Welcome to TiddlyWiki created by Jeremy Ruston; Copyright © 2004-2007 Jeremy Ruston, Copyright © 2007-2011 UnaMesa Association
!description
The quality of interaction and affection __between members of the immediate family__ (parents and siblings and others living in the home). If variable, rate the best available relationship.
!end of description
!breakdown
0+ = Good. Relationships are warm, confiding, including planned sharing of activities and enjoyment of each others' company.<br>
0 = No problem. Generally positive relationships, family members spend time together, no major conflicts.<br>
1 = Mild. Relationships are generally positive but with limited contact or expressed affection OR mild over-involvement.<br>
2 = Moderate. Relationships are neutral or distant, with only occasional shared activities or conversation; OR significant over-involvement.<br>
3 = Severe. Distant relationships, with no positive interaction or affection expressed, and rarely shared activities or conversation OR severely over-involved or enmeshed relationships.<br>
4 = Very severe. Relationships characterised by hostility, actively destructive, undermining of young person and other family members OR highly destructive level of enmeshed relationships/over-involvement.
!end of breakdown
in the [[Core Features of AMBIT]] you will find eight markers of the ''Stance'', which feed into five core aspects of ''Practice'' that define AMBIT (see [[Service Delivery]]).
The approach provides a wide range of home- and community-based [[Specific interventions]], that are [[Multimodal]], [[Integrative]], and are delivered at a [[Level of intensity]] aimed at minimising or avoiding hospitalisation of young people in significant psychiatric crises. Interventions are divided into [[Phases of AMBIT work]] which are mapped on a suggested [[Intervention timeline]] but the KeyWorker is able to work flexibly deciding WhichInterventionWhen in consultation with the team's strong SupervisoryStructures.
Any practitioner working in the field will also require access to [[Local Protocols]], which can (and should) be edited into this manual.
!If you already know about Manualization
If you know how to do [[Manualization]] (one of the [[Core Features of AMBIT]]), and just want to get on with it, go straight to [[+ Manualize our work]]!
!If you want to learn more about it:
See [[Learning about Manualization]]
>//"As an ~AMBIT-influenced team we want to [[+ Manualize our work]]; to build, develop and share our own local expertise in doing __//this//__ work, with __//these//__ clients, in __//these//__ streets."//
!What practical things do you need to get started:
In order to edit a local team's version of the manual ''you need:''
# Your own local team's __''locally-adaptable version of the manual.''__
## If you don't have one and are reading this in someone else's version, or in the ambit 'core content' version that is curated from the [[Anna Freud Centre]], then you can find how to get one for yourself at the @tiddlymanuals signposting site.
## Or go direct to [[Install a local, adaptable, version of ambit for me|http://ambit-install.tiddlyspace.com]] to get started.
# __''To be a [[Registered|Register on TiddlySpace]] with TiddlySpace''__ (you will have a username and a password.)
# __''To be [[a Member|Making someone a member of a space]]''__ of your local team's manual.
# __To be [[Logged in|Log in]].__
#__''Your manual switched to [[Edit mode]]''__ (use the little panel, top right to select this option.)
!What to do next
* To start editing just go to [[+ Manualize our work]]
* So long as you are logged on and have the correct permissions (see above) you will see a list of buttons, that will allow you to generate new content.
* NOTE: If you open the [[+ Manualize our work]] page //before// you have switched to the [[Edit]] mode, you won't see the editing buttons - sorry! If so, just close the page, and then reopen it and you'll see the editing buttons!
!When to do [[Manualization]]?
* See [[How to do team manualization]] for more detail on this highly ''//interactive and team-based//'' aspect to AMBIT, using the TiddlyManual as the way to achieve this. (Wiki-[[Manualization]] is one of the [[Core Features of AMBIT]].)
* Teams are expected to engage in regular bouts of [[Manualization]] of their practice - recording how they agree to try to manage the specifics of implementing this work in their local setting.
* This does not need to take ADDITIONAL TIME, but rather should be done as part of ordinary team meetings, much as minute-taking might be a part of day to day practice.
!How? Why?
* There should be a SCRIBE and a CHAIR to facilitate discussion - it is best if these two roles are not taken by the same person.
* There are ManualizationBoundaries to help clarify the rules - essentially, the team's version of the manual aspires to be representative of the working practices of that specific group of workers; recording material and practices that define their team culture, and which they would want a new worker joining the team to understand. (//"The totem pole, or maypole, around which we dance"//)
!How to do editing
See [[Understanding TiddlyManual format]] and [[Using the Manual]], as well as specific instructions at [[Edit]] and the [[Video introduction to editing a tiddlymanual]].
!description
Skills/talents in activities such as athletics, art, music, mechanical, computers
!end of description
!breakdown
0+ = Very good. Young person excels in at least one area of interest, recognized by others as being talented or exceptionally skilled, e.g. wins art competitions, star basketball player, soloist in city-wide choir.<br>
0 = Good. Shows talent and persistent interest in at least one area, e.g. takes music lessons and plays in orchestra for several years,develops skills working on cars.<br>
1 = Average. Has some interests, and participates in individual or group hobbies or activities, but has not developed any one area where skills or abilities make him or her stand out.<br>
2 = Significant difficulties. Has few interests or activities, or moves quickly from one to another without persisting long enough to develop skills; e.g. joins soccer team and quits after a few weeks, tries an instrument but drops it when frustrated.<br>
3 = Major difficulties. No special interests or activities acknowledged by the young person.<br>
4 = Very severe difficulties - no one in the young person's network can identify interests or activities, even ones that were evident in the past.
!end of breakdown
!Purpose
Explaining the purpose of an assessment of a young person with complex needs, and the main components: what to ask about, and how to ask.
!Why assess?
Assessment is key to ''delivering the most appropriate interventions for this particular young person's needs''.
Many of the target youth that [[AMBIT]] is directed at are functioning poorly, or demonstrating symptoms in multiple domains, and this //co-morbidity// is often a major reason for the failure of interventions. A common problem is that practitioners tend to deliver those interventions (from psychoanalysis to kicking a football around!) that they are most confident with, or enjoy delivering most, //rather than the interventions that this particular array of problems most calls for at this particular time//; as a result the young person and their family may not experience any meaningful change, so at best expensive professional time may have been wasted, and at worst they may be more likely to dis-engage, or have suffered unnecessary harm from the delay or inappropriate treatments.
!What to do:
To avoid overfocus on any //one// area, to the detriment of understanding in //other// areas, the assessment involves four parts.
Ideally the KeyWorker starts from a "wide-angled lens" view, and then homes in on the most important KeyProblems to target:
!!!Timescale
This should be completed by the end of the second week of working, but preferably within a week of first contact. ASSESSMENT IS A CONTINUOUS ACTIVITY and needs to be continuously updated as facts change and new information emerges.
!1. NARRATIVE ACCOUNT
>//The details of the story - who, when, how, where...//
See [[Narrative History]] for suggestions on what to cover. You might find [[Topics covered by the AIM - a checklist]] helpful to ensure that you cover all the key areas that the [[AIM]] (see below) requires you to provide information about. //The resulting history and background details can be added to as additional information comes to light.// Once you have covered the [[Narrative History]] you should have the information to complete the next stage of the assessment:
!2. AIM QUESTIONNAIRE
>//A structured set of scored questions//
The questions we suggest using are found at [[AIM Form]], a questionnaire using validated questions that link directly to material in the manual (see [[AIM]] for more explanation); this is completed by the KeyWorker during or after one or more interviews, preferably within a week of first contact, but definitely within 2 weeks. This questionnaire covers all the major domains, ensuring that the worker does not focus too narrowly, too quickly. It is where [[KeyProblems]] are first identified. It //also// acts as one of the key [[Outcomes measures]], as well as interacting with manualized material to generate lists of suggestions for appropriate interventions ([[AIM suggested interventions]]) to consider given this particular problem set.
!3. RISK ASSESSMENT
>//A structured set of questions about risk//
There is an example of a Risk Assessment at [[Risk Assessment - paper form]], but a team's local [[Clinical Governance]] structures may require alternatives to be used in its place - what is important is that //some explicit consideration of Risk is made//. (If you are using the [[ICR]] version, then [[Make or View Client Notes]] also contains the AIM Risk Assessment that should be completed, or you can go direct to this via [[Make or View notes on RISK ASSESSMENT]].)
!4. ~DIS-INTEGRATION GRID
>//A structured way of [[Addressing Dis-integration]] in networks//
A specific tool, the [[Dis-integration grid]], which highlights potential areas across the multiple domains (individual, family, team, inter-agency, etc) where a lack of integration across the various systems may influence outcomes, should be completed.
!@@color(blue):AFTER the assessment?:@@
>//Putting together the information to plan the most helpful interventions.//
Follow [[Starting a NEW CASE - CheckLists]] to ensure that you translate your findings into clinically useful information and plans. This is where [[Active Planning]] is at its most active - in developing your [[Formulation and Treatment Aims]].
Listed below are all the local Edits that YOUR team has made so far. Note that local edits may be ''__PUBLIC__'' (visible to all) or ''__PRIVATE__'' (only visible if you are MEMBER of the space, and are logged in). If you have editing rights (are a [[member|Making someone a member of a space]] of this [[Space|Spaces]]), then it is easy to [[Switch the "status" of tiddlers from Private to Public, or vice versa]].
''@@color(green):You can toggle between the lists of PUBLIC and PRIVATE pages by clicking on the two tabs below.@@''
<<tabs
txtMainTab
"Public" "All public tiddlers" [[TiddlySpaceTabs##Public]]
"Private" "All private tiddlers" [[TiddlySpaceTabs##Private]]
>>
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<div class="navigation left">
<a class="previous button">Prev<span></span></a>
<a class="next button">Next<span></span></a>
</div>
<ul class="AIMmenu">
</ul>
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<div class="item"></div>
<div class="navigation">
<a class="next button">Next<span></span></a>
</div>
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This is the main area on your screen: to the left is the [[Sidebar]], to the right at the top is the [[Mode and Login panel]] and if you switch in [[Advanced mode]] you reveal the [[Top menu bar]] across the top.
The [[Desktop]] is the main space on your screen - where you open [[Tiddler]]s, the 'pages' within this document. A TiddlyManual is just a large collection of these 'notes' (pieces of '[[MicroContent]]'), that can be used, and sorted, in many different ways.
As you open [[Tiddler]]s you will notice that their titles appear in the [[Currently Open]] list in the [[Sidebar]]. If you have clicked on [[Links]] to open those tiddlers then they will have opened at the ''bottom of your list'' - this is so that you do not lose the page you are currently reading. Instead of jumping from page to page, this way the reader selects and 'lines up' the "chapter" that she requires.
Each Tiddler has its own [[menu|Menus]] that allows you to edit it, close it, etc.
Each Tiddler also has a section that slides open called "[[Show references and info]]" - and this is important as it helps the reader place this material in a wider context (//"How does THIS piece of information fit alongside all of THAT information?... and what related areas to this content might also be of interest and value to me.//)
Print a set of cards with common psychiatric and other "day-to-day" symptoms or problems on them. Examples are listed below.
You will use these as a helpful way of externalising problems, and in particular placing problems into a //timeline//...
It is helpful to be quite playful in these sessions, and potentially to have a digital camera to hand to photograph the visual reresentation of the crisis that you will generate.
Select which of these cards are relevant to the young person. Flick through them, as if you are playing a game of cards - show, or read out, each one, and if necessary expand on the meaning of the symptom described (this may be especially necessary for some of the symptoms of psychosis such as ideas of reference, or paranoia.) It can be helpful to have symptoms written out, as this makes asking about them less intrusive. Any cards that are rejected, as not being recognised or remembered can be tossed away in a playful way, so that what is left is a pile of symptoms that have all at one time or another been acknowledged.
You may need to have some blank cards handy to write additional symptoms on, that were not covered on the original card set.
Once you have selected the relevant cards, spread them out on the floor, and use the whole length of a room to lay out a "cascade" of symptoms, starting from the earliest things noticed, and leading up to the wide range of symptoms and signs that were apparent at the most florid part of the episode. this can take a while to arrange - typically the number of cards fans outwards as you approach the critical point (hospitalisation, attendance at A+E, Police called, etc...) and young people may find this exercise moving, educative, or upsetting.
You can photograph the finished work if the young person agrees.
Inviting family members or other trusted friends, etc, to come and examine the cascade, and perhaps to ADD any details that the young person may not have noticed, is a helpful way to develop a more systematic understanding of the difficulties, and may shed new light on the development of symptoms.
Then try to divide the timeline/cascade that you have created into three clear "phases":
*''Amber'' - Early warning signs
*''Red'' - Late warning signs
*''Blue-light'' - Crisis signs
These can subsequently go towards planning your ''Relapse Drill'', which is really a particular version of your [[Crisis Contingency Planning]] - different actions will apply (who to call, what to do, what medication to take, etc...) for each of the different stages you have identified.
!Examples of useful symptoms to include:
These ones focus on [[Psychosis]] and are taken from Max Birchwood, Elizabeth Spencer and Dermot McGovern //"Schizophrenia: early warning signs"// Advances in Psychiatric Treatment (2000) 6: 93-101, but additional signs and symptoms can easily be added as required...
Thoughts are racing
Senses seem sharper
Thinking you have special powers
Thinking that you can read other peoples minds
Thinking that other people can read your mind
Receiving personal messages from the TV or radio
Having difficulty making decisions
Experiencing strange sensations
Preoccupied about 1 or 2 things
Thinking you might be somebody else
Seeing visions or things others cannot see
Thinking people are talking about you
Thinking people are against you
Having more nightmare
Having difficulty concentrating
Thinking bizarre things
Thinking you thoughts are controlled
Hearing voices
Thinking that a part of you has changed shape
Feeling helpless or useless
Feeling afraid of going crazy
Feeling sad or low
Feeling anxious and restless
Feeling increasingly religious
Feeling like you’re being watched
Feeling isolated
Feeling tired or lacking energy
Feeling confused or puzzled
Feeling forgetful or far away
Feeling in another world
Feeling strong and powerful
Feeling unable to cope with everyday tasks
Feeling like you are being punished
Feeling like you cannot trust other people
Feeling irritable
Feeling like you do not need sleep
Feeling guilty
Difficulty sleeping
Speech comes out jumbled filled with odd words
Talking or smiling to yourself
Acting suspiciously as if being watched
Behaviour oddly for no reason
Spending time alone
Neglecting your appearance
Acting like you are somebody else
Not seeing people
Not eating
Not leaving the house
Behaving like a child
Refusing to do simple requests
Drinking more
Smoking more
Movements are slow
Unable to sit down for long
Behaving aggressively
As the description suggests, this is the point at which the client is putting plans into action. A good set of plans, including [[Crisis Contingency Planning]] will help to support the changes.
Consider the establishment of establishing some positive [[Reinforcement]] for the new behaviours, by altering [[Contingencies]] - sometimes in simple ways such as putting aside all the money that would have been spent of drugs, and spending this on something positive each week, etc...
Most of the other functions in this area are only for advanced users.
!Finding it:
You find the [[Top menu bar]] by switching the manual to [[Advanced mode]]. On this bar (across the very top of your desktop, soo you may need to scroll up to find it) you'll see a small blue/pink "Target" icon to the right. Click it. A drop-down menu is revealed. Most of this is not relevant to you as a [[TiddlyManual]]s user.
!What's there?
This is a menu provided by the web-based "hosting" site (in [[BT Osmosoft|http://osmosoft.com/#TiddlySpace]]).
Included in this is:
**The [[Space menu]] - Referred to as "THIS SPACE" - about your wiki (members, content, etc)
**The [[User menu]] - Referred to as "YOUR ACCOUNT" - about YOU as a member of TiddlySpace.
The theory on which this technique is based is one of circular causality: there is an assumption that human behaviour can best be understood from a point of view that regards actions as both responses to other actions and the triggers for further actions.
While it is possible to describe behaviour so as to show a ''linear connection'' between cause and effect:
>//"She is ‘mad’ because this is the only way she can show her anger towards her parents"//
...a ''circular construction'' is less likely to lead to ideas of blame, and more likely to enable families to alter their interactions and belief systems:
>//"Regardless of who ‘first’ had the problem, even if it were possible to establish that, the whole family can be seen as caught in a circular loop whereby symptomatic behaviours lead to carers’ responses, such as high levels of criticism, that in turn reinforce those same symptoms, which in turn lead to more critical responses on the carers’ part, and so on..."//
!!How to do circular interviewing:
The practice of interviewing follows a circular (or spiralling) pattern, where the feedback to the KW's question will influence and shape the KW's next question, and so on.
This is a purposive and responsive interviewing style: ''Purposive''... because the KW is central as the primary asker of questions. Yet ''responsive'' to feedback and openings offered by the various family members.
In this way both KW and family together can construct a new understanding of the situation. Circular interviewing involves a ''particular interest in questions of difference'', since it is through the perception of difference that we construct new information, and different perceptions of self and others become possible.
There are a variety of questioning techniques which make it possible for KW and family to explore issues of difference and the definition of relationships, such as:
!!Comparison questions
//"Were you closer before or after he became psychotic?"//
!!Ranking questions
//Who would be most surprised if she stopped being low and withdrawn?" "...Who the second-most?" etc//
!!Triadic questions
One person is asked to comment on the relationship between the two others, e.g. //"When her father got ill, did your mother become closer to her father or more distant?"// The answer to questions such as these will stimulate further exploration, e.g. by asking another family members to comment on the answer of the first one, and then exploring differences or similarities in their perceptions of relationships and events etc.
By participating in such an interview the family members perceive themselves through the eyes of the other; not only may they hear other people's views differently, but also their own views, expressed in this context, may look different to them. The links between this style of questioning and [[Mentalization]] are obvious.
Thus for the KW and the family, their interest and curiosity about one another remains stimulated, and changed perceptions of actions or relationships may lead to new and different behaviours and relationships, as well as a re-examination of belief systems which had to date been held with firm conviction.
!!Hypothetical questions
A special sub-category of this style of questioning is known as hypothetical questions. These are particularly useful when individuals or couples are locked in a rigid stance of blaming about who is "at fault" or "ill" and who is not. In the face of such a stuck interactional pattern the KW can proceed via an "as-if" stance, which makes it possible to consider change in fantasy, even if it does not - yet - seem possible in reality.
These are a particular form of hypothetical questions, where couples are invited to project current relationship patterns and problems into the future, and consider the effects of such lack of change on their future lives:
//"So if you continue to argue in this way about James coming home late for the next week, do you see anything changing? ...What about for the next couple of months? for the next 2 years?..."//
!Aim of circular questioning
The effect of circular questioning is to invite the family's curiosity about the history, context and pattern of their unsatisfactory interactions, which includes any psychiatric disorder and associated symptoms. Just as the KW gains an understanding of how these interactions fit together to result in a relationship pattern which is stressful to the family, so the aim is to help the family members themselves see their situation differently, make new connections, and see new opportunities for change and flexibility.
Another effect of circular interviewing is to disrupt and perturb set patterns of thinking and action, functioning as an intensive but contained challenge to the family's previously held views. Thus while overtly it may seem less challenging than some more directive techniques (see under Challenging techniques), it tends to have similar effects, namely of altering set balances in relationships by interrupting habitual patterns.
!Paper version of the AIM Risk Assessment tool:
The [[ICR]] function is not working yet (at early 2013) - so use the [[Risk Assessment - paper form]], or your own team's paperwork
!For [[ICR]] users:
You can view existing Risks by clicking here:
|@@<<tag RiskAssessment>>@@|
!!!Making a new risk assessment - INSTRUCTIONS
*Leave blank if no risk identified, or no change in risk identified.
*If a new risk or changed risk identified, click on the "New Risk" button and follow the instructions.
*Keep descriptions SHORT and stick to KNOWN FACTS, or document where these are uncertain.
!Use the Risk Grading System!
__''@@color(red):Always RATE the risk in the Title (from A - E)@@''__
* You must delete the phrase "[Rate risk here: A - E]" in the pre-formed title
* Then replace it with a single letter (A - E):
|@@color(red):''A:''@@|@@color(red):''Person’s history and/or warning signs indicate the presence of risk and this is considered imminent. Highest priority to be given to risk prevention.''@@|
|@@color(orange):''B:''@@|@@color(orange):''Circumstances such that a risk management plan should be / has been drawn up and implemented.''@@|
|@@color(brown):''C:''@@|@@color(brown):''Person’s history and condition indicate the presence of risk and this is considered to be a significant issue at present. Requires a contingency risk management plan.''@@|
|@@color(lightgreen):''D:''@@|@@color(lightgreen):''Low apparent risk. No current indication of risk, but person’s history and/or warning signs indicate //possible// risk. Required precautions covered by standard care plan i.e. no special risk prevention measures or plan required.''@@|
|@@color(green):''E:''@@|@@color(green):''No apparent risk. No history/warning signs indicative of risk. In most cases this would mean that you would not click on the risk item at all, but it is left in here in case a risk that was previously assessed as being present is re-assessed and found to have resolved itself, etc...''@@|
*Adding these gradings means that individual risk items are //sorted in order of priority//.
*This means you can quickly identify which risks need [[Crisis Contingency Planning]], and which require immediate prioritisation, or action, etc.
!!!!!Behaviours
><<newJournal label:"Physical harm to others - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
YOU MUST RATE THE RISK (see below)
Record any risk of Physical harm to others here. This item is concerned with ACTUAL harm, rather than threats or intimidation (see separate item for this).
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes [[Active Planning]] and RiskAssessment; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Physical Harm to others" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Threats, intimidation, including bullying by the young person - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
YOU MUST RATE THE RISK (see below)
Record any risk relating to the young person making threats, intimidating or bullying others.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Threats, intimidation, including bullying by the young person" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Preparation to harm others inc. carrying weapons - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
YOU MUST RATE THE RISK (see below)
Record any risk relating to preparation to harm others inc. carrying weapons.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Preparation to harm others inc. carrying weapons" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Reckless behaviour - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
YOU MUST RATE THE RISK (see below)
Record any risk relating to Reckless behaviour.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Reckles s behaviour" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Suicide attempts - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
YOU MUST RATE THE RISK (see below)
Record any risk relating to Suicide Attempts.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Suicide attempts" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Plans or preparations to commit suicide - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to planning or preparing to commit Suicide (notes, declared plans, putting affairs in order, etc). NOTE do NOT include Deliberate Self harm without explicit suicidal intent - as this is coded for separately.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Plans or preparations to commit suicide" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Deliberate self-harm - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to planning or enacting Self-Injurious Behaviours (cutting, burning, non-lethal overdoses, etc).. Do NOT code explicit SUICIDE attempts here as they are coded elsewhere.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Deliberate self-harm" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Drug or alcohol misuse - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Drug or Alcohol use here. Make sure you also complete a good Drug and Alcohol history under 'Problems' in [[Make or View Client Notes]]. Risks include accidental overdose, blood-borne infections (injecting), danger relating to drug debts, or associated criminal activity, etc
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Drug or Alcohol misuse" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Self-neglect - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Self-neglect here.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Self-neglect" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Absconding - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Absconding from home here.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Absconding" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Truancy - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Truancy here (includes Educational failure, exclusion, negative peer influences, risk of exploitation, etc)
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Truancy" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Damage to property - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Damage to property here (includes criminal record, expulsion from home, etc).
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Damage to property" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Fire-setting including excessive interest in fire - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Fire setting or excessive interest in fire.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Behav - Fire-setting including excessive interest in fire" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
!!!!!Personal Circumstances
><<newJournal label:"Family break-up or other family difficulties - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Family-based difficulties - i.e. imminent parental break-up and loss of housing, or witness to domestic violence, etc.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Family break-up or other family difficulties" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Risk - Personal circs - Recent severe stress (e.g. end of relationship) - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to recent severe stress (e.g. end of relationship, bereavement, etc.)
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Recent severe stress." tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Concern expressed by others (relatives, carers) - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Concerns expressed by others in the young person's care network.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Concern expressed by others." tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Recurrence of circumstances previously associated with risk behaviour - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to recurrence of circumstances that were previously associated with a risk behaviour.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Recurrence of circumstances previously associated with risk behaviour" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Abuse/victimisation by others, inc. bullying - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to abuse or victimisation BY OTHERS (including bullying). Do not rate abusive, victimising behaviour carried out BY the young person here - there is space to code that under the Behaviours section.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Abuse or victimisation by others, inc. bullying" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Social isolation - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Social Isolation here. Is it a factor? possible or likely outcomes?
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Social isolation" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Homelessness - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to Homelessness. Include unstable housing arrangements such as "sofa-surfing" (staying on friends sofas) or unsuitable accomodation such as a youth in an adult hostel.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Homelessness" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Problems at school (e.g. drop-off in performance) - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to school-based problems such as drop-off in performance, changing profile, recent onset school-refusal, etc...
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Problems at school" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Other contextual factor indicative of risk - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to other contextual factors (i.e. events or relationships in the young person's social ecology.)
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Personal circs - Other contextual factor indicative of risk" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
!!!!!Clinical Signs
><<newJournal label:"Ideas of harming others - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to IDEAS of harming others.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Ideas of harming others" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Ideas of self-harm/suicidal ideation - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to IDEAS of self-injury or suicide.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Ideas of self-harm/suicidal ideation" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Delusions (esp involving violence/3rd party) - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to DELUSIONS, especially delusions involving, or 'justifying', violence towards a 3rd party.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Delusions esp involving violence or 3rd party" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Command hallucinations - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to HALLUCINATIONS, especially hallucinations that command the young person to act violently towards self or others.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Command hallucinations" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Depression - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to a diagnosis of DEPRESSION, especially insofar as this relates to suicidality.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Depression" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Impulsivity/lack of impulse control - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to symptoms of Impulsivity and or Lack of Control - especially relevant if there are also ideas or plans of suicide or violence.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Impulsivity or lack of impulse control" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Social withdrawal - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to evidence of social withdrawal by the young person.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Social withdrawal" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Other clinical indicator - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to any other clinical indicators (i.e. other factors identifiable in the young person's current mental state.)
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - clinical signs - Other clinical indicator" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
!!!!!Care-related indicators
><<newJournal label:"Discontinuation of medication - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to the recent DISCONTINUATION of MEDICATION, either with or without the knowledge and consent of the prescriber.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Care related - Discontinuation of medication" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Failure to attend appointments - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to the recent FAILURE to ATTEND APPOINTMENTS - indicating a loss of ENGAGEMENT. Note if there has been complete disengagement from services, code this on the next item.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Care related - Failure to attend appointments" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Unplanned disengagement from services - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to the recent unplanned disengagement from services.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Care related - Unplanned disengagement from services" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Compulsory admission - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to a history of Compulsory Admission - especially recent.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Care related - Compulsory admission" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
!!!!!Forensic History
><<newJournal label:"Conviction for violent or sexual offences - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to a history of convviction(s) for violent of sexual offences.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Forensic history - Conviction for violent or sexual offences" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Other conviction (e.g. joy-riding, theft) - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to a history of (non-violent, non-sexual) conviction(s) such as joy-riding or theft.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Forensic history - Other conviction (e.g. joy-riding, theft)" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Involvement of police - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to the involvement of Police with the young person - especially recently.
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; add any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Forensic history - Involvement of police" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
><<newJournal label:"Admission to Secure unit - New Risk item here" focus:text text:"JUST START TYPING to delete these notes and over-write them.
Record any risk relating to admission to secure unit (especially recently.)
RATE your approximation of this risk by deleting the square brackets in the title, and replacing them with rating A - E.
This is already tagged with ClientNotes, RiskAssessment and [[Active Planning]]; you should ADD any additional tags that might help sort this entry in the future." title:"[Rate risk here: A - E]-YYYY-MM-DD hh:mm Risk - Forensic history - Admission to Secure unit" tag:ClientNotes tag:RiskAssessment tag:[[Active Planning]]>>
!This is a tag for Quick Wins that have been identified
You can see tagged content at the bottom of this tiddler.
!To record a new Quick win... go to the assessment part of [[Make or View Client Notes]] or click right here:
<<newJournal label:"Record a new Quick Win here" focus:title text:"Describe the quick win here..." title:"JUST START TYPING to title this new QUICK WIN" tag:ClientNotes:QuickWins>>
!What is a Quick Win?
Another way of describing these is as 'low hanging fruits' - //easily achievable goals// that have obvious intrinsic value to the young person or their family. This may be the case even though such gains may not easily fit into the stepwise progression towards one of the major treatment aims (see [[Formulation and Treatment Aims]]) such as may be lain out in a typical [[Cognitive Behavioural]] programme.
!!Examples of QuickWins might include:
*Tidying up a chaotic bedroom (or a corner of a bedroom!)
*Filling forms for a benefits claim (may not be quite so quick!)
*Buying some new clothes (internet, shopping mall?)
*Connecting one or other parent to a relevant adult service.
*Registering with a GP.
*Simply "going for a coffee/burger" to get a breatherr, etc...
The ideal situation is to keep a stock of possible QuickWins available, so that if treatment seems to be stalling, or engagement is faltering one of these could be focussed on to keep a sense of momentum and 'potency' in the intervention as a whole.
!Quick wins identified:
This refers to the loss of ordinary connections between thoughts, so that language flows in a broadly logical direction, with one thought leading to another, and so on.
At its most severe the person can hardly make any sense in conversation at all, or be appearing to talk nonsense; in more subtle forms there may just be a "loosening of associations" between the thoughts expressed so that the person appears to keep 'losing the point' or 'going off on a tangient'.
This is symptom of [[Psychosis]] although [[Cannabis Misuse]] or intoxication with other drugs can cause it, too.
This is the state in which change is 'not on the agenda' - there is NO contemplation about change at this stage. In Cognitive terms, (see [[Cognitive approaches to SUD-Rx]]) the "sums do not add up" in favour of change (see [[Weighing Pros and Cons]]); however, this may simply be because that there has been no opportunity or motivation to examine these "sums" to date.
!A Mentalizing take on this:
The 'pre-contemplation' stage is really the same as saying that [[Pre-mentalistic stances]] are active.
The person who is not contemplating (or [[Mentalizing]]) their behaviours is generally in a [[Pretend mode]] (//"It's fine, there isn't any problem, in fact this way of doing things is working just fine for me..."//) or a [[Teleological thinking]] (//"Whoops, lets do it again..."//). Often there may be a kind of hopelessness (//"There's no point in trying anything else, this is just the way it is..."//) that could be described as [[Psychic equivalence]].
!...and the point of this is...
Understanding that a client is in the Pre-contemplative position is vital if the KeyWorker is to keep to one of the [[SUD-Rx principles]] that states you should [[Adapt your Discourse]] to fit the stage, or state of mind, that is being addressed (this is a profoundly [[Mentalizing]] stance, too, of course.)
Record scores from the END of treatment here. Record scores from earlier phases in treatment at:
[[Outcome measures (T1, initial)]]
[[Outcome measures (T2, 3 months)]]
!Final meeting score
[_] - [[AIM]] scores completed and exported to database
[_] - [[CGAS]] (0 - 100) scores completed and exported to database
[_] - [[CGI-S]] (1 - 7) Severity score
[_] - [[CGI-I]] (1 - 7) Improvement score - complete and export to database.
[_] - [[HoNOSCA]] (0 - 52) scores completed and exported to database
[_] - [[SDQ]] - scores completed and exported
[_] - [[Treatment Outcomes Profile]] if DRUGS or ALCOHOL are features.
All [[Web browser]]s allow you to set the homepage - that is the page(s) that open when you first open your browser. Below we show you how to set which page(s) your browser will automatically open on starting up.
!!!Getting round the corporate homepage
If you are in a corporate system (eg most NHS Trusts, or most organisations, full stop!) it is not uncommon that your web browser will already be set to open with the corporate homepage as your "starting point", and that this will be fixed.
This is fine, and we wouldn't wish to alter this, but most modern browsers can have a number of different "Tabs" open, so that you can have several websites open simultaneously. What we suggest is that you add your AMBIT manual as an additional tab that will open automatically on start-up. If your browser has a ''//corporate//'' homepage, then you will probably find it is "locked", and that you have to request permission to add another tab to your homepage from your I.T. department. If this is awkward, then there is advice on getting [[Organisational support for the technology to run TiddlyManuals]] which might help you argue your case, though in most cases I.T. departments are only too happy to be able to help.
!How to set the homepage
This is slightly different according to what browser you are using, but the principles are the same.
* __First__: Open up exactly the page(s) that you want to open //automatically// on starting up your browser.
* __Second__: Look for a menu that is to do with "Settings" or "Options" in one of the drop-down menus on your browser's menu bar. It may also be signified by a little spanner or cogwheel or list icon.
* __Third__: Look for options in that menu to do with //"on start up"// or //"set home page"// etc and select the item about setting new homepages, or "pages to open on start-up"
* __Fourth__: Find the option "use //current// pages" and select it!
* __Fifth__: ''Sit back and relax''. Perhaps close your browser, and then re-open it to check that your work is done.
* __Sixth__: Offer to show your colleague how to do this, avoiding all outward signs of smug satisfaction, but knowing inwardly that you have achieved yet another of many steps towards mastery.
!What is the APrAT?
This is a simple questionnaire and exercise to give teams a basic reflective measure of how closely they have followed AMBIT principles in a particular case, and to help them [[SUSTAIN best practice]].
!How to do it?
#Try to do at least one APrAT every three months with the team - set aside an hour to do this.
#Pick one case - preferably one that has given particular cause for concern in the recent past.
#Using the questions below, audit the 8 AMBIT stance indicators (see [[Core Features of AMBIT]]) around this case.
#Look at the results, identify //which stance indicator is the most relevant for the team to improve its practice//, and look at the [[AMBIT Stance Exercises]] to locate a relevant exercise to practise this.
!The Questionnaire:
You can download a PDF version [[here|https://docs.google.com/file/d/0B5h_CVBdhJPYLWFHdmJzSXZrSGc/edit?usp=sharing]]
!!!See the PDF version of the APrAT questionnaire here:
<html><iframe src="https://docs.google.com/file/d/0B5h_CVBdhJPYLWFHdmJzSXZrSGc/preview" width="640" height="480"></iframe></html>
!!!Or read an online version here:
![[Mentalization]]
|Have you maintained a mentalizing stance with the young person/family?||Yes/No|
|Do you have a mentalized understanding of their difficulties?||Yes/No|
![[KeyWorker]]
|Has the keyworker developed a //predictable// relationship with the young person?||Yes/No|
|Has the team kept to all the arrangements and plans it has made with the young person and family?||Yes/No|
|Would the young person call the keyworker or the team if they were worried?||Yes/No|
![[Clinical Governance]]
|Have you completed a risk assessment?||Yes/No|
|Have you kept notes up to date?||Yes/No|
|Have you kept to other governance protocols?||Yes/No|
![[Respect local practice and expertise]]
|Is there evidence of inter-professional or inter-agency conflict in your practice?||Yes/No|
|Is there evidence that you have acted to minimise this?||Yes/No|
|Do team members hold respectful boundaries in discussions about other professionals?||Yes/No|
![[Scaffolding existing relationships]]
|Have you identified resiliencies in existing relationships?||Yes/No|
|In the informal network?||Yes/No|
|In the Professional Network?||Yes/No|
|Have you Care Planned work to strengthen these?||Yes/No|
![[Keyworker well-connected to wider team]]
|Are you checking in with team members?||Yes/No|
|Is it possible to consult and comment on each other’s practice in a sensitive, mentalized fashion?||Yes/No|
|Are team using phones in the field, using Passed Outwards discussion/Thinking Together routines?||Yes/No|
![[Intervening in multiple domains]]
|Which domains have intervention care-planned for them?||...........................|
|Which of these intervention are being/have been deployed?||...........................|
![[Taking Responsibility for integration]]
|Have you done a Dis-integration grid?||Yes/No|
|Have you done any interpreting of other agencies for the young person?||Yes/No|
![[Respect for Evidence]]
|Have you done an [[AIM]]?||Yes/No|
|Other outcome measures?||Yes/No|
|Are interventions the most evidence-based ones (check [[AIM suggested interventions]] rankings)?|| Yes/No|
!Work in Progress
The content of this manual and its layout is continually being updated and improved (your [[Feedback please!]] will help this.) The [[Authors]] see this as a dynamic, working document, not a product set in stone; feedback helps us to improve its shape and coherence. If needed (e.g. for formal intervention trials) it is possible to separate out a 'fixed' version.
You can keep a track of recent changes (last 21 days) in content here:
<<recentChanges 21>>
A Sub-topic is what we call a page ([[Tiddler]]) that has been [[tagged|Tags]] with the title of another tiddler; being tagged by 'A' denotes 'B' as standing //underneath// Topic A in the hierarchy
That other tiddler (if you are [[Edit]]ing it is the title you type in the "tags" box) is known as the [[Topic]], and is the 'headline' over any other tiddlers that it tags.
See the [[Show references and info]] panel to reveal lists of topics and sub topics.
If you are reading LOCAL version of the manual (see them listed out at @tiddlymanuals) then you may want to know:
(a) Is this LOCALLY - CURATED material?
(b) Is this CENTRALLY - CURATED material?
(c) Who actually wrote this material?
This is one of the [[Comparing and Sharing functions]] that the [[TiddlyManual]] format offers.
!!(a) Is it LOCAL or CENTRAL?
If a page ([[Tiddler]]) is ''newly authored'' by a LOCAL team, then a small sub heading that will tell you this will appear beneath the main page heading.
If a page has been ''adapted from the original'' (i.e. the so-called 'AMBIT core content' [found at @ambit], authored and curated by the Anna Freud Centre) then a small sub-heading will appear beneath the main page title to announce this.
!!(b) Who actually wrote this?
* Open the [[Show references and info]] panel on the tiddler.
* Look at the ''Information'' column, and you will see ''"Edited by"''... You can also click on the ''Revisions'' heading, too, to see if any other authors wrote or edited earlier versions of this tiddler.
* You can also [[List LOCAL EDITS to the manual]] which reveals a list of all the ~LOCALLY-edited material.
!!(c) How do I //compare// page contents between manuals?
It is easy to compare and contrast pages ("[[Tiddler]]s") that have been adapted by different authors across different manuals.
These pages may have been //customised// by a local team, adapting (or adding) material in ways that improve the "fit" of what is being delivered to their //local// culture, in response to particular //local// problems, or to their a //local// service ecology, etc...
See the ''Elsewhere'' column in the [[Show references and info]] panel of any tiddler for this, or look at other ways in which [[Comparing and Sharing functions]] are available in the manual.
These are your basic record of contact and activity with a young person or their network - effectively an 'audit trail' of your thinking and actions with a client.
#. [[Setting up Mentalization based work]]
#. [[Introducing Mentalization based work - addressing resistance]]
#. [[Early phase of individual therapy - establishing trust and setting Guidelines]]
#. [[Middle Phase of Mentalization based Work]]
#. [[End Phase of Mentalization based work]]
#. [[Follow-up after Mentalization based work]]
#. [[Course of a session - some interventions in detail]]
This is the manual describing [[AMBIT]], a method of working formerly known as Integrative Multimodal Practice, or [[IMP]], and also as as M-BIO
The [[Introduction]] offers access to [[AMBIT: an overview]].
!Content
This TiddlyManual is an attempt to synthesise the work of a group of clinicians and academics based in London and Cambridge, UK:
*Dr DickonBevington
*Dr PeterFuggle
*Dr EiaAsen
*Prof PeterFonagy
*Dr MaryTarget
*NeilDawson
*RabiaMalik
The group has been working together since 2000 to develop the notion of Integrative Multimodal Practice (IMP), subsequently called M-BIO, and which is now called [[AMBIT]], and to develop a [[Training]] for a new form of KeyWorker.
[[Training]] modules are delivered by the [[Anna Freud Centre]].
!~TiddlyManual
TiddlyManual is the copyright of Dr Dickon Bevington ([[link|http://www.tiddlymanuals.com]]).
!Software and Programming:
The Software that this manual is written in is called [[TiddlyWiki|www.tiddlywiki.com]], and was originally invented by [[Jeremy Ruston|http://osmosoft.com/]]. It is licensed separately, and is an OpenSource product. With a bit of work a beginner can quickly learn to do a lot with it (Dickon).
We acknowledge with gratitude the support of Jeremy, and his colleagues at [[Osmosoft|http://osmosoft.com/]], and in particular Jonathan Lister and Joshua Bradley at [[withjandj|http://www.withjandj.com/]] who have supported the design and programming of the new AMBIT [[theme|http://ambit-theme.tiddlyspace.com]], with the generous backing of our [[Sponsors]].
!Introduction
This is a set of questions that workers might find helpful in identifying where they are in the therapeutic journey with a particular young person.
There are |<<tag [[Phases of AMBIT work]]>>|, but while these may provide a map for clarifying "where are we?" they do not necessarily (or perhaps ever!) unfold in a routinely sequenced [[Intervention timeline]]. Indeed, if they were a rigid, timetabled, programme, they would likely be perceived as [[Non-contingent]] by the client.
So the therapeutic journey may pass back and forth between phases - perhaps returning to the [[INITIAL PHASE]] from the [[INTERVENTION PHASE]] when a new challenge or area of work presents itself. What is very clear in [[Active Planning]] is that the worker should know were he or she IS on this map so that planning can be applied for that stage, and momentum be maintained towards longer term goals and aims.
See also material on considering your client's [[Relationship to help]], which will help in mentalizing their motivational state and therapeutic engagement.
!Questions to ask
[[How motivated is my client?]]
[[How much time have I spent with this client?]]
[[Is my client showing help-seeking behaviours towards me/the team?]]
[[Am I guilty or worried about putting increasing demands on my client?]]
[[Is my client showing evidence of trust in his/her relationship with me?]]
[[How much anticipatory anxiety do I get before sessions with my client?]]
[[How much do I feel frustrated with my client's progress in therapeutic work?]]
[[How much effort do I think my client is investing in our work/getting better?]]
[[How frequently are there crises for my client? Is this increasing/decreasing?]]
[[Is there measurable progress against any outcomes goals?]]
[[How much am I worrying about my client "after we finish working together?"]]
[[Is there any evidence of Crisis Contingency Plans that are ready to use?]]
!description
Rating of general impairment or disability from any cause that limits or prevents movement, or impairs sight or hearing, or otherwise interferes with personal functioning. Includes impairment resulting from congenital conditions, side effects of medication, physical disabilities resulting from accidents, etc. DO NOT SELECT THIS AS A KEY PROBLEM if the disability is not amenable to change.
!end of description
!breakdown
0 = No physical impairment/disability.<br>
1 = Mild. Impairment/disability imposes mild restriction on activity/mobility, e.g. mild CP makes young person clumsy and impairs ability to compete in sports, hearing loss causes some problems in academic functioning.<br>
2 = Moderate. Restriction in significant areas of activity due to impairment/disability, severe seasonal asthma keeps the young person from participating in outdoor activities for several months each year.<br>
3 = Severe. Major restrictions in activity due to impairment/disability, e.g. confined to a wheelchair.<br>
4 = Very severe. Fully dependent. Activity/mobility severely restricted by impairment/disability e.g. quadriplegic, or confined to bed because of severe malnutrition related to anorexia.<br>
!end of breakdown
!description
The extent to which the young person seeks out, relates to, and becomes attached to peers
!end of description
!breakdown
0+ = Good. Enjoys/seeks out peers, identifies peers as friends, interacts with a range of peers, admired within peer group.<br>
0 = No problem. Mixes with peers, seen as 'one of the gang', no obvious difficulties with peers.<br>
1 = Mild. Mixes with peers but slow to warm up and form relationships e.g. does not respond initially to friendly overtures from peers, but does interact and engage in some situations.<br>
2 = Moderate. Interacts socially at times, but does not form relationships that persist from one time to the next; or, extremely selective, will only interact with one or two individuals. Tends to be 'a loner'.<br>
3 = Severe. Rarely engages with peers; may watch peers, but does not interact. Not perceived as part of peer group.<br>
4 = Very severe. Shows no interest in peers at all, ignores or treats them as objects. Rejected by peers.
!end of breakdown
A formulation is a [[mentalized|Mentalization]] summary of your assessment, that offers rational avenues for therapeutic work. Formulations may change over time, reflecting learning on the part of the clinician, or changing circumstances.
The formulation is like the map, helping client and worker come to agreement on //"where we are"//, how we got here, and where we should start heading. The process of arriving at this is [[Assessment]], or we often refer to it as [[Taking Aim]]. To aim accurately, I need to know //where I am// as well as //where I want to go.// A structured assessment supports this; in the AMBIT manual we provide the [[AIM]], which is 'built in and ready to go', but other local teams may have their own assessment schedule that they would want to replace it with.
A good formulation will include the following:
* PresentingProblems
* [[Upstream (Background) Factors]]
* [[Triggers for problems]]
* [[Maintaining factors for problems]]
* [[StrengthsResiliencies]]
* [[Barriers to treatment]]
* The development of [[Aims and Goals]]
* [[Advice on setting Treatment Aims and Goals]]
!!!!Recording Formulations:
If you are using a downloaded copy of this manual as an [[ICR]], then you can go to [[Make or View Client Notes]] or click here: <<newJournal label:"Update your Formulation & Treatment Aims" focus:text text:"JUST START TYPING to overwrite these instructions.
!PRESENTING PROBLEMS
!UPSTREAM (BACKGROUND) factors
!TRIGGER factors
!MAINTAINING factors
!RESILIENCIES
!LIKELY BARRIERS to TREATMENT
!TREATMENT AIMS" title:"YYYY-0MM-0DD 0hh:0mm - Current case FORMULATION" tag:ClientNotes:Formulation>>
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|Date:|$Date: 2008-02-27 02:34:38 +1000 (Wed, 27 Feb 2008) $|
|Source:|http://mptw.tiddlyspot.com/#PrettyDatesPlugin|
|Author:|Simon Baird <simon.baird@gmail.com>|
|License:|http://mptw.tiddlyspot.com/#TheBSDLicense|
!!Notes
* If you want to you can rename this plugin. :) Some suggestions: LastUpdatedPlugin, RelativeDatesPlugin, SmartDatesPlugin, SexyDatesPlugin.
* Inspired by http://ejohn.org/files/pretty.js
***/
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You are trying to make statements that might help reduce the level of anxiety (fostering security) in a young person. Statements that increase the sense that a particular pathological mental state (e.g psychosis) is not only //more common// than people might think, but also that it is still //understandable// (or can at least be //withstood//) help diminish the fear of [[Stigma]]. For instance:
//"Many people I have met, when they are under stress of one kind or another, experience episodes when they feel very worried, or have odd or frightening experiences - from research and from my own experience it is a lot more common than people think..." //
Training in [[AMBIT]], and use of the TiddlyManual digital manualization, is offered via the [[Anna Freud Centre]] - there is a link to the training page in the AFC website describing the core components of the 4 day AMBIT team trainings [[here|http://www.annafreud.org/courses.php/14/the-basic-ambit-training-4-days]], or see that page included right here, just below:
<html><div align="center"><iframe src="http://www.annafreud.org/courses.php/14/ambit-training-for-teams-4-days" frameborder="0" width="100%" height="600"></iframe></div></html>
!Format of AMBIT trainings
Training is ONLY offered to whole teams, as this is very much a team-based approach to practice.
However, another aspect of AMBIT is its strong commitment to [[OpenSource]] working; trying to provide a "large surface area" for interaction with workers and teams in many different settings that might find these materials useful, but which might in turn help in the continued efforts to improve them. So developing cheaper ways of training teams is another explicit task that the AMBIT project continues to explore.
!Videos - the [[AMBIT Training Tour]]
The addition of all of the major didactic teaching content from AMBIT trainings as streaming video talks embedded in the manual should be completed by the end of 2013. At this point we will offer an [[AMBIT Training Tour]] of the manual, that should step the user through all of the main elements of the training.
The AMBIT project at the Anna Freud Centre are currently working on how this resource might be used to reduce face-to-face trainer time (and training costs) but without diluting the effectiveness of training as a kind of "punctuation mark in ordinary working practice" that triggers a change of direction and new practices...
!Slides
In keeping with our [[OpenSource]] ethos, the [[Training slides]] are included in this manual, divided amongst relevant pages, but also in their complete slideshow format, that you can download.
!Exercises
There are a developing set of [[Training exercises]] that help practitioners and teams to practice elements of the [[Core Features of AMBIT]].
!Identifying training needs
Identification of one's own [[Training Needs]] is an important part of [[Work on the Self]], and requires use of the SupervisoryStructures in your team.
!Individual practitioners
Individuals are offered introductory trainings of one or two days via the [[Anna Freud Centre]], which address the overarching theoretical framework, experiential training with a number of 'tools', and a brief introduction to the manualization aspects of [[AMBIT]]. However, @@color(red):full trainings are not offered to individuals@@, as [[AMBIT]] is above all else a team practice.
!Teams
The full training is modular and is tailored to the needs of a local team, in recognition of the fact that needs differ. It is only offered to //whole teams//, in recognition of the fact that this is a mode of working that focuses on developing close collaborative relationships within a team, rather than being something that is possible to do alone.
The training involves the recruitment and use of LOCAL EXPERTISE as well as [[AMBIT]] trainers, and includes didactic material on the theoretical framework, practical and experiential training in techniques from the range of modalities, and training in the use of the TiddlyManual for [[AMBIT]] team members. The training materials
!Future developments
Future work on the manual aims to use increasing amounts of video footage, that will be accessible via the manual if the user is on-line. Such clips will offer expositions on theory and also demonstrations of techniques and skills. It is hoped that by doing this, less face-to-face time will be required in training, which will bring down costs, and integrate the manual as a training-aid in its own right, alongside it's function as a practice manual.
