I need to be left alone for a bit, then I can talk.” Listening carefully one of Euan’s teachers became curious and asked who he would like to talk with, a teacher or maybe one of his friends the teacher often saw him with. Euan was clear, a friend if possible, they “get me.”

Conclusive remarks

The described approach to peer support for individuals, as exemplified by Joseph and his friends, and Euan and his wider social network, highlights the importance of trust, shared experiences, and mutual understanding. Joseph’s decision to invite his friends into the therapeutic process not only dispelled misconceptions about his diagnosis but also fostered curiosity and engagement among his peers.

The emphasis on the shared human experiences associated with the young people’s traits and vulnerabilities served to bridge the gap between those with and without diagnosis, making the challenges of navigating emotions and relationships relatable to all. Crucially, the group’s focus on strengthening peer bonds and ensuring the well-being of their friendship, rather than acting as a support group solely for Joseph, alleviated concerns of burden and obligation. This approach not only benefited Joseph but was also appreciated by his friends.

Regular group sessions, characterized by the practice of “thinking together,” provided a platform for open dialogue, promoting unity and a sense of shared purpose. The therapist’s role in facilitating discussions, monitoring anxiety levels, and offering psychoeducation further enriched the group’s dynamics.

The therapeutic process with Euan serves as a reminder of the transformative power of genuine curiosity, empathy, and the value of “thinking together” to foster self-awareness and awareness of difference. What began as an inquiry into his increasingly concerning behavior and the possibility of a forensic assessment evolved into a deep and empathetic engagement with a young man who longed to be understood and valued.

His history, marked by early trauma and diagnoses of ASD, ADHD, and early trauma, offered a complex backdrop to his struggles. Despite facing these challenges, Euan had shown resilience in his early years, recovering and integrating into mainstream school with the support of professionals and his parents. Euan’s external behaviors intimately linked to the complex developmental processes associated with adolescence evoked polarized narratives of Euan, inhibiting of curiosity of his personal experience. Addressing this non-mentalizing system was essential to ensuring Euan remained connected to his peers and engaged in his academic life, both essential sources of resilience.

Euan’s story underscores the importance of approaching individuals with empathy and a commitment to understanding their unique experiences, particularly when they navigate complex diagnoses and social challenges.

In sum, this paper intends to underscore a crucial aspect of therapeutic interventions, emphasizing the necessity of addressing obstacles that hinder individuals from forming meaningful social connections. These approaches demonstrate the potential for peer and social support to enhance understanding, reduce stigma, and provide a supportive environment for individuals with mental health struggles and their friends. It showcases the value of promoting unity and shared experiences while addressing the unique challenges associated with mental health coping. This theme is of paramount significance, as human relationships play a pivotal role in mental health and well-being (for further reading, see also Bo et al., 2022).

The mention of peer support networks as agents for fostering resilience is apt. Such networks allow individuals to connect with others who may have shared experiences, leading to a sense of belonging and understanding. However, we highlight the need to create conducive environments where these networks can flourish. This is a crucial point; more is needed to recognize the value of peer support. We must actively create spaces and structures that facilitate these connections.

Furthermore, it is crucial to thoroughly examine and break down the barriers of diagnosis. Mental health diagnoses can sometimes stigmatize individuals and hinder their social integration. By addressing these barriers, therapists can empower their clients to transcend the limitations imposed by diagnostic labels, thereby promoting a more comprehensive approach to well-being.

Furthermore, the importance of addressing barriers to social connection, advocating for creating supportive environments, and exploring issues related to diagnosis and epistemic injustice cannot be emphasized enough. Adolescents often face the challenge of having their experiences and self-knowledge dismissed or devalued by adults or society at large. This phenomenon, referred to as epistemic injustice, merits further exploration within the context of therapy. Recognizing and validating adolescents’ perspectives and self-awareness can be instrumental in promoting their mental health and self-esteem. By weaving these themes together, therapists can emphasize the significance of these considerations in the therapeutic process, ultimately promoting better mental health outcomes for their clients.

Embrace creativity and participant involvement

Our approaches challenge traditional boundaries by seeking to co-construct mentalizing contexts that address barriers to accessing social support. By emphasizing the external support network and the power of the “we-mode,” we strive to foster resilience and promote adolescent well-being. Let us embark on this journey together, embracing creativity and participant involvement as we navigate the ever-evolving context of adolescent support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Maria Svernell

Maria Svernell is a Clinical Psychologist, Psychotherapist, Supervisor and PhD student in Sweden, and a trainer and supervisor in MBT-A for the Anna Freud National Center for Children and Families, London. She is co-editor of Mentalization-based treatment for adolescents: A practical treatment guide (Routledge, 2021).

Holly Dwyer Hall

Holly Dwyer Hall is a Psychotherapist and Training Lead MBT for Children, Families, Parents and Carers Anna Freud National Centre for Children and Families.