The third day of this training is for the AMBIT lead(s) within the team. It is often helpful if this role is taken by two people in the team so often two people from each team attend this training day.
The learning objectives of this day are to:
# provide an opportunity to consider the AMBIT lead role in your team
##[[The AMBIT Lead - role and responsibilities]]
# become familiar with the manual
##[[Using the Manual]]
# plan a training event for you to facilitate in your team
##[[Planning a training event in your team]]
# practice manualizing as a team process
##[[Manualization]]
!The approximate plan for the day:
* 09:00 - Coffee,
*09.30 Registering and logging on to local manuals.
*10.00 Introductions and planning the day: what are the key training outcomes for your group of services
*10.30 How do your services link together: sculpting out the relationships and authority in the team. The notion of the [[Reflective Quorum]] and [[Scaffolding|Scaffolding existing relationships]] the existing power/authority structures, not undermining these!
*11.00 What is an AMBIT lead? - [[The AMBIT Lead - role and responsibilities]]
** whole group discussion
** The AMBIT lead job description
*11.30 Coffee
* 11.45 Getting familiar with [[Using the Manual]]
** Finding your way around
***finding text
***finding videos
*11.45 Getting even more familiar with the manual
**Opening a new tiddler (page)
***writing some text ([[Edit]])
***[[Editing conventions|EditingConventions]]
*12.45 Lunch
*1.30 Thinking about the training needs of your team
** The next stage of training is [[Practising AMBIT Basic skills]] within the team, so as to have experience to reflect on at the final "Start-up" day of formal training.
** This will include [[Planning a training event in your team]].
*2.15 The manualization sequence [[Manualization]]
**Going through the sequence from problem, team discussion, ideas, agreeing, recording: [[How to do team manualization]]
*3.15 Tea
*3.30 Planning your work in the team
*4.00 Reflections on the day
*4.30 Finish
It is important to look back with the young person (and family) to build a narrative of "what has happened since our paths met"...
Narrative coherence is an indicator of successful mentalizing ([[SELF REPRESENTATION]]).
This ties in with the notion of recognising a relapse signature and developing a drill to address this - which is part of [[Relapse prevention]].
Therapists at times get caught up in heated exchanges themselves, or feel paralysed by the family’s dynamics.
Here it is important to ''take a ‘breather’''. This can be done by getting up and stating:
''//“Sitting here in the midst of it all makes my head spin…. It stops me from having useful ideas. I need to clear my head – I think I’ll take a short break, I’ll be back in 5 minutes…. feel free to take a break as well or continue arguing if you need to”.//''
The purpose is to create a reflective space for the therapist who may, away from the battlefield of the family, literally clear his head for new ideas and direction, talking to himself outside the consulting room – or indeed with colleagues if this is possible. Leave the session with an explanantion along the lines of: "my own mentalization is really under pressure here!"
You are modelling the fact that ''//"I know my own mentalization (like everyone's) is fragile and I take responsibility for sustaining it."//''
See [[Affect storms]]
Substance Use Disorder (also known as [[SUD]]) in young people may be serious - and should be distinguished from experimentation; Disorder implies that the use of substances is repeated, and that it causes impairment.
There are various ways to classify the seriousness of SUD (commonly a distinction is made between HARMFUL USE and DEPENDENT USE) but in Children and Adolescents we can also speak of ''"early at risk"'' and ''"late at risk"'' stages in the journey towards harmful use and dependence, as it is in the ''initiation'' and ''early progression'' phases that we meet most young people with Substance Use problems (direct external link to this table is [[here|https://lh4.googleusercontent.com/-utBsBfmyG7o/UHMdJBNY02I/AAAAAAAAFRU/p9T0iJwr2SI/s864/SUDClassification.jpg]]):
[img[https://lh4.googleusercontent.com/-utBsBfmyG7o/UHMdJBNY02I/AAAAAAAAFRU/p9T0iJwr2SI/s864/SUDClassification.jpg]]
!What to do for SUD
[[Assessment for SUD-Rx]] - (we use the abbreviation Rx to mean "treatment".)
[[Substance use disorder - treatment]]
This refers to perceiving sensations that are not caused by 'real' external stimuli:
*Hearing noises or voices
*Smelling strange odours
*Tasting flavours without any obvious cause
*Feeling touch sensations when there is no external cause (this can be a trigger for [[Violence]] in a [[Paranoid]] client.)
*Seeing things that are not there.
One of the commonest causes of hallucinations is //acute intoxication// with [[Substances|Substance use]], but they may also be a result of serious illness such as [[Psychosis]], or other [[Physical Health matters]], or of very high levels of [[Anxiety]].
Some hallucinations are part of normal experience - although these may often be understood as "misinterpretations" of ordinary perceptions - such as thinking that you hear someone call your name in the street. At the point of falling asleep, or waking up, some people //without any psychiatric illness// have 'true hallucinations' (known as hypnogogic and hypnopompic hallucinations).
Any such symptoms may well require assessment by a psychiatrist, and should be discussed in your SupervisoryStructures.
This is designed to:
1. Slow down the interactions between family members, so that there is space for Mentalizing...
2. Question or express a specific interest in exactly //"what person x is feeling/thinking as this interaction unfolds"//.
This //may// involve using images of DVD or video as a way of providing some emotional distance between family members and the emotional drama that is unfolding between them. By conjuring the image of their interactions being on film, the therapist offers opportunities for imagining a 'meta-position'.
If appropriate this activity can even be "dramatised", with the therapist calling "Freeze frame!" and gesturing with his or her hand to freeze the activity.
>//“I notice b and c when you talk – can we just pause the action here for a brief moment. Let’s pretend for a minute that we had video-recorded this exchange and that be are going to do a replay of a previous segment, to see how things developed and built up. How do you think it all started?”//
See [[Simmering Down]] for more examples.
Amongst other [[Developmental Considerations]], there are Neurodevelopmental challenges faced by the young person: these include freshly enhanced cognitive complexities, that in turn face the young person with integrating a far more complicated set of thoughts about her own and others' feelings and motivations.
!Brain changes:
The outpouring of gonadal hormones in early and middle adolescence is implicated in the major changes that occur in ''brain development'' at this stage of life. the changes in the adolescent brain are more dramatic than any since the earliest stages of childhood. During this phase, the previous ''efflorescence'' (branching and re-branching) of neurones, with the formation of huge numbers of ''synapses'' (chemical 'bridges' carrying nerve impulses between neurones), that dominates the antenatal period and the earliest years of life, //effectively goes into reverse//. The dominant process at this stage in life is then ''Synaptic Pruning'', and this occurs in relation to use-dependent iterative processes, so that unused neural pathways are actively shed, whilst pathways with heavy traffic are reinforced. Put crudely, then, the adolescent development of the brain refines capacities so as to preserve those that are socially adaptive and advantageous, and losing those that are less relevant.
In effect, although some degree of 'plasticity' remains throughout life (we can to some extent relearn skills that have been lost after a stroke), the adolescent years are when the major brain architecture is laid down and finessed into its mature form, one that will have to carry that individual through adult life. An analogy that can be helpful to explain this uses the image of a nation's public transport system: this is the period when the brain's main motorway or railway systems are laid down. It is largely because of the sensitive nature of these changes, and the implications associated with getting a poorly adaptive "transport system" at the other end of adolescence, that early and intensive intervention in adolescence is justified.
Three 'functional nodes' have been proposed, which have more or less identifiable neural structures, and whichfucntion together to help to govern social interaction. These have been called the "Social Information Processing Network" (Nelson et al, Psychological Medicine, 2005). The first node (Detection) appears to fucntion by comparing incoming socially relevant information to pre-ordained (learned/remembered) 'social scripts'; it alerts the system if this information appears to err from these scripts. The second node (Affective) attaches an emotional reaction (generally fight/flight) to such instances. In the adolescent, crucially, the neurodevelopment of the third functional node normally lags about two years behind the development of the first two nodes described - this is the Cognitive Regulatory Node, and is a frontal function, which operates by inhibitting the impulsive affect-driven responses to such situations by applying higher order analysis to the situation, taking context into account, etc ([[Mentalization]], in short).
!Effects
As a result, there is a developmental hypersensitivity to mental states, which may overwhelm the adolescent's capacity to cope with thoughts and feelings except through action on his body or the world.
Although such adolescents may seem able to talk about feelings quite fluently, more abstract psychological ideas create great strain on the adolescent's system. This can lead to an apparently dramatic breakdown in [[Mentalization]], withdrawal from the young person's SocialEcology and the intensification of [[Anxiety]] and enactments ([[Acting Out]]). The extent to which this leads to long-term difficulty depends not only on the inherent strength of the YP's psychic structures, but also on capacity of the environment to support his weakened mentalizing function.
Naturally, this is further complicated by the fact that the YP may undermine the capacity of institutions to support him. An important principle, in integrating the different therapeutic interventions, is to create such support as strongly as possible, by reinforcing the understanding (and thus the effectiveness of the support) available in the YP's social environment.
AMBIT is not an individual therapy but is designed to be delivered by teams who develop a shared approach to their work. Taking part in a team approach may evoke different reactions for individual workers. From our training work we have come to characterise some of the different positions that people may adopt in response to the training. Some of these are listed below.
*''The enthusiasts'' -those that like mentalization as a theory and an approach
*''The non-conformists'' -'I hate people telling me what to do' (we include ourselves in this group!)
*''The pragmatists'' -'I do this already, why do they have to have so much theory!'
*''The simplifiers'' - 'I cant understand all this complicated language - I cant use this with young people'
*''The experimenters'' -makes sense and might be useful - might be helpful but we will only find out in practice
These [[Individual Differences]] are obviously a simplification, and there are obviously lots of other thoughts and reactions to AMBIT training. A genuinely mentalizing approach must be inclusive of all these different reactions to the AMBIT model.
''One of the key challenges for a team using an AMBIT approach is to ensure that all these different states of mind are enabled to have a voice'' while simultaneously recognising that one of the [[Post-training outcome goals]] must be to ensure that appropriate [[Clinical Governance]] structures are in place and that the team is "on task" in respect of its //primary// [[Outcomes measures]] - those of the young people and families it is working with.
An important idea from training is to try to ensure that there is an inclusiveness insofar as all types of positions are recognised as //real// to those who are occupying them, and to avoid one position becoming dominant in ways that could be seen as [[Psychic equivalence]] (//"I __know__ that you are in the wrong, and you are damaging this team's work!"//) or examples of [[Teleological thinking]] (//"You MUST think like me!"//) .
In this way, a mentalization based approach is explicitly non-conformist, without descending into "formless relativism"!
''__Child Protection concerns "trump" all others__''
!Before making a Child Protection Referral:
The KeyWorker will make all reasonable attempts to discuss this with senior staff in the team, //''though not if the delay that this would cause could add to the immediate risk to the child''//.
!Local protocols
There will be Local Protocols about the mechanics of how to contact the local Child Protection Team, and these should be CUT and PASTED in here (see instructions on how to [[Edit]] if you are uncertain.)
!!CBT involves the use of a wide range or techniques
The key ones are listed below, in an approximate "running order", although this is something that must remain flexible and adaptive to the needs of the client:
*[[PsychoEducation]] - key early stage of CBT, orienting the client to the reasons behind the work they will be doing.
*[[Rating Scales]] - useful to include early on - changes in ratings are evidence for the client and therapist as "Co-experimenters"...
*[[Progressive Muscle Relaxation]] - a useful early engagement tool, allowing experimentation with [[Rating Scales]] and preparation for more challenging aspects of therapy.
*[[Re-breathing]] - a more physiologically-directed relaxation techniques for panics with hyperventilation.
*[[ABC Diary-keeping]] - useful in the assessment phase, helping to guide the keyworker in...
*[[Breaking down tasks into steps]] - useful at the planning stage in developing
*[[Graded Exposure]] programmes and other forms of...
*[[Behavioural activation]] - treatment by changing behaviours, that in themselves change mood and thinking...
*[[Contingencies]] - developing programmes that change the way in which a young person's social ecology may or may not offer [[Reinforcement]] to positive behaviours and help to extinguish negative ones.
*[[Problem solving]] - a structured and collaborative approach to solving problems.
*[[Weighing Pros and Cons]] - also known as a decisional balance - part of [[Problem solving]].
*[[Life practice]] - is the transporting of these techniques into real life situations
*[[Training Challenge]] - or "homework"...
!The TiddlyManual sorts and ranks //evidence-based interventions//.
It does this in relation to the results entered in the [[AIM]] assessment (see [[AIM results]]), or according to a formal diagnosis. Each item in the [[AIM]] is tagged with one or more suggested interventions/techniques; the interventions tagging these problems/items are those ones that evidence (or, in its absence, expert opinion/guidelines/accepted best practice) suggests have the best chance of delivering improvements in that specific symptom area. These suggested interventions are sorted according to a number of ''different algorithms'' (see below.)
The fact that //''different lists''// of suggested interventions are generated is in itself designed to communicate to the KeyWorker that, because the lives and difficulties of young people we work with a generally marked by COMPLEXITY, ''there is NOT a simple mechanical relationship between "problem //a//" and "intervention //x//"''.
Thus the KeyWorker is encouraged to use these lists as an additional layer of 'mentalized' oversight on the case; one that offers a more or less objective //perspective// on the options open to him or her. The lists should be used to monitor whether or not what is being delivered is broadly in line with other thinking, and to stimulate questions if there is wide variance between what is suggested and what is actually being offered:
''//"Am I offering my favourite interventions rather than the ones most suited to the needs of this time and this place?"//''
!Different ranking of suggested interventions:
!!1. @@color(red):GLOBAL RANKINGS@@:
This lists interventions according to ''how many times they are associated with different individual [[AIM]] items that are scored at 2 or over''. Using this sorting method looks at the //spread// of interventions required TO COVER THE WHOLE RANGE of the young person's life, rather than just those which are highlighted dramatically because of risk, or severity of symptoms. This may bring forwards interventions that address MAINTAINING factors that may otherwise have been overlooked in the urgency of the immediate clinical situation.
!!2. @@color(red):FOCAL RANKINGS@@:
This lists interventions in order of the //averaged [[AIM]] item severity scores// that are associated with each one. Thus, if an intervention is only suggested by association with two problems from the [[AIM]], but those two problems are both rated as "very severe" (Scoring 4 each) then the //average item score// would be 4; this would be different from another intervention that was associated with, say, //fifteen// different problems, but ones which are generally less severe (with an average score of, say, 2.8). This selection thus ''focusses more on the most clinically-urgent or immediate concerns, but at the risk of underestimating more globally relevant approaches'' (ones that may potentially address maintaining factors) that listing #1 ([[AIM]] item count) may capture.
!!3. @@color(red):LIMIT suggestions only to Key Problems identified in the AIM@@:
This can be applied //in addition// to either of the above sorting options, and further filters the interventions suggested, so that //only to those associated with problems marked in the AIM as "Key Problems"// are suggested.
!!4. ''By Diagnosis'' (14.03.09: Not yet functional):
This lists suggested interventions according to a formal diagnosis if this has been made (by a Psychiatrist) - i.e. offering those evidence-based interventions (in keeping with or evidence based guidelines such as NICE in the UK, or, in the absence of firm evidence, expert-authored practice parameters) related to specific formal diagnoses, as opposed to the whole case [[Formulation and Treatment Aims]].
See also [[AMBIT: an overview]] and the [[Core Features of AMBIT]] for a more general overview of the framework.
!There are 4 phases of work:
!!!1. THE INITIAL PHASE
>[[INITIAL PHASE]]
!!!2. THE INTERVENTION PHASE
>[[INTERVENTION PHASE]])
!!!3. THE MAINTENANCE PHASE
>[[MAINTENANCE PHASE]]
!!!4. THE ENDING PHASE
>[[ENDING PHASE]]
!A map not a timed program
The point of the phases of AMBIT is for the worker (and the client, ideally) to have a shared understanding about [[Where are we in the therapeutic journey?]], so that [[Active Planning]] can take place //from where you are//, not from where you "ought" to be.
Any timings (see [[Intervention timeline]]) for these phases are made with the proviso that clinical work rarely, if ever, works to a predictable timetable, and whilst the presence of a clear sense of direction (see [[I'm stuck: what next?]] and KeepingYourBearings) and some measurable 'waymarks' is implicit and valued throughout the whole intervention, it is still essentially a NonSequentialProcess. A strength of AMBIT with hard-to-reach youth is its //flexibility// and 'light-footedness' - responding contingently to the needs of the young person and their family.
In addition, it is useful to link to [[WhichInterventionWhen]] and [[Level of intensity]] where we answer questions such as what frequency of contact hours are expected at which stage, when would you move from two to one KeyWorker, providing lower level supportive contact prior to discharge/handover.
!A Manualization task
The phases of intervention are mapped onto a suggested [[Intervention timeline]], ''which local teams should make an effort to define with their own commissioners and [[Edit]] locally.''
See also the [[Subtance Use History]], and the topic heading [[Substance use]] which condense much of the material included in this excellent report.
<html><div align="center"><iframe src="http://www.nta.nhs.uk/uploads/nta_assessing_young__people__for__substance__misuse_yp1.pdf" frameborder="0" width="100%" height="600"></iframe></div></html>
!Keeping assessment integrated:
''NB Section A below is the least necessary information gathering activity that a KeyWorker will need to undertake in situations where an Education/Vocational Centre provision does //not// exist.''
The intention is always to integrate as much of the young person’s education/vocational realities into the overall treatment package to avoid the splitting that commonly exists between education and mental health services.
There is an [[Educational-Vocational Engagement Phase Flowchart]].
!SECTION A
''Preliminary information gathering and arrangements for attendance:''
!!!If young person is School Age (<16yrs):
(a) ''If attending school'':
Gather information from the YP and/or their family about their current education situation:
##Which school? Address? Phone number? Email address?
##What year?
##Name of tutor/head of year/SENCO?
##Position in relation to public examinations?
##Status of any course work/ deadlines missed or pending?
(b) ''If not attending school'':
##Who in the education service is, or should be, responsible for their education provision?
##Education Welfare Officer?
##Educational Psychologist involved?
##Learning mentor?
##Extend information by contacting relevant education professionals in the young person's school or college. Potentially the tutor, head of year, or SENCO (Special Educational Needs Cooordinator), in the first instance.
##Education history from records and teacher knowledge.
##Any Statement of Special Educational Needs?
###Current?
###In the past?
###Being applied for?
##Academic performance?
###Any pattern of deterioration?
##Knowledge about family circumstances? Any significant events/crises?
##Siblings/relatives in school?
##Peer group relationships? Friendship group? Isolation? History and any recent changes? Bullying? Drugs?
##Relationships with teaching staff?
##Relationships with ancillary staff?
##Public examination status?
##Course work situation, deadlines missed or pending?
##Other professionals or agencies known to be involved?
(d) ''School-age but not currently attending school:''
Information can be gathered from main school teachers, particularly the SENCO, as well as from Education Welfare Officers, Educational Psychologists, Learning Mentors or Connexions Personal Advisors (responsible for working with 13 to 19 year olds).
##How long out of school?
##Any legal action current or being contemplated?
## attempts to reengage YP in school? Who involved? What happened? Family participation/support?
##Current alternative education provision or attempt at provision?
##Other professionals or agencies known to be involved? Social Services, G.P.?
##Is there information about any previous exclusions and reports written for school governors?
!!!If above School Age:
##What educational level achieved?
###Exam results
###Basic literacy/numeracy skills
##Current employment status?
##Vocational Schemes, training, higher educational training?
##Aspirations regarding career and further educational opportunities?
!Engagement
Negotiation will need to take place between the KeyWorker and the young person, to get to (or be brought to) the Education/Vocational Centre.
##See [[Motivational Work]]
##See [[Engagement techniques]] for further detail.
##If the initial information gathering/liaison exercise turns up a significant professional or family member for the young person, they may be persuaded to accompany the young person on the first one or two occasions to the Education/Vocational Centre.
!SECTION B
''Key tasks and activities during first two weeks of actual attendance.'' - see an [[Example timetable during engagement phase]]
(a) ''Educational Assessment''
Educational tasks and activities to be given to the young person during teaching sessions to complement information already obtained from teachers and other education professionals. Because of individual or small group context the information gained will be both current and potentially more detailed than may have been available before.
National Curriculum levels in Literacy and Numeracy could be obtained, as well as getting a basic Reading Age.
A whole range of educational or psychometric tests could be used as deemed necessary for more detailed assessment profile.
(b) ''Social Assessment''
This is carried out by observing the YP in a range of contexts and activities in the education centre.
**Relationship with peers - observed in formal, semi-structured and informal contexts.
**Formal - observation of relationships in small group tightly structured teaching situations
**Semi-structured - observation in less formal activities drama, art, cooking etc.
**Informal - observation in breaks and free time around the education centre.
**Relationships with authority figures - observations made in similar contexts to above and in addition, during one-to-one conversations.
**Relationship to learning - observations made in teaching situations.
It is important to note that much information that will contribute to both the educational and social assessment will be derived from the "routine" teaching context. Everything that the young person does during this assessment phase shouldn't look only like assessment.
(c) ''Family Assessment''
As appropriate, relevant family members will be encouraged to participate in elements of the education programme. This will provide opportunities to observe relationships between the young person and their family in a range of contexts not normally available either on home visits or in mainly structured family interviews. The contexts will be based on both individual family as well as multi family activities. The information obtained will be additional to that gained in regular family interviews.
(d) ''Individual Assessment''
The young person will be withdrawn from the education programme group for individual interviews as necessary.
The AMBIT project is co-led by [[DickonBevington]] and [[Peter Fuggle]] at the [[Anna Freud Centre]] and, along with the other original [[Authors]], includes:
* Administrative support
** Suzi Bell (suzi.belll@annafreud.org)
* A growing number of Associate AMBIT trainers drawn from active [[AMBIT-influenced]] teams:
** Suzanne Hare
** Garry Richardson
** Sally Zlotowicz
** Liz Cracknell
* John Lincoln
!Specific Interventions
*[[Specific interventions]] - this topic heading gathers all the separate interventions that are in this manual (from mentalization-based approaches to individual and family work, through cognitive-behavioural interventions, to work in the social ecology and simple advice-giving... and more.)
*Remember that one of the [[Core Features of AMBIT]] is that we focus on [[Intervening in multiple domains]], rather than working in one domain alone.
!Interventions, by domain
Here we gather the interventions according to which of the different [[Domains]] they can be applied in:
*[[Working with Crises, Planning and Prevention]]
*[[Working with the Family/Carers]]
*[[Working with the Individual]]
*[[Working with the Professional Network]]
*[[Working with the Social Ecology]]
*[[Giving Advice]]
Most of what is here is ''only useful to advanced users'', and it is only available if you are using the manual in [[Advanced mode]].
!Finding the Space menu
The Space menu is found on the [[Top menu bar]], that you can access in [[Advanced mode]] (click the little "target" symbol, and select ''"THIS SPACE"'').
!Menu contents
In the panel that opens, you can see:
* ''//information about the space//'',
* information about ''//members of the space//'' (and you can [[add or subtract members|Making someone a member of a space]] if you are a member yourself).
* you can ''//[[include|Including spaces]] (or exclude) other spaces//'' here, too (but this is definitely a "high level" interaction, not for beginners, and is likely to interfere with the functioning of other bits of the manual, even though it is perfectly reversible!)
!To GET OUT of SPACE Menu
Click the button (top right) in the menu panel that says "HOME".
/***
|''Name''|RevisionsCommandPlugin|
|''Description''|provides access to tiddler revisions|
|''Author''|FND|
|''Contributors''|Martin Budden|
|''Version''|0.3.3|
|''Status''|@@beta@@|
|''Source''|http://svn.tiddlywiki.org/Trunk/association/plugins/RevisionsCommandPlugin.js|
|''CodeRepository''|http://svn.tiddlywiki.org/Trunk/association/plugins/|
|''License''|[[BSD|http://www.opensource.org/licenses/bsd-license.php]]|
|''CoreVersion''|2.6.0|
|''Keywords''|serverSide|
!Usage
Extend [[ToolbarCommands]] with {{{revisions}}}.
!Revision History
!!v0.1 (2009-07-23)
* initial release (renamed from experimental ServerCommandsPlugin)
!!v0.2 (2010-03-04)
* suppressed wikification in diff view
!!v0.3 (2010-04-07)
* restored wikification in diff view
* added link to side-by-side diff view
!To Do
* strip server.* fields from revision tiddlers
* resolve naming conflicts
* i18n, l10n
* code sanitizing
* documentation
!Code
***/
//{{{
(function($) {
jQuery.twStylesheet(".diff { white-space: pre, font-family: monospace }",
{ id: "diff" });
var cmd = config.commands.revisions = {
type: "popup",
hideShadow: true,
text: "revisions",
tooltip: "display tiddler revisions",
revTooltip: "", // TODO: populate dynamically?
loadLabel: "loading...",
loadTooltip: "loading revision list",
selectLabel: "select",
selectTooltip: "select revision for comparison",
selectedLabel: "selected",
compareLabel: "compare",
linkLabel: "side-by-side view",
revSuffix: " [rev. #%0]",
diffSuffix: " [diff: #%0 #%1]",
dateFormat: "YYYY-0MM-0DD 0hh:0mm",
listError: "revisions could not be retrieved",
handlePopup: function(popup, title) {
title = this.stripSuffix("rev", title);
title = this.stripSuffix("diff", title);
var tiddler = store.getTiddler(title);
var type = _getField("server.type", tiddler);
var adaptor = new config.adaptors[type]();
var limit = null; // TODO: customizable
var context = {
host: _getField("server.host", tiddler),
workspace: _getField("server.workspace", tiddler)
};
var loading = createTiddlyButton(popup, cmd.loadLabel, cmd.loadTooltip);
var params = { popup: popup, loading: loading, origin: title };
adaptor.getTiddlerRevisionList(title, limit, context, params, this.displayRevisions);
},
displayRevisions: function(context, userParams) {
removeNode(userParams.loading);
if(context.status) {
var callback = function(ev) {
var e = ev || window.event;
var revision = resolveTarget(e).getAttribute("revision");
context.adaptor.getTiddlerRevision(tiddler.title, revision, context,
userParams, cmd.displayTiddlerRevision);
};
var table = createTiddlyElement(userParams.popup, "table");
for(var i = 0; i < context.revisions.length; i++) {
var tiddler = context.revisions[i];
var row = createTiddlyElement(table, "tr");
var timestamp = tiddler.modified.formatString(cmd.dateFormat);
var revision = tiddler.fields["server.page.revision"];
var cell = createTiddlyElement(row, "td");
createTiddlyButton(cell, timestamp, cmd.revTooltip, callback, null,
null, null, { revision: revision });
cell = createTiddlyElement(row, "td", null, null, tiddler.modifier);
cell = createTiddlyElement(row, "td");
createTiddlyButton(cell, cmd.selectLabel, cmd.selectTooltip,
cmd.revisionSelected, null, null, null,
{ index:i, revision: revision, col: 2 });
cmd.context = context; // XXX: unsafe (singleton)!?
}
} else {
$("<li />").text(cmd.listError).appendTo(userParams.popup);
}
},
revisionSelected: function(ev) {
var e = ev || window.event;
e.cancelBubble = true;
if(e.stopPropagation) {
e.stopPropagation();
}
var n = resolveTarget(e);
var index = n.getAttribute("index");
var col = n.getAttribute("col");
while(!index || !col) {
n = n.parentNode;
index = n.getAttribute("index");
col = n.getAttribute("col");
}
cmd.revision = n.getAttribute("revision");
var table = n.parentNode.parentNode.parentNode;
var rows = table.childNodes;
for(var i = 0; i < rows.length; i++) {
var c = rows[i].childNodes[col].firstChild;
if(i == index) {
if(c.textContent) {
c.textContent = cmd.selectedLabel;
} else {
c.text = cmd.selectedLabel;
}
} else {
if(c.textContent) {
c.textContent = cmd.compareLabel;
} else {
c.text = cmd.compareLabel;
}
c.onclick = cmd.compareSelected;
}
}
},
compareSelected: function(ev) {
var e = ev || window.event;
var n = resolveTarget(e);
var context = cmd.context;
context.rev1 = n.getAttribute("revision");
context.rev2 = cmd.revision;
context.tiddler = context.revisions[n.getAttribute("index")];
context.format = "unified";
context.adaptor.getTiddlerDiff(context.tiddler.title, context,
context.userParams, cmd.displayTiddlerDiffs);
},
displayTiddlerDiffs: function(context, userParams) {
var tiddler = context.tiddler;
tiddler.title += cmd.diffSuffix.format([context.rev1, context.rev2]);
tiddler.text = "{{diff{\n" + context.diff + "\n}}}";
tiddler.tags = ["diff"];
tiddler.fields.doNotSave = "true"; // XXX: correct?
if(!store.getTiddler(tiddler.title)) {
store.addTiddler(tiddler);
}
var src = story.getTiddler(userParams.origin);
var tiddlerEl = story.displayTiddler(src, tiddler);
var uri = context.uri.replace("format=unified", "format=horizontal");
var link = $('<a target="_blank" />').attr("href", uri).text(cmd.linkLabel);
$(".viewer", tiddlerEl).prepend(link);
},
displayTiddlerRevision: function(context, userParams) {
var tiddler = context.tiddler;
tiddler.title += cmd.revSuffix.format([tiddler.fields["server.page.revision"]]);
tiddler.fields.doNotSave = "true"; // XXX: correct?
if(!store.getTiddler(tiddler.title)) {
store.addTiddler(tiddler);
}
var src = story.getTiddler(userParams.origin);
story.displayTiddler(src, tiddler);
},
stripSuffix: function(type, title) {
var str = cmd[type + "Suffix"];
var i = str.indexOf("%0");
i = title.indexOf(str.substr(0, i));
if(i != -1) {
title = title.substr(0, i);
}
return title;
}
};
var _getField = function(name, tiddler) {
return tiddler.fields[name] || config.defaultCustomFields[name];
};
})(jQuery);
//}}}
!Workers
The AMBIT TiddlyManual is designed and written with //workers// in mind as the key "audience". We appreciate that many different workers may be involved in the kind of "street level" or outreach approaches that AMBIT seeks to support and foster, and that such workers may come from very different training backgrounds. Some may be extensively and formally trained in one or more therapeutic modality, others may have much less formal therapeutic training, but may have a combination of life experience, and local knowledge to bring.
Some parts of the manual are more "technical" than others - we are trying to weed out jargon, and to use plain English wherever we can. We are also trying to expand the number of video clips to illustrate or explain particular points, as many people find this suits their learning style better than text. We are open to offers of video clips to add to existing content, as it is helpful to have a wide range of "talking heads" available.
!Commissioners
Most services are commissioned in one way or another. Commissioners may be unclear what they are ACTUALLY paying for beyond a limited set of outcomes/outputs that generally fail to portray the richness of a clinical service. A locally-adapted version of the manual (see @tiddlymanuals for examples) is extremely helpful for commissioners as a way of defining in much more operationalised detail what they are paying for.
!Clients and Families
A [[Mentalizing]] approach to therapeutic work fits well with this "[[OpenSource]]" approach to treatment manuals and to "therapy" as a whole - we work hard to make our thinking, beliefs, hopes, fears and intentions, etc, as EXPLICIT as we can, rather than leaving them as IMPLICIT, or undefined. If a young person or family member were interested to browse our practice manual, we would encourage this, and in particular we would be asking:
>//"Are there any aspects of the work in our manual that YOU have spotted, which YOU think would be helpful for us to focus on more than others?"//
As ever, it is always the young person, and those who know them best of all, who are most likely to know what will work best.
!Other professionals
The point of [[TiddlyManual]]s is to help support, develop and share best practice in ways that are efficient, affordable and effective. The "Elsewhere" heading that you will find in the [[Show references and info]] panel for each page ("[[Tiddler]]") shows if there are any other locally-edited variations of pages with the same heading, and is designed to encourage and facilitate cross-comparisons between practices in slightly different settings, or with slightly different client groups. We therefore welcome the attention of other professionals, and invite them to give [[Feedback please!]] if they are willing and able.
In the sub-topics under this heading (click the + by [[Show references and info]]) you'll find links to the different broad categories of problems (or challenges, or opportunities...) that a worker or team may be required to manage.
These are beliefs that are firmly held, but false, and out of keeping with normally-accepted cultural norms (religious beliefs would not count as delusions as they are culturally 'congruent').
They are not uncommonly a symptom of [[Psychosis]], which will require a swift response.
If the Delusion involves another person, and particularly if it involves ideas of [[Violence]] or is particularly [[Paranoid]] in nature (even if it is a delusional belief that //"X loves me!"//), then it is a risk factor for aggression that should be taken seriously (see [[Manage RISK]]).
This is only relevant if you are using the fully-interactive case recording function ([[ICR]]) of the manual.
Whilst the main interventions are delivered via the person of the individual KeyWorker, [[AMBIT]] is primarily a TEAM approach. Thus not only should there be frequent discussion amongst <<tag [[Team members]]>> (see [[Reflective Quorum]]) about our clients, but also the thoughts/reflections of OTHER team members, or external consultants (part of the "MetaTeam") are often explicitly referred to in face-to-face work.
In this way the young person is given the experience of
*The attempts of other people to mentalize them.
*Their KeyWorker modelling the use of other people to help adjust and improve the accuracy of their own thinking ([[Mentalization]]).
!introduction
There is increasing focus on [[Implementation Science]] in AMBIT - how do we best support real and [[sustainable|SUSTAIN best practice]] change in the way that teams and practitioners work?
One way that we are starting is to offer web-based seminars for the [[AMBIT Lead]]s in a team. These will focus on different aspects of AMBIT, and ill help to demonstrate different parts of the web-based manual, so that its resources can be more easily located and used by AMBIT Leads in their local teams.
Here we are building a "library of tips" on how to get the best out of the system we are about to start using - which is called [[Webex|http://www.webex.com/]]. We divide our points into general ones about how to get the best out of web-based video conferencing, and specific ones about how to get Webex to work for you.
!How to get the best out of web-based video conferencing
* Ten minutes of getting set up before the meeting is well spent
** Check your microphone and speaker (headphones are better to avoid echo) connections.
** Access your local team's AMBIT manual so you can refer to it
** Clarify your tasks for the meeting - what do you want to get out of it?
* When online, and speaking, try to ignore the people's faces while you speak, and instead look straight into your webcam lens - that way you ARE looking into their eyes!
* Use the "Raise you hand" button to ask to speak and allow the facilitator to call you to speak, rather than speaking all at once.
!How to get Webex to work for you
Detailed instructions to go here...
! ''What is Problem solving?''
Problem solving is something that everybody does already. Implicit problem solving routinely involves thinking about something that you need to sort out and deciding on what you are going to do about it. e.g. 'I feel a bit guilty about not having contacted my Mum for a while, I'll give her a call this evening'. Often implicit problem solving moves very quickly from problem to some sort of action without much in between. Commonly the decided action is then put off and/or avoided so that a few days later the problem reappears and the person again feels guilty about not contacting his mother and further resolutions of action are made. This implicit problem solving can end up stengthening the very problem that it is trying to address.
* There is a difference between ''implicit'' and more deliberate ''explicit'' problem solving methods. Explicit problem solving is part of [[Cognitive Behavioural]] methods in that it is a method which links together thoughts and actions.
* Implicit problem solving works fine for many situations but for more tricky issues it may be ineffective for several reasons
** ''The wrong issue is being focussed on.'' In this case, the problem is being experienced as about guilt towards his mother whereas the main difficulty may be something different i.e. finding it difficult to talk to his mother etc.
** ''Too rapid focus on action'' before considering a range of options.
** ''Planned actions are located at some vague point in the future.''
! ''Moving from implicit to explicit problem solving- general tips''
** ''Generally try to slow the process down''...
*** avoid getting into discussion of actions for as long as you can get away with!
** ''Try to elaborate the problem as fully as you can''
*** e.g. (from example above). 'what's your Mum like?' 'Does she like people calling her?'
** ''Develop some options''
*** At first, try to develop as many options as possible. Opportunities for humour to lighten mood may arise. May suggest some useful and some more wacky ideas. Reduce options to a few possibles.
** ''Try to evaluate strengths and weaknesses of different options'' - see [[Weighing Pros and Cons]]
*** Some options will be harder, more effort and some will be more likely to work. Get client to determine criteria as to how to evaluate what is likely to work.
** '' Dont choose option for client!''
*** Easily done as often best option is very obvious to you but not to client. Avoid persuading.
** '' Encourage options that may inolve one small immediate action''
*** Texting a message may often be a first step. In the example above, just texting the client's Mum to say that he is thinking of her etc may be something to shift pattern of avoidance.
!!A 'checklist' problem-solving model:
This is a checklist that may be usefully adapted to fit the needs of a situation: [[Problem-solving checklist]]
!Problem solving: an example
Young person (Sam) angry with friend for coming on to her boyfriend. Describes how she plans to 'batter' her friend for this. This will make Sam feel better. This is implicit problem solving. Sam wants to find relief from her anger. Hitting and hurting her friend will achieve this.
* Problem solving approach would start by ''being really interested in Sam's belief'' that this will make her feel better. How does this work? What would you feel like afterwards etc?
* Opening up other options.
Are there any other ways of feeling better in this way? What other things bring relief? However, 'battering' works best okay? Are there any downsides to 'battering'? Would these downsides apply to other options? Are there other options which relieve anger as well? Would thye have similar risks and consequences?
Obviously this example rasises some ethical dilemmas as the therapist would not want to convey encouragement for violence to others but it si provided here to indicate that problem solving can be applied to wider issues than may be generally recognised.
<html><object width="480" height="385"><param name="movie" value="http://www.youtube.com/v/Fn2PhfpYoac?fs=1&hl=en_GB"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/Fn2PhfpYoac?fs=1&hl=en_GB" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="385"></embed></object></html>
Here the use of the imaginary TV screen and the TV remote controller allows for a playful means of //slowing down// a difficult conversation, and allow different combinations of family members to be in an active or an observing/reflecting position. If the pair 'in the TV' become agitated or lose their mentalizing capacity during their conversation, the observers can playfully "turn the volume down" and discuss the discussion.
If you're done setting up, click <<completeSetup>>.
------
Welcome to your brand new manual!
To get started with this blank manual, you'll probably want to set up the following things:
* Upload a SiteIcon. A SiteIcon gives your manual an identity to make it recognisable to others. Try to keep your SiteIcon 40px or less in height.
<<binaryUploadPublic title:SiteIcon>>
* [[SiteTitle]] & [[SiteSubtitle]]: The title and subtitle of the site, as shown above (after saving, they will also appear in the browser title bar)
* [[MainMenu]]: The menu that appears in the sidebar
* [[DefaultTiddlers]]: Contains the names of the tiddlers that you want to appear when the TiddlySpace is opened
* Many features of TiddlySpace are accessed via the backstage bar located at the top of the page. You can toggle it on or off using the button in the top right corner of the screen.
/***
|''Name''|BinaryTiddlersPlugin|
|''Description''|renders base64-encoded binary tiddlers as images or links|
|''Author''|FND|
|''Version''|0.3.2|
|''Status''|@@beta@@|
|''Source''|http://svn.tiddlywiki.org/Trunk/association/plugins/BinaryTiddlersPlugin.js|
|''License''|[[BSD|http://www.opensource.org/licenses/bsd-license.php]]|
|''CoreVersion''|2.5|
!Code
***/
//{{{
(function($) {
"use strict";
var ctfield = "server.content-type";
var plugin = config.extensions.BinaryTiddlersPlugin = {
isWikiText: function(tiddler) {
var ctype = tiddler.fields[ctfield];
if(ctype) {
if (ctype === 'text/x-tiddlywiki') {
return true;
}
return !this.isBinary(tiddler) && !this.isTextual(ctype);
} else {
return true;
}
},
// NB: pseudo-binaries are considered non-binary here
isBinary: function(tiddler) {
var ctype = tiddler.fields[ctfield];
return ctype ? !this.isTextual(ctype) : false;
},
isTextual: function(ctype) {
return ctype.indexOf("text/") === 0
|| this.endsWith(ctype, "+xml")
|| ctype === 'application/json'
|| ctype === 'application/javascript';
},
endsWith: function(str, suffix) {
return str.length >= suffix.length &&
str.substr(str.length - suffix.length) === suffix;
},
isLink: function(tiddler) {
return this.isBinary(tiddler) && tiddler.text.indexOf("<html>") !== -1;
}
};
// Disable edit for linked tiddlers (for now)
// This will be changed to a GET then PUT
config.commands.editTiddler.isEnabled = function(tiddler) {
var existingTest = config.commands.editTiddler.isEnabled;
if (existingTest) {
return existingTest && !plugin.isLink(tiddler);
} else {
return !plugin.isLink(tiddler);
}
};
// hijack text viewer to add special handling for binary tiddlers
var _view = config.macros.view.views.wikified;
config.macros.view.views.wikified = function(value, place, params, wikifier,
paramString, tiddler) {
var ctype = tiddler.fields["server.content-type"];
if(params[0] === "text" && ctype && ctype !== 'text/x-tiddlywiki' &&
!tiddler.tags.contains("systemConfig") && !plugin.isLink(tiddler)) {
var el;
if(plugin.isBinary(tiddler)) {
var uri = "data:%0;base64,%1".format([ctype, tiddler.text]); // TODO: fallback for legacy browsers
if(ctype.indexOf("image/") === 0) {
el = $("<img />").attr("alt", tiddler.title).attr("src", uri);
} else {
el = $("<a />").attr("href", uri).text(tiddler.title);
}
} else {
el = $("<pre />").text(tiddler.text);
}
el.appendTo(place);
} else {
_view.apply(this, arguments);
}
};
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!!About the Index
Learn [[About the Index]]
!!As well as the Index...
There is a [[Glossary]] of technical terms that we use
!Here's the Index:
<<tabs
txtMainTab
"Recent" "Recently edited tiddlers" TabTimeline
"All" "All tiddlers" TabAll
"Public" "All public tiddlers" [[TiddlySpaceTabs##Public]]
"Private" "All private tiddlers" [[TiddlySpaceTabs##Private]]
"Tags" "All tags" TabTags
"Spaces" "Tiddlers grouped by space" [[TiddlySpaceTabs##Spaces]]
"Missing" "Missing tiddlers" TabMoreMissing
"Orphans" "Orphaned tiddlers" TabMoreOrphans
"Shadows" "Shadowed tiddlers" TabMoreShadowed
>>
!The training objectives of the fourth day are:
# To review and reflect on what aspects of AMBIT are relevant and useful to the team (see [[AMBIT Practice Audit Tool (APrAT)]])
# To learn and practice using the AMBIT Integrative Measure (see [[AIM]])
# To practice a manualization task (see [[Local Manualization Homework Tasks]])
# To write and record an implementation plan (see [[Implementation Plan]])
# To practice an on-going training session (see [[Planning a training event in your team]])
!Plan of the day
09.45 Gather and have coffee
10.00 Make plan for the day with whole group.
10.15 The AMBIT wheel (see [[Drawing the AMBIT Wheel]])
10.30 As an individual practitioner, how much do I use AMBIT core features, and what might prove useful to you in the future? (use [[APrAT]] in pairs)
11.00 Feedback to groups in teams
11.15 Coffee
11.30 Introducing the AIM (see [[AIM]])
11.45 Completing the AIM on an individual young person (in pairs)
12.15 Discuss use of the AIM in the manual ([[AIM Form]]) followed by whole team discussion about assessment methods in your team
1.00 Lunch
1.45 Implementation Science (see [[Implementation Science]], [[Implementation Team]], [[Implementation Plan]])
2.00 Developing an implementation team and plan
2.45 Tea
3.00 Manualising a hot issue within your team
3.30 Final exercise on [[Planning a training event in your team]];
4.00 Reflections on whole training
4.30 Finish
!Resources required
* Screen and projector
* Wifi availability
* Sound for videos (just in case)
* Ideally TEAMS BRING THEIR OWN LAPTOPS WITH THEIR MANUAL
* Flipchart and pens
* PAPERWORK:
** APrAT forms
** AIM paper forms
** AMBIT Wheel on paper
** TRAINING FEEDBACK forms
Unless you're delighted with the default theme you can make some quick changes by generating a new random color palette, hit this button to cycle through some alternatives.
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You can also change the look and feel completely by installing a new theme. To do this, find one you like in the @themes space, note down the name, and include it in this space by going to the space menu. You can reach the space menu by clicking on the blue and pink circle at the top-right of the page and chooshing "THIS SPACE". Here are a few to check out:
* @pip
* @caspian-ii
* @basalt
* @simplicity
* @cheesecake
* @jelly-doughnut
(//Note that if you are using a custom TiddlySpace install, these themes may not be present.//)
!description
Parent or caregiver's typical patterns of discipline, limits, and rule-setting for the young person; too harsh, inconsistent, or inadequate discipline may be a problem. If young person spends regular time in two households (e.g., divorced parents), and there are inconsistencies between discipline in the two, rate the effect of the combination of the two. If any indication of abuse, ensure that this is recorded in carefully in the history, and that Child Protection issues have been considered.
!end of description
!breakdown
0+ = A positive strength in the family. Clear boundaries that are managed without recourse to coercion, and are respected by the youth.<br>
0 = No problem. Generally consistent, clearly expressed and age-appropriate discipline with only occasional impatience or inconsistency.<br>
1 = Mild. Generally adequate discipline, but with lapses such as inconsistency in some areas, ignoring when young person breaks a rule, yielding to young person's persuasion against established policies, empty threats.<br>
2 = Moderate. Significant issues with discipline, such as frequent arguments between parents over discipline, frequent empty threats, frequent punishments inconsistent with the infraction, spanking for minor infractions, serious inconsistency, or very lax or inadequate discipline, where parent only responds when alerted by outside sources.<br>
3 = Severe. Frequent harsh, humiliating, or rejecting punishment, e.g., refusing to speak to the young person for hours, beats young person with a belt, or no attempt at discipline at all.<br>
4 = Very severe. Sadistic, extreme, abusive discipline, e.g., tying young person to a bed all day, beatings which cause injury.
!end of breakdown
Type the text for 'New Tiddler'
!!The Fifth Discipline
In 1990 ''Peter Senge'' wrote an influential book called '''The Fifth Discipline''' and produced a revised version in 2006 (The Fifth Discipline: the Art and Practice of the Learning Organisation. Peter Senge. Random House Business Books 2006). Senge proposed that successful organisations were those which had the capacity for adaptation and learning and that five 'component technologies' were necessary to support such learning. These were:-
*Systems thinking (see [[Senge: Discipline 1 - Systems Thinking]])
*Personal Mastery (see [[Senge: Discipline 2 - Personal Mastery]])
*Mental Models (see [[Senge: Discipline 3 - Mental Models]])
*Building shared vision (see [[Senge: Discipline 4 - Shared Vision]]).
*Team learning (see [[Senge: Discipline 5 - Team Learning]]).
A very brief overview by Peter Senge of some of the key themes of his work is shown in the following 5 minute clip.
<html><iframe width="560" height="315" src="http://www.youtube.com/embed/HOPfVVMCwYg" frameborder="0" allowfullscreen></iframe></html>
Senge also described the characteristics of organisations which were in his phrase 'learning disabled' (see [[Senge: the characteristics of 'Learning Disabled' Organisations]]).
Another video - from the Harvard Business School - @@color(blue):there is a particularly key part of the discussion from 4min 48sec, where they cover WHAT DO YOU HAVE TO DO to start to create a Learning Organisation...@@
<html><iframe src="http://blip.tv/play/g4Y88voiAg.x?p=1" width="720" height="433" frameborder="0" allowfullscreen></iframe><embed type="application/x-shockwave-flash" src="http://a.blip.tv/api.swf#g4Y88voiAg" style="display:none"></embed></html>
!!Online survey to assess your team's proximity to a "Learning organisation"
The survey referred to in the video above is freely available online [[here|http://los.hbs.edu]] (note - the survey does not save your results, so cut and paste your scores onto a word document to save them) - or if you are online it will be displayed below:
<html><div align="center"><iframe src="http://los.hbs.edu" frameborder="0" width="100%" height="600"></iframe></div></html>
!!'Learning Organisations' and AMBIT
AMBIT is designed to be an open system where the need for on-going learning, skill development and new knowledge is placed at the centre of the approach. This is partly because, at best, the desired outcomes of this area of work remain modest and the motivation is to find increasingly effective ways of offering help to troubled young people.
The intention is that AMBIT is designed so that it can be adapted and used in organisations with very different structures and organisational cultures. This includes both statutory and third sector organisations. However, in AMBIT, effective team practice is related to wider team functioning and this cannot be entirely separated from wider organisational factors.
In summary, the reasons for encouraging AMBIT teams to consider the ideas of Learning Organisations are:-
*to connect teams to some of the evidence base around organisational practice
*that mentalization itself is entirely consistent with a pedagogical stance
*that the theory of learning organisations is entirely consistent with core AMBIT values
*that team functioning is a core aspect of AMBIT and will be affected by organisational factors
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''"~Genito-Urinary Medicine"'' - a clinical service focused on STIs, or sexual health. Many areas will have special GUM clinics for young people, but not all.
!About the Score 15:
The Score 15 is a self-rated measure of family functioning developed by family therapists. It is free to use, and takes less than 10 minutes to complete.
<html><div align="center"><iframe src="http://www.psychotherapy.org.uk/score.html" frameborder="0" width="100%" height="600"></iframe></div></html>
There is a (downloadable) article about it [[here|http://www.aft.org.uk/SpringboardWebApp/userfiles/aft/file/Members/UsingSCORE(Jan2012).pdf]]:
<html><div align="center"><iframe src="http://www.aft.org.uk/SpringboardWebApp/userfiles/aft/file/Members/UsingSCORE(Jan2012).pdf" frameborder="0" width="100%" height="600"></iframe></div></html>
!Download or view a copy
The questionnaire is available for download via the CORC website [[here|https://docs.google.com/viewer?a=v&q=cache:JyRtXmWAOAEJ:www.corc.uk.net/wp-content/uploads/2012/05/SCORE-151.pdf+&hl=en&gl=uk&pid=bl&srcid=ADGEESgxwIc_Df6PnW2we6W0YUjpKZtcQ0U7N0mPSMf8zSrJPWP2QItVfh1R_kAh1J7JKP7aPEWl4ZsB1c6uiO75XN7fQn1-5eKoaLyS6bMnmq-X391Zbbxb1Lzmei09DYoaFz8ET08t&sig=AHIEtbS-6k63PFg-IQ5bv8ZHuWLeRjUtcw]]
View a copy:
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It is not appropriate to be overly prescriptive on this subject, but nonetheless, keyworkers will recognise the gravity and responsibility of the work that they are engaged in, and would be expected to 'practice as you preach'; in other words to have some practices built in to their own personal lives that encourage:
#''Anxiety-management'' or relaxation.
#''Recreation'' (Activities, that we might call 'play', which foster what is literally "re-creation" )
#''Mindfulness/Mentalizing practice'' - practising the capacity to take up, and sustain, a thoughtful meta-stance in relation to one's own thoughts and emotions.
#[[Self-directed learning]]: Using the manual you should try to monitor material you have covered in the manual and what you have not yet seen (later developments in the manual will facilitate this.)
!
!7 characteristics of relational strengths in Successful Mentalizing:
!!!1. Curiosity
This refers to an attitude where the individual is genuinely interested in other people’s thoughts and feelings and respectful of the respective perspectives of others. It is also characterised by an expectant attitude that one’s understanding will be elaborated or expanded by what is another person’s mind. It also implies openness to discovery and a reluctance to make assumptions, or hold prejudices, about what others think or feel.
!!!2. The stance of safe uncertainty (Mason 2002) – also referred to as ‘opaqueness’:
This refers to the open acknowledgment that one frequently does not know what other people are thinking, without being completely puzzled or overwhelmed by what happens in the mind of others. This stance is based on a general sense that the reactions of others are to some extent predictable, given the knowledge one may have of what others think and feel.
!!!3. Contemplation and reflection:
This refers to the desire to reflect on how others think in a relaxed rather than compulsive manner.
!!!4. Perspective-taking
This is a stance and attitude which is characterised by the acceptance that the same thing can look very different from different perspectives, which tend to reflect individuals’ different experiences and histories.
!!!5. Forgiveness
This refers to the understanding of the actions of others by basing this on the understanding of their mental states. An example of this is the dissipation of one’s own anger once one has understood why the other person had acted as they did.
!!!6. Impact awareness
This refers to the awareness of how one’s own thoughts, feelings and actions impact on others.
!!!7. A non-paranoid attitude
This describes the stance whereby the individual does not implicitly consider the thoughts of others as presenting a significant threat and having in mind the possibility that minds can be changed.
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|Date:|$Date: 2008-02-27 02:34:38 +1000 (Wed, 27 Feb 2008) $|
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* Borrows largely from ThemeSwitcherPlugin by Martin Budden http://www.martinswiki.com/#ThemeSwitcherPlugin
* Theme is cookie based. But set a default by setting config.options.txtTheme in MptwConfigPlugin (for example)
* Palette is not cookie based. It actually overwrites your ColorPalette tiddler when you select a palette, so beware.
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This is a tag for all tiddlers concerned with the AMBIT Outcomes Framework including all measures that could be used by AMBIT teams. See topics and sub-topics in the [[Show references and info]] panel.
!Three types of outcomes
*''Service Outcomes'' e.g. reducing the number of young people who go to hospital, come into care or go to prision.
*''Individual Outcomes'' e.g. reduced violence, increased pro-social activity, attending college, less depressed, better relationships etc.
*''Client Satisfaction'' e.g. do young people like the service, do they attend sessions or activities, do they communicate with staff etc.
!Barriers to outcomes measurement
* "We don't have time to add this to our workload"
* "These measures are just about //performance managing ME// - they will show my bosses that I am no good, they won't understand..."
* "We send these outcomes measures off, and never hear anything back - what's he point?"
* "We are asking the wrong questions! If we were asking questions I was really interested to find out about it might be different!"
Hard to reach is rather an unhelpful term from the perspective of many young people who might be labelled in this way.
They are not 'hard to reach' for local gangs, dealers or indeed for many positive figures such as youth workers who are prepared to go out to meet them.
They are often experienced as hard to reach by services offering clinic-based appointments, that might appear highly formal, and even intimidating, and which might also struggle with the stigma that is often attached to Mental Health or Youth Offending services. Without family support to attend appointments in such settings many young people opt for avoidance as a first response.
Key concepts that are often associated with the 'hard to reach' young person are [[Comorbidities]] and [[Complexity]] and there are important [[Developmental Considerations]] for this group of young people.
This is a tag that collects all the Tiddlers that include downloadable forms that can be used in the general process of assessment, formulation and care planning.
!Who does that doctor think he/she is?
Doctors have spent many years training; following their (5 years) of basic training, in order to practice with a full registration by the General Medical Council in the UK, for instance, they must also have gathered 'pre-registration experience' working under close supervision in medical and surgical specialties for 18 months. After registration many (most) will go on to do further specialist training - for instance as General Practitioners, Surgeons, Psychiatrists, or Physicians. Becoming further registered in one of these specialties requires more exams and more years of training under supervision. So it is important to understand that most doctors will, in one way or another hold a belief that:
>//"I have earned the right for my opinion to be taken quite seriously"//...
At times this can result in doctors being perceived as rather arrogant or belittling of others - and at times this is undoubtedly the experience that patients and other professionals have. MOST doctors would be very unhappy with such an exchange, and would acknowledge and value the richness of of experience that others bring to any exchange. An old saying in medical school is //"Listen to the patient! They are usually telling you the diagnosis!"//. There is increasing emphasis on communication skills in the medical training.
!What do doctors actually DO?
The first thing a doctor will try to do is to make an accurate ''diagnosis'' of the problem the patient is presenting with. This means trying to get an accurate picture of the patient's concerns in their head, and then checking various possible explanations for this concern through examining the patient, or using specialist tests such as X-rays, or blood tests.
Once there is a diagnosis, a doctor will then turn to the scientific evidence and offer the most appropriate ''//treatment//'', or refer on to a specialist who can perform that work for the patient.
!What are their values?
Aside from the fact that doctors are humans and are subject to as many variations as other members of our race, they are trained in ''scientific methods'', and this is at the heart of their ''ethical stance''. This means that they will recommend only those treatments for which they understand that there is valid scientific evidence of ''safety'' and ''effectiveness'', and they will avoid offering treatments for which there is not yet evidence from trials, or at least from the wider expert community of specialists.
!Understanding what a doctor means by "evidence" is helpful.
For a new treatment to be accepted the "gold standard" of evidence is from what is known as a "Randomised Controlled Trial" (or "RCT"). This is when a group of people are gathered together who all have the same ''diagnosis''. They are then divided randomly (on the toss of a coin, although offten more sophisticated methods are used!) into two groups. The new "trial treatment" is given to one group, and a "placebo" (a substitute that has no active properties at all) is given to the to the other group. In the best trials neither the patients nor the doctors giving the treatment know which group they have been put into (this is known as a "double blind" trial) so that there is less chance of a bias creeping in. This way doctors can tell if when a patient gets betterr it is becuase of a treatment, or just because they would have got better anyway!
Now, in the field of adolescent mental health it is worth knowing that there is (compared to many specialties) a relative //lack// of hard evidence, as it is very difficult to set up properly conducted (i.e. not //biased//) trials to see if a particular treatment is effective or not.
Doctors can appear dismissive of "new" treatments, or complementary approaches on the grounds that these may not have been subjected to rigorous trials in the way that "their" treatments will have been. At its worst, this can again be perceived as arrogance, or narrow-mindedness. From a doctor's point of view their suspicion of an "alternative" or "unproven" approach may relate to the wish to avoid raising false expectations in a vulnerable person, or spending a lot of money on a treatment that may be no better than "placebo".
!Doctors may have different priorities
Doctors tend to have had experience of people dying, and of very serious illnesses. Their first priority is always to exclude life-threatening conditions. This can lead to them appearing rather harsh, or insensitive if they appear relieved that it is "only a fungal infection"... in their mind they may be relieved that "this isn't cancer", whereas the patient may be shocked to feel that her body is being "invaded" in this way.
!Doctors are often balancing competing priorities
Most dotors work long hours and have large lists of patients. A common fear for doctors is that in their busy-ness they will miss a crucial piece of information, and will make a mistake. In keeping with their "seniority in terms of training, doctors also often feel (and are treated as) responsible when things go wrong. This anxiety that //"the buck will stop with me"// may explain what might at times appear to be an overly cautious attitude.
!Doctors and [[Confidentiality]]
Doctors (and other healthcare professionals) can be reluctant to discuss a person’s diagnosis or treatment with the carer.There is a real duty of [[Confidentiality]] between the doctor and the patient. If the person is too ill to understand what is going on, doctors //will// usually involve the carer in discussions and decisions. From the doctor's point of view it is important to remember that a breach of confidentiality is potentially a very serious breach of the professional code of conduct, which could lead to problems with the General Medical Council and even being stopped from working as a doctor - understanding this dilemma will help a worker or family member to //mentalize// the doctor's position; a refusal to share information may not simply indicate that a doctor does not value another worker, or family member, etc.
!Doctors tend to be "solution-focussed"
Temperamentally, doctors often tend to prefer to DO things that FIX problems, rather than spend a lot of time in musing and imagining possible explanations or imaginative responses. They may tend to urge people "cut to the chase" in consultations - which can easily leave the people they are talking to feeling rushed, or not listened to. An understanding of the doctor's sense that there may be several other severely unwell patients on his or her books, and the need to allocate the limited time available fairly can help to mitigate this!
You can only make changes to a [[Space|Spaces]] if you are member of that space.
!If you are a member of a Space, then you can:
* Make [[Edit]]s to the content of that space
* Add or remove OTHER members to/from that Space
* Do more advanced things such as [[Include|Including spaces]] the public content from other [[Spaces]] in this space, or remove previously included spaces.
!Adding a new member:
To make someone a member of a space, ensure you are a member of that space yourself, and that you are [[logged in|Log in]].
Obviously, to add a member to your space, they must FIRST have a username to add, which means they have to [[Register on TiddlySpace]].
Then go to the [[Space menu]] (which you find by selecting the [[Advanced mode]] from the [[Mode and Login panel]].)
The [[Space menu]] reveals simple instructions for how to add a member - type their username into the box and click "ADD MEMBER"!
There are a lot of interesting people using ~TiddlySpace that you might like to keep track of and interact with. There are a number of ways of doing this.
If you see a number in the speech bubble in one of your tiddlers, it means that someone is writing about the same thing as you. You can find out what they're saying by clicking on it. Likewise, if you see something interesting in someone else's space, you can respond to it and write up your own thoughts on the subject by clicking "Reply to this tiddler".
Additionally, if you find anyone interesting, or you find an interesting looking space and you'd like to know when it's changed, you can "follow" that space. To do this, simply create a tiddler with the title: {{{@space-name}}} and tag it {{{follow}}}. If you want, you can store some notes about that space in the body of the tiddler.
If you then want to know what happening, simply [[include|How do I include/exclude spaces?]]@docs the @tivity space and then visit your activity stream at [[/activity|/activity]], or just visit the @tapas space directly.
!Not sure who to follow?
Here's a few suggestions:
* @fnd
* @cdent
* @pmario
* @bengillies
* @dickon
!What are the Aims of Family Work?
The main aim of family work is [[Restoring family capacity]] - which relates to the [[Core Features of AMBIT]] as it is an example of [[Scaffolding existing relationships]].
The worker attempts to do this by working to //contextualize// the presenting symptom(s); that is, to develop an understanding of how these difficulties might fit in the context of the young person's current and past relationships with family members and/or significant others, as well as of social and cultural factors and discourses.
Systemic interventions aim to:
*help the young person and the various family members to get //new perspectives// or new understandings on the presenting problem(s)
*to attach different meanings to these
*to experiment with new ways of relating to one another
*to jointly find new and practical solutions to pressing problems and dilemmas. Interventions aim to
*block dysfunctional family interactions and communications
*activate new, more functional transactions.
Khan, Lorraine and Wilson Jane (2010) You just get on and do it: healthcare provision in Youth Offending Teams. Centre for Mental Health report.
See p.31-32. See online report [[here|http://www.centreformentalhealth.org.uk/pdfs/Centre_for_MH_Healthcare_provision_YOTs.pdf]]
Checking is a key component of the [[Mentalizing Loop]] and one of a range of helpful [[Engagement techniques]]).
It is important to ''check'' whether the KW has understood what people are saying (e.g. "let me just check with you that I've got this right...") Thus repetition, in slightly changed language, offers confirmation of being understood, emphasises what has been said by repetition, and offers the opportunity to begin to frame the family's presentation somewhat differently (e.g. "he always deliberately tries to hurt me..." to "when it feels to you as if he is trying to hurt you deliberately ..."). Very often the change would be to add a mentalizing stance, i.e. to recognise that the behaviour of self and others is mediated by mental states.
!//Checking// is a powerful enactment
Checking is an enactment of the [[The Therapist's Mentalizing Stance]], modelling respectful curiosity, expressed tentatively, about mental states. It models the 'not-knowing' that comes with a belief that our mental states are interesting, useful to understand accurately, but also //opaque to// each other.
It is also a helpful example of one of many [[Engagement techniques]] described in this manual.
!//Checking// the Links
Accurate mentalizing increases the narrative coherence of an event, and reinforces the assumption that our understanding of behaviours is improved when they are perceived as being embedded within (and to some extent contingent upon) a wider context, including repetitive historical patterns. Linking an observed interaction, such as a momentary loss of mentalizing in a family, with previous accounts or reports of problems is an important beginning of the task to [[Generalize (and Consider Change)]].
!//Checking// as confirming the limits of our 'mind-reading'.
Checking understandings also powerfully affirms the mentalizing notion that //we do not have privileged access to the contents of each other's minds// (mentalizing is never the same as mind-reading). It is an enactment of the [[The Therapist's Mentalizing Stance]] which offers a //tentative// stance, that is inquisitive about other people's mental states.
!//Checking// as affirming of the value of mentalizing.
Implicit in our checking understandings and feelings is that //we affirm the importance of understanding other peoples' mental states.// This is an enactment of the [[The Therapist's Mentalizing Stance]] which constantly affirms the value and signficance of mentalizing.
!//Checking// at the end of the loop
By the end of a session it is important to conclude a therapeutic sequence by getting each family members to view what happened from a meta-perspective. This is, in effect [[Mentalizing the Affect]].
This helps to evaluate what may have been a new and emotionally charged experience, giving them the opportunity to reflect together about what happened and the possible consequences:
>//“What did you make of what happened? Can you talk together about what this was like for each and all of you? Are there any conclusions you can draw from this?”//
!Warnings and Acts...
There may be suicidal ''warnings'' or suicidal ''acts''.
You should see also [[Self Injurious Behaviour]] when there are episodes of actual damage/harm or suicidal actions are ocurring.
!A suicidal warning may be:
(a) An attempt to warn people that a Suicidal Act is about to take place - so it should ''always be taken seriously''.
(b) An attempt to influence people's behaviour - which can have a negative effect on those around the young person:
>//"This person is trying to manipulate me! this is just attention-seeking!"//
*The RISK in this situation is that a genuine "cry of pain" can get overlooked.
*The REAL ISSUE if someone is seen as "attention-seeking" is:
*@@color(red):WHAT PROBLEM REALLY NEEDS ATTENDING TO?@@
(c) An attempt to communicate about an overwhelming emotional experience.
!Effects on the worker:
Hearing a young person say //"I'm going to kill myself"// will often leave the worker feeling:
*Helpless
*Hopeless
*Frightened
*Infuriated
*Panicky
This is likely to reduce the worker's ability to mentalize accurately, but if this can be overcome it is an experience that (through [[Mentalizing the Affect]]) can be a helpful opportunity to develop more accurate understandings of the client, and to deepen the authenticity of the therapeutic relationship.
If left un-processed, there is a risk that such feelings could de-stabilise the KeyWorker's own [[Mentalization]],
!What to do
The key in these situations is to use the available SupervisoryStructures to help you do some [[Thinking Together]] about this.
*''The feelings that the worker is overwhelmed with may be just the same feelings that the young person himself is struggling to cope with.'' ([[Psychodynamic theory]] would describe this as an example of 'Projective Identification'.)
*Being able to distinguish and work with experiences like this is an example of how [[Mentalizing the Affect]] can help the KeyWorker better work with the young person.
>//"I don't know quite what it must be like going through all the things that you are going through, but I am wondering if it seems important for me - to have a kind of taste of how it feels - to be kind of frightened and furious at the same time? I find myself thinking that I need to be really careful to make sure I have understood what //you// need right now for this to be helpful. Can you help me make sure I have understood things properly, as I may have got this wrong?"//
!Interventions
1. Make a proper assessment - including a good understanding of what happened, as well as covering:
(a) What is the risk of:
*[[Self Injurious Behaviour]]
*[[Suicide Attempt]]?
>See and update your RiskAssessment, and ensure that any risks are addressed in your updated [[Care Plan]]
(b) Why now?
Are there ''recent changes'' in the young person's SocialEcology or personal history (relationship issues? abuse? impending criminal proceedings? etc) that might be acting as precipitants to this?
(c) How does the young person understand this behaviour?
The young person may have a very clear idea in his or her head as to why they are making these utterances, and what they want, or they may be very confused.
Either way, if the the KeyWorker is to [[Mentalize]] the problem accurately, these are questions that need to be approached.
Ask calmly, respectfully - mindful of the [[General features of a "Mentalizing Stance"]].
!Interventions to reduce Suicidal Warnings?
This depends largely on how the young person and family understands the "behaviour" (i.e. making utterances that falsely give other people the impression that there is a risk they will kill themselves is different from giving a warning because I am worried that I might indeed kill myself)...
Of course we WANT a young person to give suicidal warnings, not to hide suicidal ideas and plans until it is too late. What we want to avoid is the kind of mixed signals whereby the young person wants one thing (care, relief from pain or fear, etc) but asks for another thing ("I want to die".)
If the worker can begin to [[Mentalize]] the young person's position accurately, then root causes can be addressed, and alternative ways for the young person to achieve their ends (i.e. //"I don't want to feel this pain any more"// or //"I want to know that there are people about there who do really care about me"// or //"I am frightened that I am about to get sent to prison."//, etc) sought.
!Techniques that may be applicable:
[[MentalizationBasedWork]]
[[PsychoEducation]]
[[FamilyWork]]
[[Cognitive Behavioural]] work
When mentalizing occurs in a session - even if it is mentalizing in only its most fleeting form (a young person who hesitates for a few seconds in the middle of a tirade, puts her head in her hands and mutters //"I dunno, its just so hard to make sense of things sometimes"//) it is important that the KeyWorker:
(a) ''NOTICES'' this
(b) ''COMMENTS'' on it - describing what was seen
(c) ''ENQUIRES'' whether the young person noticed anything slightly different about how things felt, how they thought their mind was working at that point in time
(d) ''EXPLAINS'' why this simple moment seemed important, and how this different way of thinking about things //might// come up with different kinds of solutions...
[img[https://lh3.googleusercontent.com/-ExW0YhOr4WA/UOiZqd2p3wI/AAAAAAAAGeA/0VZk-HL1AGI/s307/HighlightingMentalizing.jpg]]
The therapist aims to deepen people’s ability to connect feelings, thoughts and intentions, and in order to do so:
*Searches actively for examples (or episodes) of good mentalization
*Positively connotes these
*Enlarges upon them
>//“When you did x, I was very impressed by how you each tried to get your heads around this…. Father, you did x; mother, you did y; Johnny you did….”//
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!Online
http://www.ncbi.nlm.nih.gov/pubmed/18676591 - abstract
http://mentalizacion.com.ar/images/notas/Mentalization%20Ontogeny,%20Assessment,%20and%20Application%20.pdf
!Reference
Am J Psychiatry. 2008 Sep;165(9):1127-35. doi: 10.1176/appi.ajp.2008.07081360. Epub 2008 Aug 1.
Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder.
Choi-Kain LW, Gunderson JG.
!Abstract
This article aims to review the development of the concept of mentalization, its applications in the understanding and treatment of borderline personality disorder, and the issue of its assessment. While conceptually derivative of theory of mind, Fonagy's concept of mentalization concerns more affectively and interpersonally complex understandings of oneself and others, reflecting abilities that enable an individual not only to navigate the social world effectively but also to develop an enriched, stable sense of self. The components of mentalization can be organized around self-/other-oriented, implicit/explicit, and cognitive/affective dimensions. Concepts of mindfulness, psychological mindedness, empathy, and affect consciousness are shown to partially overlap with mentalization within these three dimensions. Mentalization is assessed by the measure of reflective function, a scale to be used adjunctively on semistructured narrative interviews such as the Adult Attachment Interview. Its validity has not been fully tested, and its usage has been hampered by the time and expense it requires. Although the concept of mentalization is a useful heuristic that enables clinicians to adopt a coherent treatment approach, it may be too broad and multifaceted to be operationalized as a marker for specific forms of psychopathology such as borderline personality disorder. Research elucidating the relationship between reflective function, overlapping concepts, and features of borderline psychopathology is needed
!What is this for?
The Snapshot is a simple and immediate way to make a record of a page or a set of pages that you have opened and want to be able to share... It allows you to generate a link (a "URL") that you can email to anyone, which will open just those pages that you have got opened on your [[Desktop]] at this time.
This is one of a number of [[Comparing and Sharing functions]] that [[TiddlyManual]]s contain.
!What do I do?
1. Get the page or pages that you are interested in opened up on your [[Desktop]].
2. Open the [[Sidebar]] and find the little Camera icon beside the [[Currently Open]] list:
<html><a href="https://picasaweb.google.com/lh/photo/wScWtP2SLM_Y_qQpeqI5t9MTjNZETYmyPJy0liipFm0?feat=embedwebsite"><img src="https://lh3.googleusercontent.com/-7DBn-KiG2js/T2DZuajleJI/AAAAAAAAEC0/rrx_sX9DYZ4/s800/SnapshotButton.jpg" height="414" width="575" /></a></html>
3. Click the SNAPSHOT button
4. Have a look at your browser's Address box (where the web address or "URL" goes that sends the browser to the right web page.)
5. Copy the new URL (web address) that is in the browser's address box.
6. Paste that address into the body of an email (or anywhere you want to save it).
7. Next time you or the person who receives the email click that link, it will open the manual with exactly those same pages already opened up.
!Why?
This can be very helpful in [[Team Meetings]] or in supervision sessions: case discussion may involve looking at content from the manual and this can be emailed directly to the worker.
This function is also known as "permaview" - clicking here <<permaview>> does exactly the same thing (try it!)
http://uk.linkedin.com/in/eiaasen
Remember that the AMBIT training is only offered to Teams. See [[Guidance for Teams Considering Applying for Training]].
There is a direct link to the Application form [[HERE|https://docs.google.com/open?id=0B5h_CVBdhJPYdUxuQUZSMnFKVUk]] (Click on ''File > Download'' to get a copy for yourself) ...Or see it below
<html><iframe src="https://docs.google.com/file/d/0B5h_CVBdhJPYdUxuQUZSMnFKVUk/preview" width="640" height="480"></iframe></html>
!First Principles
Remember the [[CultureOfHospitality]] that a team is responsible for generating and upholding.
!Adapt your local version!
Different teams will receive their referrals or meet new clients via different routes, and AMBIT does not seek to define these pathways. This is therefore a page that a LOCAL team will want to Edit and adjust to fit their circumstances.
!Initial "triage"
Team members taking referrals (telephone/letter/fax/e-mail) will need to make a preliminary assessment of whether this referral requires an EmergencyResponse.
*Is immediate liaison with Police and Social Services required?
*Use the team's SupervisoryStructures where required - in particular consider are you [[quorate|Reflective Quorum]] to make decisions about these matters?
*According to the staffing levels it may or may not be possible to provide this service, especially on a 24 hour basis.
*In such cases it will be necessary to have clear [[Local Protocols]] for the joint management of such crises with existing Crisis/Home Treatment Services.
Once decisions have been made, see [[Setting up a first meeting]].
!These are important responses to [[Affect storms]].
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!Simmering down techniques include:
#Drastic, if not dramatic, //“stop, stop, stop” interventions// ("pressing the pause button") - See [[Pause and Review]].
#The therapist may even have to ''stand up'' and use his/her hands and arms, like a conductor, to ask for momentary silence, saying: //“I can see how good you are at getting each other excited – this looks like a well rehearsed act…. How many times have you performed it so far? 10 times, 100 times, 1000 or more times? Is it getting anywhere? Does it help or stop thinking? Let us take a deep breath and think about what happened here and how helpful or useless it may be to have more of the same….”//
#''Focusing techniques'', such as those hypnotherapy-inspired manouevres suggested by Milton Erickson, may help to create a calm space. It is a deliberate move to block dysfunctional, spiralling and seemingly ‘mindless’ interactions between family members.
#''"prescribing"'' tight time-frames for each family member to express what needs to be expressed, be that thoughts or feelings. The technique of ''“60 seconds each”'' invites turn-taking and enforces temporary listening. Using a stop-watch introduces light-heartedness, particularly if the therapist is the time keeper, inviting each family member to express themselves during the allocated time slot and indicating aloud when “times is up, next please”.
#The therapist may need to actively ''change the focus and shift it'' onto another mentalizing topic.
#If working with just the parental couple, see: [[Taking a break]], which is an example of the [[Therapist's use of Self]].
Remember that all the pages ([[Tiddler]]s) in this manual are actually part of ONE single web-page, so the "Backwards", "Forwards" and "History" buttons on your BROWSER are of no use to you in a tiddlymanual. (Incidentally, clicking F11, or selecting View > Full Screen to hide the browser and make more room for the manual is a useful trick.)
So, instead of accessing the History via the browser you do it from the the left hand [[Sidebar]], where you will see a panel titled "History": this records and lists the title of each [[Tiddler]] you open during a session in the manual.
Think of this as //the piece of thread that you unravel as you go into the labyrinth// - it can be useful to remember where you have been during a session, and to re-trace your steps or revisit any content you have closed earlier. When you click on any title stored in the history widget, you will re-open that tiddler.
!Use [[SNAPSHOT]] to remember/share history
When you close the whole manual (or click "refresh" on your browser) the history will be lost, so if you want to share a page or collection of pages that you have opened, use the [[SNAPSHOT]] button (in the [[Currently Open]] panel, just beneath the History recorder.)
!@@color(red):IMPORTANT!@@
@@color(red):At present we are not supporting or recommending the use of this feature - as we have been focusing our effort on developing the browsing experience and other functions such as the [[AIM]]. The offline (downloaded) saving mechanisms are not yet finished, so saving an offline version is not easy. More importantly, we have not yet set the saving mechanism so that it is completely impossible to synchronize a downloaded copy and save it back up to the web by accident.@@
We hope to have this aspect functioning by later in 2011 (say autumn). By all means have a look around and consider giving any [[Feedback please!]].
!For users of [[ICR]]
Ensure that you are using a ''DOWNLOADED'' copy of the manual that is stored in a secure place before you make edits that include confidential client information.
''__@@color(red):DO NOT UPLOAD CLIENT DETAILS TO THE WEB!@@__''
NOTE the Information on DataSecurity.
!Interactive Case Recording
<<slider chkTestSlider [[Make or View Client Notes]] "Reveal the Client Notes »" "Click here if you wish to Make or View Client Notes">>
Remember the [[AIM]] KEY PROBLEMS offer the most specific problem-focussed outcome scale.
[_] - [[AIM]] completed and exported to database
[_] - [[CGAS]] (0 - 100) scores completed and exported to database
[_] - [[CGI-S]] (1 - 7) Severity score - complete and export to database.
[_] - [[HoNOSCA]] (0 - 52) scores completed and exported to database
[_] - [[SDQ]] - scores completed and exported
[_] - [[Treatment Outcomes Profile]] if DRUGS or ALCOHOL are features.
Add other outcome scales as appropriate
A whole series of ''balances'' must be held:
[img[https://lh5.googleusercontent.com/-Gw7lmHClo5U/UOiYbl16S4I/AAAAAAAAGdo/mpVLume7TZU/s350/HoldingTheBalance.jpg]]
* Between observance of natural interactions and intervening to promote change
* Between the contributions of different individuals in a group or family
* Between a focus upon //[[Cognitions]]// and //[[Affect]]//
* Between keeping things calm enough to allow [[Implicit mentalization]] and offering gentle challenges to [[Pretend mode]] interactions, to stimulate [[Explicit mentalization]].
Mostly this "Balance" can only be summed up across time (through a whole session, or across different sessions) - but the therapist will be looking for "//what is not being aired//" as much as the content of what //is being aired//.
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It is the therapist’s task to help the family make sense of what feelings are experienced by each family member, as well as highlighting the ways in which miscommunication or misunderstanding (or lack of understanding) of these feelings leads to interactions that maintain family problems. In practice, this requires the therapist to strike a very careful balance between allowing the family to interact ‘naturally’, or indeed actively eliciting habitual and ‘natural’ family interactions around problematic issues, as well as being directive and intervening at critical moments too.
The [[Show references and info]] panel to the right of the page title will list [[Sub-topic]]s that cover guidance from an AMBIT perspective on team working.
This is just a way of marking particular clients whose needs and [[RiskAssessment]] are perceived to be particularly concerning at present, and making a __protected space__ for them in the team discussion at [[Team Meetings]]. These are clients' whose needs MUST be discussed - as crucial questions need answering, that require the whole team as the [[Reflective Quorum]].
Jeremy wrote the original TiddlyWiki software and released its source code under a license that is owned by a charity [[UnaMesa|http://www.unamesa.org/]]. TiddlyWiki has continued to be developed by a worldwide collaboration of programmers as an "OpenSource" project, and we acknowledge the help of the [[TiddlyWiki Community|http://groups.google.com/group/TiddlyWiki]] and [[Osmosoft|http://osmosoft.com/]]
!Learning objectives for Day 2
# [[Learning about Supervisory Structures]]
# [[Learning about Addressing Dis-integration]]
# [[Learning about Manualization]]
Bevington D, Fuggle P (2012) Supporting and enhancing mentalization in community outreach teams working with socially excluded youth: the AMBIT approach. In “[[Minding the Child|http://www.amazon.co.uk/Minding-Child-Mentalization-Based-Interventions-Children/dp/0415605253/ref=sr_1_1?s=books&ie=UTF8&qid=1336178888&sr=1-1]]: mentalization-based interventions with children, young people and their families.” Ed. Midgley N and Vrouva I, Routledge, 2012.
See the [[When to suspect abuse - NICE guideline]].
See [[Child Protection]], and [[Child Protection Referral]]
!''Purpose''
One of the aims of AMBIT is to enhance mentalization both in work with clients but also in work with colleagues in the formal or informal network around the young person. [[Addressing Dis-integration]] (and the use of the [[Dis-integration grid]]) is
one of the [[Core Features of AMBIT]].
The 'What's it like to be...' exercise is designed to encourage team members to explore their capacity to make sense of the network from another person's point of view. The exercise can be done to think about differences between staff //within a single team// or //between different teams or agencies//. The basic exercise is simple and can be adapted to specific training circumstances.
!''How to do the exercise''
The exercise requires three people.
!!Two practitioners (person 1 and 2)
These identify a member of the team (or network) (person 3) that they know least well...
!!What's it like to be person 3?
Then person 1 and 2 have a conversation together imagining what it would be like to have this other person's job.
!!!Focus on the LIVED EXPERIENCE
The focus in this conversation should be on the lived experience of this other person (not their formal responsibilities) to include:
* what's fun about the job
* what's stressful
* what they do for lunch
* what a typical day comprises of
* what is the Xmas party like for them, etc.
!!Person 3
Person 3 ''simply listens'' to this conversation. Having built up a bit of picture of this (10 minutes max), Person 3 then reflects back what it is like to listen to the story of one's own work in this way. Inevitably this will include some consideration of the 'accuracy' of the description but the focus of interest is around the feelings (e.g. indignation!; supported; validated; etc) evoked by discrepancies or inaccuracies rather than the inaccuracies themselves.
If this is done in as part of a group activity, a sub-group of all "Person 3's" can be invited to feedback to the wider group (as a group [[Fishbowl discussion]]) about what it was like to see one's working life described by others.
!The aim of this exercise.
to explore the experience of a service barrier looking at that 'barriers' are relational involving difficulties between workers in different teams involved in the young person's network.
!Three examples.
*Problem 1 YOS and CAMHS. Young person (16 years) on court order with history of severe and persistent offending around violence to property and stealing. YOS worker (PERSON A) manages to negotiate that part of order can be met by the family attending family therapy appointments at CAMHS. YOS worker needs to know whether family attend as part of report back to court. CAMHS accept the referral, see the therapy as appropriate but the allocated clinician (PERSON B) believes that she cannot offer appointments if this is seen as being 'accountable' to the YOS worker for their work. The CAMHS worker has had previous experience of such arrangements becoming a little inflexible and unhelpful for the therapy. Referral is being delayed because of inability to agree this.
*Problem 2. Social Care and Adult disability services. Social care team has been referred a young person who is at risk of family breakdown. The mother of the young person has a learning disability (uncertain severity) but social care team unaware that mother is receiving help from adult learning disability services. Social care worker (PERSON A) is trying to empower mother to hold more responsibility with her son (13 years). When Adult disability keyworker (PERSON B) finds out about the work of the social care team, the keyworker feels that she has not been consulted about social care involvement and consider that the disability team are the primary agency involved with the family. The keyworker in the disability team has strong views about the rights of adults with learning difficulties to be parents and has been explicitly critical to the social care team manager about the impact of their intervention on her client.
*Problem 3. Acute hospital team and CAMHS outreach Services. Young person has been admitted for a couple of nights following an overdose and presentation at the local A and E department A mental health assessment has been completed and the locum Hospital Paediatrician (responsible doctor) (PERSON A) considers that the young person can return home but with high levels of community supervision. He has referred to the Outreach Team and the worker in that team (PERSON B) does not agree about the level of risk and feels that the young person does not require such intensive follow-up. The discharge is being delayed because of inability to agree a discharge plan.
!Instructions for exercise
1. Divide into groups of three. Two of you are going to have a conversation and one will observe. The observer will feedback their impressions in a fishbowl discussion with other 'observers'.
2. Trainers will allocate the groups of three to one of the three problems above. Then they allocate groups of three to consider PERSON A or PERSON B. (Note to trainers you will need a group of three for Problem 1a; Problem 1b etc)
2. For about five minutes, two will mentalize the state of mind of their allocated person. The assumption is that each PERSON is experiencing a dilemma? What is the dilemma that PERSON A and B are experiencing? The third person observes this conversation.
3. The 'observers' for the same problem scenario have a reflecting conversation about what they have observed. The conversing pairs observe this.
4. Each group discuss one small action (e.g. who else could help; role of family; facilitating conversation between who; recognising positions) that could be considered which would help address issues raised.
This is one of many [[Tags]] in the manual; it links content that relates to the broad team and [[KeyWorker]] task of managing their relationship with the client.
In many textbooks this is referred to as the "[[Therapeutic relationship]]".
AMBIT takes this very seriously: a core task is to develop an [[Attachment Relationship]] with the young person (NB this doesn't just mean the young person should 'become attached to' his or her keyworker, or vice versa. You can read more about the theory behind this idea in [[Attachment theory]], and how it relates to the way a young person might use his or her KeyWorker as a [[Secure Base]] from which to explore. Crucially, [[Mentalization]] depends on the activation of this [[Secure Base]] experience. This is why we emphasise [[Engagement]] with the young person, including the [[Boundaries]], such as [[Confidentiality]] that make this relationship safe.
See related material for relevant links.
!What is this?
This is the first //and last// part of [[The Active Planning Process]] - //"Taking Aim"// is a phrase that is intended to capture the [[Intentional stance]] beneath the process of [[Assessment]]; it is about a ''constant curiosity'' to learn [[What's the problem?]] so that we are better equipped to make decisions about [[What to do?]].
It promotes the use of [[Goals-based outcome measures]]: having some previously [[marked out|Marking the Task]] goals for the work you are doing with a young person of family.
Self-evidently, planning cannot take place without knowing (a) the reality of where we start from, and (b) where we intend to get to.
>In keeping with SystemsTheory (or the contributory theory of "//Cybernetics//"), achieving predictable (accurately 'targeted') change first requires accurate information to be fed into the system about //"where I am"//, so that bearings can then be taken to guide //"where I am heading."// Ironically, this theory was developed with the need for constant self-correcting guidance systems of rocketry in mind (''so it is true to say that this work is quite like rocket science'').
The point of ''//taking//'' AIM is that [[Aims and Goals]] (or more specifically the [[Formulation and Treatment Aims]]) are not //fixed// "givens" - they depend on our perception of where we are in a changing world, and this influences our ideas about where we wish to aim for...
!Mapping where we are - 4 practical steps
[img[https://lh6.googleusercontent.com/-igIsaDsH-Jg/URG2sSb78wI/AAAAAAAAGp0/u52sBQ9dF94/s640/Compare%2520Maps%2520and%2520Destinations.jpg]]
!!!(a) The AIM
* The phrase //"Taking Aim"// is also a reminder that AMBIT promotes the use of //structured// assessments for mapping //"where are we?"//, and provides one that is built in to the manual, the [[AIM]].
* The AIM is a broad [[Multi-Domain Assessment]] providing [[Goals-based outcome measures]] for the worker and client.
* Some teams may choose to use their existing structured assessments, rather than the [[AIM]]; but there are advantages to the AIM that are worth outlining:
** The [[AIM]] is embedded in this manual - it is ready to go.
** Completing it (or even just parts of it) will generate lists of [[Links]] to manualized interventions in this manual, specifically indicated for the problems you have indicated in the AIM. (See [[AIM suggested interventions]])
** These suggested interventions can act as a prompt to promote the most evidence-based interventions for specific areas of difficulty.
** In situations where there are multiple complex interacting problems the AIM can help by suggesting ''rankings'' and sequencing for these interventions.
!!! (b) Consideration of the [[Relationship to help]]
There are many ways that young people perceive and relate to the idea of help, and many of these will influence their behaviour //in ways that make it less likely that they will be helped//. There is advice in [[Relationship to help]] on some of the many experiences of help that might be encountered by workers. Recognising these accurately may help the KeyWorker to adjust the way they are [[presenting themselves|Broadcasting Intentions]] or their help so that may be seen as maore accceptable or useful.
!!! (c) Consideration of [[Where are we in the therapeutic journey?]]
It is helpful for the worker to be clear in his or her mind which of the [[Phases of AMBIT work]] they are currently in, as different factors will be in play. This will also relate to the existing [[Formulation and Treatment Aims]] that your assessment has generated.
!!! (d) Keep on Mapping!
Taking Aim applies regularly //throughout// the work, too: progress towards agreed [[Aims and Goals]] is measured (see [[Comparing Destinations]] and [[Agreeing Waymarks]] - the next steps in [[The Active Planning Process]]) using your [[Outcomes measures]] (for instance the [[Key Problems]] identified in the AIM questionnaire (see [[AIM Form]].) Adaptations of earlier plans may be required to get back on track.
The following are a list of possible team training sessions about particular themes that teams could use (or adapt) for local training sessions. There are more topics under [[Training exercises]] that would also be worth browsing, but these are the key sessions that we recommend for team-based and locally-organised training sessions.
All such training sessions provide an opportunity for updating and improving the manual.
*''Mentalization''
**[[Team training session: mentalization]]
*''Thinking Together''
** [[Team training session: thinking together]]
*''Addressing dis-integration''
** [[Team training session: addressing dis-integration]]
*''What interventions do we do''
**[[Team training session: what interventions do we do?]]
*''Deciding on the intervention''
**[[Team training session: deciding on the intervention]]
This is a tag collecting together all the tasks required in the refinement and improvement of a ''LOCAL TEAM's'' wiki manual (TiddlyManual).
!Existing "to do" list for manualizing:
See the "Show References and info" panel (click the + sign below and to the right of the title) for a list of sub-topics requiring local editing by the team.
!Logging a new Local Manualization Homework Task
Click here: @@color(red):''|<<tag [[Local Manualization Homework Tasks]]>>|''@@ and a drop-down menu appears, listing existing tasks - select the bottom item in this menu ("Create new tiddler as a sub-topic") to generate a new page ([[Tiddler]]) that is already tagged as a local manualization task. Give it a title, and put a few notes in the content section to say what is required. Click done - you have a new task!
!Technical developments/Bugs
To generate a task to fix a bug or extend a new function, please use the form at [[Feedback please!]] to provide information to direct the developers. WE CANNOT FIX/IMPROVE STUFF UNTIL WE KNOW ABOUT IT!
!Getting on with manualizing
Go to [[+ Manualize our work]] - click the appropriate link to generate a blank page (a "[[Tiddler]]"), and see [[Edit]] or [[Understanding TiddlyManual format]] if you are unsure about the process of editing content. REMEMBER THAT EDITING A TEAM'S MANUAL (TeamTemplate) is A WHOLE TEAM'S RESPONSIBILITY, so ensure that you have authority to make any changes.
!This is only for [[ICR]]
This advice is only relevant if you are using the [[ICR]] capability of the manual - which is not active at Jan 2013
!What am I doing?
When opening a new case, it is important to recognise that this is a [[Dynamic, adaptive Manualization]] which is constantly changing and adapting (except in special circumstances such as a formal treatment trial, when the editing of it may be curtailed.)
Hence it is vital that each new patient/client starts with the most up-to-date version of the Manualization. The TeamTemplate is the most up-to-date version of the team's manual, so that you (and your client!) get the benefit of the most recent work on the manual. Your TeamTemplate is either Web-based or on a specific server - your team will know how to reach it.
!Setting up a new file:
1. Use your browser to go to the TeamTemplate. Log on with your password.
2. Follow the instructions at [[Download a copy!]] after which you will end up with an "html" file that has your client's name or other identifying code as its name - for instance: ''johnsmith.html''
*__''Note:''__ - although this file will look and 'feel' just like a website, it is now functioning as a //document// and is NOT online, but is held entirely within your computer.
*You can always check that you are //not// on the web by looking in your browser's address bar (the box at the tiop of your browser which displays the web "url": it will start with the word ''file:/'' rather than ''http:/'' or ''www.''
3. Now prepare this file to be used as a workbook for your specific client.
*Open the file in your browser (just double click on it)
*Log in via the [[Backstage]] menu. You will need your password and username.
*So that your own edits are recorded, you may need to add your own name either here : <<option txtUserName>> or via the ''Options'' button on the right hand margin (the [[Sidebar]]). Once you are logged in this should occur automatically.
*Change the SiteTitle by editing it to your client's name - this is important as you need to be very clear WHOSE file you are recording in!
**see [[Edit]] if you are not sure how to do this - you can just click on the existing title to open the [[Tiddler]] that defines the title of the document, and then edit the text in that to the name of your client.
*Now you are ready to start using the manual as an interactive workbook for recording and thinking about the work with your new client.
!Where next?
See [[Starting a NEW CASE - CheckLists]] for prompts on what needs doing.
In this Manual, when we describe FamilyWork, we mainly refer to work that is carried out in line with the principles and practice of ~Mentalization-Based Treatment for Families, although in AMBIT the structure and settings for sessions may necessarily be more flexible than the structure laid out in the treatment manual for formal MBTF.
MBTF is described here under FamilyWork, and primarily consists of three elements:
#[[The Therapist's Mentalizing Stance]]
#The [[Mentalizing Loop]] (also known as the MBT-F loop).
#A wide range of [[Mentalizing manoeuvres]] - which the creative therapist can add to once the basic stance and aims of the therapy are clear.
There is a [[separate manual for MBT-F|http://www.tiddlymanuals.com]] but most of the material held there is already included within this AMBIT manual.
!description
The extent to which the young person performs tasks such as hygiene, dressing, eating, and attention to personal health needs in age-appropriate manner; if the young person has not been given the opportunity to learn a particular skill (e.g. tie shoes because he has no shoes with ties), do not penalize, and rate on overall functioning.
!end of description
!breakdown
0+ = Good. Takes an active interest in maintaining good health and appearance; i.e. is aware of and maintains personal appearance, well turned out, good hygiene, healthy diet.<br>
0 = No problem. Maintains appearance, self-care to reasonable degree with little or no prompting.<br>
1 = Mild. Has skills but sometimes refuses or neglects self-care tasks, or has a circumscribed problem that does not affect social functioning seriously, e.g. compulsive hand washing.<br>
2 = Moderate. Substantive deficit in self-care in one area that impacts social functioning, e.g. daytime enuresis, unkempt appearance that leads to peer teasing.<br>
3 = Severe. Significant deficits in self-care in more than one area, impacting social and/or family functioning, or deficits impact health, e.g. diabetic teen does not monitor food and blood sugar.<br>
4 = Very severe. Significant deficits in most or all areas of self-care, cannot function independently to bathe, dress, and prepare for school, creating major family, social, and/or health problems.
!end of breakdown
<<AIMForm AIMFormViewTemplate AIM>>
If the severity of the presenting difficulties allows it, it is better to build a relationship over a number of brief visits (coupled with telephone and/or face to face meetings with family members) which allow the young person time to build trust.
A daily succession of ten minute visits over the course of a week or more may be required to signal the worker's good faith and thus acceptability to a young person - particularly if you need to manage [[Paranoid]] states of mind. The worker must recognise that this often frustrating process may raise questions in her mind as to the value of her work, and be prepared to review this process as required, using the appropriate SupervisoryStructures.
!Unfinished!
This page is still under construction.
Links (listed in an appropriate sequence) to all the didactic content of a standard AMBIT training:
- [[Training videos]]
#...
#...
#...
#...
#...
- [[Training slides]]
#...
#...
#...
- [[Training exercises]]
#...
#...
#...
#...
#...
#...
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
/***
|Name|StorySaverPlugin|
|Source|http://www.TiddlyTools.com/#StorySaverPlugin|
|Documentation|http://www.TiddlyTools.com/#StorySaverPluginInfo|
|Version|1.4.3|
|Author|Eric Shulman - ELS Design Studios|
|License|http://www.TiddlyTools.com/#LegalStatements <br>and [[Creative Commons Attribution-ShareAlike 2.5 License|http://creativecommons.org/licenses/by-sa/2.5/]]|
|~CoreVersion|2.1|
|Type|plugin|
|Requires|MarkupPostBody|
|Overrides|confirmExit(), getParameters()|
|Description|save/restore current tiddler view between browser sessions|
This plugin automatically saves a list of the currently viewed tiddlers (the "story") in a local cookie, {{{txtSavedStory}}} and then opens those tiddlers when the document is subsequently reloaded... the tiddlers you were viewing in the last browser session are automatically redisplayed in the next session, allowing you to quickly resume working with the document from the same place you left off!!
In addition to automatic cookie-based story tracking, the plugin also provides {{{<<saveStory>>}}} and {{{<<openStory>>}}} macros that allow you to quickly save the current story definition to a tiddler, and then re-display saved stories using simple, one-click command links or droplists.
!!!!!Documentation
>see [[StorySaverPluginInfo]]
!!!!!Revisions
<<<
2008.09.07 [1.4.3] added removeCookie() function for compatibility with [[CookieManagerPlugin]]
2008.07.11 [1.4.2] in confirmExit(), corrected bracketing for titles containing spaces
2008.03.10 [*.*.*] plugin size reduction: documentation moved to [[StorySaverPluginInfo]]
|please see [[StorySaverPluginInfo]] for additional revision details|
2007.10.05 [1.0.0] initial release. Moved [[SetDefaultTiddlers]] inline script and rewrote as a {{{<<saveStory>>}}} macro.
<<<
!!!!!Code
***/
//{{{
version.extensions.StorySaverPlugin= {major: 1, minor: 4, revision: 3, date: new Date(2008,9,7)};
//}}}
// // ''save or clear story cookie on exit:''
//{{{
// if removeCookie() function is not defined by TW core, define it here.
if (window.removeCookie===undefined) {
window.removeCookie=function(name) {
document.cookie = name+'=; expires=Thu, 01-Jan-1970 00:00:01 UTC; path=/;';
}
}
if (config.options.chkSaveStory==undefined) config.options.chkSaveStory=false;
if (window.coreTweaks_confirmExit==undefined) {
window.coreTweaks_confirmExit=window.confirmExit;
window.confirmExit=function() {
if (config.options.chkSaveStory) { // save cookie
var links=[];
story.forEachTiddler(function(title,element){links.push('[['+title+']]');});
config.options.txtSavedStory=links.join(" ");
saveOptionCookie("txtSavedStory");
} else removeCookie("txtSavedStory");
return window.coreTweaks_confirmExit.apply(this,arguments);
}
}
//}}}
/***
''apply saved story on startup:'' //important note: the following code is actually located in [[MarkupPostBody]]. This is because it needs to supercede the core's getParameters() function, which is called BEFORE plugins are loaded, preventing the normal plugin-based hijack method from working, while code loaded into [[MarkupPostBody]] will be processed as soon as the document is read, even before the TW main() function is invoked.//
<<tiddler MarkupPostBody>>
***/
// // MACRO definitions
//{{{
config.macros.saveStory = {
label: "set default tiddlers",
defaultTiddler: "DefaultTiddlers",
prompt: "store a list of currently displayed tiddlers in another tiddler",
askMsg: "Enter the name of a tiddler in which to save the current story:",
tag: "story",
handler: function(place,macroName,params,wikifier,paramString,tiddler) {
var tid=params[0]?params[0]:"DefaultTiddlers";
var label=params[1]?params[1]:this.label;
var tip=params[2]?params[2]:this.prompt;
var btn=createTiddlyButton(place,label,tip,this.setTiddler,"button");
btn.setAttribute("tid",tid);
},
setTiddler: function() {
// get list of current open tiddlers
var tids=[];
story.forEachTiddler(function(title,element){tids.push("[["+title+"]]")}); // always put titles in brackets
// get target tiddler
var tid=this.getAttribute("tid");
if (!tid || tid=="ask") {
tid=prompt(config.macros.saveStory.askMsg,config.macros.saveStory.defaultTiddler);
if (!tid || !tid.length) return; // cancelled by user
}
if(store.tiddlerExists(tid) && !confirm(config.messages.overwriteWarning.format([tid]))) return;
tids=tids.join("\n"); // separate tiddler links by newlines for easier reading
var t=store.getTiddler(tid); var tags=t?t.tags:[]; tags.push(config.macros.saveStory.tag);
store.saveTiddler(tid,tid,tids,config.options.txtUserName,new Date(),tags,t?t.fields:null);
story.displayTiddler(null,tid); story.refreshTiddler(tid,null,true);
displayMessage(tid+" has been "+(t?"updated":"created"));
}
}
//}}}
//{{{
if (config.options.chkStoryFold==undefined) config.options.chkStoryFold=true;
if (config.options.chkStoryClose==undefined) config.options.chkStoryClose=true;
config.macros.openStory = {
label: "open story: %0",
prompt: "open the set of tiddlers listed in: '%0'",
popuplabel: "stories",
popupprompt: "view a set of tiddlers",
tag: "story",
selectprompt: "select a story...",
optionsprompt: "viewing options...",
foldcmd: "[%0] fold story",
foldprompt: "fold story tiddlers when opening a story",
closecmd: "[%0] close others",
closeprompt: "close other tiddlers when opening a story",
addcmd: "add a story...",
addprompt: "create a new story",
handler: function(place,macroName,params,wikifier,paramString,tiddler) {
if (params[0].toLowerCase()=="list") return this.createList(place,params);
else if (params[0].toLowerCase()=="popup") return this.createPopup(place,params);
else this.createButton(place,params);
},
showStory: function(tid) {
var tids=[];
var tagged=store.getTaggedTiddlers(tid,"title");
if (tagged.length) // if tiddler IS a tag, use tagged tiddlers as story
for (var t=0; t<tagged.length; t++) tids.push(tagged[t].title);
else { // get tiddler list from content
var t=store.getTiddler(tid);
if (t) { if (!t.linksUpdated) t.changed(); tids=t.links; }
}
// see [[CollapseTiddlersPlugin]] for more info, re: folding tiddlers
var template=null;
if (config.options.chkStoryFold) template="CollapsedTemplate";
if (!store.tiddlerExists("CollapsedTemplate")) template=null;
if (config.options.chkStoryClose) story.closeAllTiddlers();
story.displayTiddlers(null,tids,template);
},
createButton: function(place,params) {
var tid=params[0]?params[0]:"";
var label=params[1]?params[1]:this.label; label=label.format([tid]);
var tip=params[2]?params[2]:this.prompt; tip=tip.format([tid]);
var fn=function(){config.macros.openStory.showStory(this.getAttribute("tid"))};
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The following headings are found on each of the 'tabs' in the [[Index]]:
[[Recent]], [[All]], [[Public]], [[Private]], [[Tags]], [[Spaces]], [[Missing]], [[Orphans]], [[Shadows]].
One of the [[Core Features of AMBIT]] is the practitioner's STANCE of [[Taking Responsibility for integration]]. Flowing from this //principle// is the specific //application// of this towards the wider the network that surrounds the young person and their family. ''Addressing Dis-integration'' is thus the application of this stance in day-to-day practice.
!Addressing Disintegration in 40 minutes
!!!Part 1
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!!!Part 2
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!Large networks
Because of the pervasiveness of the problems of this group (and, frequently, associated risks) the ‘nominal’ number of different professionals involved in these cases tends to multiply. However, clinical experience suggests that this ‘team around the child’ may experience difficulties in working together with this hard-to-reach group. Why?
!Different explanatory models
There is the potential that, implicitly or explicitly, each different worker addresses the young person’s problem set through the ‘lens’ of a specific professional training. Each worker references different explanatory models that have largely grown up within, and may be seen as being “owned by”, specific professional groups (social-ecological, legal-criminological, biological-genetic, psychodynamic, systemic, educational, etc). From each of these explanatory frameworks is derived one or more of the different modalities of intervention accepted as being more or less evidence-based. The dilemma for the young person and their family is that, at a time of great fragmentation (‘dis-integration’), they may be expected to integrate what can appear to be both disconnected, and even contradictory interventions from different agencies - this is referred to as the TowerOfBabel effect.
!Different explicit priorities
Workers from different agencies will have explicit responsibilities for different aspects of the young person's difficulties. For example, the Youth Offending service worker will focus on the young person compliance with the Court Order and avoidance of further offending. The Educational Welfare Officer will prioritise school attendance, while the drugs worker will prioritise reduced substance misuse.
These priorities (that are inevitably required by organisations set up and funded with specific remits) may have different impacts upon the young person's psychological well-being, but if the person gains the sense that they are //in opposition// to each other this can be damaging.
!//Anticipating// misunderstanding and conflict
''A fundamental assumption is that network differences and conflicts should be //anticipated as inevitable// and not be seen as an indication that people in the network around the young person are somehow "getting it wrong".'' This is crucial as it moves towards a more mentalized understanding of the complexities of multi-professional and multi-agency working, and away from the attribution of blame and shame (demonstrating, if you like, forgiveness - one of the [[Strengths in RELATIONSHIPS]] that are [[Features of Successful Mentalizing]].)
Because of this, the AMBIT practitioner is expected to pay close attention to (and proactively to [[Mentalize|Mentalization]]) the wider network around the young person and the family. For this population of young people, the network around the young person may consist of agencies who (even more than in other areas of CAMHS) all see themselves as primary in relation to the young person.
This may include the police, the local Youth Offending Service, the young person’s school or college, the Local Authority, and the local CAMHS (Child and Adolescent Mental Health Service.)
With this typical array of agencies, [[AMBIT]] adopts a position that ''actively anticipates the likelihood of conflict and contradiction between agencies or professionals'', and promotes the explicit view that this is //understandable//, as an inevitable aspect of our best efforts to provide services for the young person. In contrast to much of the literature on integrated practice (which tends to assume a commonality of purpose between different agencies), AMBIT proposes that a context of ‘dis-integration’ is extremely likely with this population of young people.
!What to do? The Dis-integration grid
This position may appear to suggest a general negativity about the capacity of other public services to deliver what they promise. This would be entirely incorrect; the nature of such negativity is that it tends to be supported by negative attributions about the competencies of individual workers in other agencies. In contrast AMBIT adopts an entirely different position. The point is to move away from blame and shame and towards practical measures to address and minimise the impact of this state of affairs. AMBIT proposes a series of simple practices drawn from SystemsTheory and [[Cognitive Behavioural]] theory, and theories of [[Mentalization]] which:
#Actively address the likelihood of inter-agency and inter-professional differences (see the [[Dis-integration grid]], which is part of the basic [[Multi-Domain Assessment]] that every new client receives)
#Works to reduce the negative impact of this on desired outcomes.
Using notions underpinning the [[Dis-integration grid]], or that exercise itself, is a core part of the AMBIT intervention with the family and wider care network.
!Learning, Training and Practising this
There is a page on [[Learning about Addressing Dis-integration]] that describes the core didactic teaching from the AMBIT [[Training]]. There are [[Training exercises]] that we include here that explicitly encourage workers to try to practice mentalizing the network (for instance the [[Dis-integration Grid EXERCISE]]) or to practice mentalizing each other, and to consider the sensitivities required in this (for instance [[The 'What's it like to be...' exercise]].)
!Why?
The purpose of paying close attention to the wider network is partly to improve the effectiveness of interventions, but also is consistent with the overall mentalizing stance of AMBIT. One of the core aims of the keyworker is to help the family //make sense of the various professionals' behaviours// - by encouraging the family to adopt a mentalizing stance to their work. In our view, [[Mentalization]] provides a crucial technique in trying to facilitate an authentic integration of different aspects of multi-agency provision.
AMBIT may sometimes prefer to "wrap around" and assertively consult to and [[scaffold|Scaffolding existing relationships]] an //existing worker// who is identified as having a good relationship, rather than insisting that this relationship is jeopardised by insistence on forming a new relationship. This is in keeping with the AMBIT notion of the "Team around a Worker":
[img[https://lh3.googleusercontent.com/_gdhyTZpT12g/TcLAnmOCkYI/AAAAAAAADVE/IrjaD6PbMho/s640/AMBITSpokes_B%2BW.JPG]]
Asen, E. & Bevington, D. (2007): Barefoot practitioners: a proposal for a manualized, home-based Adolescent in Crisis Intervention Project. In: Baruch, G., Fonagy, P. & Robins, D. (eds): [[Reaching the Hard to Reach|http://www.amazon.co.uk/Reaching-Hard-Reach-Evidence-Based-Intervention/dp/0470019417]]. John Wiley, Chichester
//An early description of the model, with less emphasis on the __organisational elements__.//
"Modalities" of intervention refer to the different forms of practical work with patients - each of which in turn stems from particular [[Theoretical/Explanatory Frameworks]]. For instance pharmacological interventions stem from a biological explanatory framework, psychodynamic interventions from a psychoanalytic framework, family-based interventions from a Systemic framework, etc.
"Multimodal" therefore refers to the deployment of multiple modalities, more or less simultaneously, for a single case (for instance and individual may benefit from individual psychodynamic therapy, Family/Systemic therapy, Prescribing interventions and Social Ecological interventions.)
These theories and/or practices may appear dis-integrated (Dis-integratedInterventions) - especially if they are delivered by different individuals - the Integrative Multimodal Practitioner takes responsibility for delivering multimodal interventions in an integrated way - which occurs primarily as a result of how [[Service Delivery]] is arranged, with the majority of work coming from a single Keyworker.
!Purpose
To support the start-up of [[AMBIT training]] and then to sustain AMBIT-influenced practice in teams supported by [[AMBIT Lead]]s.
* Problem solving about implementation of AMBIT
* Reminders of AMBIT stance and practice
* Linking themes under discussion to material in the manual
* Modelling (by sharing our desktop) how to find stuff in the manual, and how to share it
* To increase use of the manual as a resource that AMBIT Leads find helpful
!Who is attending?
In the pilot project, there will be max 2 AMBIT Leads from each team, and there will be only two teams in the pilot. Numbers are likely increase, and we need to think about "scalability" for the future.
!How long?
One hour online, but time either side of the session for preparation and learning by the webinar operators
!How to run a web-based seminar
!!!Roles:
* Chair
* Manual "monitor"
* Minute taker - taking notes of the key points in the webinar, and including links (use the [[SNAPSHOT]] function) to the manual pages that we examined.
!!!Rules
* All participants are MUTED by default (BY THE FACILITATOR) and use the "Hands up!" facility to signal their wish to talk.
* They are ~UN-MUTED as they ask their questions.
!!!Activities:
* ~PRE-WEBINAR
** Identifying useful topics in the week(s) beforehand
** Ideally this arises from the [[AMBIT Google Discussion group|http://groups.google.com/group/ambit-tiddlymanuals]]
** Or from email circulations, etc...
** What are you struggling with, or what are you interested in?
* IN WEBINAR
** Planned activity for 20 minutes
** "Lecturettes" = UPDATING
** Specific exercises
** etc...
!Sample Curriculum for Webinar 1
* __1. Getting online__
* __2. (10 minutes) Agenda setting__ ([[Marking the Task]])
** 3 questions (in back up) for them to consider:
*** Identify 2 things that happened in the team in the past weeks in which we were ''"well within our AMBIT"''
*** Identify the range of ''individual stances towards AMBIT'' within your team... the (over?) enthusiast, the sceptic, the rebel... HOW do we work with these different positions
*** Identify ''areas for growth'' in your specific team as regards AMBIT practice - what do you want to be doing more of/less of?
* __3. Core seminar UPDATE__
** Seminar 1 is about [[Active Planning]]
** Invite feedback/comments
* __4. Discussion of agenda items__
** We take notes as we go, and will circulate these to all partiipants.
* __5. Feedback from the webinar__
** We will investigate Google Drive or other web-based feedback mechanisms
View existing <<tag TakeHomeMessages>><<newJournal label:"Make a Take Home Message" focus:text text:"Type your individual message to the client (young person or family) here. This will have been discussed in a [[Reflective quorum]] before being entered here.
VERY IMPORTANT:
REMEMBER to TAG this message with the name of the Team Member making the comment" title:"YYYY-0MM-0DD 0hh:0mm - Take Home Msg." tag:ClientNotes:TakeHomeMessages>>
The Mentalizing Loop is an important tool for devising and situating mentalization-based interventions in a structure within a session. It provides a framework for connecting the therapist’s ''observations of a family's or an individual's interaction patterns'' with ''underlying feeling states and related thoughts''.
Furthermore, it helps clients or family members to experiment with new behaviours and actions.
The Mentalizing Loop is a ''framework'', versions of which have been developed within individual and family ([[MBT-F]]) applications, which:
*Allows therapists to structure sessions, or at least parts of sessions.
*Encourages mentalizing, providing a ‘route map’ which can be followed.
!Not rigidly sequential
In sessions ''it is not always necessary or even desirable always to take each step one after the other'', but for the less experienced therapist it may at the outset helpful to do so, whereas more experienced clinicians may at times wish to ‘skip’ steps. The purpose is to offer a basic structure for the therapist to follow when the content of a session, the rising an falling of different affective states, is moving quickly.
[img[https://lh4.googleusercontent.com/-oP7Q2DCL7zc/UO3977LDsOI/AAAAAAAAGh8/t9PJ4qS5djQ/s640/MentalizingLoop.jpg]]
!!!3 Steps and 3 Checks:
!! 1. [[Notice and Name]]
>[[Checking]] - //"Is what I noticed, and the way it may link to what happens at home, what you guys see, too?"//
!! 2. [[Mentalize the Moment]]
>[[Checking]] ''again'' - //"So do we think we have got an accurate enough understanding of this pattern...?")//
!! 3. [[Generalize (and Consider Change)]]
>[[Checking]] ''again'' - //"So where are things now?"//
!A Spiral, not a Cycle
These steps are not a simple cycle, but are better conceived of as a SPIRAL; return to a "previous" step, is never quite the same, as this can only occur in the context of shared experiences and learning //that were not present at the 'first pass'//. So these are not merely linear steps which need to be taken in a prescribed order, but they are looped. Hence our attempt to represent the model as a spiral. It is possible to skip a few steps, or move across to another ‘step’, as well as going back to an earlier one.
At each or any step it is possible to use specific mentalizing techniques (see [[Mentalizing manoeuvres]]) which aim to generate specific mentalization processes in individuals or family members.
So whilst in order to explain the usefulness of the [[Mentalizing Loop]], the model is presented here in a linear fashion, starting from how the therapist uses his process observation(s) of intra-family interactions and/or communication exchanges and how he feeds this back to the family, in an attempt to create reflexive process in each family member, the practice is much more fluid and allowing of the creative use of links.
Page to be completed. Need to upload example.
This stands for [[Cognitive Behavioural]] Therapy, and is one of the most well-researched and well-evidenced approaches to helping people change.
There is a lot of information about CBT at [[Cognitive Behavioural]], which is one of the many [[Specific interventions]] included in this treatment manual.
Bevington D, Fuggle P, Fonagy P, Asen E and Target M (2012) “Adolescent ~Mentalization-Based Integrative Therapy (AMBIT): A new integrated approach to working with the most hard to reach adolescents with severe complex mental health needs.” [[CAMH Journal|http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00666.x/abstract]] (May 4th 2012 | DOI: 10.1111/j.1475-3588.2012.00666.x)
Scroll to the top of your page, and look for the menu bar that runs right across the top of the page. If it is hidden, select the "Advanced" mode in the right hand corner. (In the original version of the manual, click the blue and pink 'target' that is in the topmost right corner of the page - this should "toggle" the top menu in and out of view.)
Once you have the top menu in view, click on the CENTRAL word, "TiddlySpace".
This reveals a drop-down menu that looks like a set of "tabs" in a file (Search, tiddlers, Batch, Tweaks, Import/Export) - click on the ''"Batch"'' tab...
This reveals two more "tabs" titled ''"Public"'' and ''"Private"'' - clicking on either one will list all your locally authored material that is either Public or private.
If you want to change the status of any of these tiddlers, just tick the box beside it, and click the command that you find right below the list. (So if you want to make a //private// tiddler become //public//, go to the ''"Private"'' tab, select the tiddler you want to change, and then click "make public" at the bottom of that list.
The word stigma comes from the ancient Greek name for a mark (or tattoo) designating a low or infamous state, such as slavery. In mental health it describes the negative associations that are appended to the societal perception of mental illness (for instance such people are //assumed// to be learning disabled, morally deficient, dangerous, etc.)
The KeyWorker must be sensitive to the likelihood of this phenomenon affecting their work, most commonly by interfering with engagement, or adherence.
By following the [[Tags]] on stigma the reader will find a range of techniques that are helpful in countering its negative impact.
!What is Active Planning?
Active Planning is one of the [[Core Features of AMBIT]], and operates at two levels:
|''1. //Part of wider team culture//''|[[Active Planning in the team culture]]|
|''2. //A simple, subtle, process//''|[[Active Planning to structure the therapeutic journey]]|
!Video introduction to Active Planning (20 minutes)
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!Training about Active Planning
See [[Learning about Active Planning]] for links to material and [[Training exercises]] that will guide you through learning about this are of AMBIT.
!Some video
(Rather old - needs updating as our ideas have developed a bit further since then...)
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This is to the left of your screen. You can make it appear or slide out of view by clicking the triangle on the little tab at the top.
The Sidebar is where you can navigate and order the material in the manual so that on your [[Desktop]] you have gathered only what you are interested in, and you can jump from page to page. The following tools are here:
!SEARCH
[[Search]] box
!HISTORY
[[History recorder]]
!CURRENTLY OPEN
The [[Currently Open]] list shows you the pages you have opened on your [[Desktop]], and includes the camera icon button for the [[SNAPSHOT]] function.
!CONTENT
Here you will see an unfolding 'tree' view of all the contents of the manual. Click on the + sign by a heading, and the sub-headings under that topic will open out - click on the words and the page will open on your [[Desktop]]. You can also look at this on a separate page ([[Contents/Sitemap]].)
* The risk of substance use in children is greatly increased if there is a history of parental substance use.
* Engaging the parents in their own treatment is an effective intervention for children, both in terms of prevention and treatment of the child’s own substance use.
** Some local adult services will have facilities for family therapy, others will not.
** Young person’s substance use services should all provide family-based interventions, and the worker may have an important role to play in ensuring or insisting that these services integrate their work around the needs of the child.
* Safeguarding issues ([[Child Protection]]) will be central in planning care, in respect of potential parental neglect, or the emotional abuse implicit in exposing children to their own intoxication. Early liaison with the Local Authority in this respect is advised.
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The [[Core Features of AMBIT]] suggest that taking measures that support a [[Keyworker well-connected to wider team]] are important.
Teams or larger groups can often inhibit some people from expressing their thoughts views experiences, which means that the Team's understanding of itself is always at risk of being defined by those team members who are louder, more confident at speaking in larger groups, or [[writing things in the team's manual|Manualization]]!
!The Exercise
*The large team (or group of teams) divides into a number of //smaller groups// in order to discuss a specific issue.
**The size of these groups will be determined by the overall numbers, etc, but ideally they will be intimate enough so that every member of those small groups will feel able to talk freely.
*In each of these small groups one person will be the nominated "consultant".
**Who gets to ''//be//'' the consultant will be determined by circumstances...
**Some situations will allow someone from a //separate team// to fulfil this role
**Alternatively, someone who does not work so directly with the other members of that small group would be appropriate.
**Alternatively, some team members may wish to volunteer or agree to being "volunteered".
*After discussion for an agreed period of time, the separate small groups return to the large group setting.
*At this point a single "fishbowl discussion" is set up, between just the consultants, who discuss their experiences and thoughts about what it was like to be in their separate small groups, whilst the rest of the large group listen, without interrupting
**After a set period of time, there may be scope for some reflection in the larger group about what they have heard.
!Why?
The point of this is:
* To sift a wider variety of viewpoints that may not ordinarily get heard in the larger group
* To stimulate reflection ([[Mentalization]]) on the viewpoints of others
* To generate a clearer shared understanding of what the shades of opinion and beliefs are in this team - to which it is intended that individual will be [[well-connected|Keyworker well-connected to wider team]].
* More generally, this is a good exercise to help discussion about an issue that may raise strong feelings and differences.
!What then?
* If some consensus or learning points are generated from this discussion, then this might well be an ideal opportunity to move to [[Manualization]] of these points.
Focussing on FUNCTION and DISTRESS rather than on the presence or absence of MENTAL HEALTH symptoms is more meaningful to the patient and significantly less stigmatising.
It is easier to engage a patient if some common ground is present: if, for instance, there is evidence of response to auditory hallucinations, or paranoid delusions, but the young person is guarded and apparently insightless, it is important to avoid the first meetings focusing too heavily on the single "axis" of :
"Evidence of Mental illness" //Versus// "Absence of Mental illness"
This axis is often perceived by the YP as representing the interests of the mental health professional more than their own, and therefore more often than not sets an //adversarial// context for the exchange of information, as though the KeyWorker is seen as trying to 'catch out' the young person.
In such a situation, the KW will try to explore //different// axes, which may allow for more common ground in the delineation of what the problem areas are. For instance:
"Interrupted Functions of Daily Living" //Versus// "Uninterrupted Functions"
Or:
"Distressed" //Versus// "Undistressed"
Thus the YP’s experience is mapped onto //multiple// dimensions, in which there is scope to include areas of //functionality// and //resilience// as well as dysfunction and distress.
[img[dimensions of concern|http://picasaweb.google.com/dickon.bevington/IMPManualPictures/photo#5011401011522862690]]
Type the text for 'Educational/Vocational centre'
Trauma-focussed CBT is recommended by NICE. An excellent web-based resource is provided by the Medical University of South Carolina at:
> http://tfcbt.musc.edu/
This web resource is highly recommended, and although it will not turn the trainee into a "certified" practitioner it will build on skills and knowledge to support improved practice. Trauma-focussed CBT builds on the work of many dedicated individuals and we quote from the ~TF-CBT website here:
>//~Trauma-Focused ~Cognitive-Behavioral Therapy, was developed jointly by Esther Deblinger, Ph.D., ~Co-Director of the New Jersey CARES Institute at the University of Medicine and Dentistry of New Jersey's School of Osteopathic Medicine, and Judith Cohen, M.D., and Anthony Mannarino, Ph.D., who are the Medical Director and Director of the Center for Traumatic Stress in Children and Adolescents, Allegheny General Hospital, in Pittsburgh, PA.//
!Key elements:
Here we distil the key elements that distinguish Trauma-focussed work.
!Setting up sessions
Most CBT is about making and carrying out rational plans (see also [[Active Planning]]) - and in trauma-focussed work this planning is particularly important. Trauma-focused work should not be something that a young person and worker 'dip into', but instead it is something that they spend time setting up, so that there are a pre-arranged number of sessions (usually a minimum of 6 - 8) about a week apart.
!1. Psychoeducation
''[[PsychoEducation]]'' is where to start, as it frames what you will be doing, and why. It needs to be pitched at the right level for the young person (and/or carer) to understand. In particular attention needs to be given to explaining the way that AVOIDANCE in PTSD tends to amplify fear, and that in fearful states it is very difficult to think ([[mentalize|Mentalization]], if you like).
Rather as in [[Marking the Task]], it is easy to skip over the preparatory work involved in setting the scene for what will follow once the 'work' gets started - and particularly in this work this is unhelpful.
At least one session will be devoted to this
!2. Managing Stress
This is important, and is achieved using
*[[Rating Scales]] that help to increase the accuracy with which feelings can be communicated and understood, and if necessary directing action to help manage these feelings.
*[[Progressive Muscle Relaxation]] and [[Re-breathing]] are among many other relaxation techniques that can help to give a young person more of a sense of mastery over their own feeling states (knowing that moods come and go, and that I can to some extent alter them at will, is useful knowledge, but also reduces my anxiety in and of itself.)
Some evidence suggests this part of the work is mostly important because //it reassures the young person that their therapist cares// - i.e. because it supports [[Engagement]], rather than being the most important 'change-engine' which is probably the graded exposure (see below).
At least one session will be devoted to this.
!3. Telling the Story
This is really a special version of [[Graded Exposure]] and ''this forms the heart of the therapy''. You can read about this in more detail at [[Graded Exposure]].
This may take 4 or more sessions.
!4. Reworking Beliefs
This is only possible when some [[Mentalization]] has been recovered - i.e. when the levels of anxiety have reduced a bit. Here you are focussing on some of the beliefs about the self (//"I was a coward"//, //"I am a failure"//, //"I can never be safe in the street again"//...) and are using gentle questioning ([[Weighing Pros and Cons]]) and [[Coaching]]. We usually use coaching in relation to how a young person might handle a parent in a given situation, but in this setting it would be how they might handle the appearance of a particular thought in their mind.
To some extent this work is interlaced with the sessions recalling the narrative, and as the narrative work continues it may be found that more time is spent homing in on, and addressing particular beliefs (or "cognitive disortions"). It is important not to rush into this aspect of the work before the anxiety provoked by 'being in the act of remembering' has begun to reduce through the repeated telling of the story.
Allow 2 sessions for this work
!5. Reinforcing Behaviour Change
This is about setting up [[Contingencies]] for the young person, that will support new ways of managing the self addressing some of the more 'outward signs' of the PTSD, such as the avoidance of going out, etc. Other [[Graded Exposure]] programmes may be relevant here, along with a range of other [[Cognitive Behavioural]] techniques.
The key point is that although changes can happen quite quickly (not always!) there is a natural tendency for people to 'slip back' into previous habits, such as AVOIDANCE (which as you will remember is one of the key features of PTSD.) This element of the work is directed at strengthening and sustaining new patterns of behaviour.
This work, again, is increasingly "interlaced" with the earlier stages, and is largely about setting up [[Training Challenge]]s (or 'homework'!) for the young person, preferably supported by carers.
!6. Working with Carers
Although FamilyWork alone has not been shown to be effective for childhood PTSD, there is good reason to focus some energy on ensuring that family members understand the nature of the problem, and the plan for treatment, as family members may be absolutely key players in reinforcing some of the key therapy tasks and 'homework' ([[Training Challenge]]s.)
!Confidentiality
[[TiddlyManual]]s that are edited, stored and accessed online are never to be used for the collection or publication of patient-specific data, which always needs to be stored according to rigorous local protocols and procedures.
When a team is manualizing its own practice, it must limit descriptions of protocols to //general// rather than //specific// situations, and if referring to scenarios must always ensure that these are appropriately anonymised.
''@@color(orange):Teams remain responsible for any content that they add to their online version of the AMBIT manual, and the AMBIT project accepts no responsibility for content that is authored by others, whether or not it is added to content included from the AMBIT core content site.@@''
!Interactive Case Recording (ICR)
[[ICR]] is a ''@@color(orange):currently non-functional@@'' aspect of tiddlymanuals, that relies on the fact that you can download an entire tiddlymanual and run it in a browser that is completely disconnected from the internet. A downloaded tiddlymanual is just an "html" file, and it is possible to edit this, just as one might edit, say, a "Word" document - storing it safely in a secure setting
The following notes relate to [[ICR]], which is not yet (2012, February) recommended for use.
Recording patient-specific data in a TiddlyManual is technically no different to storing the same data in the form of, say, a "Word" document. You must consider:
!(a) WHERE the file is stored
This should be on a secure server, and NEVER on a personal laptop/USB memory stick etc, unless this is for a very specific reason and for a limited time-period, and the data is held in an encrypted format. If that were so, then a locally-stored file should only ever be a COPY of the original file, and NOT the original file itself. Any such copy held would be the responsibility of the holder. Local I.T. rules will apply to the level of encryption required for transporting data in this way. Copies transported thus should be deleted as soon as the reason for transporting them is no longer valid.
!(b) HOW the file is stored
Save the file as an anonymised name (for instance the child's first name and initial, rather than their surname). Do not keep personal identifiers such as Date of Birth/Address in the file - these will be stored in the paper notes.
!(c) BACKUPS
The file will //automatically// back itself up each time you save it. This allows you to keep track of older versions of the manual, and you can (and should) specify where these backups are stored, according to the [[Set up a new patient TiddlyManual]] instructions (this is a very simple procedure, in which you just define a name for the backups folder for this specific file.) If the file is stored on your main secure server, then it will //also// be backed up alongside all other data on that server (this is not the practitioner's responsibility to do this but is done by the I.T. department), to prevent against catastrophic loss of data in the event of a computer crash. Remember that the //local// back-ups that your manual makes (as referred just above)each time you save are still vulnerable to being lost if the whole computer crashes without back-ups in a separate place, so if you are using the manual outside the main server (even though this would only be in exceptional circumstances) you should keep a back-up copy on a separate (equally secure) device.
Document the Child Developmental history via [[Make or View Client Notes]].
Developmental history may give us clues about early brain development that might have had an impact on the development of later problems. Sometimes it gives important information about conditions that may have been missed, such as Autistic Spectrum disorders or neurodevelopmental disorders such as [[ADHD]]. There may be important information about cognitve abilities (intelligence), etc.
There is further information about [[Developmental Considerations]].
!Ask about:
*Physical problems during pregnancy, at or around birth
*Temperament as an infant and toddler
*Relationship to mother/other carers
**Separations - how did child react to going to childminders/play group/starting school?
**Reunions - how did the child react when the carer returned?
*Early milestones (walking, talking, smiling, etc) - parents may not remember precisely WHEN something happened but they generally remember if something was amiss...
*Early social interactions (sociable, invited to other children's birthday parties? or a loner, unable to share and take turns?), early play and habits...
*Play as a young child (did they use make-believe? Did they use toys to represent the things 'in real life' - a car as a car, or a doll as a person - or did they just line them up and use them as 'objects'?)
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These brief notes on Senge's use of systems thinking are not intended to be comprehensive. For those of you interested in the organisational aspects of your team or service, we would recommend reading 'The Fifth Discipline'. The intention here is to illustrate some of the main themes so that you can judge whether further reading would be useful.
!'Laws' or principles of the Fifth Discipline
Senge lists eleven 'laws' that underpin his systems approach.
#Today's problems come from yesterdays solutions
#The harder you push, the harder the system pushes back.
#'Solutions' often result in short term gain before they get worse.
#The easy way out of a problem often leads back into the problem
#The cure can be worse than the disease
#Faster is slower
#Cause and effect are not closely related in time and space
#Small changes can produce big results but the areas of highest leverage are often not obvious.
#High quality and low cost may not be opposites but may be related to each other over time.
#Dividing an elephant in half does not produce two small elephants
#There is no blame
!Processes in systems
The core process is ''feedback'' in relation to goal directed behaviour. Senge emphasises two types of feedback:- ''amplifying'' and ''balancing feedback''. Amplifying feedback is more obvious and similar to positive feedback. Balancing feedback is often implicit and unrecognised and represents the process of adaptation to the goal behaviour (e.g. new initiative). Balancing feedback may be experienced by managers as 'resistance' but often represents the adaptation of systems to the wider implications of whatever new developments are taking place.
!Common system 'archetypes'
Senge suggests that there are several repeated system patterns that are helpful to be able to recognise.
#''Limits to growth''- 'running out of steam'
#'''Shifting the burden'' - moving the problem to somewhere else
For organisations (and leaders) the challenge is to try to gain ''leverage'' on systems that may be behaving in unintended or unstable ways.
PAGE IN PROCESS OF BEING DRAFTED
<<tree "Introduction [[Team working]] [[What's the problem?]] [[What to do?]] [[Who does what?]] [[Why do this?]]">>
!By going further into this manual
You are agreeing that...
>//"I have understood the rules about DataSecurity, and agree to abide by these. I am responsible for the security of any data about my client."//
>//"I understand and accept the ''restrictions on use'' in keeping with the [[Licensed]] status of this manual"//
!Making Changes?
The website is password protected, so you cannot alter the main template on the web, or your TeamTemplate, without authorisation and a password.
!Disclaimer
Users remain responsible for their own clinical practice. Before using the manual and [[AMBIT]] in clinical settings, practioners are advised to receive [[Training]].
!description
The extent to which the young person is successfully engaged in the development and carrying out of his or her treatment and care.
!end of description
!breakdown
0 = Good. Fully involved in assessment, planning and implementation of care. Works towards realistic personal goals; co-operative with procedures and assessments.<br>
1 = Mild. With support involved in assessment, planning and implementation of care at a level appropriate to age, but some reluctance/resistance to comply with care plan. Co-operative in most but not all areas. <br>
2 = Moderate. Significant difficulties in engaging with treatment plan and/or formulating realistic age-appropriate goals. <br>
3 = Severe. Refusal to engage or passive compliance with many aspects of care. Cannot agree realistic age-appropriate goals.<br>
4 = Very severe. Will not comply with most aspects of treatment/care plan. Refuses to/unable to engage in age-appropriate discussion of goals.
!end of breakdown
!What is an Affect Storm?
When feelings ("[[Affect]]") run high in a particular situation, a person’s ability to mentalize is at risk of being impaired. If family members are present, this can be ‘infectious’, leading to ‘emotional knee jerk’ reflexes all round.
In family sessions one can then observe heated interactions, with the participants blaming each other:
''//“you never….”'' or ''“you always”//''
Here the therapist’s task is to reduce the heat, so as to help family members to recover some degree of successful mentalization.
!What to do in an affect storm
See [[Simmering Down]], [[Taking a break]] and [[Therapist's use of Self]].
To fully understand the young person, the family and their social ecology, the cultural context needs to be taken into account.
AMBIT strongly supports the idea of [[Cultural consultation]] as an appropriate way to approach transcultural working, and [[The Therapist's Mentalizing Stance]] is well adapted for use in culturally-diverse settings, with it respectful not-knowing and inquisitive stance.
!What is culture?
'Culture' can be broadly defined as a system of shared meaning. It patterns and constructs the relationships through which we come to know ourselves. Our very notions of personhood, our motivations, cognitions and emotions are given meaning through culture. We are, however, seldom consciously aware of this.
This is not to say that cultural patterns are given or fixed. It is only in the performing of these shared meanings that culture is constructed. Thus, on the one hand culture constructs us and on the other we construct it. Meanings are constantly open to reworking and renegotiating and so 'cultures' are always emerging and subject to change.
!!Cultures within Cultures
Within the context of multicultural societies, cultures exist within cultures and in a hierarchical power relationship. Institutions, such as the NHS and the models and theoretical frameworks they are based on, as well as the practitioners that operate within them are rooted in culturally constructed normative ideas about health and dysfunction. Minority cultural groups within this social context are often left to negotiate these differences and may at times experience the involvement of these institutions and practitioners as an imposition and as in conflict with their values and beliefs, even though, as various governmental reports and directives clearly suggest, the onus of this should not fall on 'users' but rather on institutions to guard against discriminatory practices.
!!The impact of culture
The potential strain of living 'in between' cultural spaces has in the past been referred to as 'culture conflict', and has been alluded to as one possible explanation for disproportionately higher rates of certain mental disorders and suicide and self-harm in ethnic minority adolescents. In practice, this viewpoint has often led to the construction of 'minority cultures' as being the source of the problem, as opposed to the relationship and difference between cultures.
Minority families and adolescents, who are navigating these differences, often become embroiled in this polarizing dynamic of cultures. Health professionals working with cultural minority adolescents, therefore, need to keep in mind these multiple contexts and hold multiple views of 'the problem' and 'solutions'. It is important to be aware that, whilst cultures may pattern people's lives, meanings are subject to reworking within the broad cultural framework. The work of the health professional may then be geared towards improving the ecological 'fit' between the cultural contexts in which the YP moves.
!!Manualizing approaches to culture
AMBIT's stress on the need to [[Respect local practice and expertise]] extends to a reticence to dictate how teams should best work in different culturally-influenced settings, but local attempts to [[manualize|Manualization]] their work will be helpful to others. There may a wide range of SpecificEthnoSpiritualTheories in a local setting (we do not presume to define them here) that a local team could record, along with their experience of how best to work with these.
''__Child Protection concerns "trump" all others__''. First, decide if you need to to take action (see "What to do if you are concerned" just below.) Then, underneath that you will see more guidance and information to help you think through and plan your responses in more detail.
!If you are concerned right now:
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If there are Child Protection Concerns then you must consider making a [[Child Protection Referral]], and you will want immediate contact with your SupervisoryStructures to discuss this.
!Background
See this external link to [[Working Together to Safeguard Children|https://www.education.gov.uk/publications/eOrderingDownload/00305-2010DOM-EN-v3.pdf]] - the UK government's guidance on this whole area, which particularly emphasises the need for good inter-agency practice (see [[Addressing Dis-integration]] which is one of the [[Core Features of AMBIT]]).
Child Protection relates to the notion of "[[Significant harm]]": if there is a risk of significant harm to any child (note, not just your own client/patient) then as a professional you are OBLIGATED to take action.
!Note!
This guideline is for adults (>18 yrs) although it may be relevant to younger people, who are in the care of an Early Intervention in Psychosis Service.
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There are always individual differences in teams; different clients have different needs too. The act of manualizing our work not infrequently makes ''explicit'' what has previously been ''implicit'', and this marks growth within the team rather than any kind of failure, although differences can be uncomfortable. Similarly, AMBIT is a team approach which involves whole teams taking part in basic training.
|We are very aware that individual workers will have different views and experiences|
|about taking part in AMBIT training (see [[Individual differences and AMBIT training]]).|
In the event of significant differences arising in relation to proposed material for the Team's [[Manualization]], the first questions for the protagonists of each view to consider are:
*//Under what specific circumstances would I consider the alternative view to be applicable?//
*//To what extent is my view influenced by recent (or distant) events in my own history of work, or other events?//
If a resolution (for instance //"in circumstance 'a', then approach 'x' is most appropriate, in circumstance 'b', then approach 'y' should apply"//) cannot be achieved, then the SupervisoryStructures should be invoked and outside (MetaTeam) consultation applied to to help resolve this.
!Does Mentalizing imply a new ORTHODOXY?
It is reasonable to ask if mentalization-based approaches are another way of insisting upon a new orthodoxy - having everyone in the team //"see things the same way"//. [[Mentalization]] doesn't work like that - it is precisely about acknowledging the facts that:
* We (humans) see things from different perspectives
* We act upon our own perceptions
* We are not always very good at making sense of each others' different respective perspectives.
''We do not presume that a mentalizing team will all agree!''
''We do presume'' that just as one way of making sense of the __evolutionary advantage__ that Mentalizing offers is that //it makes violence towards those to whom we are [[attached|Attachment]] less likely//, so a mentalizing team might be rather better at coming to an understanding of different perspectives among its members!
For definitions of attachment styles, behaviours and other concepts click on [[Attachment Definitions]]
Following Bowlby, we assume that attachment is an essential facet of human development and that a key function of the family is to provide a framework for the development of increasingly autonomous personality functioning, underpinned by a secure attachment system.
Families in which serious psychiatric crises arise in adolescence tend to have distortions of the attachment system. This may be a result of chronic disturbance in a specific individual, or the parental relationship; additionally it may reflect the behaviour of a caregiver in the past, the intense pressures placed on the caregiver by the child earlier in development, or most commonly both of these.
In some key respect, the family has ceased to be a [[Secure Base]], in that either the YP does not feel reassured by the presence of other family members, or those family members have ceased to be able to offer support and acceptance, thus the attachment system does not function to contain the YP's disturbed emotional states or behaviour.
Within our framework, the capacity of the family to have a sufficiently coherent picture of each others' states of mind is a key facet of attachment (see [[Mentalization]]). One sign of the disturbance in the attachment system is that there are massive distortions of perceptions of other people's attitudes and intentions, and that an aim of the intervention is to reinforce attachment processes through enhanced understanding.
The moment of crisis may be understood as a breakdown of the attachment system, in which the parents and/or the YP are willing to give up the bond that would normally make the troubled YP seek security and safety in the family. This may be a reaction to a long history of dismissing attachment style, or preoccupied entanglement, or the dramatic exaggeration of a developmentally appropriate move away from the family. Whatever the roots may be, the aim of the crisis intervention is to make the family a more secure base for the YP. What may be most important in that context is that the keyworker (KW), through his intensive and reassuring presence, begins this experience for the family members of a more secure base. The calm, sensitive, appropriate behaviour of the KW is intended to activate more secure [[Internal Working Model]]s of attachment relationships for all members of the family.
!Sleep problems are a real problem!
Insomnia is a very serious problem for many young people, and it is easy for professionals to overlook this. Young people (or indeed parents) can become extremely worried about the effects upon health of sleeplessness, and this itself makes [[Mentalizing]] the problem more difficult. As anxiety rises, so sleep becomes harder still.
!What to do
Establishing a clear, simple routine is referred to as "sleep hygiene" and there is evidence to support the fact that this can be an effective way to deal with sleep problems. Below is a link to a good NHS resource advising how to approach sleep problems.
!What is causing the sleep problem?
Ask about whether they have //always// found getting to sleep difficult, or whether this is quite a new problem.
* Longstanding sleep problems are likely to have more complicated causes, and to be more ingrained.
* Recently-triggered sleep problems may have clearer causes and simpler solutions.
Ask about the total number of hours that the young person is actually sleeping.
* Are they not sleeping enough hours - about 8 hours is normal.
* Or are they just suffering from a night that has "shifted forwards" so they are going to sleep very late, and waking very late?
* Are they napping in the day time?
Ask about the pattern of sleeplessness.
* Not getting off to sleep at night is often associated with [[Anxiety]]
* Frequent or early-morning waking is often associated with [[Depression]]
Ask about other common causes:
* Are they drinking coffee (or tea, or Colas, that all contain caffeine) at night?
* Are they engaging in very exciting/arousing activity last thing at night (playing fast video games that trigger adrenaline, doing vigorous exercise last thing before bed, etc)?
* Are they using substances to try to help them sleep?
** Many young people with problematic [[Substance use]] refer to using substances like cannabis or alcohol to help them sleep.
** In their turn, these substances might become ''part of the problem'' (cannabis can make people sleepy, but it can also make them very anxious or stimulate thoughts that keep them awake.)
* Are they using distractors (Substances, TV, Facebook, music, etc) to block out other problems, but which then keep them awake? It is worth asking if this might be the case, as this would suggest other approaches to treatment that target the underlying problem the young person is trying to get relief from.
** Blocking out more distressing ([[Anxiety]]-related) thoughts.
** Blocking out memories (that may be related to flashbacks associated with [[Post Traumatic Stress]])
!Treatments
See this [[Link|http://www.nhs.uk/Conditions/Insomnia/Pages/Treatment.aspx]] to an NHS resource giving advice (it should display in the page below, too).
Some pointers:
* ''A helpful treatment for insomnia is an alarm clock!''
** Establishing a __set time to wake up,__ and __not allowing naps in the day__ is a powerful way to help "reset" the biological clock.
** Young people or parents might need reassurance that //being tired in the day is not bad for your health// as this is sometimes given as a reason for allowig a young person to sleep late into the day.
* ''Routine is comforting, but it takes a while for it to be routine!''
** Warn a young person that any attempt to change patterns of behaviour is going to take a while - don't be disappointed when it doesn't work on day 1!
** Select "rituals" that the young person knows they like - some may like warm baths, others may find these are not relaxing (if they have a negative body image, or bad past associations with bathtimes, etc), others may like warm millky drinks.
* ''Keep beds just for sleeping!''
** Watching thrilling movies or Facebooking, or doing other exciting activities whilst in bed will risk giving your body/brain "double messages" about your bed - that it //may// be a place to sleep, or it may //also// be a place to be very wide awake and excited.
*** An odd analogy about "house-training a puppy" can be helpful to illustrate this. A puppy will mess all over the place at first, but if you keep putting it out, and praising it //just when it is most likely to make a mess// then bit by bit it comes to associate being outside with doing its "business"... If instead of this we made it OK for the puppy to mess indoors too, it would never learn this! Teaching our own bodies that bed is the place for sleeping in, not being restless and wide awake is rather similar!
** Encourage the young person to ''get out of bed'' if they really cannot sleep (they can try to sleep for 30 minutes before taking a break like this) and watch TV from a chair or in another room - so that bed is ''only associated with sleeping''.
** Ideally ''avoid using TV or screens at all if you cannot sleep!'' - as these things are designed to grab our attention and hold it. Better to try to read a book - even a rather boring book!
!NHS advice
Here is more advice (the web link is given above)
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!WHAT IS THIS FOR?
The purpose of this questionnaire is to help teams in defining their [[Post-training outcome goals]].
|There is also a [[Mini-PREACHY]] that is rather shorter and easier to use!|
!PREACHY (Practice, Relationships, Education, Attitudes, and Coherence in Helping Youth)
|This questionnaire is designed to help us learn about|
|You,Your work, What supports it, What hinders it.|
This will help us develop better support for workers.
!Acknowledgements:
Many of the questions that follow are drawn directly, or adapted from the ~CO-MORBIDITY AND ~CO-MORBID CLIENTS’ PROBLEMS PERCEPTIONS QUESTIONNAIRE produced by the Scottish Effective Interventions Unit in 2005 (Hazel Watson, William Maclaren, Fraser Shaw, Andrew Nolan; Glasgow Caledonian University and Greater Glasgow Primary Care NHS Trust).
In addition work by members of the AMBIT project at the Anna Freud Centre is acknowledged, especially Pippa Sweeney, Aine O’Callaghan and Yvette Boateng.
!1. Please tell us a bit about yourself
Indicate which of the following most closely fits your current level of training/education:
#No formal training, but life experience/time/willingness
#Some formal training/education, but not to degree level.
#Degree, but a non-clinical subject
#Currently in training for a professional Clinical or Social Care role (e.g. training to be an occupational therapist, social worker, nurse, clinical psychologist, medical doctor, etc.)
#Qualified as a health or social care professional (e.g. occupational therapist, social worker, nurse, clinical psychologist medical doctor, etc)
#Professional (clinical) qualification AND additional specialist therapeutic training.
!2. How long have you worked in face-to-face clinical situations, either in statutory or
in non-statutory services?
#Less than one year
#1 - 2 years
#3 - 5 years
#6 - 10 years
#Greater than 10 years
!Some statements about working with young people
|''Please say how much you agree or disagree with each one.''|
|1 = strongly AGREE 7 = strongly DISAGREE 0 = Don’t Know|
1. I feel I have a working knowledge of the common problems faced be complex 'hard to reach' youth.
2. I feel I know enough about the causes of complex (or "comorbid") problems in youth to carry out my role when working with these young people.
3. I feel I can advise complex 'hard to reach' youth appropriately about the range of common issues that come up.
4. I feel I know how to do effective therapeutic work over longer periods of time with complex hard to reach youth.
5. I feel I have a clear idea of my responsibilities in helping complex hard to reach youth.
6. I feel I know enough about the physical effects of drugs and alcohol use to carry out my role when working with my clients.
7. I feel I know enough about the psychological effects of drugs and alcohol use to carry out my role when working with my clients.
8. I am interested in the nature of the problems faced by complex hard to reach youth, and in the different ways workers can respond to them.
9. I want to work with complex hard to reach youth.
10. I feel that the best I can personally offer complex hard to reach youth is referral to somebody else.
11. I feel that there is little I can do to help complex hard to reach youth.
12. Pessimism is the most realistic attitude to take toward complex hard to reach youth.
13. I feel I am able to work just as well with complex hard to reach youth as with other client groups that I (may) work with.
14. All in all I am inclined to feel I am a failure with complex hard to reach youth.
15. In general, I have less respect for complex hard to reach youth than for most other patients/clients I work (or have worked) with.
16. At times I feel anxious working with complex hard to reach youth.
17 On the whole, I am satisfied with the way I work with complex hard to reach youth.
18. In general, it is rewarding to work with complex hard to reach youth.
19. In general, I feel I can understand complex hard to reach youth.
20. In general, I like complex hard to reach youth.
21 In general you can’t teach people how to work with complex hard to reach young people; they either have the skills or they don’t.
22. In general you need creativity and instinct in this work much more than technical knowledge and skills from books.
23. If I felt the need when working with my clients I could easily find someone with whom I could discuss any personal difficulties that I might encounter.
24. If I felt the need when working with my clients I could easily find someone who would help me clarify my professional responsibilities.
25. If I felt the need I could easily find someone who would be able to help me formulate a care plan for a client.
26. In a team doing this work, it is more important to have people who can offer a range of very different models of understanding and working, than it is to have a shared model.
27. In my own team, staff have very different ways of understanding human behaviour, and use very different ways of working.
28. In my own team we have a clearly agreed way to record any ‘learning points’ from discussions we have about 'how we do this work here', so that we can refer back to these and build on our experience.
29. Our team works according to instructions laid out in a treatment manual.
30. If you wish, please add any additional comments about why you do this work, or what makes it easier or more difficult, etc:
If (only if) your team uses a specific treatment manual please anser the next question:
31. In the past four working weeks I have actively looked at material from our treatment manual (either alone or in company) for a total of approximately:
Please tick the appropriate box: 0 minutes; 1 - 15 minutes; 15 – 60 minutes; > 60 minutes
32. If you wish, please add any additional comments about accessing your treatment manual here:
!If your team uses a treatment manual (even if you don’t use it yourself) please answer the following questions:
33. In my experience, using a treatment manual helps me work more effectively for my clients.
34. Treatment manuals don't change what practitioners actually do
35. I know exactly where I could find our treatment manual if I wanted to look something up right now.
36. I find treatment manuals are more of a burden than a support
37. Film clips showing techniques, or explaining ideas, are much less use than a page or two of text.
38. Treatment manuals never seem to fit the local culture or to cover the local problems we see at my place of work.
39. If I am honest I don’t like being told how to do things by distant “experts”
40. If you wish, please add any other comments about your experience of treatment manuals:
41. My team’s treatment manual is:
Paper-based -------------- Online ----------------------
If (only if) your treatment manual is an Online version:
42. The benefits of an online treatment manual outweigh the problems.
43. My poor technical (I.T.) skills mean I can't work the manual out at all.
44. Being able to search for key words is helpful
45. My access to computers at work is so limited that I can’t access the manual in working hours.
46. I like the video content
47. Although I have access to a computer, the I.T. systems at work make it very hard to access and use an online manual (as content is blocked, etc.)
48. Adding (editing) in our own team’s local expertise to the online manual makes it more relevant to our work.
49. If you wish, please add any other comments about your DIGITAL treatment manual
!Supervisory responsibilities:
50. Do you have a duty to offer formal supervision sessions to other staff at work? No/Yes
IF YES (i.e. if you DO give formal supervision people in your job) then please complete the questions below:
51. I always refer to our treatment manual in the supervision sessions I provide.
52. I always email/send copies of relevant material from the manual to my supervisees after case discussion.
53. Referring to treatment manuals in supervision sessions actually prevents good communication.
54. Our team’s treatment manual provides a supportive framework for my supervision.
!ABOUT A SPECIFIC CASE
The last questions are about a SPECIFIC CASE you have worked with.
Please recall a SPECIFIC RECENT CASE that you have worked with within the past two months. (NB the questions which follow do not ask anything that would breach confidentiality about your work). Please choose the case that you feel best illustrates the REALITY of your work and remember that your answers are confidential and will not be passed back to your managers! Answer each question by illustrating how much you agree or disagree with the statement (1 = Strongly AGREE 7 = Strongly DISAGREE) Please choose a SPECIFIC case that you feel best illustrates the reality of your work.
55. I deliberately and explicitly tried to develop a mentalized understanding of their difficulties
56. I deliberately and explicitly tried to maintain a mentalizing stance when with my client.
57. An understanding of mentalization was helpful in the work I did.
58. I completed a risk assessment, filed it, and kept it regularly updated.
59. In accordance with local protocols, I kept notes up to date and in good order, including a clear and regularly updated care plan.
60. There was evidence of conflict or disagreement between the different workers (or teams, or agencies) involved in the case, that threatened (or actually damaged) the outcomes of my work.
61. In situations of inter-professional or inter-agency conflict, I knew I could relieve my tension by criticising those people in the privacy of my own team.
62. I deliberately and explicitly identified (or tried to identify) resiliencies in my client's existing relationships.
63. I deliberately and explicitly planned work to support or strengthen these relationships.
64. I talked frequently, and in disciplined/structured ways, with other team members about the work I was doing.
65. If need be I know I could have consulted, or actually did consult, "live" with colleagues via phone whilst in the field.
66. I deliberately and explicitly planned and carried out work in MORE THAN ONE "domain" of functioning (e.g. physical health, individual psychological functioning, family, social-ecology, professional network, etc)
67. I deliberately and explicitly took responsibility for explaining or clarifying the roles and responsibilities of other professionals or agencies involved in the case.
68. I deliberately and explicitly tried to identify any elements in the network around my client that appeared contradictory or poorly integrated, using structured/disciplined methods to do this.
69. I deliberately and explicitly planned action to minimise or resolve any inter-professional or inter-agency disagreements or contradictions.
70. I completed one or more outcome measures at the appointed time(s)
71 Wherever necessary I took steps to check that the work I planned was faithful to the team's agreed protocols and what evidence supports as best practice.
YOU HAVE FINISHED! WE ARE EXTREMELY GRATEFUL TO YOU FOR THIS TIME
Fixsen and his colleagues reviewed the literature on implementation science ([[Fixsen, et al (2005) Implementation Research: A Synthesis of the Literature]]) and suggested that implementation tends to follow four discrete stages. These stages have been estimated to take between 2-4 years and emphasise that program implementation is a process rather than an event. .
!Exploration and Adoption
Teams may engage in exploration for a wide range of reasons such as a wish to improve effectiveness or to ensure a better fit between community needs (the client group) and the skills and resources of the team or service. The process may be guided by feedback from staff around training needs and service managers exploring different training opportunities for their staff teams.
!Program Installation
This stage involves organisations ensuring that all the components of the program are properly installed and supported. This is likely to include staff training, organisational changes and basic systems such as IT.
!Initial Implementation
This has been described as 'the initial awkward stage' of implementation. The organisation will probably experience considerable anxieties about adopting new methods and leaders and supervsiors may lack confidence in sustaining new methods during this period. Many implementation projects end during this phase.
!Full Operation
The new method of working becomes firmly established and it becomes 'business as usual'. Staff have become more confident in the methods and experienced in handling common challenges to the adopted method of working.
The initial [[Engagement]] tends inevitably to be the period of greatest intensity of staff input - perhaps even requiring two [[KeyWorker]]s to be present, especially if there is a risk of violence (see [[Violence]]) and before basic trust has been established. Remember that a core task is to try to establish some form of [[Secure Base]] phenomenon in the relationship between young person and KeyWorker. Frequency of contact and [[Reliability]] are two powerful aides to this.
!!What frequency of contact hours are expected, when?
This is dictated by feedback from the young person and the KeyWorker's own assessment of risk, etc.
!!When would you move from two [[KeyWorker]]s to just one?
As soon as the situation is sufficiently predictable the KeyWorker s should move towards providing lower level supportive contact - and ''this aim should be made clear from the very start'', in order to:
#Reduce the likelihood of claustrophobic [[Anxiety]] and the paradoxically //increased// aggression that this can trigger.
#Set the scene for building [[Self-efficacy]] within the young person and their existing network (one of the [[Core Features of AMBIT]] is a focus on [[Scaffolding existing relationships]].)
!Click the button to reset the AIM assessment:
Note - this will clear all current settings... Are you SURE you want this? Have you EXPORTED any existing results yet (see above - "Export AIM")?
<<reset fields:'tt_rating,tt_keyproblem' options:'txtAIM_ID,txtAIM_date,txtAIM_assessor' label:'reset the AIM - make sure you have exported any existing data or you will lose it' filter:'[tag[H-CAMA]]' message:'AIM reset done. Re-open the AIM form to see the changes.'>>
This video gives you a quick tour of the simple rules for laying out text, headings, italics, bullet points, etc - so you can make the text in your pages look clear and readable. See also EditingConventions and the page on how to [[Edit]]...
<html><iframe width="480" height="360" src="http://www.youtube.com/embed/tWb-UAePQvk?rel=0" frameborder="0" allowfullscreen></iframe></html>
!!Material on Theory
*[[Theory]] and [[Theoretical/Explanatory Frameworks]]
!!Material on the Practice of [[AMBIT]]
*[[Practice]]
!!Theory and Practice in AMBIT
*[[AMBIT: an overview]]
*[[Core Features of AMBIT]]
!Linking Theory and Practice:
[[AMBIT]] is not a single "thing", but an //orientation// that is primarily about //linking// [[Theory]] to [[Practice]], and developing an organisational structure that can provide the kind of well-structured supervisory/support sytems that can sustain such [[Service Delivery]]. It is a framework for developing attuned, evidence-based practice, as much as ready-made thing-in-itself.
Practitioners should have an understanding of the theoretical models that underpin their practice, not least because this instils confidence in their technique. They are encouraged to browse this via links from manualized practical instructions (or to add such links if they wish - see instructions on how to [[Edit]] the manual.
This is not a comprehensive textbook. The descriptions of theory contained in this manual are designed to provide the KeyWorker with a sufficient conceptual grasp to:
#Understand why she is doing what she is doing in respect of any particular intervention technique.
#Provide a corresponding level of confidence in the technique and its evidence-based effectiveness which will inevitably be conveyed to the patient.
In other words [[Theory]] (and an evidence base) underpins individual interventions but the manual's focus is on supporting and framing clinical [[Practice]] in newly integrated and integrative ways (see [[Taking Responsibility for integration]].)
As one of a new breed of BarefootPractitioners the KeyWorker is not expected to be a theoretician or indeed an expert in any specific theoretical or interventionist framework, but to understand basic concepts insofar as this empowers him or her to deploy //techniques// - the expertise is in deploying existing "technologies" in integrated ways, to a target group that has previously been poorly served by conventional services, rather than in brand new (and "branded") technologies.
The KeyWorker is supported in the work by strong SupervisoryStructures within the wider team, but also through possession of a 'toolbox' of different techniques (see [[Specific interventions]] and WhichInterventionWhen) which are themselves drawn from a range of theoretical and explanatory frameworks.
Will a young person and family in crisis be able to //make sense of and to use// such a wide range of interventions? Perhaps the sheer diversity of the different interventions could simply confuse the recipient? This question of UserAcceptability is particularly relevant if we consider that the interventions are being delivered in the midst of a crisis.
An important question regarding this notion of Theory in Practice is [[Why intervene simultaneously in multiple domains?]]
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This is a core concept in AMBIT. [[Addressing Dis-integration]] is one of the [[Core Features of AMBIT]]. There is a [[Video introduction to disintegration]] if you want, too.
In any system which contains separate minds, different organisational constraints and goals, and the possibility of misunderstandings, it is easy for tasks and arrangements that are developed out of the best of intentions to pull in opposite directions, or inadvertently to undermine each other.
AMBIT takes a position that only very rarely are these dis-integrations ever __purposeful__ (it is very rare to think of any worker in any agency going to work one day and saying to him or herself //"I am going to really work at disintegrating the care around my client Jonny today!"//) but that given the complexities of diaries, separate budgets, different institutional agendas, and diverse explanatory models it is quite impressive if such networks actually manage to coordinate themselves at all. In this way, we suggest that teams and workers need to "re-callibrate" their expectations so that the //expect// disintegration and then //proactively intervene// to reduce its impact upon client care - rather than expecting integrated care and then too often being subject to disappointment and despair when things "don't work out as they should have."
|There are [[DOMAINS and LEVELS of dis-integration]] that explain this process in more depth.|
|There guidance on [[Learning about Addressing Dis-integration]] to support the [[AMBIT training]]|
The [[Dis-integrativeProcesses]] and [[Dis-integratedInterventions]] that follow are worth knowing about so as to be be quicker at spotting them and designing interventions to address them. Mostly, these "interventions" are what we call "Connecting conversations" (see the [[Dis-integration grid]] for details on this).
The Professional Network is a key domain for the IMP to work across. Dis-integrative practice (see [[Dis-integratedInterventions]]) may easily result from differences between members of the professional Network in:
*CONCEPTUAL understanding - //WHAT IS THE PROBLEM?//
*PRAGMATIC understanding - //WHAT IS TO BE DONE?//
*NETWORK understanding - //WHO IS TO DO IT?//
!To add a new professional to your clients professionals
This can be done via [[Make or View Client Notes]], in the NARRATIVE ACCOUNT OF ASSESSMENT: this will generate a separate [[Tiddler]] to record each Professional in the Network. Alternatively, it can be done right from here (remember to check that there is not already a record):
>View existing <<tag ProfessionalNetworkMembers>><<newJournal label:"Record members of the Professional Network around the young person here" focus:title text:"You can delete these notes and over-write them.
Record information about the young person's PROFESSIONAL network (not the FamilyInformalNetworkMembers) here...
Name:........................................
Role:........................................
Contact details:...................................................
Brief description of the relationship (positive, distant, rejecting, supportive, etc):...........................
This note is already tagged with ClientNotes and ProfessionalNetworkMembers; add any additional tags that might help to sort this entry in the future." title:"JUST START TYPING TO OVER-WRITE THIS: Record name and role of prof. network member here" tag:ClientNotes:ProfessionalNetworkMembers>>
!!!For each professional record the following:
Name:........................................
Role:........................................
Contact details:...................................................
Brief description of the relationship between this person and the young person/family (positive, distant, rejecting, supportive, etc):.....................
!Professionals in the young person's care network:
If you are not [[logged in|Log in]] then you only have access to the ''BROWSING'' mode.
This is the simplest way to use the manual. It is just a website to all intents and puposes - you can open and close pages, and that is it.
The KW engages in some ''"social" conversation'' at times and particularly in the first sessions, to put families at their ease (e.g. "how long have you lived here? What's the neighbourhood like?"). Part of this process may also be accomplished by discussion of the context of the intervention (e.g. worker's background and team, length and frequency of meetings, use of telephone contact, KW's, YP's and family's expectations etc)
This is the title of one of the [[Tabs]] in the [[Index]].
It is of particular use if material is being added frequently, as it lists all the [[Tiddler]]s in date order ''according to which ones have been most recently edited/worked upon'' (N.B. NOT in the order in which they have most recently been opened for reading.)
!@@color(red):NB this is a sample Care plan@@
!LIKELY CRISES and CONTINGENCY PLANS:
(a) Comes home drunk - avoid confrontation, speak calmly, agree to do our talking in the morning.
(b) Becomes aggressive at home - clear verbal warning first, remind about the agreed plan, if no de-escalation within 3 mins, call Police.
!PLANNED CARE
#[[Cognitive Behavioural]] to address [[Depression]] and [[Anxiety]] early on. By: [date] Responsible: ANOther
#Regular monitoring of RiskAssessment - mainly risk of suicide/self injury. By: [date] Responsible: ANOther
#Liaise with School - encourage graded re-introduction. By: [date] Responsible: ANOther
#etc...
Training teams in the AMBIT approach aims to follow the principles and findings of Implementation science.
Implementation science is a rapidly developing area of research which has been stimulated by the increasing realization that the dissemination of evidence based practice into health and welfare systems is far from straightforward. Long time delays between the development of practice in a specialist centre and wider use are common, even where new developments are welcomed and supported. There is some more info about this at [[Fixsen's Stages of Implementation]]
The core idea is that ''effective dissemination needs to focus on more than just staff training'' and should in fact include three areas of change, namely:
!1. Staff //training//.
See [[AMBIT Basic Four Day Training]]
!2. Addressing //organisational challenges//
See [[Implementation Team]]
!3. Having clear, explicit //programme outcomes//.
See [[Implementation Plan]]
Further aspects of this research area that are considered to be relevant to AMBIT will be gradually included in the manual.
! What is engagement?
Engagement is a process of making (and sustaining) a therapeutic [[Attachment Relationship]] with your client. One of the [[Core Features of AMBIT]] is its stress on the [[Individual Keyworker Relationship|KeyWorker]] as the means by which we help to restore, stimulate or sustain more accurate [[Mentalizing]] in the young person, and their family. It is therefore intimately about the client's [[Relationship to help]].
!When do I do this?
Naturally enough, engagement tends to be the focus at the beginning of treatment, but it continues as a theme throughout the work. There are a lot of [[Engagement techniques]] described in this manual.
! Some theory:
* Engagement describes the process whereby a young person (or any patient) becomes invested in the //co-construction// of a //therapeutic relationship//, and in taking up shared work, with the therapist or team.
* We assume that such a move is made, inspired by a belief that these actions will help suggest a way forward out of mental anguish.
* However, we also know that many young people or families have different, and much less 'optimistic', [[Internal Working Model]]s of how relationships with 'authority-figures-who-offer-help' tend to work (see [[Relationship to help]]).
* So engagement relates to the extent to which the young person is able accurately to [[Mentalize]] my 'good intentions' as a therapist .
* We know from empirical research that //from very early in life// infants are preferentially drawn to pay attention (a very rudimentary form of engagement!) to activities that are perceived as being influenced by //intentions//. In later years, this same propensity to be 'drawn in' by perceived intentions (ones perceived as authentically //helpful//) can be built on by the worker's efforts to 'mentalize aloud' - and as much as possible to make explicit his or her thinking, beliefs, hypotheses, concerns and intentions. This accounts for the emphasis in AMBIT (especially in [[Active Planning]]) on the notion of [[Broadcasting Intentions]].
!How do I do this?
See:
* [[Manage CLIENT RELATIONSHIP]]
* [[Engagement techniques]]
* [[Relationship to help]]
* [[Active Planning]]
Engagement (or Joining) is the process of "//accommodation//" between the KeyWorker, the young person and the family, the search for a "fit" that will be good enough to allow the //difference// (new ways of looking at things, new ways of doing things) that will be introduced by the keyworker to be explored in a context of safety.
It can be described as the "formation of a therapeutic alliance", the "development of rapport" - it is the "//non-specific but essential ingredient of all therapy//".
While a KeyWorker may be more conscious of using joining techniques initially, joining is an ongoing process which needs to be maintained throughout therapy and aims both at establishing engagement and facilitating change. Joining is established through the use of technique integrated with the KW's presentation of self. This is also explored one of the [[Core Features of AMBIT]], which is [[Active Planning]] - where the balancing-act of (a) //joining// and (b) //"going somewhere useful together"// is described.
From the point of view of the therapist, [[Engagement techniques]] seek to reduce the activation of certain [[Attachment]] behaviours (see [[Secure Base]]), and can do so only in the context of very clear [[Boundaries]], including those boundaries that dictate the nature and limits of the relationship between patient and keyworker ([[Patient-Worker Boundaries]]).
!Specific Engagement problems:
A variety of factors can make engagement more difficult, and call for specific awareness and techniques to work around these problems. For instance:
*There may be a perception that intensive home-based care is not what is required - [[We want a hospital bed, not a home visit!]]
*Adolescents may be reticent to engage - [[Adolescence and Engagement]]
*Mental Health stigma - [[Stigma and Engagement]]
*Families may act to undermine engagement - [[Families and Engagement]]
*Lack of insight (eg Psychosis) - [[Insight and Engagement]]
*Other symptoms of psychosis may also undermine engagement - [[Other Symptoms of Psychosis and Engagement]]
----
Click the [[Show references and info]] panel to reveal sub-topics under this heading, suggesting ways of achieving or enhancing engagement.
This is a description of a phrase used in the technical workings of the manual, rather than (in this instance) referring to children whose parents have died.
The [[tab|Tabs]] that you will find in the [[Index]] lists any Tiddlers ''that are not [[linked|Links]] to from any other Tiddlers. This is quite useful to know if you are an author/editor, but otherwise quite boring.
!A 'Mentalizing Stance'?
Working with ''Families'' requires that the worker adopts what is referred to as "[[The Therapist's Mentalizing Stance]]", just as they might also do in working with an individual.
!A way-of-being-with:
The [[The Therapist's Mentalizing Stance]] is a //way-of-being-with// people, and in Family work it is especially helpful to grasp with confidence this simple "4-legged stance": in working with families, it is not uncommon to be exposed to high levels of affect, and to fast-moving communication, so that one's //own capacity// for [[Mentalization]] is constantly under threat. Knowing these simple "rules of thumb" makes it more likley that the worker can "keep his/her head" at these times of stress, and thus remain helpful for the family, while modelling the very skill that we hope to stimulate and support in all family members.
!Used with a //structure//
This stance is used in combination with a simple //structure-for-sessions// that is described under the Mentalizing Techniques, and is referred to as the [[Mentalizing Loop]]
This describes how a carer (often the mother) helps a baby/child begin to develop [[Mentalization]].
The mother responds contingently (see [[Contingencies]] for a definition) to her baby's emotional states and does so by mentalizing what might be motivating the baby to behave in the way he is - i.e. when the baby is crying she may conclude that
>//"He is likely to be angry, or upset, and that might be because he is hungry, or has a dirty nappy, or needs to be 'winded', etc..."//
She then ''mirrors'' the emotional state that she imagines the baby is in the middle of -
>She might frown at the baby, etc... ''BUT''
She also @@color(blue):''marks''@@ this mimicking of what she thinks is the baby's mental state...
>She deliberately ''engages'' the infant (using eye contact, and a certain amount of exaggeration - what is referred to as [[Ostensive communication]]) talking in a cheerful, sing-song voice, or holds the baby particularly gently...
This is as if to emphasise that:
>//"Wake up baby, I'm going to tell you something important about yourself!... This is what ''I think may be going on for you right now'' [say, anger] - this is __you__ ''"being-angry"'', it is ''not __me__'' being-angry with __you__!..."//
When this happens ''iteratively'' (again and again, hour by hour) it helps the developing baby begin to develop a sense that...
>//"I have a mind, and that mind can exist in different states - happy, sad, frightened, angry, etc..."//
Which is the beginnings of mentalization...
!Using this in our work:
We often speak of ''MARKING'' things out in our work (particularly OUR thoughts/guesses/hypotheses about the MENTAL STATE of the other person.)
In "marking" we are placing a "frame" or a "highlighter" around our communications at these specific times. This is just the same as when the mother deliberately uses "caricaturing" or other ways to show that she is "just painting you a picture of what //I think that I am seeing in you!//" - she is not BEING or EXPERIENCING those same things herself (a mother with a cross baby does not shout or roar back at it, although she may frown while talking in a sing song voice.)
This marking helps "//wake us up//" to the fact that somebody is trying to offer a //"best guess at how I see what is happening right now"// - and is exactly how the mentalizing practitioner tries to broadcast his or her understandings/imaginings and [[Intentional stance]]. The marking invites the recipient to stop and mentalize!
At the risk of overstating this, there is a sort of analogy with the use of specific rituals in some religious ceremonies - the ringing of bells, lighting of incense, etc, which serve to //mark// the presence of "//extra levels//" in the interaction at that particular point in time.
Learning to navigate around the manual
Clues to find individual tiddlers in the manual
*Find the page that would help you ...
**Clue is the "second word on the page"
For each item, please mark the box for Not True, Somewhat True or Certainly True. It would help us if you answered all items as best you can even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of how things have been for you over the last six months.
<<option txtYourName>>
<<option txtDateOfBirth>>
<<openStory [[Strengths and Difficulties questions]] [[Click here to take the questionnaire Questionnaire]] [[Strengths and Difficulties]]>>
Cognitive Behavioural therapy (CBT) provides an explanatory model, based on SocialCognitiveTheory and [[Developmental Considerations]], and this model underpins a series of quite simple ''therapeutic techniques'' that are aimed at improving psychological functioning.
The model evolved from Behaviour Therapy and emphasises the triangular way in which an individual's [[Behaviour]] is influenced by patterns of [[Thinking]] (including your [[Implicit Core Beliefs]] about your self ([[Self-efficacy]]), the world, the future) and [[Feeling]].
<html><img src="https://docs.google.com/drawings/pub?id=15NSkmut8m3ML2TrGZQ-M4H3ySAYBsEPNvj38aIbOIjU&w=600&h=400"></html>
There are many different techniques under the tab ''CBT techniques'' ([[CBT techniques]]) in the manual; note that many of these have been derived from work with adults and some therefore require adaptation for use with young people. See [[Cognitive Behavioural work - CheckLists]] for a checklist to help structure your intervention.
!What does "Meta-" mean?
"Meta-" refers to the quality of sitting "at one remove" from the action, and thus having a "different perspective". Examples to explain this include the [[Ripples in a Pond]] and [[Dive Boat]] analogies.
!The Meta-team
The Meta-team may in some situations be those [[KeyWorker]]s who are not working directly with a particular young person, but who make themselves available to the Keyworker who is "in the thick of it" via a [[Reflective Quorum]]. More formally, the MetaTeam refers to the team of specialist professionals who may not sit directly //within// the team, as keyworkers with caseloads themselves, but who have given consent to an agreed level of consultation to the team about areas requiring more specific expertise.
The nature of these agreements will vary from setting to setting and may range from a formal regular consultation slot, to something more fluid and informal, based on a shared understanding of the task and model. During the [[Training]] of [[AMBIT]] workers these local experts will ideally be involved in sharing core skills from their area of expertise, as a means of:
#Extending the reach of specialist interventions into hard-to-reach settings.
#Engaging the local experts in the work of the AMBIT team and fostering local ownership of this resource (an analogy would be the expert working "through" the keyworker in the same way that a surgeon might work in inaccessible places via an endoscope.)
#Reducing the cost of training, on the grounds that many of the core evidence-based skills required for an effective AMBIT intervention are probably already held within professionals employed locally.
Adolescents are often diffident, avoidant, and socially awkward, especially in conversation with adults, and even moreso in relation to subjects that are perceived as embarrassing, or in any way "odd" (as much of a mental state examination frankly is, when judged according to common sense standards.)
Research on Adolescent [[NeuroDevelopmental]] characteristics, demonstrates that (primarily on account of a mismatch between their relatively under-developed frontal brain regions compared to other components of the limbic system which log socially relevant communications and generate affective responses to these) they are easily overwhelmed by the //emotional impact// of social situations. This triggers "fight or flight" responses or attachment behaviours, both of which inhibit [[Mentalization]] and limit the capacity for engagement.
The [[Core Features of AMBIT]] defines eight markers of the AMBIT ''STANCE'', and these collectively define the five key features of [[AMBIT]] ''PRACTICE'' that are the elements of //service delivery// without which AMBIT cannot be said to be delivered. These key features of practice are laid out below:
!!1. [[Mentalization]]
Just as it is a skill that is //formed// within relationships, and is essentially about //negotiating and acting adaptively// within relationships, so [[mentalizing|Mentalization]] in AMBIT might be seen as the 'oil' that helps to lubricate the various related parts in the complex system required to help very complex young people and families; different workers and different methods of working.
AMBIT insists on taking a //[[multi-domain|Intervening in multiple domains]]// approach to assessment and [[formulation|Formulation and Treatment Aims]] - which is essentially about developing a [[mentalized|Mentalization]] understanding of [[What's the problem?]].
Many of the interventions that an AMBIT practitioner makes with young people or their families are designed explicitly to increase or repair mentalizing.
In AMBIT, mentalizing is also plays a key part in determining how //individual// and relatively //autonomous// team members work together in a //[[team-based|Keyworker well-connected to wider team]]// approach.
!!2. [[Active Planning]]
A key innovative feature of this approach is [[Intervening in multiple domains]] mainly via one keyworker - who has also been described as a //"[[barefoot practitioner|BarefootPractitioners]]//, trained to deliver a wide variety of interventions in multiple domains and contexts.
To avoid the gravitational pull towards chaos in such conditions, [[Active Planning]] is applied //to make explicit the goals// (intentions) underlying all work - from the briefest interactions (//[[Thinking Together]]//) to the long term [[Care Plan]].
!!3. [[SupervisoryStructures]]
Clear [[SupervisoryStructures]], including //[[disciplined ways of managing peer-to-peer case discussion|Thinking Together]]// support the KeyWorker who is often exposed to highly invalidating environments that reduce their own capacity to use [[Mentalization]]
!!4. [[Addressing Dis-integration]]
As part of the [[AMBIT stance|Core Features of AMBIT]], the KeyWorker //[[takes responsibility|Taking Responsibility for integration]]// for trying to increase the integration of services and informal support networks around the young person by taking active steps in [[Addressing Dis-integration]].
!!5. [[Manualization]]
[[Specific interventions]] are [[manualized|Manualization]], using a novel wiki-based approach, that encourages a marriage (or conversation) between 'top-down' evidence-based modules, and 'bottom-up' ''//locally-authored//'' material that documents a local team's ongoing learning ("practice-based evidence") and existing expertise. Included in the manual are the [[Boundaries]] that help to [[SUSTAIN best practice]].
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!Miller and Rollnick describe:
!!4 core aspects to any motivational interview:
1. [[Express Empathy]]
2. [[Develop Discrepancy]]
3. [[Roll with Resistance]]
4. Support [[Self-efficacy]]
!Structuring these elements:
Motivational work can be delivered across a number of sessions, or in a single session - it is as much a way of being with a client as it is a formulaic set of instructions. A typical interview will start with some [[Engagement techniques]], developing a sense of connection and a sense of empathic joining (accurately [[Mentalizing]] the client would be an alternative way of expressing this). As part of this the worker elicits hopes and dreams for the future - which may be elaborate, or very down-to-earth ("to not be in trouble with the police for six months") - and then draws reflections upon the impact of the targetted behaviour upon progress to this goal ([[Develop Discrepancy]]). Avoiding 'de-railment' ([[Roll with Resistance]]), the worker moves towards exploration of how the client may be able to support him or herself within existing structures that are already available (family and friendships, etc; this (supporting [[Self-efficacy]]) is a good example of one of the [[Core Features of AMBIT]], namely [[Scaffolding existing relationships]].
This is a tag that lists material that needs further content authoring by the AMBIT authorial team ([[Authors]]).
Record details of the young person's past psychiatric history. Note that past history of problems is fairly predictive of future problems.
Use the [[Make or View Client Notes]].
*What problems occurred in the past? //Record diagnoses if these are remembered, if not the description of the symptoms.//
*Who did the child see for help? //Record the name of the clinician and the clinic address if possible.//
*What treatments were offered? //Talking therapy? Medication? Family therapy?...//
*Were they helpful?
This section is extremely relevant to AMBIT and readers are encouraged to read this section of the book (The Fifth Discipline pages 223-254)
!Key themes
*The difference between ''discussion'' and ''dialogue''. Discussion (like 'concussion' and 'percussion') is characterised as being a process of passing things back and forth between people in order to see which idea will prevail i.e. 'win'. Dialogue is different and means to 'a free flow of meaning between people'. People are no longer primarily in opposition but are participating in developing common meaning. One feature of dialogue is that ''people become observers of their own thinking'' i.e. mentalize.
*Dialogue needs three conditions.
**All participants must suspend their assumptions
**All participants must view each other as 'colleagues'.
**There must be a facilitator who 'holds the context' of dialogue.
*Dialogue may not necessarily lead to action. Focusing back on action and decisions may need discussion. ''Teams need both dialogue and discussion.''
*Learning organisations are characterised by 'productive conflict' i.e. they are not conflict free. Non-learning teams tend to be characterised as either 'conflict free' (on the surface) or being 'highly polarised'.
*Defensive processes which block dialogue are common and pervasive. Hierarchical structures may present particular challenges for overcoming defensive positions e.g. I don't want to show my boss that I don't feel confident of what to do. Learning teams are not free of defensive processes but aim to recognise and address them when they can be observed.
*Teams need structures or processes that enable them to practice team learning.
!Implications for AMBIT
#AMBIT is a team approach and team learning is central to the effective delivery of such an approach.
#In AMBIT, manualization has been an operational technique to promote team learning. It may be helpful to conceptualise manualising within a broader process of team learning i.e. the purpose of the manual is to support team learning.
#Further development and clarification of the role of the facilitator in team learning processes may be useful, particularly taking into account hierarchical structures and ways of addressing likely defensive processes which will occur in all teams.
Type the text for 'Family'
H-CAMA stands for Hampstead Child Adaptation Measure - Adapted.
The H-CAMA is a multilevel/multidimensional assessment, taking in psychiatric symptoms, social ecology, relationship networks/qualities, and resiliencies, and was originally authored by Prof PeterFonagy and Dr MaryTarget. A modified version of this is available for use in the this TiddlyManual for [[AMBIT]], called the [[AIM]] (adapted by DickonBevington and PeterFuggle).
/***
|''Name''|TiddlySpaceRevisionView|
|''Description''|Show tiddler revisions in a stack of cards view|
|''Author''|BenGillies|
|''Version''|0.2.0|
|''Status''|beta|
|''Source''|http://github.com/TiddlySpace/tiddlyspace|
|''CodeRepository''|http://github.com/TiddlySpace/tiddlyspace|
|''License''|[[BSD|http://www.opensource.org/licenses/bsd-license.php]]|
|''CoreVersion''|2.6.0|
|''Requires''|TiddlyWebAdaptor|
!Usage
The viewRevisions macro can be attached to any element, which should be passed
in as a parameter.
For example:
<<viewRevisions page:10 link:"<<view modified date>>">>
would show the revisions "stack of cards" view, 10 at a time, when the modified
date is clicked.
!Code
***/
//{{{
(function($) {
var me = config.macros.viewRevisions = {
revisionTemplate: "RevisionTemplate",
revSuffix: " [rev. #%0]", // text to append to each tiddler title
defaultPageSize: 5, // default number of revisions to show
defaultLinkText: "View Revisions", // when there's nothing else to use
offsetTop: 30, // in px
offsetLeft: 10, // in px
shiftDownDelay: 50, // in ms
visibleSlideAmount: 20, // amount of revisions to show on left hand edge after sliding
zIndex: 100, // default z-index
handler: function(place, macroName, params, wikifier, paramString, tiddler) {
params = paramString.parseParams(null, null, true)[0];
var tiddlerElem = story.findContainingTiddler(place);
var revButton;
var pageSize = parseInt(params.page[0], 10) || me.defaultPageSize;
var linkObj = params.link ? params.link[0] || me.defaultLinkText : false;
if(linkObj) {
revButton = $('<span class="button openRevisions" />')
.appendTo(place);
wikify(linkObj, revButton[0], null, tiddler);
} else {
revButton = place;
}
$(revButton).click(function() {
if (!$(tiddlerElem).hasClass("revisions")) {
me.showRevisions(tiddlerElem, tiddler, pageSize);
} else {
me.closeRevisions(tiddlerElem);
}
});
},
// initialisation for revision view
showRevisions: function(tiddlerElem, tiddler, pageSize) {
var context = {
host: tiddler.fields["server.host"],
workspace: tiddler.fields["server.workspace"]
};
$(tiddlerElem).addClass("revisions").attr("revName", tiddler.title);
// ensure toolbar commands deactivate RevisionsView
$("a", ".toolbar", tiddlerElem).each(function(index, btn) {
var _onclick = btn.onclick;
btn.onclick = function(e) {
me.closeRevisions(tiddlerElem);
_onclick.apply(this, arguments);
};
});
// ensure default action deactivates RevisionsView
var _ondblclick = tiddlerElem.ondblclick;
tiddlerElem.ondblclick = function(e) {
me.closeRevisions(tiddlerElem);
_ondblclick.apply(this, arguments);
};
var type = tiddler.fields["server.type"];
var adaptor = new config.adaptors[type]();
var userParams = {
tiddlerElem: tiddlerElem,
pageSize: pageSize,
title: tiddler.title
};
me.createCloak(tiddlerElem);
adaptor.getTiddlerRevisionList(tiddler.title, null, context, userParams,
function(context, userParams) {
// strip the current revision
context.revisions.shift();
me.expandStack(context, userParams);
});
},
// fetch the actual revision and put it in the tiddler div
showRevision: function(place, revision, callback) {
var context = {
host: revision.fields["server.host"],
workspace: revision.fields["server.workspace"]
};
var userParams = {
revElem: place
};
var type = revision.fields["server.type"];
var adaptor = new config.adaptors[type]();
var revNo = revision.fields["server.page.revision"];
adaptor.getTiddlerRevision(revision.title, revNo, context, userParams,
function(context, userParams) {
var tiddler = context.tiddler;
tiddler.title += me.revSuffix
.format([$(place).attr("revision")]);
tiddler.fields.doNotSave = true;
if (store.getTiddler(tiddler.title)) {
store.deleteTiddler(tiddler.title);
}
store.addTiddler(tiddler);
//now, populate the existing div
var revElem = userParams.revElem;
$(revElem).attr("id", story.tiddlerId(tiddler.title));
$(revElem).attr("refresh", "tiddler");
var getTemplate = function() {
var themeName = config.options.txtTheme;
if (themeName) {
return store.getTiddlerSlice(themeName,
me.revisionTemplate) || me.revisionTemplate ||
"ViewTemplate";
} else {
return (store.getTiddler(me.revisionTemplate)) ?
me.revisionTemplate : "ViewTemplate";
}
};
var template = getTemplate();
story.refreshTiddler(tiddler.title, template, true);
callback(tiddler);
});
},
createCloak: function(promoteElem) {
var el = $(promoteElem);
// cache styles for resetting later
el.data({
top: el.css("top"),
left: el.css("left"),
zIndex: el.css("z-index")
});
$('<div class="revisionCloak" />').css("z-index", me.zIndex)
.click(function() {
me.closeRevisions(promoteElem);
})
.appendTo(document.body);
el.css("z-index", me.zIndex + 1);
},
// clean up, removing all evidence of revision view
closeRevisions: function(promoteElem) {
var el = $(promoteElem);
// revert the original tiddler back to its previous state
el.removeAttr("revName").removeClass("revisions").css({
top: el.data("top"),
left: el.data("left"),
zIndex: el.data("zIndex")
});
// remove any revisions still in the store
var revisions = $(".revisions");
revisions.each(function(index, revision) {
var revAttributes = revision.attributes;
if ((revAttributes.revname) &&
(revAttributes.revision)) {
var revName = revAttributes.revname.value;
var revNo = revAttributes.revision.value;
var title = revName + me.revSuffix.format([revNo]);
if (store.getTiddler(title)) {
store.deleteTiddler(title);
}
}
});
// delete the previous revisions
revisions.remove();
// remove the cloak
$(".revisionCloak").remove();
},
// calback from getting list of revisions
expandStack: function(context, userParams) {
var pageSize = userParams.pageSize;
var from = userParams.from || 0;
var tiddlerElem = userParams.tiddlerElem;
userParams.defaultHeight = $(tiddlerElem).height();
userParams.defaultWidth = $(tiddlerElem).width();
if (from < context.revisions.length) {
me.displayNextRevision(tiddlerElem, userParams, context, from,
from + pageSize - 1);
}
},
// place the next div above and behind the previous one
displayNextRevision: function(tiddlerElem, userParams, context, from, to) {
var revision = context.revisions[from];
var callback = function() {
var revText = revBtn.getRevisionText(tiddlerElem, revision);
tiddlerElem = me.createRevisionObject(tiddlerElem, context,
userParams, revText);
$(tiddlerElem)
.attr("revision", (context.revisions.length - from));
if ((from < to) && ((from + 1) < context.revisions.length)){
me.displayNextRevision(tiddlerElem, userParams, context,
from + 1, to);
} else if ((context.revisions.length - 1) > to) {
me.showMoreButton(tiddlerElem, context, userParams, to + 1);
}
};
me.shiftVisibleDown(userParams.title, callback);
},
createRevisionObject: function(tiddlerElem, context, userParams, text) {
var newPosition = me.calculatePosition(tiddlerElem, context);
return $('<div class="revisions tiddler" />')
.css({
position: "absolute",
top: newPosition.top,
left: newPosition.left,
"z-index": me.zIndex + 1,
height: userParams.defaultHeight,
width: userParams.defaultWidth
})
.attr("revName", userParams.title)
.append(text)
.insertBefore(tiddlerElem);
},
// move the already present revisions down by 1 to fit the next one in
shiftVisibleDown: function(title, callback) {
var revisions = $("[revName='%0'].revisions".format([title]));
var revisionCount = revisions.length;
$(revisions).animate({top: "+=" + me.offsetTop},
me.shiftDownDelay, function() {
revisionCount -= 1;
if ((callback) && (!revisionCount)) {
callback();
}
});
},
// where we put the new revision
calculatePosition: function(elem, context) {
var offset = $(elem).offset();
var currentPosition = $(elem).position();
var newPosition = {
top: currentPosition.top - me.offsetTop
};
if ((context.restrictLeft) ||
((offset.left - me.offsetLeft) <
$("#contentWrapper").offset().left)) {
newPosition.left = $(elem).position().left;
context.restrictLeft = true;
} else {
newPosition.left = currentPosition.left - me.offsetLeft;
}
return newPosition;
},
// equivalent of displayNextRevision, but for the more button
showMoreButton: function(tiddlerElem, context, userParams, moreIndex) {
userParams.from = moreIndex + 1;
me.shiftVisibleDown(userParams.title, function() {
var btn = me.createRevisionObject(tiddlerElem, context, userParams,
"");
var more = createTiddlyButton(btn[0], "more...", "show more revisions",
function() {
if ($(".viewRevision").length) {
return;
}
userParams.tiddlerElem = btn[0];
$(btn).text("")
.append(revBtn
.getRevisionText(btn[0], context.revisions[moreIndex]))
.attr("revision", context.revisions.length - moreIndex);
me.expandStack(context, userParams);
});
$(more).css("float", "right");
});
},
stripRevFromTitle: function(revisionTitle) {
return revisionTitle.split(/ ?\[rev\. #[0-9]+\]$/)[0];
},
onClickRevision: function(revElem, revision, callback) {
// don't do anything if we are still loading
if ($(".revisions").hasClass("loading")) {
return null;
}
var origTitle = me.stripRevFromTitle(revision.title);
if ($(revElem).hasClass("viewRevision")) {
$(".revisions").addClass("loading");
me.slideIn(revElem, revision, origTitle, function() {
store.deleteTiddler(revision.title);
revision.title = origTitle;
$(revElem).text("").append(revBtn.getRevisionText(revElem,
revision))
.removeAttr("tags").removeAttr("tiddler")
.removeAttr("refresh").removeAttr("template")
.removeAttr("id");
$(".revisions").removeClass("loading");
if (callback) {
callback();
}
});
$(revElem).removeAttr("prevPos").removeClass("viewRevision");
} else {
var viewRevision = function() {
var prevPos = $(revElem).position().left;
$(revElem).addClass("viewRevision").attr("prevPos", prevPos);
$(".revisions").addClass("loading");
me.showRevision(revElem, revision, function(rev) {
me.slideOut(revElem, rev, origTitle, function() {
$(".revisions").removeClass("loading");
});
});
};
// make sure another revision isn't already out
if ($(".viewRevision").length) {
var newRevElem = $(".viewRevision")[0];
var newRevision = store.getTiddler($(newRevElem)
.attr("tiddler"));
me.onClickRevision(newRevElem, newRevision, viewRevision);
} else {
viewRevision();
}
}
},
slideOut: function(revElem, revision, title, callback) {
var leftMostPos = $("[revName='%0'].revisions".format([title]))
.offset().left;
var width = $(revElem).width();
var originalLeftPos = $(story.getTiddler(title))
.position().left;
var slideAmount = leftMostPos + width - me.visibleSlideAmount;
$("[revName='%0'].revisions:not(.viewRevision)".format([title]))
.animate({left: "-=" + slideAmount}, 1000);
$(revElem)
.attr("baseHeight", $(revElem).css("height"))
.css("height", "auto")
.animate({left: originalLeftPos}, 1000, callback);
},
slideIn: function(revElem, revision, title, callback) {
var slideAmount = $(revElem).offset().left -
$(story.getTiddler(title)).offset().left;
var origRevPos = $(revElem).attr("prevPos");
$("[revName='%0'].revisions:not(.viewRevision)".format([title]))
.animate({left: "+=" + slideAmount}, 1000);
$(revElem).animate({left: origRevPos}, 1000, function() {
$(revElem)
.css("height", $(revElem).attr("baseHeight"))
.removeAttr("baseHeight");
callback();
});
}
};
var revBtn;
config.macros.slideRevision = revBtn = {
btnText: "created by %0 at %1 on %2",
handler: function(place, macroName, params, wikifier, paramString, tiddler) {
var btn = revBtn.getRevisionText(place, tiddler);
$(place).append(btn);
},
getRevisionText: function(place, revision) {
var text = revBtn.btnText.format([revision.modifier,
revision.modified.formatString("0hh:0mm"),
revision.modified.formatString("0DD MMM YYYY")]);
var btn = $('<a href="javascript:;" class="button revButton" />')
.text(text)
.click(function() {
var revElem = story.findContainingTiddler(this);
me.onClickRevision(revElem, revision);
});
return btn;
}
};
})(jQuery);
//}}}
//background position functions
var $ = jQuery;
function getBgPosY(elem) {
var bgPos = $(elem).css('backgroundPosition');
if(bgPos) {
return bgPos.split(" ")[1];
}
}
function setBgPosY(elem, pos) {
var bgPos = $(elem).css('backgroundPosition'),
posX;
if(bgPos) {
posX = bgPos.split(" ")[0];
$(elem).css('backgroundPosition', posX+" "+pos);
}
}
var delay = (function(){
var timer = 0;
return function(callback, ms){
clearTimeout (timer);
timer = setTimeout(callback, ms);
};
})();
function positionPage(open) {
var newLeft,
viewportWidth = $(window).width(),
sidebarWidth,
sidebarGutter = 30,
paperWidth = 720,
sidePanelWidth = 210;
if(open) {
sidebarWidth = 10;
} else {
sidebarWidth = 270;
}
if(viewportWidth >= sidebarWidth + paperWidth + sidePanelWidth) {
// center paper between sidebar and sidePanel
newLeft = (sidebarWidth+sidebarGutter)/2 + (viewportWidth-paperWidth-sidePanelWidth)/2;
} else if(viewportWidth >= sidebarWidth + paperWidth) {
// stick paper to sidebar
newLeft = sidebarWidth;
} else {
// let paper move to left side
newLeft = viewportWidth - paperWidth;
if(newLeft < 0) {
newLeft = 0;
}
}
if(newLeft) {
$('#screenWidth').stop(true,true).animate( {
left: newLeft
}, 200);
}
}
// the sidebar
$('#sidebarIcons').click(function(e) {
e.preventDefault();
var curLeft = parseInt($('#sidebar').css('left'),10),
open = curLeft===0,
$target = $(e.target),
$panel = $('#sidebar').find('.panel').eq($target.index()-1);
if($target.attr('id')==="toggle") {
$('#sidebar').animate( {
left: open ? "-260px" : "0px"
}, 200);
// determine whether the screen is wide enough to centre between the statuspanel and sidebar
positionPage(open);
setBgPosY('#toggle', open ? "-540px" : "-490px");
} else {
if(!open) {
$('#toggle').click();
}
if($target.attr('id')==="search") {
$('#searchBox').find('input').click().focus();
} else {
if($panel.hasClass("closed")) {
$panel.children('h2').click();
}
}
}
});
// keep Currently Open count up-to-date
function updateCurrentlyOpenCounter(e, closing) {
var count = $('#contentWrapper .tiddler').length;
if(closing) {
count -= 1;
}
if(count<0) {
count=0;
}
$('#sidebarIcons #current span').each(function() {
if(!count) {
$(this).hide().text('');
} else {
$(this).show().text(count);
}
});
}
updateCurrentlyOpenCounter();
$(document).bind("StoryUpdated", updateCurrentlyOpenCounter);
$(window).resize(function() {
delay(function() {
var open = parseInt($('#sidebar').css('left'),10)!==0;
positionPage(open);
}, 500);
});
/*
sidebar toggle
always toggles sidebar in/out
click on icon
if sidebar is open
opens accordion section
if sidebar is closed
opens accordion section and sidebar
-width
find screen width
when sidebar opens
change #screenWidth to be screen width minus the width of the sidebar
when sidebar closes
vice versa
240
if the #screenwidth is large enough for the statuspanel to not overlap the tiddlers
centre the tiddler content between the statuspanel and the extended sidebar
is the screenwidth wide enough?
statuspanel+padding = 240px
sidebar+padding = 300px
tiddler = 720px
Total = 1260px
so if viewport width is 1260+, add right:240px and width:-240 to #screenWidth
if sidebar is closed and width is 1000+, add right:240px and width:-240 to #screenWidth
*/
/*
the accordion generic click behaviour
principle: make the sidebar handle clicks;
if click on panel>h2 or input, toggle accordion stage, unless noToggle exists on panel
*/
var viewportHeight = $(window).height() / 3;
$('#sidebar .panel').not('.closed').find('ul.browsingTool').height(viewportHeight);
$('#sidebar .panel').click(function(e) {
var $target = $(e.target),
$panel = $(this),
panelClosed = $panel.hasClass('closed'),
$otherPanels = $(this).siblings('.panel');
if(!$target.is('input[type=search], h2') && !$target.parent().is('h2')) {
return true;
}
// close other panels
$otherPanels.each(function() {
var $panel = $(this),
$ul = $panel.find('ul.browsingTool'),
panelClosed = $panel.hasClass('closed');
if($ul.length && !panelClosed) {
$ul.stop().animate({
height: 0
}, function() {
$panel.addClass('closed');
});
setBgPosY($panel.find('h2'), "-391px");
}
});
// toggle this panel
if($panel.hasClass('noToggle')) {
return;
}
$panel.find('.browsingTool').animate({
height: panelClosed ? viewportHeight : 0
}, function() {
$panel.toggleClass('closed');
});
setBgPosY($panel.find('h2'), panelClosed ? "-437px" : "-391px");
});
// the info toggle
$('.infoToggle a').live('click', function() {
$(this).parent().siblings('div.info').slideToggle(200, function() {
if ($(this).is(':visible')) {
$('.infoToggle a span').text('-');
} else {
$('.infoToggle a span').text('+');
}
});
return false;
});
// the status panel timeout
window.setTimeout(function() {
if($('#statusTab span').hasClass('panelOpen')) {
$('#statusTab span').click();
}
},5000);
// the status panel overall toggle
$('#statusTab span').live('click', function() {
var $clicked = $(this);
if($clicked.hasClass('panelOpen')) {
$('#rightPanel').animate({'right': '-210px'}, 100);
} else {
$('#rightPanel').animate({'right': '0px'}, 100);
}
$clicked.toggleClass('panelOpen');
});
// the status panel internal toggles
$('#statusPanel a').live('click', function() {
var $clicked = $(this);
if($clicked.hasClass('current')) {
$clicked.parent().next().slideToggle(100);
$clicked.toggleClass('open');
}
});
$('#statusPanel #modeStatus a').live('click', function(e) {
e.preventDefault();
var $clicked = $(this),
$dropDownContainer,
$current;
if(!$clicked.hasClass('current')) {
$dropDownContainer = $clicked.closest('.dropDown');
$current = $dropDownContainer.prev().children('.current');
$clicked.insertBefore($current).addClass('current');
$current.prependTo($dropDownContainer).removeClass('current');
}
// handle advanced toggling
if($clicked.hasClass('advanced')) {
if(!backstage.isVisible()) {
backstage.show();
$('#app-picker').show().css({'visibility':'visible'});
}
} else {
if(backstage.isVisible()) {
backstage.hide();
$('#app-picker').hide().css({'visibility':'hidden'});
}
}
if($clicked.hasClass('browsing')) {
readOnly = true;
refreshElements(document.getElementById('tiddlerDisplay'));
$('#statusTab span').addClass('browsing');
} else {
if(readOnly) {
readOnly = false;
refreshElements(document.getElementById('tiddlerDisplay'));
$('#statusTab span').removeClass('browsing');
}
}
});
$('#statusPanel').mouseleave(function() {
if ($('div.dropDown').is(':visible')) {
$('div.dropDown').slideUp(100);
$('#statusPanel a.current').removeClass('open');
}
});
// login/logout box
function updateAccountDisplay(name) {
var $status = $('#statusPanel #accountStatus'),
$title = $status.children('.title'),
$current = $status.children('.value').children('.current'),
$dropDown = $status.children('.dropDown');
if(!name) {
$title.text('Not logged in');
$current.text('').css('visibility','hidden');
} else {
$title.text('Logged in as:');
$current.text(name).css('visibility','visible');
}
}
function addLoginForm() {
var $loginForm = $('#loginForm').show();
}
function disableModeToggle() {
$('#statusPanel #modeStatus a').click(function() {
return false;
});
}
config.extensions.tiddlyweb.getUserInfo(function(info) {
var anon = info.anon,
name = info.name;
if(anon) {
disableModeToggle();
updateAccountDisplay();
addLoginForm();
} else {
updateAccountDisplay(name);
}
});
$('#statusPanel #accountStatus form').submit(function(e) {
e.preventDefault();
var token = config.extensions.tiddlyspace.getCSRFToken();
this.action += "?csrf_token="+token;
this.submit();
});
// sidebar links
createTiddlyLink($('#feedback').get(0),'Feedback please!',true);
createTiddlyLink($('#manualizingOurWork').get(0),'+ Manualize our work',true);
!Reference:
Kaminski J, Pitsch A, Tomasello M (2012) Dogs steal in the dark. Animal cognition (electronic publication 2012)
!Abstract
All current evidence of visual perspective taking in dogs can possibly be explained by dogs reacting to certain stimuli rather than understanding what others see. In the current study, we set up a situation in which contextual information and social cues are in conflict. A human always forbade the dog from taking a piece of food. The part of the room being illuminated was then varied, for example, either the area where the human was seated or the area where the food was located was lit. Results show that dogs steal significantly more food when it is dark compared to when it is light. While stealing forbidden food the dog’s behaviour also depends on the type of illumination in the room.
Illumination around the food, but not the human, affected the dogs’ behaviour. This indicates that dogs do not take the sight of the human as a signal to avoid the food. It also cannot be explained by a low-level associative rule of avoiding illuminated food which dogs actually approach faster when they are in private. The current finding therefore raises the possibility that dogs take into account the human’s visual access to the food while making their decision to steal it.
[img[https://lh4.googleusercontent.com/-WHgi7Bo5YOQ/US9d72FvokI/AAAAAAAAHEw/oqk3A0DWRac/s646/DiveBoatAnalogy.jpg]]
This is an analogy to explain the mentalizing principles of distance-supervision (including "real-time" peer-to-peer supervision) in [[AMBIT]].
We know that [[Mentalization]] is hard to sustain in high-affect //"pressurised"// environments. Imagine the KeyWorker were a deep sea diver entering the pressurized and challenging world of the client; other team members (or a supervisor in a more formal sense) should see themselves acting (and we emphasise that these are often //pro-active// actions) as a //''support team''// on the dive boat above, pumping an "air supply" down to their colleague. In the case of [[AMBIT]], that "air" is the capacity to mentalize.
There is nothing new in the use of a person (or a flexible [[Reflective Quorum]], or a MetaTeam) //''that is, a person or people who are distant from the immediate pressure and affect''// to help with thinking in high pressure situations.
Ideally, such people are //well-known to the KeyWorker// (we refer to one of the [[Core Features of AMBIT]], which is that we seek to produce a [[Keyworker well-connected to wider team]]); remember that [[Mentalization]] arises out of, and is most powerfully supported or recovered in the context of a relationship that provides a [[Secure Base]].
Using flexible mobile techniques - including technologies such as mobile phones, or mobile video-conferencing, and very clear, disciplined procedures (see [[Thinking Together]]) explicitly aims to support practitioners to regain or maintain this capacity.
A related analogy is the [[Ripples in a Pond]].
The important point in using this tool, which simplifies and adapts Maslow's [[HierarchyOfNeed]], is to ''get to the sharing of your "first effort"'' - and to ''invite the young person to help you improve it''.
When you are sharing your first effort, with the kind of tentativeness, hesitancy, self-deprecating humour and invitation to "//help me get this much more accurate than i can on my own//"... that is [[Broadcasting Intentions]]!
Go to [[this link|https://docs.google.com/file/d/0B5h_CVBdhJPYNkJNamFPVXhsYXM/edit?usp=sharing]] to download this in PDF format, or just use the back of an envelope!
[img[https://lh5.googleusercontent.com/-loMP5VnnI1Q/URG08pJR4OI/AAAAAAAAGpY/o21-QH6rBw0/s640/ActivePlanningSheet.jpg]]
[img[https://lh5.googleusercontent.com/-EXERk6bOad4/URG07sRVqzI/AAAAAAAAGpc/W6cVjCoCoHA/s640/ActivePlanningSheet_DEMO.jpg]]
/*
This CSS file contains all the generic CSS framework stuff.
Combined into one file to reduce http calls, could be reduced further later eg. by removing unused elements.
1. Reset.css
2. Grid.css
3. Jbase.css
4. Stickyfooter.css
reset.css from http://meyerweb.com/eric/thoughts/2007/05/01/reset-reloaded/ */
html, body, div, span, applet, object, iframe,
h1, h2, h3, h4, h5, h6, p, blockquote, pre,
a, abbr, acronym, address, big, cite, code,
del, dfn, em, font, img, ins, kbd, q, s, samp,
small, strike, strong, sub, sup, tt, var,
dl, dt, dd, ol, ul, li,
fieldset, form, label, legend,
table, caption, tbody, tfoot, thead, tr, th, td {
margin: 0;
padding: 0;
border: 0;
outline: 0;
font-weight: inherit;
font-style: inherit;
font-size: 100%;
font-family: inherit;
vertical-align: baseline;
}
/* remember to define focus styles! */
:focus {
outline: 0;
}
body {
line-height: 1;
color: black;
background: white;
}
ol, ul {
list-style: none;
}
/* tables still need 'cellspacing="0"' in the markup */
table {
border-collapse: separate;
border-spacing: 0;
}
caption, th, td {
text-align: left;
font-weight: normal;
}
blockquote:before, blockquote:after,
q:before, q:after {
content: "";
}
blockquote, q {
quotes: "" "";
}
/*
.....................................
TiddlySpace specific resets
(using #displayArea to avoid unstyling the backstage)
.....................................
*/
#displayArea #sidebar {
font-size: 100%;
right: auto;
}
#displayArea {
margin: 0;
}
.tiddler {
padding: 0;
}
a:hover {
background-color: transparent;
color: black;
}
#displayArea .title {
font-size: 100%;
font-weight: normal;
}
#displayArea h1, h2, h3, h4, h5, h6 {
border: none;
color: inherit;
/* font-weight: normal;
margin: 0;
padding: 0; */
}
#displayArea .viewer br {
margin-bottom: 24px;
content: '';
display: block;
}
#app-picker, #backstageButton {
visibility: hidden;
display: none;
}
#backstageArea {
display: none;
height: 28px;
left: 0;
position: absolute;
top: 0;
width: 100%;
}
.externalLink {
text-decoration: none;
}
.viewer h1 {
font-size: 32px;
line-height: 36px;
margin: 0px 0px 12px;
}
.viewer h2 {
font-size: 28px;
line-height: 30px;
margin-bottom: 14px;
padding-top: 4px;
}
.viewer h3 {
font-size: 24px;
line-height: 30px;
margin-bottom: 13px;
padding-top: 5px;
}
.viewer h4 {
font-size: 20px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
.viewer h5 {
font-size: 18px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
.viewer h6 {
font-size: 14px;
line-height: 24px;
margin-bottom: 12px;
}
.viewer {
line-height: 24px;
padding: 0;
}
.title {
color: #303030;
}
/*
.....................................
jBase - Grid
http://www.withjandj.com/jbase
https://github.com/Joshuwar/fragments
Licensed under GPL and MIT.
.....................................
TO-DO
- check ie6 & ie7 are compatible with row system (if not, make sure it doesn't break anything else!)
- will require selectivizr
- maybe only support this feature in modern browsers
Generic & Global
................................................................................................ */
.grid1col,
.grid2col,
.grid3col,
.grid4col,
.grid5col,
.grid6col,
.grid7col,
.grid8col,
.grid9col,
.grid10col,
.grid11col,
.grid12col {
/*
keep this here in case you need to apply something to all column sizes
*/
}
body {
min-width: 960px;
}
/* Basic Columns
................................................................................................ */
.grid1col {
width:60px;
}
.grid2col {
width:140px;
}
.grid3col {
width:220px;
}
.grid4col {
width:300px;
}
.grid5col {
width:380px;
}
.grid6col {
width:460px;
}
.grid7col {
width:540px;
}
.grid8col {
width:620px;
}
.grid9col {
width:700px;
}
.grid10col {
width:780px;
}
.grid11col {
width:860px;
}
.grid12col {
width:940px;
}
/* Columns with boxes
................................................................................................ */
.grid1col.box, .ie6 .grid1col-box {
width: 20px;
}
.grid2col.box, .ie6 .grid2col-box {
width: 100px;
}
.grid3col.box, .ie6 .grid3col-box {
width: 180px
}
.grid4col.box, .ie6 .grid4col-box {
width: 260px
}
.grid5col.box, .ie6 .grid5col-box {
width: 180px
}
.grid6col.box, .ie6 .grid6col-box {
width: 420px;
}
.grid7col.box, .ie6 .grid7col-box {
width: 500px
}
.grid8col.box, .ie6 .grid8col-box {
width: 580px;
}
.grid9col.box, .ie6 .grid9col-box {
width: 660px;
}
.grid10col.box, .ie6 .grid10col-box {
width: 740px
}
.grid11col.box, .ie6 .grid11col-box {
width: 820px
}
.grid12col.box, .ie6 .grid12col-box {
width: 900px;
}
/* Boxes within Boxes
................................................................................................ */
.box .grid1col.box {
width: 0px;
}
.box .grid2col.box {
width: 80px;
}
.box .grid3col.box {
width: 160px
}
.box .grid4col.box {
width: 240px;
}
.box .grid5col.box {
width: 320px
}
.box .grid6col.box {
width: 400px;
}
.box .grid7col.box {
width: 480px
}
.box .grid8col.box {
width: 560px
}
.box .grid9col.box {
width: 640px;
}
.box .grid10col.box {
width: 720px
}
.box .grid11col.box {
width: 800px
}
.box .grid12col.box {
width: 880px;
}
/* Rows of Boxes
(uses first/last-child pseudo elements to push rows of boxes within boxes back onto the grid)
................................................................................................ */
.row {
overflow: hidden;
}
.row .grid1col.box {
width: 20px;
}
.row .grid2col.box {
width: 100px;
}
.row .grid3col.box {
width: 180px
}
.row .grid4col.box {
width: 260px;
}
.row .grid5col.box {
width: 340px
}
.row .grid6col.box {
width: 420px;
}
.row .grid7col.box {
width: 500px
}
.row .grid8col.box {
width: 580px
}
.row .grid9col.box {
width: 660px;
}
.row .grid10col.box {
width: 740px
}
.row .grid11col.box {
width: 820px
}
.row .grid12col.box {
width: 900px;
}
.row > .grid1col.box:first-child, .row > .grid1col.box:last-child {
width: 0px;
}
.row > .box.grid2col:first-child, .row > .grid2col.box:last-child {
width: 80px;
}
.row > .grid3col.box:first-child, .row > .grid3col.box:last-child {
width: 160px;
}
.row > .grid4col.box:first-child, .row > .grid4col.box:last-child {
width: 240px;
}
.row > .grid5col.box:first-child, .row > .grid5col.box:last-child {
width: 320px;
}
.row > .grid6col.box:first-child, .row > .grid6col.box:last-child {
width: 400px;
}
.row > .grid7col.box:first-child, .row > .grid7col.box:last-child {
width: 480px;
}
.row > .grid8col.box:first-child, .row > .grid8col.box:last-child {
width: 560px;
}
.row > .grid9col.box:first-child, .row > .grid9col.box:last-child {
width: 640px;
}
.row > .grid10col.box:first-child, .row > .grid10col.box:last-child {
width: 720px;
}
.row > .grid11col.box:first-child, .row > .grid11col.box:last-child {
width: 800px;
}
.row > .grid12col.box:first-child, .row > .grid12col.box:last-child {
width: 880px;
}
/* Modifiers
................................................................................................ */
.marginleft {
margin-left:20px;
}
.marginright {
margin-right:20px;
}
.left {
float: left;
}
.right {
float: right;
}
.clearboth {
clear: both;
display: block;
overflow: hidden;
visibility: hidden;
width: 0;
height: 0;
}
.alignright {
text-align: right;
}
.alignleft {
text-align: left;
}
.aligncentre {
text-align: center;
}
/* Box modifiers
................................................................................................ */
.right.outbox, .outboxright {
margin-right: -10px;
padding: 12px 10px;
margin-left: 0px;
}
.outbox, .outboxleft {
margin-left: -10px;
padding: 12px 10px;
margin-right: 0px;
}
.box {
padding: 12px 20px 12px;
margin-bottom: 24px;
}
/* browser fixes */
.ie6.box {
width: auto;
}
/*
.....................................
jBase - Baseline & Typographic defaults
http://www.withjandj.com/jbase
https://github.com/Joshuwar/fragments
Licensed under GPL and MIT.
.....................................
TO-DO
................................................................................................
- a jquery script which checks out <p>s within an element of a certain class, checks their height, and then extends their bottom margin to the nearest multiple of 24px - so that new paragraphs come back in rhythm
- fix the 'p.large' baseline (1px out of step)
- forms
- buttons (?)
- image (& caption?) sizes, boxes etc
- Sort out the push/pull controllers with the .small and .large modifiers (padding overriden etc) - try to do this without conditional combinators... ?
*/
/* Generic & Global
................................................................................................ */
body {
font-size: 15px;
line-height: 24px;
position: relative;
}
html {
}
.jbasewrap {
width: 960px;
margin: auto;
position: relative;
padding: 0px 20px;
}
a {
text-decoration: underline;
}
/* Typography
................................................................................................ */
p {
margin-bottom: 24px;
}
.smallcaps {
font-variant: small-caps;
}
strong {
font-weight: bold;
}
del {
text-decoration: line-through;
}
dfn {
font-weight: bold;
}
em, dfn {
font-style: italic;
}
address {
font-style: italic;
}
pre, code, tt {
font-family: 'andale mono','lucida console',monospace;
}
abbr, acronym {
border-bottom: 1px dotted;
}
table {
margin-bottom: 24px;
}
th {
}
ul, ol {
margin: 0 0 24px 24px;
}
ul li, ol ul li {
list-style: disc;
}
ol li, ul ol li {
list-style: decimal;
}
li ul, li ol {
margin: 0 0 0 24px;
}
dl {
margin-bottom: 24px;
}
dl dt {
font-weight: bold;
}
dd {
margin-left: 24px;
}
blockquote {
font-style: italic;
padding-left: 24px;
}
hr {
border: none;
height: 1px;
color: #858585;
background: #858585;
margin: -1px 0 12px 0;
}
p.small, span.small, ul.small, ol.small, blockquote.small {
font-size: 12px;
line-height: 18px;
padding: 3px 0px;
}
p.large, span.large, ul.large, ol.large, blockquote.large {
font-size: 20px;
line-height: 30px;
margin: -5px 0 23px;
}
sup {
vertical-align: top;
font-size: 12px;
}
sub {
vertical-align: bottom;
font-size: 12px;
}
h1, h2, h3, h4, h5, h6 {
font-weight: normal;
}
h1 {
font-size: 32px;
line-height: 36px;
margin: 0px 0px 12px;
}
h2 {
font-size: 28px;
line-height: 30px;
margin-bottom: 14px;
padding-top: 4px;
}
h3 {
font-size: 24px;
line-height: 30px;
margin-bottom: 13px;
padding-top: 5px;
}
h4 {
font-size: 20px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
h5 {
font-size: 18px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
h6 {
font-size: 14px;
line-height: 24px;
margin-bottom: 12px;
}
h1.large {
font-size: 40px;
line-height: 54px;
margin: 0 0 12px;
padding-top: 0;
}
h2.large {
font-size: 32px;
line-height: 36px;
margin: 0px 0px 12px;
padding-top: 0px
}
h3.large {
font-size: 28px;
line-height: 30px;
margin-bottom: 14px;
padding-top: 4px;
}
h4.large {
font-size: 24px;
line-height: 30px;
margin-bottom: 13px;
padding-top: 5px;
}
h5.large {
font-size: 20px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
h6.large {
font-size: 18px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
h1.small {
font-size: 28px;
line-height: 30px;
margin-bottom: 14px;
padding-top: 4px;
}
h2.small {
font-size: 24px;
line-height: 30px;
margin-bottom: 13px;
padding-top: 5px;
}
h3.small {
font-size: 20px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
h4.small {
font-size: 18px;
line-height: 24px;
margin-bottom: 14px;
padding-top: 4px;
}
h5.small {
font-size: 14px;
line-height: 24px;
margin-bottom: 12px;
padding-top: 0px
}
h6.small {
font-size: 12px;
line-height: 24px;
margin-bottom: 12px;
}
h1.fixed, h2.fixed, h3.fixed, h4.fixed, h5.fixed, h6.fixed{
font-size: 14px;
line-height: 24px;
margin-bottom: 12px;
padding-top: 0px
}
/* Div Modifiers
................................................................................................ */
.push1 {
padding-top: 6px;
}
.push2 {
padding-top: 12px;
}
.push3 {
padding-top: 18px;
}
.push4 {
padding-top: 24px;
}
.pull1 {
margin-top: -6px;
}
.pull2 {
margin-top: -12px;
}
.pull3 {
margin-top: -18px;
}
.pull4 {
margin-top: -24px;
}
/* NEED to find a better way of doing this with small/large p's etc - JB */
p.small.push2, span.small.push2, ul.small.push2, ol.small.push2, blockquote.small.push2 {
padding-top: 15px;
}
.margintop {
margin-top: 24px;
}
.marginbottom {
margin-bottom: 24px;
}
.marginbottomsmall {
margin-bottom: 12px;
}
.margintopsmall {
margin-top: 12px;
}
.padtop {
padding-top: 24px;
}
.padtopsmall {
padding-top: 12px;
}
.padbottom {
padding-bottom: 24px;
}
.padbottomsmall {
padding-bottom: 12px;
}
.borderbottom {
border-bottom: 1px solid #ccc;
margin-bottom: 23px; /* JB - this may need modifiers for h1-6 and others, if that becomes necessary */
}
.bordertop {
border-top: 1px solid #ccc;
margin-top: -1px;
}
.bartop {
border-top: 6px solid #ccc;
}
.barbottom {
border-bottom: 6px solid #ccc;
}
.overflow {
overflow: hidden;
}
::selection { background:#ff5656; color:#fff; }
::-moz-selection { background:#ff5656; color:#fff; }
/* Forms
................................................................................................ */
/* Buttons
................................................................................................ */
/* thanks Ryan Fait - http://ryanfait.com/sticky-footer/ */
* {
margin: 0;
}
html, body {
height: 100%;
}
#wrapper {
min-height: 100%;
height: auto !important;
height: 100%;
margin: 0 auto -207px;
}
#footer {
height: 183px;
padding-top: 24px;
}
.push {
height: 207px;
}
/*
AMBIT theme v3.5
designed by J&J
Palette:
Red #ff2b2b;
off-white: #fcfcfc;
dark grey: #303030;
*/
/*
----------------------------------- Generic
*/
body {
font-family: "Helvetica Neue", Helvetica;
background: #ddb78c;
background-image: url(wood-texture.jpg);
background-attachment: fixed;
color: #303030;
}
a {
text-decoration: none;
color: #ff2b2b;
}
a:hover {
text-decoration: underline;
}
#displayArea iframe {
height: 340px;
width: 100%;
}
#displayArea button, #displayArea a.button {
font-size: 11px;
font-family: "Helvetica Neue", Helvetica;
font-weight: bold;
letter-spacing: 0.04em;
border: 1px solid #dadada;
line-height: 30px;
padding: 0px 6px;
color: #303030;
-webkit-border-radius: 2px;
-moz-border-radius: 2px;
border-radius: 2px;
-moz-background-clip: padding; -webkit-background-clip: padding-box; background-clip: padding-box;
background: #eeeeee;
background: -moz-linear-gradient(top, #ffffff 0%, #f3f3f3 14%, #ededed 51%, #eaeaea 97%, #e0e0e0 100%);
background: -webkit-gradient(linear, left top, left bottom, color-stop(0%,#ffffff), color-stop(14%,#f3f3f3), color-stop(51%,#ededed), color-stop(97%,#eaeaea), color-stop(100%,#e0e0e0));
background: -webkit-linear-gradient(top, #ffffff 0%,#f3f3f3 14%,#ededed 51%,#eaeaea 97%,#e0e0e0 100%);
background: -o-linear-gradient(top, #ffffff 0%,#f3f3f3 14%,#ededed 51%,#eaeaea 97%,#e0e0e0 100%);
background: -ms-linear-gradient(top, #ffffff 0%,#f3f3f3 14%,#ededed 51%,#eaeaea 97%,#e0e0e0 100%);
background: linear-gradient(top, #ffffff 0%,#f3f3f3 14%,#ededed 51%,#eaeaea 97%,#e0e0e0 100%);
filter: progid:DXImageTransform.Microsoft.gradient( startColorstr='#ffffff', endColorstr='#e0e0e0',GradientType=0 );
}
#displayArea button:hover, #displayArea a.button:hover {
border-color: #999;
cursor: pointer;
-webkit-box-shadow: 0px 1px 2px #c8c8c8;
-moz-box-shadow: 0px 1px 2px #c8c8c8;
box-shadow: 0px 1px 2px #c8c8c8;
background: #f5f5f5;
text-decoration: none;
}
#displayArea button:active, #displayArea a.button:active {
box-shadow: none;
-webkit-box-shadow: none;
-moz-box-shadow: none;
border: #ccc 1px solid;
}
a.button {
display: inline-block;
}
#displayArea .noButton a.button {
border: none;
background: transparent;
display: inline;
filter: none;
text-decoration: none;
color: #ff2b2b;
font: inherit;
padding: 0px;
letter-spacing: inherit;
}
#displayArea .noButton a.button:hover, #displayArea .noButton a.button:active {
-webkit-box-shadow: none;
-moz-box-shadow: none;
box-shadow: none;
border: none;
background: none;
color: #303030;
text-decoration: underline;
}
#screenWidth {
position: absolute;
z-index: 0;
left:330px;
}
#tiddlerAIM_Form div.error {
background-color: #EF6565;
color: white;
display: block;
font-weight: bold;
letter-spacing: 0.08em;
margin: auto;
padding: 5px 10px;
text-align: center;
font-size: 12px;
}
.highlight {
background: #fbff9a;
}
/*
----------------------------------- Sidebar
*/
#sidebar {
background-color: #303030;
color: #fcfcfc;
position: fixed;
height: 100%;
width: 230px;
padding: 20px;
z-index: 10;
}
#sidebar #SiteIcon {
display: block;
margin-bottom: 9px;
}
#sidebar h1 {
font-size: 13px;
line-height: 20px;
}
div#searchBox {
background-color: #303030;
margin-bottom: 10px;
}
#searchBox ul {
margin: 1px 0px 10px 0px;
padding-left: 24px;
background-color: #fcfcfc;
}
ul#searchResults {
padding-left: 0px;
}
ul#searchResults li.loading {
font-weight: normal;
font-size: 10px;
background-image: none;
cursor: default;
display: none;
}
ul#searchResults li.loading:hover {
color: #777;
}
ul#searchResults li {
list-style: none;
font-weight: bold;
color: #777;
border-bottom: 1px dotted #777;
background-image: url(v3sprite.png);
filter:none;
background-repeat: no-repeat;
background-position: 195px -593px;
cursor: pointer;
line-height: 16px;
padding: 0px 0px 5px 10px;
margin-top: 3px;
}
ul#searchResults li:hover {
color: #303030;
}
ul#searchResults li.open {
background-position: 195px -692px;
}
ul#searchResults ul {
display: none;
}
ul#searchResults .open ul {
display: block;
}
ul#searchResults ul li {
list-style: disc;
color: #303030;
padding-left: 0px;
border-bottom: none;
background-image: none;
}
#searchBox h3 {
margin: 0px 0px 0px 0px;
background-color: #fcfcfc;
font-size: 11px;
padding: 0px 0px 0px 10px;
letter-spacing: 0.08em;
color: #aaa;
}
#searchBox div.allManuals {
text-align: right;
overflow: hidden;
height: 18px;
}
#searchBox .allManuals label {
color: white;
font-size: 10px;
letter-spacing: 0.05em;
}
#searchBox input[type=search] {
background-color: #fcfcfc;
border: none;
width: 220px;
height: 18px;
padding: 5px;
font-weight: bold;
font-family: Helvetica Neue;
font-size: 13px;
margin-top: 10px;
background-image: url(v3sprite.png);
filter:none;
background-position: 209px -42px;
background-repeat: no-repeat;
margin-bottom: 0px;
}
#searchBox button#clearSearch {
background: none;
filter: none;
position: absolute;
width: 20px;
height: 20px;
border: none;
opacity: 0.6;
right: 45px;
top: 211px;
font-size: 17px;
line-height: 17px;
}
#searchBox button#clearSearch:hover {
background: none;
border: none;
box-shadow: none;
opacity: 1;
}
#sidebar .panel h2 {
font-size: 15px;
margin: 0px;
border-top: 1px #fff solid;
background-color: #303030;
padding: 0px;
background-image: url(v3sprite.png);
filter:none;
background-position: 5px -437px;
background-repeat: no-repeat;
position: relative;
}
#sidebar .panel h2 a {
color: #fcfcfc;
display: block;
padding: 0px 0px 0px 20px;
}
#sidebar button#snapshot { /* camera image from The Noun Project http://thenounproject.com/noun/camera/#icon-No476 */
background-position: 7px -992px;
background-image: url(v3sprite.png);
filter:none;
background-repeat: no-repeat;
display: block;
text-indent: -999px;
width: 30px;
height: 30px;
cursor: pointer;
z-index: 100;
position: absolute;
right: 0px;
top: 0px;
padding: 0px;
border: none;
background-color: transparent;
}
#sidebar #snapshot:hover {
opacity: 0.6;
-webkit-box-shadow: none;
-moz-box-shadow: none;
box-shadow: none;
}
#sidebar .panel h2 a:hover {
text-decoration: none;
}
#sidebar .closed ul {
height: 0px;
}
#sidebar .closed {
padding: 0px;
}
#sidebar .closed h2 {
padding: 0px;
background-position: 5px -391px;
}
.panel {
color: #303030;
font-size: 12px;
background-color: #fcfcfc;
}
.panel ul {
margin-bottom: 0px;
padding: 0px;
overflow-y: auto;
position: relative;
}
.panel ul ul {
overflow: auto;
height: auto;
}
#sidebar .panel a {
color: #303030;
}
.open {
}
#sidebar a {
color: #fcfcfc;
}
#sidebar #currentlyOpenPanel li span.close {
padding-right: 10px;
position: relative;
top: -1px;
font-size: 13px;
}
#sidebar #currentlyOpenPanel li span.close:hover {
cursor: pointer;
color: #ff2b2b;
}
#sidebar #contentsPanel ul {
margin-left: 20px;
padding-left: 20px;
line-height: 15px;
}
#sidebar #contentsPanel ul ul {
margin-left: 0px;
overflow: hidden;
}
#sidebar #contentsPanel li {
list-style: none;
margin-top: 10px;
}
#sidebar #contentsPanel li span.closed:after, #sidebar #contentsPanel li span.open:after {
content: '+';
float: left;
width: 10px;
height: 10px;
font-weight: bold;
padding-right: 10px;
position: relative;
top: -1px;
background-color: #fcfcfc;
text-decoration: none;
padding-bottom: 4px;
margin-left: -20px;
}
#sidebar #contentsPanel li span.open:after {
content: '-';
}
#sidebar #contentsPanel li span:hover {
cursor: pointer;
color: #ff2b2b;
}
/*
----------------------------------- Status and Sync Panels
*/
#rightPanel {
position: fixed;
right: 0px;
top: 30px;
width: 210px;
z-index: 1;
}
#statusPanel, #syncPanel, #messageArea, #loginForm {
position: relative;
width: 210px;
top: 0px;
background-color: rgba(241, 241, 241, 0.8);
-ms-filter: "progid:DXImageTransform.Microsoft.gradient(startColorstr=#E5FBFBFB,endColorstr=#E5FBFBFB)"; /* IE8 */
filter: progid:DXImageTransform.Microsoft.gradient(startColorstr=#E5FBFBFB,endColorstr=#E5FBFBFB); /* IE6 & 7 */
zoom: 1;
font-size: 12px;
padding-left: 10px;
font-weight: bold;
z-index: 10;
}
.ie7 #statusPanel, .ie7 #syncPanel, .ie7 #messageArea, .ie7 #loginForm {
border: 1px 0px 1px 1px #303030 solid;
}
#loginForm {
margin-top: 20px;
padding: 10px;
font-weight: normal;
font-size: 11px;
letter-spacing: 0.04em;
display: none;
}
#loginForm input {
margin-bottom: 10px;
border: 1px solid #ccc;
padding: 7px;
width: 170px;
}
#statusPanel .title {
width: 90px;
display: inline-block;
}
#statusPanel a, #statusPanel #logOutForm input {
background-image: url(v3sprite.png);
filter:none;
background-repeat: no-repeat;
background-position: 90px -592px;
display: inline-block;
width: 116px;
height: 25px;
}
#statusPanel span.plain {
float: right;
margin-right: 20px;
}
#statusPanel span.plain a {
background-image: none;
width: auto;
}
#statusPanel #logOutForm input {
font-size: 13px;
font-weight: bold;
font-family: 'Helvetica Neue', Helvetica;
color: #ff2b2b;
background-color: transparent;
border: none;
background-image: none;
text-align: left;
}
#statusPanel a.open {
background-position: 90px -692px;
}
#statusPanel a:hover {
text-decoration: none;
}
#statusPanel .dropDown {
position: relative;
background-color: transparent;
width: 200px;
padding-left: 84px;
}
#statusPanel .dropDown {
display: none;
}
#statusPanel a.browsing {
color: #74c276;
}
#statusPanel .dropDown a {
background-image: none;
padding-left: 10px;
}
#statusPanel .dropDown a:hover, #statusPanel #logOutForm input:hover {
background-color: #303030;
color: #fff;
cursor: pointer;
}
#statusTab {
position: absolute;
left: -30px;
background-color: rgba(241, 241, 241, 0.8);
-ms-filter: "progid:DXImageTransform.Microsoft.gradient(startColorstr=#E5FBFBFB,endColorstr=#E5FBFBFB)"; /* IE8 */
filter: progid:DXImageTransform.Microsoft.gradient(startColorstr=#E5FBFBFB,endColorstr=#E5FBFBFB); /* IE6 & 7 */
}
#statusTab:hover {
border-left: 2px solid black;
left: -32px;
}
#statusTab span {
background-image: url("v3sprite.png");
filter:none;
background-position: 8px -1143px;
background-repeat: no-repeat;
text-indent: -9999px;
width: 30px;
height: 30px;
display: block;
cursor: pointer;
}
#statusTab span.browsing {
background-position: 8px -1192px;
}
#syncPanel {
margin-top: 20px;
padding-bottom: 10px;
display: none;
}
#messageArea {
margin: 0px;
padding: 10px;
border: none;
line-height: 18px;
font-size: 11px;
letter-spacing: 0.06em;
font-weight: normal;
margin-top: 20px;
}
#messageArea div {
margin-right: 20px;
}
#messageArea .messageToolbar {
text-align: left;
padding: 0px;
}
#messageArea a.button {
margin-bottom: 10px;
}
#messageArea a {
text-decoration: none;
}
#syncPanel h3 {
font-size: 13px;
font-weight: bold;
padding-right: 10px;
margin-bottom: 10px;
line-height: 18px;
}
#syncPanel.error h3 {
color: #ff2b2b;
}
#syncPanel.success h3 {
color: #74C276;
}
#syncPanel p {
font-size: 12px;
line-height: 18px;
font-weight: normal;
padding-right: 10px;
margin-bottom: 0px;
}
#syncPanel ul {
padding-right: 10px;
margin: 8px 0px 10px 20px;
}
#syncPanel span {
background-image: url("v3sprite.png");
filter:none;
background-position: 0 -749px;
background-repeat: no-repeat;
display: block;
float: left;
height: 15px;
margin-top: 8px;
margin-right: 5px;
width: 15px;
text-indent: -999px;
overflow: hidden;
}
#syncPanel .negative span {
background-position: 0 -799px;
margin-top: 7px;
}
/*
----------------------------------- Tiddler layout
*/
.jbasewrap {
width: 720px;
}
#tiddlerDisplay {
padding: 30px 0px;
z-index: 1;
}
.tiddler {
background: #fcfcfc;
position: relative;
margin-bottom: 40px;
-webkit-box-shadow: 0px 1px 2px #000;
-moz-box-shadow: 0px 1px 2px #000;
box-shadow: 0px 1px 2px #000;
}
.tiddler img {
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Document the FamilyHistory via [[Make or View Client Notes]].
This element of the [[Narrative History]] relates directly to the FamilyInformalNetworkMembers, which in turn defines the whole of the informal care network relating to the young person.
!!!Specific things to ask about include:
*Psychological or psychiatric difficulties in other family members
**Is there a genetic vulnerability factor to take into account?
**Might early exposure to parental mental illness have impacted upon the young person's development?
*Substance use difficulties in parents or other family/network members?
*Who is living where?
*How do different family members spend their days?
**Employment, economic status
**A family culture of work, high achievement or unemployment, criminality, etc?
*Relationships between other key members of the family/network.
**//"Who gets on best in this family?... Who gets on the worst? Who is the peacemaker?"//
Mentalization is one of the [[Core Features of AMBIT]] and underpins all of its [[Service Delivery]]. Below is material on Mentalization in general, and there is also material on [[Mentalization in AMBIT]].
!Definition:
Combining the framework of psychoanalytic theory, attachment theory and aspects of research on social-cognitive development, a relatively new frame of reference for psychopathology and psychotherapy has been proposed by a group of psychologists working in the United States and Europe.
The core idea, mentalization (or [[Mentalizing]] as many practitioners prefer), originates as a hybrid, and not essentially novel, idea from: Philosophy of Mind, [[Attachment]] studies, [[SystemsTheory]], and [[Neuroscience|NeuroDevelopmental]], and describes a uniquely human capacity:
----
@@color(blue):
<html><CENTER><P>The imaginative activity of making sense of the actions<br>
of oneself and others<br>
on the basis of intentional mental states<br>
such as desires, feelings and beliefs.</P></CENTER></html>@@
----
!A 40 minute talk about Mentalization and AMBIT
This is film from a [[conference by MAP|<object width="640" height="360"><param name="movie" value="http://www.youtube.com/v/4YHoHphDm5U?version=3&hl=en_GB&rel=0"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/4YHoHphDm5U?version=3&hl=en_GB&rel=0" type="application/x-shockwave-flash" width="640" height="360" allowscriptaccess="always" allowfullscreen="true"></embed></object>]] in Norwich, November 2012.
<html><object width="640" height="360"><param name="movie" value="http://www.youtube.com/v/4YHoHphDm5U?version=3&hl=en_GB&rel=0"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/4YHoHphDm5U?version=3&hl=en_GB&rel=0" type="application/x-shockwave-flash" width="640" height="360" allowscriptaccess="always" allowfullscreen="true"></embed></object></html>
You can access teaching slides about mentalization here:
Go to https://docs.google.com/open?id=0B5h_CVBdhJPYa1FDcDFnTUp0QUU to download or view
Remember these slides are released under a Creative Commons Licence:
<html><a rel="license" href="http://creativecommons.org/licenses/by-nc-sa/3.0/deed.en_GB"><img alt="Creative Commons Licence" style="border-width:0" src="http://i.creativecommons.org/l/by-nc-sa/3.0/88x31.png" /></a><br /><span xmlns:dct="http://purl.org/dc/terms/" property="dct:title">Mentalization A Useful Idea</span> by <a xmlns:cc="http://creativecommons.org/ns#" href="https://docs.google.com/open?id=0B5h_CVBdhJPYa1FDcDFnTUp0QUU" property="cc:attributionName" rel="cc:attributionURL">Dickon Bevington</a> is licensed under a <a rel="license" href="http://creativecommons.org/licenses/by-nc-sa/3.0/deed.en_GB">Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License</a>.<br />Based on a work at <a xmlns:dct="http://purl.org/dc/terms/" href="http://ambit.tiddlyspace.com" rel="dct:source">http://ambit.tiddlyspace.com</a>.<br />Permissions beyond the scope of this license may be available at <a xmlns:cc="http://creativecommons.org/ns#" href="www.annafreud.org" rel="cc:morePermissions">www.annafreud.org</a>.</html>
----
!Complexities
Mentalizing is a complex and uncertain process for a variety of reasons including:
*''A person can act according to a belief that is wrong''.
*''Beliefs'' arise through a complicated interaction between sensory perceptions, memory, and motivation and so ''may change for many reasons'', perhaps because the environment has changed, or because some hidden mental process has occurred.
*Because beliefs are just //representations// of reality, ''people can have very different beliefs and feel very different emotions about apparently similar things.''
*''We do not just mentalize at a //conscious// (or verbal) //level//'', but also at a //procedural level// - which involves non-conscious and non-verbal affective (feeling-based), motor and perceptual strategies to grasp and convey mental states.
*''Mentalizing is central to understanding, regulating and communicating emotions'', since emotions relate very directly to one’s desires or goals and, beliefs about whether they are being met, or frustrated or threatened. Reflecting on one’s own beliefs, desires, and feelings is also important for maintaining a healthy inner life.
Almost all aspects of social interaction entail the capacity to mentalize: //to understand the other person's behaviour in terms of the activity that has taken place inside their minds - that may provide a good explanatory model of their actions.//
* Mentalizing emphasises the ''//uniqueness//'' and ''//specificity//'' of the human's subjective experience, and carries with it the implication that ''//making sense of this in each other//'' (or indeed at times within ourselves) ''//is a complicated task at which we are only only ever partially successful//''. See below a brief video of the famous scientist (and extraordinary communicator) Richard Feynman - describing how he came to understand that even the most basic mental functions (like counting, or reading) that we might take for granted as being the same for all of us, may in fact be conducted in extremely different ways:
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!Further material:
*There are many helpful [[Mentalizing Quotes]] that help to define this very old concept.
*There is a hierarchical series of [[Mentalizing levels]] that can be observed, and which the therapist tries to build on.
*There are [[Features of Successful Mentalizing]] that can be useful 'checklists' for therapists (and clients!)
*There are [[Features of UNsuccessful Mentalizing]] that can be useful 'checklists' for therapists (and clients!)
*There is [[The Therapist's Mentalizing Stance]] which is one of the core features of mentalizing practice.
!A Developmental Concept:
There is material on [[Developmental Considerations]], especially as they affect the //adolescent//, including video.
The rudimentary capacity to grasp mental states becomes evident in the second year of life and it continues to be refined over the whole course of our lives.
In the process of development, the perception of //goal-directed behaviour// takes on greater complexity and richness, as the nature of mental states is grasped with increasing sophistication.
!Mentalizing and Clinical work
Making sense of behaviour in this way is the cornerstone of //clinical practice//, too. Therefore, ''the ability of the clinician to mentalize'' is particularly important, especially when behaviour fails to make sense in obvious ways, or seems inexplicable. Mentalizing is fragile, though - in therapists as well as clients (in this sense it is a great "leveller" in the power dynamics of the patient-therapist relationship.)
This explains the strong emphasis on SupervisoryStructures in AMBIT - so that stimulating and sustaining our //colleagues'// mentalizing is //as important// as the work we do face to face with our clients.
!Attachment and Mentalizing:
There is an important relationship between [[Attachment theory]] and mentalization.
Attachment in infancy is primarily a behavioural or procedural construct. According to Bowlby, at about the age of three, behaviours signifying a goal-corrected partnership begin to emerge. The central psychological processes for mediating goal-corrected partnerships are the [[Internal Working Model]]s.
''Mentalizing emerges from [[Attachment Relationship]]s''
Meta-cognitive capacities, such as the capacity for psychological interpretation, are the product of the complex psychological processes engendered by close proximity in infancy to another human being, the attachment figure.
In order to develop mentalization, the individual needs:
*A symbolic representational system for mental states ([[Internal Working Model]]).
*To be able to selectively activate states of mind in line with particular intentions (attentional control).
!When Attachment is Disrupted:
Early disruption of attachment relationships creates a developmental vulnerability for a failure of the complex meta-cognitive capacities referred to above.
The relationship between attachment and mentalization, however, is //bidirectional//.
The inability to represent the mental state of the self, attentional problems, and difficulties in reflecting on the mental states of others obviously disrupts attachment relationships which in turn undermines the natural emergence of mentalizing capacities. In this way, in some families, the very process that could lead to the child overcoming problems arising out of interpersonal challenges is undermined by the difficulties in the child’s attachment system.
!When Mentalizing fails:
When the [[Attachment]] system is activated by stress/anxiety, etc, [[Attachment Behaviours]] are triggered. These behaviours function to adjust the individual's proximity to their [[Attachment Object]]. Whilst this process is active, Mentalization is effectively de-activated.
>Another way of understanding this is that the prefrontal cortex (where mentalizing occurs) is a very sophisticated and recently-evolved part of the brain, that is easily 'drowned out' by the relatively much more primitive (and "louder") brain centres such as those dealing with Attachment and Stress-Arousal.
''Crucially, this rapid (minute-by-minute) switching on and off of the mentalizing capacity occurs //in both the client/patient as well as the Practitioner// at times of high anxiety.''
Clinical work of all kinds crucially depends on a focused endeavour to understand the seemingly anomalous actions that we construe as psychopathology in mental state terms, eg mistaken beliefs, inappropriate desires, conflicting motivations, incoherent thoughts, etc.
A broad range of psychopathology can be seen as involving one or another form of specific mentalizing dysfunction.
!Pre-mentalizing stances:
Three key concepts that help to describe the “primitive” states of mind ([[Pre-mentalistic stances]]) that are adopted when mentalizing fails are:
>[[Psychic equivalence]]
>[[Pretend mode]]
>[[Teleological thinking]]
How these affect an individual and his or her relationships are laid out in [[Features of UNsuccessful Mentalizing]].
!Common Mental Health problems
We have suggested that ''all that we label as //"psychopathological"//'' may be seen as the mind misperceiving or misinterpreting the status of its own contents and its own functions. See [[Specific diagnoses and their corresponding mentalizing failures]].
!Learning Objectives for the day
The five main learning objectives for Day 1 are:
# [[Initial introductions at a Training event]] - 20 mins
# [[Developing Team Learning Objectives]] - I hr
# [[Learning about mentalizing]] - 90 mins
# [[Learning about AMBIT]] - 60 mins
# [[Learning about Active Planning]] - 2 hrs with a 20 minute break
!Possible timetable
09:15 Introductions
09:50 Team Learning Objectives
----
''10:50 Coffee break''
----
11:10 Mentalizing
----
''12:40 Lunch break''
----
1:40 - AMBIT intro
2:40 - Active Planning 1
----
''3:10 Tea break''
----
3:30 - Active Planning 2
4:20 - Questions and Discussion
4:45 - End
The AMBIT approach adopts a position of showing [[Respect for Evidence]]. The assumption is that increasing effectiveness of a team will be promoted by using evidence based methods of intervention.
Evidence based practice not only applies to interventions with young people but also applies to how services function and develop.
*''For individual clients, the aim is to achieve a positive outcome''.
*''For teams or services, the aim is to achieve positive 'value' for the population of people that the service serves.''
There are many ideas and beliefs about how to increase the 'value' of public services and this is a core theme of many government initiatives. However, the achievement of increased quality of services is often illusive and that many initiatives are either poorly implemented or abandoned before they have been properly evaluated.
The basic stance of the AMBIT approach is important in relation to a number of key themes in the 'value' literature. For example, AMBIT adopts an explicit position of respect for local expertise as a starting point for service development and change (see [[Respect local practice and expertise]]). This is a 'value' position which may contrast with some government initiatives which may suggest a different starting point for a process of change.
The work of [[Michael Porter|Increasing 'value': the work of Michael Porter]], [[John Seddon|Increasing service value: the work of John Seddon]] and others will be acknowledged in the pages linked to this theme.
Using clay, or large paper and felt pens, invite families to work together to create a portrait or 'sculpt' of their family.
Invite the family to portray themselves in an activity, such as "our family at tea time" - each member creates a self portrait and then places it in relationship to the other family members. The point is to stimulate curiosity and discussion, not to create a 'work of art'.
Each family is then invited to view and be inquisitive about the other's sculpts, initially in an active 'touring' around the various sculpts, and then in a plenary, facilitated by keyworker(s).
/***
|Name|TaggedTemplateTweak|
|Source|http://www.TiddlyTools.com/#TaggedTemplateTweak|
|Documentation|http://www.TiddlyTools.com/#TaggedTemplateTweakInfo|
|Version|1.6.1|
|Author|Eric Shulman|
|License|http://www.TiddlyTools.com/#LegalStatements|
|~CoreVersion|2.1|
|Type|plugin|
|Description|use alternative ViewTemplate/EditTemplate for specific tiddlers|
This plugin extends the core function, story.chooseTemplateForTiddler(), so that any given tiddler can be viewed and/or edited using alternatives to the standard tiddler templates.
!!!!!Documentation
>see [[TaggedTemplateTweakInfo]]
!!!!!Revisions
<<<
2009.09.02 [1.6.1] apply field-based template (if any) *before* tag-based template
| please see [[TaggedTemplateTweakInfo]] for previous revision details |
2007.06.11 [1.0.0] initial release
<<<
!!!!!Code
***/
//{{{
version.extensions.TaggedTemplateTweak= {major: 1, minor: 6, revision: 1, date: new Date(2009,9,2)};
if (!config.options.txtTemplateTweakFieldname)
config.options.txtTemplateTweakFieldname='template';
Story.prototype.taggedTemplate_chooseTemplateForTiddler = Story.prototype.chooseTemplateForTiddler
Story.prototype.chooseTemplateForTiddler = function(title,template)
{
// get core template and split into theme and template name
var coreTemplate=this.taggedTemplate_chooseTemplateForTiddler.apply(this,arguments);
var theme=""; var template=coreTemplate;
var parts=template.split(config.textPrimitives.sectionSeparator);
if (parts[1]) { theme=parts[0]; template=parts[1]; }
else theme=config.options.txtTheme||""; // if theme is not specified
theme+=config.textPrimitives.sectionSeparator;
// look for template using title as prefix
if (!store.getTaggedTiddlers(title).length) { // if tiddler is not a tag
if (store.getTiddlerText(theme+title+template))
{ return theme+title+template; } // theme##TitleTemplate
if (store.getTiddlerText(title+template))
{ return title+template; } // TitleTemplate
}
// look for templates using custom field value as prefix
var v=store.getValue(title,config.options.txtTemplateTweakFieldname);
if (store.getTiddlerText(theme+v+template))
{ return theme+v+template; } // theme##valueTemplate
if (store.getTiddlerText(v+template))
{ return v+template; } // valueTemplate
// look for template using tags as prefix
var tiddler=store.getTiddler(title);
if (!tiddler) return coreTemplate; // tiddler doesn't exist... use core result
for (i=0; i<tiddler.tags.length; i++) {
var t=tiddler.tags[i]+template; // add tag prefix to template
var c=t.substr(0,1).toUpperCase()+t.substr(1); // capitalized for WikiWord title
if (store.getTiddlerText(theme+t)) { return theme+t; } // theme##tagTemplate
if (store.getTiddlerText(theme+c)) { return theme+c; } // theme##TagTemplate
if (store.getTiddlerText(t)) { return t; } // tagTemplate
if (store.getTiddlerText(c)) { return c; } // TagTemplate
}
// no match... use core result
return coreTemplate;
}
//}}}
/***
|Name|ImageMapPluginInfo|
|Source|http://www.TiddlyTools.com/#ImageMapPlugin|
|Documentation|http://www.TiddlyTools.com/#ImageMapPluginInfo|
|Version|1.2.1|
|Author|Eric Shulman|
|License|http://www.TiddlyTools.com/#LegalStatements|
|~CoreVersion|2.1|
|Type|documentation|
|Description|documentation for ImageMapPlugin|
!!!Usage
<<<
{{{
[img[...]]<<imageMap MapName>>
}}}
applies an image map to the embedded image immediately preceding the macro. ''~MapName'' is the title of a tiddler (or a tiddler section) that contains an ''~HR-separated list'' of items, where the first line of each item is the ''tiddler to link to'' and the second line is a ''list of polygon coordinates'' using standard HTML <AREA COORDS="..."> syntax (e.g., a ''comma-separated series of X,Y pairs'': "x1,y1,x2,y2,x3,y3,...", that trace out the desired shape).
{{{
[img[...]]<<mapMaker MapName>>
}}}
adds interactive point-and-click calculation of X,Y map coordinates that are automatically entered into a text input field that you can then edit and save to a tiddler to create an ~HR-separated map definition.
<<<
!!!imageMap Example
<<<
{{{
[img[images/california.gif]]<<imageMap ImageMapPluginInfo##county_map>>
}}}
~~//(click a county to open a tiddler)//~~
[img[images/california.gif]]<<imageMap ImageMapPluginInfo##county_map>>
<<<
!!!mapMaker example
<<<
{{{
[img[images/california.gif]]<<mapMaker ImageMapPluginInfo##county_map>>
}}}
~~//(click anywhere inside image to record x,y coordinates)//~~
[img[images/california.gif]]<<mapMaker ImageMapPluginInfo##county_map>>
<<<
!!!Revisions
<<<
2009.05.14 1.2.1 added cursor changes
2009.05.13 1.2.0 add MAP/AREA elements using innerHTML
2009.05.12 1.1.1 fixed mapMaker event handling for IE
2009.05.10 1.1.0 added {{{<<mapMaker>>}}}
2009.05.10 1.0.1 open tiddlers following current tiddler instead of at top of story column
2009.05.09 1.0.0 initial release
<<<
!!!Sample Map
<<<
{{{
!county_map
San Francisco
50,231,51,225,54,222,55,226,55,231,50,231,50,231
----
San Mateo
59,252,60,242,58,239,55,238,54,232,49,233,50,240,50,244,50,249,54,253,59,252,59,252
----
Santa Clara
94,242,90,244,80,243,75,242,66,243,60,243,58,251,63,255,70,258,75,270,79,268,95,268,97,260,97,254,94,254,93,252,97,250,94,248,95,246,94,242,94,242
----
Alameda
94,223,95,242,90,243,80,242,75,241,65,242,66,235,63,225,70,224,80,226,94,221,94,224,95,225,95,231,94,223,94,223
----
Contra Costa
97,213,97,221,83,226,69,224,63,224,62,220,67,214,73,217,79,214,98,214,96,214,97,213,97,213
----
Santa Cruz
53,254,59,251,63,255,70,258,75,268,73,273,68,273,67,266,53,254,53,254
----
San Benito
117,292,116,302,114,304,110,302,111,307,104,304,101,306,91,292,91,288,87,288,87,285,73,273,75,271,78,269,96,270,116,292,117,292,117,292
----
Monterey
128,325,86,325,83,319,83,313,78,309,78,305,64,286,64,283,67,282,67,273,73,273,87,284,86,288,90,287,91,292,101,305,104,303,110,306,113,303,126,318,128,325,128,325
----
Fresno
123,266,133,278,149,271,164,269,170,261,176,261,176,257,181,258,182,254,190,252,194,245,203,237,211,243,213,248,211,253,218,267,221,276,215,276,214,278,195,278,195,282,179,282,177,285,166,285,162,289,154,291,152,294,146,294,146,302,126,318,116,304,118,302,116,299,117,290,106,278,123,265,123,266,123,266
----
Merced
114,249,117,245,142,238,145,245,148,249,153,251,152,256,143,256,136,258,130,262,125,263,106,278,96,269,97,261,99,255,113,250,114,249,114,249
----
Madera
167,243,173,243,174,239,178,238,179,234,192,227,194,228,193,235,198,232,203,236,192,245,188,252,180,254,180,258,172,257,175,261,168,260,163,269,146,270,132,278,122,266,124,263,130,262,135,258,142,256,151,256,152,252,167,243,167,243
----
Kings
162,324,161,303,164,302,164,295,162,294,162,289,153,291,151,295,146,295,146,303,128,318,128,325,161,324,162,324,162,324
----
Tulare
232,324,233,316,234,314,229,310,229,303,228,299,230,296,219,276,213,276,212,279,193,278,193,282,177,282,176,286,164,285,161,289,163,295,164,303,160,304,161,325,232,324,232,324
----
Mono
183,182,183,188,185,194,181,200,181,209,185,211,185,213,191,218,191,224,196,227,194,235,198,233,203,236,211,243,243,243,183,182,183,182
----
Inyo
241,243,320,324,233,324,233,317,235,314,229,310,229,303,228,299,231,295,220,276,217,267,211,253,213,247,211,242,242,244,241,243,241,243
----
San Luis Obispo
111,348,97,340,86,325,127,325,129,332,139,341,144,343,145,346,150,348,156,354,156,358,159,360,161,368,157,371,153,364,136,358,133,354,131,360,126,362,126,366,120,363,112,364,111,356,106,353,112,348,111,348,111,348
----
Santa Barbara
121,387,117,383,111,381,111,365,121,362,127,367,125,362,132,360,135,353,137,359,154,365,157,372,161,368,164,372,163,394,143,390,126,384,121,387,121,387
----
Ventura
186,402,175,401,163,395,163,372,166,369,172,371,177,376,186,376,193,397,186,402,186,402
----
Los Angeles
205,409,184,402,193,397,186,376,234,376,236,388,238,408,232,416,222,420,217,424,211,420,205,409,205,409
----
Kern
240,325,128,325,130,334,139,342,150,348,159,359,162,370,167,368,176,377,235,375,237,374,239,343,241,341,241,325,240,325,240,325
----
San Bernardino
392,401,320,324,240,325,241,342,238,345,236,374,234,377,237,407,256,422,264,413,290,414,303,417,386,414,390,409,392,401,392,401
----
Riverside
379,441,388,429,387,412,303,417,289,414,263,413,255,421,260,424,260,428,265,428,265,436,271,438,275,443,352,444,379,442,379,441,379,441
----
Orange
258,441,221,421,232,415,237,407,255,421,259,424,260,428,266,428,265,438,258,443,258,441,258,441
----
San Diego
322,482,284,484,280,475,276,464,270,451,258,440,264,437,272,438,275,443,283,445,321,444,321,483,322,482,322,482
----
Imperial
378,480,321,482,322,445,378,443,382,451,378,461,383,468,382,475,378,480,378,480
----
Stanislaus
113,229,95,240,98,257,113,249,118,244,141,237,132,228,127,214,124,230,112,229,113,229,113,229
----
Mariposa
168,228,154,225,151,228,148,227,147,231,144,231,145,236,141,237,143,245,151,254,165,242,172,243,172,238,177,238,177,234,191,227,194,226,189,224,184,221,181,223,178,220,169,229,157,226,153,226,151,229,152,229,168,228,168,228
----
Alpine
173,172,172,176,164,180,164,192,179,201,185,194,183,181,173,173,173,172,173,172
----
Calaveras
125,203,127,214,132,223,144,220,165,195,163,191,158,194,150,194,135,203,125,203,125,203
----
San Joaquin
108,205,97,213,97,222,94,225,95,240,113,229,124,229,127,215,125,203,120,206,107,206,108,205,108,205
----
Amador
125,189,126,194,125,203,135,203,150,194,158,194,163,191,164,179,154,186,142,189,124,189,125,189,125,189
----
Sacramento
83,212,96,213,107,205,118,205,124,203,125,195,123,188,120,180,104,180,106,189,103,197,102,203,94,206,93,210,79,212,83,212,83,212
----
Yolo
102,174,98,174,97,170,92,165,68,164,74,178,79,181,81,189,91,190,93,187,97,187,99,197,104,197,106,189,104,180,102,174,102,174
----
Solano
79,197,72,204,73,209,82,211,94,210,95,205,103,203,104,196,98,196,97,186,91,187,90,190,80,189,78,193,79,197,79,197
----
Napa
58,177,59,183,65,192,65,205,71,204,79,197,77,192,80,188,78,181,73,178,67,164,64,166,64,173,58,177,58,177
----
Sonoma
24,168,48,165,56,175,57,182,64,192,64,203,45,198,43,191,32,180,31,176,23,168,24,168,24,168
----
Marin
44,210,50,212,52,216,57,218,60,217,59,212,62,210,64,203,46,199,43,209,44,210,44,210
----
Tuolumne
165,195,144,219,131,223,132,227,142,237,146,236,145,230,149,230,149,226,154,228,155,225,169,228,178,220,182,222,185,221,190,225,190,218,185,213,185,210,180,209,180,200,165,193,164,196,165,195,165,195
----
Mendocino
10,107,16,116,16,126,15,132,20,151,21,161,24,169,50,165,43,158,46,155,46,150,43,145,45,137,53,132,53,114,56,109,11,108,10,107,10,107
----
Humboldt
21,38,17,50,19,59,12,70,9,70,1,85,2,92,10,107,31,108,33,73,32,65,39,65,39,59,45,53,43,51,44,42,33,43,30,37,21,37,21,38,21,38
----
Del Norte
24,14,19,24,20,37,29,37,32,43,37,42,38,37,35,34,42,31,43,21,50,15,24,14,24,14
----
Siskiyou
130,19,51,15,44,21,43,31,36,33,39,37,38,43,43,42,42,50,45,53,54,57,55,61,59,61,59,65,64,61,69,63,67,54,71,52,76,54,80,48,90,46,90,55,131,57,132,31,129,30,130,19,130,19
----
Modoc
183,22,130,19,131,57,179,60,182,22,183,22,183,22
----
Trinity
56,98,57,102,55,105,55,109,31,108,33,72,31,65,39,65,40,58,44,52,54,57,55,61,58,61,58,65,65,61,69,63,67,53,71,52,76,55,79,47,90,46,90,55,90,59,75,70,70,84,56,98,56,98
----
Shasta
124,95,120,96,115,94,111,96,94,96,83,97,78,95,71,98,67,96,57,98,69,84,74,70,90,59,89,54,131,57,132,93,124,95,124,95
----
Tehama
130,105,125,110,109,116,104,122,93,122,93,124,53,122,53,114,57,108,55,106,56,101,56,97,65,96,71,98,77,95,84,98,94,97,112,96,116,94,120,96,123,95,126,98,126,101,130,105,130,105
----
Lake
64,150,67,162,64,167,64,173,58,178,50,164,42,159,46,154,46,149,43,145,45,137,52,133,55,131,61,132,61,141,55,141,54,143,57,149,63,151,64,151,64,150,64,150
----
Colusa
95,143,92,149,92,156,94,164,67,163,64,151,57,149,53,143,56,141,83,142,84,140,87,141,89,143,95,143,95,143
----
Glenn
99,131,97,133,97,137,101,139,96,143,89,143,86,141,82,140,82,142,60,142,61,132,55,131,53,123,92,123,99,131,99,131
----
Sutter
113,166,111,170,111,179,103,180,102,174,97,173,97,169,93,164,92,156,91,149,108,151,108,157,113,166,113,166
----
Butte
120,143,115,144,115,146,107,151,91,149,95,143,101,139,96,137,96,132,99,131,92,123,102,122,109,116,125,109,128,117,126,124,130,128,132,135,126,140,121,138,120,143,120,143
----
El Dorado
170,160,163,160,157,164,149,164,148,167,131,166,122,177,126,188,143,188,155,185,162,180,172,176,173,172,170,169,170,160,170,160
----
Placer
171,152,146,151,138,158,135,158,129,163,121,161,113,165,111,170,111,179,120,179,122,177,131,166,146,168,150,164,157,164,163,161,171,160,171,153,171,152,171,152
----
Yuba
135,145,131,145,129,148,124,150,122,159,113,166,108,157,108,151,115,146,115,143,122,143,120,139,127,140,133,135,135,134,135,145,135,145
----
Nevada
172,143,150,142,146,139,136,144,131,144,129,148,124,150,122,161,130,164,136,157,138,158,146,151,170,152,171,143,171,144,172,143,172,143
----
Sierra
172,131,145,130,139,126,134,134,134,145,145,139,150,143,172,144,173,131,172,131,172,131
----
Plumas
141,94,124,94,126,102,130,105,125,110,128,117,126,124,130,129,132,134,140,126,145,130,168,131,171,124,169,117,154,102,149,103,148,106,141,102,141,93,141,94,141,94
----
Lassen
177,93,174,130,167,131,170,124,169,115,153,101,148,104,148,106,141,103,141,93,132,93,131,59,179,60,176,94,177,93,177,93
!end county_map
}}}
<<<
***/
!Purpose
To ensure an assessment covers all the most important elements of the client's story.
!Domains to cover
Assessment must cover ''all'' of the [[Domains]] in which a young person functions, including any StrengthsResiliencies, as well as difficulties. In parallel to the list below, you may find the [[Topics covered by the AIM - a checklist]] helpful in ensuring that important areas of enquiry are not left out.
!!!What do the young person and other people report?
These are the problems that a young person, their carers, or other professionals report
See PresentingProblems
!!!''Activities of Daily Living (ADL)''
Including Education, Employment or Training, Social activity, Self-care, and other basic 'living skills', etc.
See [[EducationEmploymentTraining]], StrengthsResiliencies,
!!!''Family''
Including family relationships, resources, etc.
See [[FamilyHistory]]
!!!''Interpersonal''
Including relationships, supports, social skills
See FamilyInformalNetworkMembers
!!!''Mental Health and Behaviour''
Which involves the intra-psychic domain (thoughts, feelings, perception, insight, etc) as well as 'externalising' behaviours (aggression, violence, etc) and [[Substance Use History]]
See PastPsychHistory
!!!''Physical/Biological''
Which includes physical health, early development, diet, drug and alcohol use, etc.
See [[Substance Use History]] (which cuts across the physical and psychological history for obvious reasons), PastMedicalHistory, DevelopmentalHistory
!!!''Network/Systems''
Including the young person's response to care, inter-agency issues (the integration or dis-integration of services working with the young person and family)
See ProfessionalNetworkMembers
In the interactive case recording version ([[ICR]]) of the manual these can be recorded at [[Make or View Client Notes]].
Add locally-relevant material here:
*Who to contact for specific problems/geographic areas?
*Existing liaison protocols?
*Etc
//{{{
jQuery(document).bind("startup", function() {
var _tmpCloneTiddlerHandler = config.commands.cloneTiddler.handler;
config.commands.cloneTiddler.handler = function(ev, src, title) {
_tmpCloneTiddlerHandler.apply(this, arguments);
var tiddler = store.getTiddler(title);
if(tiddler) {
tiddler.fields["server.workspace"] = config.extensions.tiddlyspace.getCurrentWorkspace("public"); // the default is private
}
};
});
//}}}
!THE 7 FEATURES of the perception of one's OWN Mental Functioning
!!!1. Taking a //developmental perspective//
This refers to the individual’s ability to understand that with development one’s views of others deepen and become more sophisticated and complex. For example, as the individual grows, she is able to begin to understand her parents’ actions better.
!!!2. //Realistic scepticism//
This refers to the recognition that one’s feelings can be confusing.
!!!3. Internal //conflict awareness//
This refers to the capacity of being aware of having seemingly incompatible thoughts and feelings.
!!!4. //Self-inquisitive// stance
This refers to an individual’s genuine curiosity about his own thoughts and feelings, as well as to the interest in how the way other people’s minds function (given their differences in terms of, for example, different age group, gender, culture) relates to oneself. This interest in difference leads to the questioning of one’s own assumptions.
!!!5. The awareness of the //impact of affect//
This requires the individual to have insights into how strong emotional states can distort one’s understanding of oneself and others.
!!!6. The //acknowledgment of un- or pre-conscious// functioning
This is a mentalizing strength which recognises that at any one time one may not be (fully) aware of all that one feels, particularly when conflicts arise.
!!!7. The belief in //changeability//
This denotes the appreciation that //one’s views and understanding of others can change// in line with changes in oneself.
!Keeping on Task
*In the sessions therapists will often find themselves in the position of having to hold the young people to task; that is, reminding them that the group is their group, to help them find a way through the difficulties they have experienced. A balance has to be struck between allowing the group to move at its own pace and be enjoyable enough for the young people to consider returning to it, yet holding on to its serious purpose.
*Similarly, the therapists must be mindful of their own hopes and expectations for the group, as its constant cycling of formation, dissolution and reformation around the task can be exhausting and dispiriting.
!Agenda
*The agenda for the group is left open and unstructured. This ensures that the group works in the 'here and now' rather than being a re-enactment of the traditional classroom setting, which may be perceived as aversive by some group members.
*Whilst the agenda is open, it may be appropriate for the therapists to point out the times when a topic that the group had been discussing has been suddenly dropped, and to be curious as to why people think that was.
*A degree of tenacity is required to resist the temptation to accept the initial rebuttal that often follows this line of questioning, along the lines of //"there's nothing more to say about it"// or //"it's boring"//.
>The //"It's boring"// response can be looked at with equal curiosity, calling up the double meaning of the word; 'to bore' as in to be dull, but also 'to drill into'. It may be helpful to ask a question along the lines of //"I wonder whether there was something particular about [the boring topic] that really drilled into people, got under their skin - what do you think that would have been?"//
!Managing silences:
*Notwithstanding the advantages of having an open agenda, it often leads to periods of silence, particularly at the beginning of the session, and young people may find these at least as aversive as structured teaching sessions, if not more so.
*A sensitive response is required from the therapist, who must try to be attuned to //'the music behind the silence'// and judge when it risks becoming too persecuting for the group members.
*At a certain point (perhaps earlier than group therapists working with adults might think appropriate) it is appropriate to comment on the silence, thus not entirely rescuing the group by introducing a brand new topic for discussion, but breaking the silence itself. The therapist might ask how group members are finding the silence, thus leaving it open as to where the group take this.
!Adolescent subversions
*The Therapists' role is to keep the group on track (on task): Young people in group-settings will frequently subvert the group task, turning it variously, and often creatively, into a gossip shop, a gladiatorial ring, a karaoke bar, etc.
*In responding to this daily reality of work with young people, the therapists will want to keep in mind the concept (Foulkes) of //'Foreground and Background'//:
**Behind the foreground clamour there is often something that is unsayable, or unbearable, that the group is collectively (and usually unconsciously) covering up with conversation or outright drama that effectively takes everyone’s ‘eye off the ball’.
!Foreground/Background
*Reframing is a response to this thinking about the group process:
**If there is noisy excitement and pleasure in a 'karaoke bar' atmosphere in the 'foreground', the therapist will ask herself //what silent pain is hidden in the background?//
***Empathic statements reframing the dilemma the group faces can help it to find its way back to the task:
***//"It seems hard for the group to know what to do. Is it better to drown out the painful feelings that brought everyone here in the first place - by turning the group into a karaoke bar? Or should we risk everyone getting sad by trying to think about what went wrong to bring this group together?"//
**If there is conflict in the foreground, what fear of intimacy does this mask?
***This might be reframed by commenting //"There seems to be a struggle between the idea of turning the group into a boxing ring - which could end up with people getting hurt - and listening really closely to one another's stories - which could also end up with people getting hurt. I wonder which seems the worst?"//.
!The role of the therapist:
At times more assertive interventions will be called for, to maintain the boundary of task.
*Therapists may find it helpful to think about the role they are being 'co-opted into' at these times.
*Introducing this dynamic or dilemma to the group can help to contain the group - this is an example of the [[Therapist's use of Self]].
*For instance a statement such as //"It seems to me that the group needs me to become a boxing referee/policeman - maybe that is preferable to having someone try to think about the group and understand what happens here?"//
!Looking for differences:
*In instances such as those given above it is helpful to follow up quickly by trying to look for ''differences within the group''. If the therapist's comments are dismissed by one group member, then ask:
>//"What do other people think?"// and look for different opinions that might allow a new, more task-centred dialogue to arise.
*Alternatively the therapist may wish to follow up a reframing with questions asking about group members' own experiences of similar dilemmas (an example of [[Generalize (and Consider Change)]]):
>//"Has anyone had an experience in their own past of finding it hard to have someone try to help them?"//
!Other techniques
*[[Circular interviewing]]: Asking one young person to comment on how they think another might be feeling, or why they think X made a particular comment, or why they think X might be silent; these questions exercise the function of reflection or [[Mentalization]].
*Circular interviewing helps extend cognitions beyond the belief that specific behaviours are a function of the person's character (a form of [[Psychic equivalence]]), towards recognition that they may be more motivated by the person's current state of mind.
*Circular interviewing also reinforces the fact that ''multiple perspectives'' coexist in the group, and stimulates curiosity as to what other people may make of oneself, or of the group as a whole.
**The comments of one person about another can be checked with that person: //"How did x do in explaining things from your perspective?"// or //"Has x made a good job of saying what it's like to be in your shoes?"//
**''If the commentator 'gets it wrong''' this might lead on to dialogue about how the young person being considered communicates his or her feelings, or to discussion of how, ultimately, thoughts are private, and none of us are mind readers (this is an example of the //opaque nature of other peoples' minds// (see [[Strengths in RELATIONSHIPS]].)
!Video cameras: Introducing 'Big Brother'
*Rooms used for groups may well have video cameras installed for use by other professionals, for instance family therapists. The presence of a camera may raise anxieties, and the therapist may wish to pre-empt such responses by acknowledging its existence from the beginning (and when introducing new members to the group), and clarifying the fact that it is not in use during sessions.
*If there is a camera present, it will usually draw comment, often with comparisons to the popular TV programme, 'Big Brother'. Most young people in the UK will be aware of this programme, in which a group is minutely observed by multiple cameras as they interact, before they vote each other (and are voted by the public) off the programme, the last survivor winning a large prize.
*The concept of close observation of, and critical comment upon, group processes, is therefore much more in the public domain than at previous times. This can be used by the therapists to stimulate further reflective thinking, for instance asking //"If the camera ''was'' in operation, what do you think an observer would make of this group?"//
**The group's ideas about the camera, and a hypothetical observer, can also bring information about projections upon the therapists, who are also, in part, in the role of critical observers.
**The theme of scrutiny is a preoccupation for many young people, who are struggling with the [[developmental task of identity formation|Developmental Considerations]]. **Helpful contrasts might be drawn between the boundaries pertaining in the 'Big Brother' format (which are designed to maximise conflict and drama) and those in the therapeutic group.
!Modelling relationships
*The interaction of the two therapists (preferably one male, one female) is inevitably subject to close scrutiny by the group, and provides the opportunity for modelling healthy relatedness.
*Differences between the two therapists should if possible be explored openly in the group.
>//"You saw x's outburst in that way, but I was wondering whether it could also be seen as an attempt at... What do you think? Are we being set up as 'good cop, bad cop'?"//
!Therapists well-connected
During the session therapists are encouraged to remember to maintain contact with each other (for instance through regular eye contact) to minimise the effects of the powerful processes of splitting and projective identification, which are likely to be active in the setting - this is a very immediate example of one of the [[Core features of AMBIT]], which is [[Keyworker well-connected to wider team]].
!Regular supervision
*This is important, in order to provide a reflective space in which various unconscious processes are most likely to be recognised. [[Thinking together]] is one of the AMBIT SupervisoryStructures that might help to provide this opportunity, especially focussing on the step known as [[Mentalizing the Affect]].
*In the session, catching one's own sense of relief, or even satisfaction, that the heat is on the other therapist is a good clue to their existence.
!Young peoples' ideas about us
*Along with (unconscious) drives to //split// the therapists, there are commonly fantasies in the group that the therapists' relationship extends beyond their co-working in the group, even that it contains an erotic component.
*This fantasy or 'yearning' can function as a ''group defence against anxiety''. (Technically, this is a version of what Wilfred Bion describes as 'Basic Assumption functioning - Pairing'. In this, the group 'dreams' of a //pairing of one group member with another// - something which is unconsciously associated with the production of some form of saving event, or 'saviour', for the group).
*In such a case the therapists need to balance their need for grounded 'reality-checking', with the opportunity to //become curious about what it is that the group avoids having to think about// by becoming preoccupied with their relationship.
!Why do it?
*[[Manualization]] is one of the [[Core Features of AMBIT]].
*This can be considered as an exercise in which the team //mentalizes together// about ''"what, how and why we are doing what we are doing?"''. [[Manualization]] refers to the systematic way in which the team then agrees to //record the results of these discussions//. Many team discussions result in unanimous agreement about how to deal with an issue, but this solution is then forgotten and has to be 'reinvented' again the next time the same issue arises.
*This process promotes sharing of information and knowledge about individual practitioners' and the team's practice.
*We hypothesise that repeated efforts to manualize the team's practice means that the whole manual gradually comes to represent more and more accurately the work of the team, but also increasingly //guides// and //influences// the work of the team.
*It is a pleasant coincidence that the words //mentalization// and //manualization// are so similar: our hypothesis is that a team that is manualizing itself is probably mentalizing!
>//"Why do we do that in this particular way, and not like that?"//
*The process of manualization can mean that [[Individual Differences]] are brought to light, and teams should avoid being disheartened by this, which is evidence of proper engagement in the shared task.
!Practical aspects:
!!1. Organisational aspects:
!!!!(a) Boundaries and shared responsibility
There are [[Rituals and Disciplines]] that dictate how a team does this, documented at ManualizationBoundaries.
It is important that this process is not driven and controlled by a single authority figure in the team, or by one enthusiast, but that it is seen as the responsibility of ''All team members''. As one of the [[Core Features of AMBIT]] everyone in the team should understand the nature of the [[Dynamic, adaptive Manualization]] and be prepared to offer up material for the team as one of the [[Rituals and Disciplines]] of working in this way.
!!!!(b) Making time for Manualizing
We recommend there should be a ''Manualization'' slot in [[Team Meetings]], where the team attends to the //ongoing task// of manualizing itself.
Alternatively, teams might wish to set aside a regular (say monthly) meeting specifically for this purpose - collecting an "agenda" for this from the business that has preoccupied the team in the past weeks.
!!!!(c) Allocating Roles
We recommend that there are two roles in the team meeting for manualizing, and these should not held by the same person:
* ''The Chair'' - Chairing is a skill that requires practice and some authority in the team - having a "rotating chair" may feel democratic and inclusive, but risks ineffective chairing, and loss of task.
* ''The Scribe'' - Some teams might prefer to scribe on paper, and then delegate someone to load the material into the manual later, others may want to manualize "live" into the manual, via an LCD projector.
!!!!(d) Equipment and permissions
It is helpful for an AMBIT team to have regular access to computers and to internet access.
An ''LCD Projector'' is useful, so that the manual can be projected during team meetings, and clinical discussions minuted //"in vivo"//.
[[TiddlyManual]]s run on any modern browser, but especially in accessing the other web-based materials that are embedded in the the manual, we recognise that there may be teething troubles in getting [[Organisational support for the technology to run TiddlyManuals]] and we provide pointers and resources for this.
!!2. Content: What to focus on.
See also [[What material to share in team reflection and manualization?]].
!!!!(a) Keep to //real// issues
Ideally the material a team manualizes should be related to real dilemmas or challenges that have arisen in the course of recent work - about which the team agree:
>//"Are there any specific matters that have arisen today that could have been addressed better, or which we are particularly pleased with, which should be recorded by customising our manual?"//
>//"We could do with a plan for how to deal with that kind of scenario if and when it crops up again..."//
Concentrate on keeping manualization of material as "close to the ground" as possible, looking for the areas of team working where there is perhaps some friction over what to do (//"Under what circumstances would we choose to do X rather than Y?"//, or //"Is this a situation where we are agreeing that there are range of options, and some common pitfalls to avoid?//"), or where having a shared protocol would really make a difference.
!!!!(b) Include mentalizing as part of this process
Often with live issues for a team, it is likely that this may evoke strong feelings and beliefs in the team. As part of developing ideas around a particular clinical dilemma or practice, it may be helpful to explicitly acknowledge team states of mind linked to the issue. For example, it may be helpful to acknowledge that the situation being manualized may often make people feel quite anxious or that it easily results in very different individual viewpoints and possible team conflict. The intention is that the manual is not just a dry statement of procedures but that it acts as guide to enable people to anticipate what to do and how they might feel. This is rather different from the usual protocol documents that are drawn up.
!!!!(c) Consider new staff
Think abouut the way that te team would like to ''INDUCT a NEW TEAM MEMBER into the work'' - what would we like them to understand about the way we do things round here?
!!!!(d) Highlighting local excellence:
Also, look around for excellent snippets of practice that one or other worker in the team does
>//"I noticed X has a really neat, sensitive way of asking young people about risky sexual behaviour/ introducing themselves/ managing boundary-pushing behaviour... do you think she could be persuaded to let us video her demonstrating it in a very short roleplay?"//
> Then whack this video into the manual (see [[Adding IMAGES, DOCUMENTS or VIDEO clips]].)
!!!!(e) Showing off and sharing
Consider what skills and experience the team has developed that might be of interest and use to other teams working with similar groups (see [[Community of Practice]]).
!!3. Fitting what you ADD into what is ALREADY THERE
!!!!(a) Think about how you title and tag your offerings
Using the [[+ Manualize our work]] buttons will automatically place the new material into some order, but you can add other [[Tags]] to include your material as a sub-topic of other subject areas. Use a title that is as self-explanatory as possible to help people searching.
!!4, Technical Aspects
*See [[Customising your local TeamTemplate]] or [[Understanding TiddlyManual format]] for the technical knowledge and skills (simple, honest) on how to add new material to your team's local version of the AMBIT manual (your "TeamTemplate").
!Turning the camera on oursleves
After sessions, the [[KeyWorker]]s turn the video camera upon themselves, and film a brief feedback on each family. The feedback needs to be brief, and to the point - focus on the current concerns as witnessed in the multi-family sessions (i.e. do not introduce material that has not already been presented in the 'public'/multi-family domain), emphasise what changes and improvements have been noted, and what further changes are seen as potentially helpful from this point onwards - perhaps as a focus for the next week's work. The point is to provide a clear - though (in keeping with [[The Therapist's Mentalizing Stance]]) //tentatively// stated, and always highly respectful - point of view; this will provide material for the families to then discuss and build upon in a feedback session.
!Reviewing the video
These video clips are then viewed by all the families (or a facilitated a group consisting of just parents if the children are younger.)
This meeting needs to be carefully facilitated, preferably by //someone other than the keyworkers//, who can thus maintain a more neutral/critical stance towards the keyworkers' feedback.
The review meeting takes place with everyone sat around a TV screen. The facilitator holds the remote control, showing the feedback in brief clips, stopping frequently to ask the opinions of family members (both the family being discussed, and their peers in other families) about what is being said. The facilitator encourages and models a critical stance towards the feedback - this is not "''EXPERT'' opinion", but "''AN'' opinion" - thus the video becomes an "ice-breaker" to set the context for the more crucial family-to-family feedback. The tone (//respectful, tentative// - [[Mentalizing]]) of the original video feedback thus helps to "set the tone" rather than to set the agenda or represent a "last word".
/***
|''Name''|RandomSortFilter|
|''Version''|0.1.2|
!Description
Updates the sort filter to take a keyword *random
!Usage
{{{
[sort[*random]]
}}}
***/
//{{{
(function() {
var _sort = config.filters.sort;
config.filters.sort = function(results,match) {
if(match[3] === "*random") {
results = results.sort(function(a, b) {
var r = Math.random();
return r < 0.5 ? -1 : 1;
});
return results;
} else {
return _sort.apply(this, arguments);
}
};
})();
//}}}
!Where is it?
This is the panel at the top right of your screen. You will see it as you first open the manual and then it will fold itself away leaving just a small icon:
* a ''@@color(lightgreen):Green reading book@@'' - to denote BROWSING MODE
* a ''@@color(red):Red pen@@'' - to denote EDITING or ADVANCED modes
Tapping on that icon (top right corner of your screen) will make the hidden panel unfold and reveal itself again.
<html><iframe width="640" height="480" src="http://www.youtube.com/embed/BNE2EnOTYPU?rel=0" frameborder="0" allowfullscreen></iframe></html>
!What is it for?
It is where you can [[Log in]] as a member of a particular manual (or "[[space|Spaces]]") and you can set the "mode" to determine how the manual behaves (how much you want to interact with the content). It is also one place from which you can open a page to give [[Feedback please!]]
!Logging in
See [[Log in]]
!Modes
There are three "modes".
* 1. [[Browsing mode]]:
If you are not [[logged in|Log in]] then you only have access to the ''BROWSING'' mode. This is the simplest way to use the manual. It is just a website to all intents and puposes - you can open and close pages, and that is it.
* 2. [[Edit mode]]:
If you have logged in then this option will appear. When you select it you will see that each page ([[Tiddler]]) that opens now has an "edit" icon in the top right corner; clicking this will allow you to start to [[Edit]] content in your manual.
** ''__NOTE__'': Some pages have buttons embedded in the middle of their content to start you off on [[Edit]]ing brand new material (for instance [[+ Manualize our work]], which will generate new pages ready for you to edit...)
** if you //already// have a page (such as [[+ Manualize our work]]) open when you switch to EDIT MODE, then these buttons won't appear until you have CLOSED that page, and then reopen it (you can look in the [[History recorder]] to find it again.)
* 3. [[Advanced mode]]:
This mode opens the [[Top menu bar]] across the very top of the page (//you may have to scroll up to see it.//) for more advanced actions.
** The [[Top menu bar]] gives access to additional menus that allow you to:
*** make other people [[members|Making someone a member of a space]] of this space
*** manipulate content in more complex ways
*** browse content in the wider TiddlySpace (beyond just [[TiddlyManual]]s), etc...
* 4. [[Feedback please!]]:
We also include this link, as we do want you to see it often and think of giving us feedback often! We rely on this to shape and improve the manual. Feedback can be very quick to give:
** From very quick reports of broken links, or glitches (if you can use the [[SNAPSHOT]] to send us a link to the broken bit, that would be fantastic!)
** To spending just a few minutes to fill in a short questionnaire.
** Or you can tell us we are doing OK, and make our day.
[[Respect for Evidence]] is one of the [[Core Features of AMBIT]].
There are [[Academic references]] that underpin much of the theory and practice of AMBIT (though the references included are by no means exhaustive.)
[[TiddlyManual]]s are easily editable in local versions (the "TeamTemplate") by teams taking responsibility for the way they develop their own [[local practice and expertise|Respect local practice and expertise]]. This forms a //"bespoke"// adapted manual fit for their own local needs, and also represents a reflective (mentalized) approach to the representation of TAU (Treatment as Usual) - this is very close to what Weisz et al have referred to as a "~Deployment-Focused" approach to treatment development.
In addition the manual also provides [[Comparing and Sharing functions]] that allow different teams to compare and share how they are deploying and developing this material, as part of the development and support of a [[Community of Practice]].
The [[core feature|Core Features of AMBIT]] of [[Respect for Evidence]] also promotes the active //gathering// of evidence by teams using AMBIT, building on AMBIT and developing their own best practice, and of putting this information to use in a feedback loop to practitioners. See material on [[Monitoring OUTCOMES]].
!description
A style of opposition, noncompliance, and/or refusal to follow directives from authority figures; some degree of defiance is normally expected, and behaviour should be rated as problematic only if it deviates from age and cultural norms.
!end of description
!breakdown
0 = No problem. Occasional non-compliance, but usually responds to requests when limits and rules are clear.<br>
1 = Mild. Often ignores or argues with adult requests, but will usually comply after repeated demands and limits.<br>
2 = Moderate. Ignores or refuses to comply with adult requests often (e.g. half the time);often requires threats of punishment and ultimatums to comply.<br>
3 = Severe. Most of the time that requests or demands are made refuses and engages in a battle of wills; defiance is present in more than one setting or relationship.<br>
4 = Very severe. Most interactions with adults are characterized by opposition, defiance, and conflict, leading to major behavioural, academic, and social problems, and interfering with social and cognitive development.
!end of breakdown
Families need to be engaged, just as surely as does the young person who is the 'identified patient'. Without the support of the family the practitioner is severely limited (note one of the [[Core Features of AMBIT]] which is [[Scaffolding existing relationships]]
Major problems in engaging families can occur because of issues of [[Keeping secrets/different levels of disclosure within the family]].
Alternatively, the family may already have a very strong idea/narrative about the nature of the problem and the required solution; "[[We want a hospital bed, not a home visit!]]" In this situation, any service offering something //different// from the family's agreed diagnosis and treatment will find itself struggling to engage them collaboratively.
!An exercise
Work with family members either separately or apart:
#Ask them to try to help you understand what different members of the family might hope for out of your intervention.
#Acknowledge that different people may want different things out of the work - normalise this understanding: //"because members of this family are clearly individuals!"//
#Once a family member has offered their own hopes, reflect this back - Check: have you understood this correctly?
#Then ask that member to do their best to try to guess or use their intuition to estimate what they think other members of the family may be wanting - what is similar, what is different? If they are being seen alone, then you can use a "virtual client" technique:
>//"So if we can imagine your mother sitting here, what do you think she would say if I asked her// [turning to the empty chair] //what do you really hope for out of the work we are considering?"//
The focus is on ''hopes for therapy'' - and it is important to steer family members quite actively away from the temptation of describing their //fears// about what will go wrong, who will fail to engage, etc.
In keeping with one of the [[Core Features of AMBIT]] (specifically, [[Respect local practice and expertise]]), the [[AMBIT]] worker always avoids making assumptions - especially negative assumptions - about the motivations, capacities, and intentions of other agencies and professionals.
It is easy to be drawn into very negative positions as regards these institutions and individuals, either in casual conversation with colleagues, or, worse, with the young person or family:
>//"Social Workers are always doing this...!"//
>//"Typical doctor...!"//
It is important to remember that many of the young people that an [[AMBIT]] service works with will have experience of relationship breakdown, hostility or domestic violence between the people that would ideally be working together in support of them.
It is easy for the professionals arrayed around a young person to be drawn into replicating this experience, through some of the Dis-integrativeProcesses that in turn fuel Dis-integratedInterventions.
!Biased feedback
There are ''powerful biases'' at work, insofar as we tend to remember the one //bad// outcome, rather than the many interactions that went smoothly. Also, one of the ways that young people or family members may seek to "join" with a new professional, or team, is to //criticise// the team that has referred them - so that workers in one team will often receive negative appraisals of other teams, but may overlook the possibility that similarly negative things are said about them, too!
!Using each other
In keeping with our [[SupervisoryStructures]], team members should be ready to use address with each other, in order to question, and help each other towards a more [[Integrative]] understanding of the ProfessionalNetworkMembers.
Rather than be surprised or disappointed by discovering such Dis-integrativeProcesses at work, the [[AMBIT]] worker assumes that these processes ALWAYS occur in a complex care network, and in keeping with one of the [[Core Features of AMBIT]] ([[Taking Responsibility for integration]]) s/he makes the development of a proper understanding of the different roles and responsibilities shared by the ProfessionalNetworkMembers part of everyday practice.
Using the [[How to speak to a...]] advice, and SupervisoryStructures, together with tools such as the [[Dis-integration grid]], the KeyWorker will develop a [[Mentalization]]-based understanding of the positions of individual components of the care network.
This [[Tab|Tabs]] within the [[Index]] lists [[Tiddler]]s that //have links to them, but have not got any content written//.
For instance [[This one right here...]] - if you click that link it will offer the philosophical conundrum, telling you that "this tiddler does not exist - in that nobody has given it any content - it is 'just a link'!!
Being able to list "missing" tiddlers is quite useful for authors/editors.
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This will generally require reference to multiple causes that have been working at multiple levels, or in multiple domains to cause these problems.
Consider the FamilyHistory, DevelopmentalHistory, PastPsychHistory and PastMedicalHistory - where there may be information that suggests vulnerability to stresses in the present.
/***
|''Name:''|FilterTiddlersPlugin|
|''Description:''|Filter the tiddlers in a TiddlyWiki|
|''Author''|JonathanLister|
|''CodeRepository:''|http://svn.tiddlywiki.org/Trunk/contributors/JonathanLister/plugins/FilterTiddlersPlugin.js |
|''Version:''|0.4|
|''Comments:''|Please make comments at http://groups.google.co.uk/group/TiddlyWikiDev |
|''License''|[[BSD License|http://www.opensource.org/licenses/bsd-license.php]] |
|''~CoreVersion:''|2.4|
! Usage
{{{
store.filterTiddlers(filter)
}}}
where "filter" is a filter expression, as explained below
Returns an array of Tiddler() objects that match the filter expression
! Filter expressions
Filter expressions are of the form:
{{{
filterStep | filterStep | ... // only one filterStep is required
}}}
where filterStep is of the form:
{{{
[filterElements]
}}}
where filterElements is one or more of the following:
* [TiddlerName]
* tag[TagName]
* sort[SortField]
* limit[NoOfResults]
***/
//{{{
if(!version.extensions.FilterTiddlersPlugin) {
version.extensions.FilterTiddlersPlugin = {installed:true};
TiddlyWiki.prototype.filterTiddlers = function(filter) {
var makeStore = function(tiddlers) {
if(tiddlers && tiddlers.length===0) {
return store;
}
var TW = new TiddlyWiki();
for(var i=0;i<tiddlers.length;i++) {
TW.addTiddler(tiddlers[i]);
}
return TW;
};
var findRawDelimiter = function(delimiter,text,start)
{
var d = text.indexOf(delimiter,start);
if(d==-1)
return -1;
var b = {start:-1,end:-1};
var bs = text.indexOf('[',start);
if(bs==-1 || bs >d)
return d;
var s1 = -1;
if(bs!=-1 && bs <d) {
var be = text.indexOf(']',bs);
if(be!=-1) {
b.start = bs;
b.end = be;
}
}
if(b.start!=-1 && d>b.start)
s1 = b.end+2;
return s1==-1 ? d : findRawDelimiter(delimiter,text,s1);
};
var filterTiddlers = function(filter,tiddlers)
{
var store = makeStore(tiddlers);
var results = [];
var accumulator = [];
var addToResults = function(results,tiddlers) {
for(var i=0;i<tiddlers.length;i++) {
results.pushUnique(tiddlers[i]);
}
};
var addAllToResults = function(results,toExclude) {
if(toExclude && toExclude.length) {
var titles = [];
for(var i=0;i<toExclude.length;i++) {
titles.push(toExclude[i].title);
}
store.forEachTiddler(function(title,tiddler) {
if(titles && !titles.contains(title)) {
results.pushUnique(tiddler);
}
});
} else {
store.forEachTiddler(function(title,tiddler) {
results.pushUnique(tiddler);
});
}
};
var removeFromResults = function(results,tiddlers) {
for(var i=0;i<tiddlers.length;i++) {
var n = results.indexOf(tiddler[i]);
if(n!=-1)
results.splice(n,1);
}
};
var tiddlerSort = function(field) {
// if the accumulator is empty, sort the results array
if(accumulator.length==0)
results = store.sortTiddlers(results,field);
else
accumulator = store.sortTiddlers(accumulator,field);
};
var limitResults = function(limit) {
// if the accumulator is empty, limit the results array
var arrayToSplice = accumulator.length==0 ? results : accumulator;
if(arrayToSplice.length>limit) {
arrayToSplice.splice(limit,arrayToSplice.length-limit);
}
};
if(filter) {
var tiddler, tiddlers;
var re = /([^ \[\]]+)|(?:\[((?:[ \w-+!]+\[[^\]]+\])+)\])|(?:\[\[([^\]]+)\]\])/mg;
var re_inner = /([ \w-+!]+)\[([^\]]+)]/mg;
var match = re.exec(filter);
while(match) {
if(match[1] || match[3]) {
var title = match[1] ? match[1] : match[3];
if(title=="*") {
addAllToResults(results);
} else {
tiddler = store.fetchTiddler(title);
if(tiddler) {
addToResults(results,[tiddler]);
} else if(store.isShadowTiddler(title)) {
tiddler = new Tiddler();
tiddler.set(title,store.getTiddlerText(title));
addToResults(results,[tiddler]);
}
}
} else if(match[2]) {
// loop through the nested matches of the form 'tag[word]'
var match_inner = re_inner.exec(match[2]);
while(match_inner) {
switch(match_inner[1]) {
// Note: all 'tag' case fall-through are intentional
case "-tag":
tiddlers = store.getTaggedTiddlers(match_inner[2]);
removeFromResults(accumulator,tiddlers);
break;
case "tag":
case "+tag":
tiddlers = store.getTaggedTiddlers(match_inner[2]);
addToResults(accumulator,tiddlers);
break;
case "!tag":
tiddlers = store.getTaggedTiddlers(match_inner[2]);
addAllToResults(accumulator,tiddlers);
break;
case "-sort":
// this is a syntax error
displayError(config.messages.filterSortError);
break;
case "+sort":
// this fall-through is intentional
case "sort":
tiddlerSort(match_inner[2]);
break;
case "limit":
limitResults(match_inner[2]);
break;
}
match_inner = re_inner.exec(match[2]);
}
}
// push accumulator onto results stack
for (var i=0; i<accumulator.length; i++) {
results.pushUnique(accumulator[i]);
}
accumulator = [];
match = re.exec(filter);
}
}
return results;
};
var results = [];
if(filter) {
var delimiter = "|";
var inc = delimiter.length;
var start = 0;
var end = findRawDelimiter(delimiter,filter,start);
while(end!=-1) {
results = filterTiddlers(filter.substr(start,end),results);
start = end+inc;
end = findRawDelimiter(delimiter,filter,start);
}
results = filterTiddlers(filter.substr(start),results);
}
return results;
};
// Move this to config.messages once approved
merge(config.messages,{
filterSortError:"Error in tiddler filter expression: '[-sort[field]]' is invalid; use '[sort[-field]]' instead"
});
} //# end of 'install only once'
//}}}
/***
|''Name''|TiddlyWebConfig|
|''Description''|configuration settings for TiddlyWebWiki|
|''Author''|FND|
|''Version''|1.3.2|
|''Status''|stable|
|''Source''|http://svn.tiddlywiki.org/Trunk/association/plugins/TiddlyWebConfig.js|
|''License''|[[BSD|http://www.opensource.org/licenses/bsd-license.php]]|
|''Requires''|TiddlyWebAdaptor ServerSideSavingPlugin|
|''Keywords''|serverSide TiddlyWeb|
!Code
***/
//{{{
(function($) {
if(!config.extensions.ServerSideSavingPlugin) {
throw "Missing dependency: ServerSideSavingPlugin";
}
if(!config.adaptors.tiddlyweb) {
throw "Missing dependency: TiddlyWebAdaptor";
}
if(window.location.protocol != "file:") {
config.options.chkAutoSave = true;
}
var adaptor = tiddler.getAdaptor();
var recipe = tiddler.fields["server.recipe"];
var workspace = recipe ? "recipes/" + recipe : "bags/common";
var plugin = config.extensions.tiddlyweb = {
host: tiddler.fields["server.host"].replace(/\/$/, ""),
username: null,
status: {},
getStatus: null, // assigned later
getUserInfo: function(callback) {
this.getStatus(function(status) {
callback({
name: plugin.username,
anon: plugin.username ? plugin.username == "GUEST" : true
});
});
},
hasPermission: function(type, tiddler) {
var perms = tiddler.fields["server.permissions"];
if(perms) {
return perms.split(", ").contains(type);
} else {
return true;
}
}
};
config.defaultCustomFields = {
"server.type": tiddler.getServerType(),
"server.host": plugin.host,
"server.workspace": workspace
};
// modify toolbar commands
config.shadowTiddlers.ToolbarCommands = config.shadowTiddlers.ToolbarCommands.
replace("syncing ", "revisions syncing ");
config.commands.saveTiddler.isEnabled = function(tiddler) {
return plugin.hasPermission("write", tiddler) && !tiddler.isReadOnly();
};
config.commands.deleteTiddler.isEnabled = function(tiddler) {
return !readOnly && plugin.hasPermission("delete", tiddler);
};
// hijack option macro to disable username editing
var _optionMacro = config.macros.option.handler;
config.macros.option.handler = function(place, macroName, params, wikifier,
paramString) {
if(params[0] == "txtUserName") {
params[0] = "options." + params[0];
var self = this;
var args = arguments;
args[0] = $("<span />").appendTo(place)[0];
plugin.getUserInfo(function(user) {
config.macros.message.handler.apply(self, args);
});
} else {
_optionMacro.apply(this, arguments);
}
};
// hijack isReadOnly to take into account permissions and content type
var _isReadOnly = Tiddler.prototype.isReadOnly;
Tiddler.prototype.isReadOnly = function() {
return _isReadOnly.apply(this, arguments) ||
!plugin.hasPermission("write", this);
};
var getStatus = function(callback) {
if(plugin.status.version) {
callback(plugin.status);
} else {
var self = getStatus;
if(self.pending) {
if(callback) {
self.queue.push(callback);
}
} else {
self.pending = true;
self.queue = callback ? [callback] : [];
var _callback = function(context, userParams) {
var status = context.serverStatus || {};
for(var key in status) {
if(key == "username") {
plugin.username = status[key];
config.macros.option.propagateOption("txtUserName",
"value", plugin.username, "input");
} else {
plugin.status[key] = status[key];
}
}
for(var i = 0; i < self.queue.length; i++) {
self.queue[i](plugin.status);
}
delete self.queue;
delete self.pending;
};
adaptor.getStatus({ host: plugin.host }, null, _callback);
}
}
};
(plugin.getStatus = getStatus)(); // XXX: hacky (arcane combo of assignment plus execution)
})(jQuery);
//}}}
AMBIT has a strong sense of [[Theory]], but it particularly stresses [[Theory in Practice]].
Sometimes different theoretical or explanatory frameworks, applied to the same problem in life, can appear frankly contradictory.
As a variety of interventions flow from these different explanatory frameworks, this can easily lead to services or teams inadvertently (out of the best of intentions) delivering interventions that lack overall coherence (see [[Dis-integratedInterventions]]).
AMBIT aims to explicitly to minimise this (see the one of the [[Core Features of AMBIT]] which is [[Taking Responsibility for integration]].
An earlier version of AMBIT was called [[Integrative Multimodal Practice]] which emphasises how //integration// has been central theme of AMBIT from its inception.
Alongside integrative work with differnt theories and practices, there is also a pervasive emphasis on sensitivity to the [[Cultural Context]] and the involvement of users, '[[ExpertsByExperience]]'.
!Links
[[Attachment theory]],
[[Mentalization]],
[[Biology]],
[[Psychodynamic theory]],
[[SocialCognitiveTheory]],
[[SocialEcology]]
SystemsTheory
SpecificEthnoSpiritualTheories - we leave this page open for editing by local users. Certainly [[Mentalization]] and [[The Therapist's Mentalizing Stance]] is a capacity or orientation that is well suited to trans-cultural working. Indeed, it has been argued that Mentalizing may have evolved as a capacity at least in part to allow the human species to make sense of different culturally-influenced manifestations of behaviour.
<<tabs Notes
"Management" "Important case management info for quick reference" CaseManagement
"Contact" "Daily contact records" ContactRecording
"Risk" "Risk Assessment" RiskAssessmentTab
"More" "Material on Assessment, Formulation, and Care Plan" AssessmentMoreTab>>
!Introduction
This manual has a huge amount of material about the theory and practice of mentalizing. (see [[Mentalization]] as starting point). This page will simply describe the learning about mentalizing during the first day of training.
!Learning Outcomes
(a) To know the basic idea of [[Mentalization]] and its developmental roots.
(b) To know about ''non-mentalizing'' (or the "[[Pre-mentalistic stances]]") and some of the factors that are associated with these states of mind and how to address people who are in them.
(c) To explore the basic idea by carrying out an exercise in mentalizing
!Teaching
The first two learning outcomes will be covered by a 30-45 minute didactic presentation (either live or by video) followed by questions and discussion.
!Training Exercise
There are a number of exercises that could be used to illustrate aspects of mentalizing and trainers may want to shape this depending on the group that is being trained (see [[Training exercises]]). In general the [[Passed-outwards Discussion]] has proved a useful starting exercise for this.
!Time allocation
90 minutes
!In relation to Motivational Stage of Change:
A key part of the [[Assessment for SUD-Rx]] consists of identifying which of the [[Stages of Change]] best describes your client's state of mind or motivation.
A young person in [[Pre-contemplation]] will not be interested in [[Making plans for change]], or developing [[Relapse prevention]] strategies. There is a high risk of a loss of [[Engagement]] in such circumstances.
!In relation to the here-and-now Mentalizing state:
If a client is mentalizing well (able to reflect on their own and other people's behaviours in terms of wishes, fears, feelings and the context that has influenced these) then conversation can be more challenging than if there is evidence of [[Pre-mentalistic stances]] (failed mentalizing).
This is what happens when [[Mentalization]] fails - usually in response to overwhelming affect (when feeling states overwhelm - referred to as [[Affect storms]]) or the activation of the [[Attachment]] system.
It is important to recognise that these states of mind are not in themselves //pathological// - they are just relatively 'primitive' methods of thinking. In their right place, they may be "just what is required". For instance:
* Much of a child's learning about the world is carried out through [[Pretend mode]], i.e in make-believe;
* On being threatened by a life-or-death situation, some [[Psychic equivalence]] may improve the likelihood of my taking the threat seriously and responding appropriately, and may thereby improve my survival chances!
* ditto for [[Teleological thinking]] - ''there is little survival advantage in sitting and explicitly mentalizing the tiger as he prowls towards me, salivating as he comes...''
Another way of putting this is to say that we should avoid ''"sentimentalising mentalizing"''.
!The 3 common pre-mentalistic stances are:
[[Psychic equivalence]] - 'inside out thinking'
[[Pretend mode]] - 'elephant in the room thinking'
[[Teleological thinking]] - 'quick-fix thinking'
The content of this tiddler should be customised by each team using this approach.
This is knowledge __that we don't necessarily know we have__ (what might be referred to as //"unknown knowns"//) and it relates to the [[Implicit psychoanalytic model]] that clearly connects Mentalizing approaches - which in many ways are radically //different// - to more classical forms of psychoanalysis.
This knowledge base may be acquired ((brought into explicit awareness) by each person working psychoanalytically from personal analysis, clinical work under supervision, clinical experience in psychotherapy as well as other more informal contexts such as discussions, listening to case material and so on.
See [[Broadcasting Intentions]] for how this links to mentalizing theory about the progress of therapeutic work, and one of the [[Videos]] at [[Active Planning]] describes this journey that client and KeyWorker make: from partially-shared implicit beliefs and intentions, towards larger areas of explicitly shared intentions.
This hidden, private or implicit knowledge base, if it becomes more explicit, can actually serve to guide clinical work; it contains unique information about both appropriate interventions and dynamic understandings ([[Mentalization]], in other words) of behaviour. For example, the way past relationships impact on current relationships is never fully explicated in psychoanalytic writing, yet it is the bread and butter of the daily work of psychoanalytic clinicians.
!!Addressing Specific Failures in Mentalizing, Fostering Effective Mentalizing.
Mentalization based work is aimed at reducing dysfunction in mentalizing, and encouraging successful mentalizing.
Key concepts that help to describe the ''primitive ('pre-mentalizing') states of mind that are adopted when mentalizing fails'' are described at [[Pre-mentalistic stances]].
In fact, we have suggested that ''all that we label as "psychopathological"'' may be seen as the mind misperceiving or misinterpreting the status of its own contents and its own functions. See [[Specific diagnoses and their corresponding mentalizing failures]]
----
||''It follows from this formulation that a common component of effective psychological therapy must be the restoration of normal mentalizing.''||
----
Most systems of psychological therapy recognise the important role of the patient-therapist relationship as a key ingredient of change. The most critical yet generic facet of the therapeutic relationship is the therapist's mentalizing in a way that fosters the patient's mentalizing and undoes dysfunctions of mentalizing such as those considered above.
Further, a young person's family may be in trouble as an interpersonal system because of a collective failure of mentalization where selectively or in combination the family's 'mind' no longer functions to represent the feelings, thoughts, ideas and aspirations of each of its members consistently, truthfully and comprehensively.
In these situations, just as in the case of intervention with an individual, the therapist is there as a mind who has the client's mind in mind, whether the client is an individual or the family. The kind of intensive interpersonal interaction concerning emotionally significant issues has the potential to recreate the interactional matrix of attachment in which thinking about thoughts and feelings originally develops and flourishes. This framework emphasises the process of interpretation rather than the content of any understandings. It is the act of making sense of the sense made by another which has the promise of being therapeutic, that is, if it is experienced as being understood.
This approach to psychotherapy may almost be considered one of offering developmental help to a family or system collectively stuck at a phase of individual development that antedates the acquisition of a genuine understanding of mind.
!What are you working to achieve?
There are 3 core tasks in all MentalizationBasedWork, and this involves addressing the different [[Mentalizing levels]]:
#The first concerns restoring [[Implicit mentalization]]
#The second concerns fostering [[Explicit mentalization]]
#The third and "highest" function of mentalization is learning about and fostering [[Attachment and affective mentalization]], or [[Mentalizing the Affect]].
!!Aims of individual Mentalization based work
Individual therapy with the young person (YP) has a variety of aims:
#. To ''offer the YP a relationship with an adult who has the YP's best interests as his central concern and who keeps the YP in mind''. The keyworker (KW) has an overview of the YP, his family, his social network, his school etc. An important aim is to convey to the YP the KW's central interest in the YP, as a person-who-matters within this matrix. It is possible that some of the youngsters in crisis may, due to the distress of the adults around them, have experienced a loss of this sense of mattering. Some may never have had it. It is thought that this element of the relationship with the KW is likely in itself to be containing and therapeutic.
#. To ''help the YP to bring together and integrate his experience of the other aspects of the intervention'' (family meetings, multi family meetings, adolescent group meetings, educational interventions and pharmaceutics). Wherever possible the KW will be the worker undertaking these other interventions and will therefore have seen the YP in a variety of situations. Sometimes some interventions may be made by a colleague (eg. in running an adolescent group of which the YP is a member). The KW will be in close and regular contact with any other worker involved in the programme and this will be explicit to the YP.
#. To ''provide a safe setting for the YP to express feelings and concerns and have these heard and understood''. While it will be explicit that the team will share these concerns with each other it will also be made clear that anything the YP tells the KW will not be repeated to his family or, for example in a group with other patients, without negotiation with the YP. The exception to this will be anything which makes the KW think that the YP or some other person is likely to be in danger and the family may have to be involved in keeping him safe.
#. To ''help the YP become aware of thoughts, feelings and behaviours which impact negatively on his wellbeing''. Further, to help him examine the sources and causes of these as well as the effects and to consider whether these ways of being are the most adaptive that can be achieved. This aim further divides:
##. Helping ''to make explicit rational perceptions that have been suppressed'', e.g. that a parent is ill or that the YP is at risk or is actively being harmed
##. Increasing ''awareness and understanding that some thoughts and feelings (both explicit and more implicit - less conscious), about himself and/or about others may be inaccurate'' (e.g. his belief that people know his ‘disgusting’ thoughts and therefore hate him), helping the YP develop the capacity to take a perspective on himself and others and promoting reflection about himself and his relationships. In this aim the YP's relationship with the KW may sometimes be used as the locus for the therapeutic work, encouraging the YP to think about his relationship to the KW.
#. To ''enable the young person to develop and use more adaptive psychological responses and behaviours outside of the immediate context of the therapy''. Traditionally, CognitiveBehavioural approaches have used more explicit techniques for generalising shifts in understanding and feelings into real life situations. The aim of integrated therapy would be to equally promote psychological change both within and outside the therapy itself.
!Theoretical underpinnings of the approach
The individual treatment of the young person rests on and uses a mixture of attachment theory, cognitive behavioural theory and techniques and psychodynamic theory. There are fewer techniques from psychodynamic treatment, as community-based treatment of severely disturbed young people is not a context where we see the direct application of psychoanalytic therapy techniques as appropriate. The influence of this model is more through incorporating some of the principles into the keyworker’s understanding of the motivations and problems of the young person. A derivative of psychoanalysis, attachment theory, is used more explicitly in shaping technique, as is the idea of mentalization, rooted in psychoanalysis and seen by us as underpinning therapeutic work of various orientations.
*A main assumption is that the relationship of the young person to the keyworker will provide a context where an [[Attachment]] may develop (a safe, dependent relationship on a trusted adult, within which good independent functioning can be developed), where the nature of this attachment can be examined (at least by the keyworker and perhaps by the young person) and where consistency and reliability may promote security of attachment thus leading to the possibility of enhanced reflectiveness.
*[[Cognitive Behavioural]] techniques will be used to help the young person examine his assumptions and develop more adaptive modes of functioning.
*[[Psychodynamic]] ideas will also be used to help the keyworker form hypotheses about possible unconscious reasons for the young person's behaviour. Sometimes such hypotheses will be shared with the young person if it is thought this might help. For example, if a young person is behaving in a negative and maladaptive manner which does not seem amenable to rational discussion the keyworker may see an opportunity to offer him a hypothesis about this, usually related to the way he may unconsciously be perceiving the keyworker (e.g. //"I may be wrong //{note the tentativeness in this} //but I get the impression you expect me to want to get away from you, as you feel your Dad wanted when he left you and your Mum..."//)
It is acknowledged that the theoretical integration of these theories presents potential difficulties in the implementation of therapy and that there is a risk that sessions could become theoretically incoherent. The aim of this manual is to address this risk. We believe that these difficulties are more than outweighed by the advantages of trying to address limitations in each of the theories as separate therapy models. For example, in [[Cognitive Behavioural]] work, the relationship with the therapist is seen as crucial but the nature and processes involved in establishing an effective therapeutic relationship are much less fully articulated than in psychodynamic theory.
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!Why?
This second step in the [[Mentalizing Loop]] is deployed in order to share and provoke curiosity amongst and between the family members.
!Doing it with our colleagues
Note the strong similarities (they are the same!) between this part of the Loop, and the third step in the "dance" that we call [[Thinking Together]], which describes peer-to-peer case discussion/supervision; for clarity we discuss this under the separate heading "[[Mentalizing the Affect]]".
!What does it look like?
As noted above, the most important features of a [[mentalizing stance|General features of a "Mentalizing Stance"]] are respect for, and curiosity about, the minds of others and an attitude that learning about how others are thinking and feeling is //enlightening// and //valuable// to both parties.
In fact, ''the therapist models this by her very stance'', modelling what has been called //"safe uncertainty"// (another way of describing the assumption that ''minds are opaque'' - see the [[Strengths in RELATIONSHIPS]] associated with good mentalizing]].)
She may also enquire about how others are feeling, or how the young person //believes// they might be feeling, or what they might be thinking...
She scrupulously avoids ever making //assumptions// that she //knows// about either of these things (''@@color(red):MINDS ARE OPAQUE!@@''), and she may literally or metaphorically use scratching or tapping of her head as a way of [[Marking|Marked mirroring]] very explicity the fact that
>//"these are just my ideas, I do not assume that they are TRUE, I want your help to get them more accurate to how YOU see things... "//
Thus, the therapist may say:
>//“This is fascinating, I wonder Sally what it feels like for you when your dad does x?” “Dad, what do you think it feels like for Sally? If one could see thought bubbles come out of your wife’s head, what might be in there about how she thinks Sally feels right now?”//
>//“Let me see if I got this right – are you saying that when your dad does x that makes you feel y, and you think to yourself z? Does anyone here have a different view?” “Can you discuss this with each other?!”//
Much of this is a process of the therapist [[Checking]] and encouraging family members to rehearse their own [[Checking]].
!The major aim
The major aim of this "status quo mentalizing" ...is to set a safe context for what could be termed //‘emotional brainstorming’//.
It encourages family members (or an individual) to voice feelings and theories; once mutual exploration unfolds and gains its own momentum, the therapist can decentralize herself and see her role as being that of a facilitator, enabling discussions between family members, or a kind of "exploratory self-talk" in the case of individual work.
<<tabs GroupworkTabs Principles GroupPrinciples GroupPrinciples "Sessions and Structure" GroupSessionStructure GroupSessionStructure Techniques GroupworkTechniques GroupworkTechniques>>
Whilst there are four practical "legs" that more formally define [[The Therapist's Mentalizing Stance]], below we list a more general set of features that characterise the broad "flavour" of this //"way-of-being-with"//...
These have much in common with the [[Features of Successful Mentalizing]] - as the mentalizing therapist seeks to be a focus of consistent attempts to relate through accurate (and thus compassionate) mentalization.
!!Tentativeness
This refers to the lack of absolute certainty about what is right or wrong and it also implies a preference of for viewing things as being relative and complex.
!!Humility (moderation)
This refers to having a balanced attitude to most statements about mental states, based on the acceptance of not being in a privileged position to know the contents of another person's mind.
!!Playfulness and humour
These permit interacting and reflecting in a relaxed and creative manner.
!!Flexibility
This is an attitude which allows individuals not to get ‘stuck’ in one point of view or position, but permits to change their minds in response to feedback, considering alternatives.
!!‘Give and take’
This enables individuals to solve problems, by involving others and appreciating turn-taking, implying an overall appreciation of one’s own as well as the other person’s thoughts and views. Turn-taking manifests itself of allowing space for each person to describe their experience ( “Let me tell you what I think or feel when such and such happens”) rather than defining other people’s experience or intentions.
!!‘Responsibility and accountability’
This is an attitude which takes ownership for one’s own thoughts, feelings and actions, rather than conveying a sense that these ‘happen’ to the person, implying a victim stance rather than a sense of agency.
My children:
[[TagTwoChild]]
[[OtherTiddler]]
<<tabs txtMoreTab "Tags" "All Tags" TabAllTags "Miss" "Missing thoughts" TabMoreMissing "Orph" "Orphaned thoughts" TabMoreOrphans "Shad" "Shadowed tiddlers" TabMoreShadowed>>
!description
Mood which is unusually 'high', 'giddy', manic, unrealistically happy, out of proportion to real events. Irritability associated with manic states is rated separately.
!end of description
!breakdown
0 = No problem. Normal range of mood; may be giddy/silly at times, but settles down age-appropriately in a serious situation.<br>
1 = Mild. Often silly or giddy, and has trouble settling down in serious setting.<br>
2 = Moderate. Seems markedly 'high', unrealistically optimistic, hard to focus on realistic plans and goals; this interferes with functioning in some areas.<br>
3 = Severe. Elated mood clearly interferes with functioning (e.g. stays up late at night working on projects and cannot stop, makes grandiose plans).<br>
4 = Very severe. Elated mood dominates behaviour and severely disrupts judgment and functioning (e.g. wildly excessive ideas and plans, racing thoughts, promiscuity, dramatic overspending, does not sleep for several days).
!end of breakdown
<html><div align="center"><iframe src="https://docs.google.com/Doc?id=d6h2gb4_533f69cntdc" frameborder="0" width="100%" height="600"></iframe></div></html>
The KW's communication and engagement skills are essential elements in facilitating change. For the purposes of joining, attention will be paid to the way in which ''even-handed attention'' is given to the different family members and their views and belief systems. Thus, even if these views are opposed to each other, the KW's giving equal weight to each will, at one and the same time, communicate her or his interest in understanding ([[Mentalizing]]) each person, and will begin to offer the therapeutic suggestion that more than one point of view may be valid. This stance of even-handedness, and the sense of "being in tune", will be communicated via words (e.g. reflecting language used by the family members themselves), conscious posture (e.g. mirroring), tone etc
Literally "~Self-Teaching" it means [[Self-directed learning]].
!Why monitor outcomes?
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One of the [[Core Features of AMBIT]] is [[Respect for Evidence]] - so the use of regular and systematically gathered [[Outcomes measures]] is important both for the individual worker and for the team as a whole.
!How to monitor outcomes
* Systems of outcome evaluation need to be kept very simple.
* In general, each team can decide on their own //method// of outcomes evaluation.
** The [[AIM]] is a core measure for AMBIT that can be used for assessment, treatment planning and outcome evaluation.
** A range of other useful [[Outcomes measures]] are included in the manual.
* Outcomes evaluation works best when it is integrated into the basic recording systems of the organisation i.e. how the service records its activity.
!Three types of outcomes
*''Service [[Outcomes]]'' e.g. reducing the number of young people who go to hospital, come into care or go to prision.
*''Individual [[Outcomes]]'' e.g. reduced violence, increased pro-social activity, attending college, less depressed, better relationships etc.
*''Client Satisfaction'' e.g. do young people like the service, do they attend sessions or activities, do they communicate with staff etc.
!Barriers to outcomes measurement
* "We don't have time to add this to our workload"
* "These measures are just about //performance managing ME// - they will show my bosses that I am no good, they won't understand..."
* "We send these outcomes measures off, and never hear anything back - what's he point?"
* "We are asking the wrong questions! If we were asking questions I was really interested to find out about it might be different!"
<<selectPalette>>
<<RandomColorPaletteButton>>
[_] - [[Outcome measures (T1, initial)]]
[_] - [[Outcome measures (T2, 3 months)]]
[_] - [[Outcome measures (T3, treatment close)]]
''This is the fourth stage of the [[Social-Ecological Work]] that AMBIT recomends.''
!1.Encourage realistic expectations.
* Engaging the young person in normative activities using the above scheme is clearly core to the target of stabilising their mental health.
* At the same time it needs to be acknowledged that some of the tasks required of the young person may be highly stressful, and that some of the plans may not work out the way it was hoped.
* Preparing the family and the young person for the (almost inevitable) occasional setbacks, and even failures, is important; not least because it reduces the opportunity for self-criticism by the young person, or external criticism from the family.
!2.Plan small achievable steps.
* Having said that some set backs are inevitable, it is important to grade the demands placed upon the young person (and also the family) so that if at all possible progress is made in small, achievable (and self-reinforcing) steps, and major retreats are not required.
* The KW will have to judge the (possibly widely divergent) expectations upon the young person and their surrounding family network, and encourage the compromise that offers the best chance of sustainable progress.
!3.Timing
* Monitoring of the mental state of the young person should inform the planned timetable for their introduction to more normative social interactions.
* In keeping with the encouraging of realistic expectations (see above) the worker needs to emphasise the need to titrate exposure to potentially socially stressful situations to the mental state of the young person.
* Timetables of 'what should happen when' are necessarily fluid, therefore.
!4. Preparation
* Before (re)-introducing the young person to new social situations ensure that, if required, pre-emptive planning and rehearsal has taken place. (see Mapping needs).
!5. Monitor progress
* Using the identified needs/goals, and the allocated tasks and suggested timings, monitor the progress, and feed this back to the family.
* If the process is moving more slowly than the initial plan had suggested, reframe this as evidence that the family and network are responding to the needs of the young person rather than slavishly adhering to the initial sketch for the timeframe.
* If necessary remind people of the likelihood of slips and delays that you discussed earlier.
* Keep in mind the brief overall timeframe of the intervention.
* It may be that certain parts of the rehabilitation plan will not be achieved during contact with the outreach team, and that these uncompleted tasks will have to form part of the handover when the current intervention comes to an end.
These will be arranged and delivered differently in different areas.
!Edit this for your team Template
Protocols for how to access local Crisis services can and should be recorded here by teams setting up to use the TiddlyManual, so that their own TeamTemplate carries this local information, using the [[Edit]] feature. When you have edited your Local version of this, remember to delete the tag [[Local Manualization Homework Tasks]].
Normally, Crisis services will consist of the basic emergency services (Police, Ambulance, Fire Services) as well as local arrangements for providing emergency psychiatric assessments, and emergency Social Services responses (for situations involving acute child protection concerns, etc).
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Wiki comes originally from the Maori word for "Quick" or "Fast"...
it is used to describe any collection of web-based pages that are related to a particular subject and are open to easy editing by users. Perhaps the best known example is the internet-based encyclopaedia, [[www.wikipedia.org/|http://www.wikipedia.org/]]. There are problems with web-based Wiki's such as this, in that there is little control over the quality of information put into them, and this manualization uses a new technology to get around this so that there are "valves" applied to what content can and cannot be altered. Crucially, the Tiddlymanual is not a web-based application, but a document that can live on a server, a hard disk, a USB stick, etc, rather than being open to the world.
The format of this TiddlyManual is an adaptation of this Wiki format, and the software underpinning this novel format is called TiddlyWiki.
This button/heading is found on one of the Tabs, in the [[Index]]. It lists all the [[Tiddler]]s in the whole manual, in alphabetical order. You can also use the [[Search]] facility to look for the information you want.
Sometimes young people or family members ask directly for advice.
*__''Advice-giving and PsychoEducation:''__
Giving advice has much overlap with, but is also subtly different from the kind of "curriculum-based" teaching about a particular area of difficulty (say for [[Psychosis]] or [[Depression]]) that we might choose to offer [[PsychoEducation]] for. The section on PsychoEducation has plenty of information on the more practical "how to do it" elements of imparting knowledge about an area.
* __''Not so fast! - What do you actually //want// advice about?''__
It is important to avoid moving straight into advice giving before you are completely sure about what the young person or family wants advice about, and whether you have accurate information about this area. Remember the curious, inquisitive, tentative [[The Therapist's Mentalizing Stance]].
* __''Modelling Mentalizing:''__
You can model [[Mentalization]] and the humility implied in acknowledging the //limits// of ones knowledge or understanding.
** Coupled to this, you can model the process of 'finding things out' with a young person, or family.
**Perhaps this wuld be something as simple as "phoning a friend"
**Perhaps using the Internet to search and sift your findings
**Perhaps a more intensive search strategy, such as attending a library, asking for advice, or contacting experts for specific advice.
* __''Specific Information:''__
If you need to give information or advice about issues to do with mental health, you may find useful information in the website for the Royal College of Psychiatrists (if the window doesn't display properly you can use [[this link|http://www.rcpsych.ac.uk/expertadvice/youthinfo/youngpeople.aspx]]:
----
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the tabs below contain material on Family work:
<<tabs FamilyWorkTabs
"Aims and Principles" "Aims and Principles"
"Family-Aims and Principles"
"Settings and Arrangements" "Settings and Arrangements for Family work"
"Family-Settings and Arrangements"
"Stance" "Stance"
"Mentalizing Stance in Family Work"
Techniques Techniques
"Mentalizing manoeuvres">>
This page acts as a Topic Heading (it [[Tags]] all relevant content) for material that a local team creates that describes:
''@@color(red):|<<tag [[OUR LOCAL Teamwork and Governance]]>>|@@''
Check for subtopics in the [[Show references and info]] panel for this page, or by clicking the button above and selecting from the drop-down picklist. If you are looking at the "core" AMBIT manual, rather than a local version, you won't find any material here!
[img[https://lh4.googleusercontent.com/-LsLA8EGpIJ0/URYYBCsRgJI/AAAAAAAAGyY/D4GSq5YI-M4/s512/Stance-Relationship.JPG]]
One of the [[Core Features of AMBIT]] is the principle of implementing an [[integrative|Taking Responsibility for integration]] model of practice, and this is particularly done through [[Engagement]] of the young person in an individual therapeutic [[Attachment Relationship]], in which what we call [[Epistemic Trust]] can be established (though we might just as well refer to it as "Trust" in ways - the point is that new research can tell us about establishing this kind of trust, and why it is crucial to "opening the doors" to learning from another human being.)
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!What's integrative work?
In order to support this aim, the great majority of work with the young person and his or her family and wider network is provided by a ''single specially trained member of staff'' - and developing the relationship between this worker and young person is crucial to the success of the intervention (see [[Manage CLIENT RELATIONSHIP]]).
The keyworker is familiar with the principles and techniques of a number of theoretical frameworks.
!But AMBIT's a //team-based// approach!
If AMBIT is described as a team-based approach, isn't this stress on the the KeyWorker relationship a contradiction?
Paradoxically, although great effort goes in to //reducing// the number of different individuals who actually interface with the young person and family, individual Keyworkers are very actively supported by a team of colleagues, who can provide ongoing supervision and consultation (see SupervisoryStructures). We use the idea of a "Team around a Worker" as much as the the more conventional idea of the "Team around a child". So //from the perspective of the young person and others involved in the crisis//, the work is carried out by one main person, but they will also be aware that their keyworker is supported in their work by a team that is experienced as being //active and present in the background.//
[img[https://lh3.googleusercontent.com/_gdhyTZpT12g/TcLAnmOCkYI/AAAAAAAADVE/IrjaD6PbMho/s640/AMBITSpokes_B%2BW.JPG]]
This models to the young person the way that we can all use our relationships to support the work that we do - AMBIT works very hard to avoid the dangerous illusion that any one person, //unsupported//, has the resources to sustain this work successfully. This relates to the second of the [[Core Features of AMBIT]], which is ([[Keyworker well-connected to wider team]]).
!Why work like this?
The thinking behind this is rooted in [[Attachment theory]]; what contributes to the wish to hospitalise the child (whether expressed by the YP or by the family, school, etc) is the breakdown of the perception of a [[Secure Base]]. The introduction of a key individual, (supported by a second co-worker who will be Keyworker to other patients), who is equipped and skilled at a basic ("Barefoot") level to deal with //all// aspects of the family's problems within the home context, is intended to lay the ground as quickly as possible for the re-establishment of a [[Secure Base]] for the future. The Keyworker is not a 'Jack-of-all-trades' but a "specialist generalist".
A contributory factor to the crisis may have been a collapse of confidence in the [[Family]]'s ability to cope with the young person's behaviour and problems. Thus, there is a loss of 'self-efficacy' at the Systems level, added to by a number of external systems of care coming to the aid of the family simultaneously, each trying to help the family by taking on some of the responsibility which the family are assumed no longer to be able cope with, or by taking a young person away from a family which has become unbearable to him.
In either case it is very important that through FamilyWork a service should offer strong support for the family's //own// care of the YP, [[Restoring family capacity]] by [[Scaffolding existing relationships]], if you like, rather than seeking to replace these.
In [[AMBIT]] this is provided via an integrated system delivered primarily through a single Keyworker (and his or her co-worker - keyworkers will support and cover each other for leave, study days, etc). This is a fundamental difference from the conventional [[Multi-Disciplinary Team]] or MultiAgency context whereby a variety of different services offer different types of support to different people within the crisis situation. Freqently such multi-agency input unwittingly fragments the support on offer (something we refer to as the TowerOfBabel experience.) Hence one of the [[Core Features of AMBIT]] is specifically directed at ensuring that the Keyworker is [[Taking Responsibility for integration]] through, amongst other things, the development of a therapeutic relationship that allows activation within the young person of some version of a Secure [[Internal Working Model]] of an [[Attachment Relationship]].
Having a keyworker system allows the family and its social network to be held in mind continuously, offers contact as frequently as is needed in the early stages in order to help the network to regain its effectiveness, and delivers whole range of basic interventions (that are more or less EvidenceBased) flexibly, light footedly, via a single person who is known and trusted, and //contingently// - according to the demands of the moment. (It is well known that adolescents are often poor at deferring the gratification of their wishes, and families in crisis will often also have a very limited capacity to wait for another unknown professional to arrange and deliver a specific intervention - by the time the intervention is on offer they will often feel "the moment has passed".
The Keyworker also engages with the [[Community]]
A Description of the [[Person Specifications for an AMBIT Keyworker]] is available.
[img[https://lh6.googleusercontent.com/-_T-rjCov0CA/URYYAYs29FI/AAAAAAAAGyY/8o-1XKPY65Q/s512/Stance-Governance.JPG]]
AMBIT works with high risk young people and their families, where things can go very wrong, very quickly, with potentially catastrophic implications, so unsurprisingly the adoption of clear clinical governance structures is one of the [[Core Features of AMBIT]].
This is ''analogous to the control systems within an airport'': none of us would feel comfortable flying if there were not confidence that clear, robust systems are in place that [[Manage and minimise risk|Manage RISK]] and which also learn actively from "near misses", and search pro-actively the possibility of new risks. Given that the AMBIT team is [[Scaffolding existing relationships]], where these relationships may be known to be far from ideal (but where better alternatives do not exist), the requirement for a stress on this is clear.
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Rather than presuming to 'reinvent the wheel', AMBIT recommends the adoption of __Local Risk Management and Clinical Governance structures__ and it is essential that these are implemented to high standard. Where local Clinical Governance structures are poorly defined, or inadequate, this is a matter for the wider management structures around the AMBIT team to address. There are a range of recommended [[Boundaries]] recorded and manualized in this manual help to support this.
All subsequent aspects of AMBIT are underpinned by this basic principle. Clinical Governance includes matters such as clarity in line-management and clinical supervision arrangements, appropriate Risk Management protocols, and attention to processes such as Audit that ensure the 'institution' (or team) is set up to learn from experience.
There are a series of topics within this manual relating to the management of risk, which are gathered together by the tag [[Manage RISK]]. There is a built in RiskAssessment that is based on the Hampstead Child Adaptation Measure (see an adapted form of this being embedded within this manual in the form of the [[AIM]].)
This is a tag that gathers together brief advice on the kinds of aims, beliefs, and intentions that ProfessionalNetworkMembers may hold, as well as the common dilemmas that they might face in their day to day work. If the KeyWorker is to act upon one of the [[Core Features of AMBIT]], which is [[Taking Responsibility for integration]], then the capacity for [[Mentalization]] must be applied to these other workers.
One important principle in the KW's integrative work is to link the family with resources in the community. The community is multi-layered, but an important element of it is the group of [[ExpertsByExperience]] and their families, who are able to contribute in unique ways to supporting the YP and family during and after their time of acute crisis.
They, like the KW, have the experience of having to integrate the different aspects of the intervention, and are experts both in their own past difficulties and in how the intervention could be helpful in pulling together better support for the YP currently in severe difficulties. The past users and their families will be involved at both the level of practical mentoring and advising of the young person and the family, and at the level of participating in planning and managing the service.
We have suggested that ''all that we label as //"psychopathological"//'' may be seen as the mind misperceiving or misinterpreting the status of its own contents and its own functions:
!Trauma
Trauma and its re-experiencing in flashbacks (PTSD) may entail a collapse of mentalizing, evident in an experience of mind-world correspondence wherein mental states are equated with reality ([[Psychic equivalence]]) while simultaneously the sufferer is decoupled from current reality ([[Pretend mode]]).
!Depression
Depression entails the adoption of an over-involvement with mood-related cognitions ([[Psychic equivalence]] in relation to negative self statements, and statements about the world, or the future.)
!Borderline personality
May be viewed as a fear of minds - with a proneness either to avoid mentalizing - using [[Teleological thinking]], or at times to engage in //over-active// (pseudo)-mentalizing that is nonetheless inaccurate ([[Pretend mode]]) and may be overinterpreted ([[Psychic equivalence]]).
!!Psychosis
May be seen as an an overactivity of mentalizing, with [[Psychic equivalence]]
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!Introduction
The [[SupervisoryStructures]] in AMBIT are designed to counterbalance the potentially destabilising effects of privileging an [[Individual keyworker relationship|KeyWorker]] with clients who are potentially disturbed and/or disturbing. Hence AMBIT stresses as //equally important// the need for a [[Keyworker well-connected to wider team]]. The principle way of developing coherence in a team is to develop a strong culture of disciplined communication about the work, which we call [[Thinking Together]].
!Learning Outcomes
(a) To understand the impact of affect on workers, and their own capacity to [[mentalize|Mentalization]].
(b) To understand the value to a worker of being accurately mentalized by a colleague in relation to a specific clinical problem.
(c) To know (and have practised) the four steps of [[Thinking Together]]
!Training Exercise 1:
* Discussion in small groups or pairs about the impact of clients upon workers, and the inevitability of anxiety on the work (10 minutes)
* The [[Passed-outwards Discussion]] - FOLLOWED by discussion of the [[Ripples in a Pond]] and the [[Dive Boat]] analogies to illustrate the effect of proximity to affect on mentalizing capacity, and the function of the team in this respect.
!Didactic Teaching
A 20 minute didactic presentation to explain anxiety in the workplace, and the unhelpfulness of shame as a response to this. Then we describe the 4 steps of [[Thinking Together]] and show the two videos of 'Thinking Apart' and 'Thinking Together', followed by questions and discussion. Emphasise the "Airline Safety Talk" analogy (put your own mask on before attending to your child) - see [[Mentalizing the Affect]].
!Training Exercise 2:
Practise [[Thinking Together]]
!Time allocation
90 minutes
!Hmmm...!
Could you please define what you wanted to do (the task you had marked out for yourself when you opened the manual, which we have not provided a simple path for) ...and then give us [[Feedback please!]]
!Use your team
AMBIT stresses that we often think ([[Mentalize]]) more clearly when we are communicating with people to whom we feel securely attached. Hence the stress on SupervisoryStructures. Consider talking to a team member. Practice [[Thinking Together]] with a colleague.
!Check for help:
There is technical help at [[Using the Manual]]
There is advice for how to get outside help at [[Feedback please!]]
!description
Depression may be manifest in sadness, tearfulness, irritability, lethargy, boredom, etc.; one of the principal factors being an inability to take pleasure in normally pleasurable things. Lack of activity or withdrawal associated with negative symptoms of psychosis are not rated unless there is clear evidence of dysphoric mood.
!end of description
!breakdown
0 = No problem. Is sad in response to normal stressors, appropriate range of affect.<br>
1 = Mild. Often sad, bored, or irritable, may cry often, is noticed by others as appearing sad, but also has periods of happiness and can engage in normal activities with pleasure.<br>
2 = Moderate. Seems sad, bored, or irritable much of the time, does not engage in normally enjoyable activities.<br>
3 = Severe. Appears sad, bored, irritable, or withdrawn almost all the time, cannot persist in normal activities, does not seem to derive pleasure from anything, may express morbid or suicidal ideation.<br>
4 = Very severe. Sad, tearful, or withdrawn almost all the time, is inactive and disengaged, cannot be cheered up by any intervention; sleep, appetite, and activity level may be affected; persistent morbid or suicidal ideation.
!end of breakdown
In 1943 Abraham Maslow described a helpful ''hierarchy'' of human needs and motivations, and this is helpful to bear in mind for [[Active Planning]].
This is simplified and adapted in the [[Active Planning Map]] - a tool to help develop collaborative care planning.
!!!The KEY POINT
...is that trying to address needs in the higher levels before needs in the lower levels have been met is pointless, even dangerous, and is likely to lead to rapid dis-engagement by a young person or family who perceive you as not only unhelpful, but potentially threatening (by taking thero attention off more IMMEDIATE and PRESSING needs.
[img[https://lh3.googleusercontent.com/-neZc5Nv-1-o/US_1Vtzyc4I/AAAAAAAAHFM/7Xezqpdyh0k/s434/maslow-need-hierarchy.gif]]
!1st (highest): @@color(blue):~SELF-ACTUALISATION Needs@@
The motivation to realize one's own //maximum potential and possibilities//. This is the "master motive" or the only real motive; all other (lower) motives are variants on this theme. But Self-actualization can only be pursued in itself, once lower level needs have been satisfied. Examples of people fully achieving this are rare (Gandhi, Dalai Lama, etc) - includes morality, creativity, spontaneity, etc...
!2nd: @@color(green):ESTEEM Needs@@
Self esteem and the esteem of others; confidence and achievement.
!3rd: @@color(lightgreen):LOVE & BELONGING Needs@@
Friendship, Family, Social, and (in adults) sexual intimacy.
!4th: @@color(orange):SAFETY & SECURITY Needs@@
This level acknowledges the yearning for a predictable world in which injustice and inconsistency are under control. Safety and Security needs include: Personal security (safety from violence or theft, for instance, but also basic SHELTER and CLOTHING), financial security, health and well-being, and having some form of safety net against accidents/illness and their adverse impacts. Such features have been lacking for most of human history, but at this point are mostly satisfied in the "First World" -- although the poor, and crucially the YOUNG, must often still address these needs. In considering young people we should include [[Child Protection]] needs at this level.
!5th (most basic): @@color(red):PHYSIOLOGICAL Needs@@
For the most part, physiological needs are obvious - they are the literal requirements for human survival. If these requirements are not met (with the exception of clothing and shelter), the human body simply cannot continue to function. They include Breathing, Food, and Sexual activity. Lack of air and food will kill an individual. A lack of sexual activity would mean the extinction of humanity, probably explaining the strength of the sexual instinct in individuals.
! First steps
1. Go to [[Active Planning]] - this describes how to go about developing a rational and safe plan for how to approach a young person and their family's complex difficulties.
2. There is a helpful checklist at [[Starting a NEW CASE - CheckLists]] which lays out all the necessary tasks for you to go through.
3. If you have completed an [[AIM]] assessment, then look at [[AIM suggested interventions]], which is designed to give you a variety of ways of sorting, ranking and sequencing the different [[Specific interventions]] that you might select.
!Still need help?
!1. I am lost!
You may find support in [[I'm stuck: what next?]] or KeepingYourBearings.
The KeyWorker in [[AMBIT]] offers great flexibility - the ability to shift from one intervention to another very quickly, so as //to maintain a sense of momentum//. For instance, it is not necessary to wait for the arrival of the Family Therapist before some family work can take place //if that is what is called for here today.// This is about providing [[Contingent|Contingencies]] care. However, working with so many options immediately at hand requires a systematic approach to sequencing interventions, and structures to assist the keyworker in KeepingYourBearings.
!2. Consider Hierarchy of Need
Placing the [[Formulation and Treatment Aims]] within a hierarchy/sequence may also be helped by using a modified version of Maslow's HierarchyOfNeed. the most basic needs MUST be supplied BEFORE trying to work on higher order needs. (If a child is not ''safe'' then no amount of perfectly-delivered and sophisticated psychotherapy will deliver what he or she needs.
!3. Maintaining engagement
This is ALWAYS a Treatment Aim.
Included in the generation of [[Formulation and Treatment Aims]] should be the identification of some achievable "QuickWins" which, although they may not feed into the sequence of interventions directed at major treatment aims, are nonetheless effective as a tool for assisting [[Engagement]], or to instil optimism if work in other areas appears to be "stalling".
Recognise the need for //parallel planning// and the capacity to switch flexibly between different tasks. It is very important to keep a sense of momentum.
!4. A Balancing act:
@@color(green):Sensitivity@@ & @@color(red):Chaos@@ Vs A @@color(green):"Clear Steer"@@ & @@color(red):Rigidity@@
The KeyWorker always tries respond with sensitivity to ServiceUserFeedback in choosing what tasks to focus on, and when. However, ''__an important balance must be struck__'', because //alongside// the valued capacity to provide:
> ''[[Contingent|Contingencies]] Care'' - i.e. to be guided by, and responsive to, a young persons' demands..
...there is often //also// the need to provide:
> ''Clear and authoritative guidance''; a "clear steer" for a young person and family in crisis.
Responding to the latter requirement //avoids// the KeyWorker being carried along by the chaos that may characterise the young person's life.
!5. Using the team
The use of the team SupervisoryStructures assists in this latter task, harnessing the reflective meta-position of team members/supervisors to help to provide a reflective stance and to avoid the pitfall of the KeyWorker becoming paralysed (for instance by the quite understandable avoidant tendencies within the family and young person as regards very challenging psychological work.)
!5. Direct and Systemic work
There is a balance to be found between Face-to-face work Vs. Liaison/networking.
The KeyWorker will bear in mind the need to balance face-to-face contact with the need to be [[Working with the Professional Network]]. One of the earliest of the Treatment Aims (see[[Formulation and Treatment Aims]]) will be the development of a strong therapeutic alliance (attachment security) with the young person and family, and this will necessarily require more direct (face-to-face) contact time in the early stages. However, the keyworker may calculate an advantage in the opportunity of gaining one of the identified QuickWins if an external agency can be rapidly recruited to provide (for instance) benefits assistance.
Measuring Outcomes is one aspect of the core stance feature, [[Respect for Evidence]]. There are a wide range of outcomes measures available within this manual, and others that may be used in their place. Teams will need to decide which ones to use.
!The AIM - more than just an outcomes measure
The [[AIM]] provides a 'front door' into the manual, linking assessment material on an individual to suggestions for evidence-based interventions that are present in the manual.
It also acts as a more detailed outcome measure as it offers a multi-domain assessment framework that includes numeric ratings for each problem/strength area. The items identified in the AIM as "Key Problems" can (and should) be repeated at the end of treatment.
!Other measures
The [[CGAS]], [[SDQ]], [[Clinical Global Impression (CGI)]], [[TOP - Drug and Alcohol Outcomes]] and [[HoNOSCA]] are all well validated measures, and are also included here.
Peter Fuggle is a clinical psychologist by background and has worked in a number of CAMHS services since he qualified in 1984. Since 1995, he has been Clinical Director of Islington CAMHS and has worked on the AMBIT Project at the Anna Freud Centre since 2007.
Peter has had a long standing interest in developing services for young people and their families who are not explicitly help seeking from professional services. These young people have traditionally been described as 'hard to reach'. In Islington Peter contributed in developing a joint agency team managed by social care to work with adolescents on the edge of care. This team known as the Adolescent Multi-Agency Support Service (AMASS) has adopted a number of the features of the AMBIT approach.
Along with Dr Dickon Bevington, Peter is one of the senior AMBIT trainers in the AMBIT Project based at the Anna Freud Centre in London.
!Mentalizing manoeuvres
This is a series of pages that all contain practical techniques that are designed to foster or sustain mentalizing in young people or families. Because Mentalization-based treatments draw heavily on a range of other models of working (arguing that most therapy that is effective has the effect of increasing mentalizing) some of these techniques are more "generic" than others...
!!General Systemic/Therapy Techniques
#[[Engagement techniques]] or "Joining"
#[[Hypothesizing]]
#[[Circular interviewing]]
#[[Enactments]]
#[[Focussing on Strengths]]
#[[Problem solving]]
#[[Challenging techniques]]
#[[Family Life Space (Genogram) Techniques]]
#[[Reframing]]
#[[PsychoEducation]]
!!Specific Mentalizing manoeuvres
#[[Mentalizing Loop]]
#[[Colombo-style Curiosity]]
#[[Pause and Review]]
#[[Feeling Spinner]]
#[[Mind-Scanning]]
#[[Simmering Down]]
#[[Therapist's use of Self]]
#[[Taking a break]]
#[[Coaching]]
#[[Training Challenge]]
#[[Stethoscope Games]]
#[[TV phone-in or Documentary games]]
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This is an old medical abbreviation for "Recipe" which means TREATMENT in ordinary English
''Sessions/Contacts/Medication''
<<tag ClinicalContactNotes>>
<<newJournal label:"New record" focus:text text:"Type your client record here. In addition to documenting what happened, include the following: (i) a brief account of the mental state, especially if it has changed. (ii) an update of the risk assessment, especially if it has changed in any way (iii) a clear plan for what you plan to address next session. (iv) Finally, tag this entry with any [[Specific interventions]] that you delivered." title:"YYYY-0MM-0DD 0hh:0mm - Clinical Contact Note" tag:ClientNotes:ClinicalContactNotes>>
!
''Medications''
<<tag PrescribedMedication>>
<<newJournal label:"New record" focus:title text:"Delete these instructions. Give details of the medication. WHO is prescribing? WHAT is the DOSE? WHEN is it taken and HOW (tablet, syrup, etc), any WARNING signs to look out for?" title:"JUST START TYPING to overwrite the name of the prescribed medication." tag:ClientNotes:PrescribedMedication>>
!
''Themes and Warnings''
<<tag ClinicalThemes>>
<<newJournal label:"Record New" focus:title text:"You can delete these notes and over-write them.
If a theme occurs it may be difficult to fit it into the other categories, but these may be helpful in making hypotheses or coming to novel treatment approaches.
This is already tagged with ClientNotes and ClinicalThemes; add any additional tags that might help sort this entry in the future." title:"JUST START TYPING TO OVER-WRITE THIS: Title for CLINICAL THEME here" tag:ClientNotes:ClinicalThemes>>
!
<<tag OtherWarnings>>
<<newJournal label:"Record New" focus:title text:"You can delete these notes and over-write them.
Ensure that any serious warnings are refelcted in the Risk Assessment.
Do NOT include Allergies or Medications here - they are recorded separately.
This is already tagged with ClientNotes and OtherWarnings; add any additional tags that might help sort this entry in the future." title:"JUST START TYPING TO OVER-WRITE THIS: Title for CLINICAL THEME here" tag:ClientNotes:OtherWarnings>>
!
''Take Home messages''
<<tag TakeHomeMessages>>
<<newJournal label:"Record new" focus:text text:"Type any specific messages for the client (the young person or family) here. This will have been discussed in a [[Reflective quorum]] such as [[Team Meetings]] before being entered here.
REMEMBER to TAG this message with the name of the Team Member making the comment" title:"YYYY-0MM-0DD 0hh:0mm - Take Home Msg." tag:ClientNotes:TakeHomeMessages>>
!Introductory comments:
Compared to the immediacy of the concrete steps suggested by a plan, treatment [[Aims and Goals]] are more distant pointers/directions - that act like the compass and map for the therapeutic journey, providing the [[Intentional stance]] and intermediate [[waymarks|Agreeing Waymarks]] against which progress can be measured.
The [[Aims and Goals]] will shape those changes that various parts of the system ([[Family|FamilyInformalNetworkMembers]], ProfessionalNetworkMembers) consider to be ''the minimum change necessary'' to make a real, and positive difference.
!Taking Aim
[[Taking Aim]] is a specific aspect of the AMBIT approach to [[Active Planning]], that takes into account the fact that a young person's, the family's and also the worker's //ideas about the goals of work// may change over time, but that [[Goals-based outcome measures]] are also immensely helpful. Aims and Goals cannot be set until there is first clarity about what resiliencies and problems are present within, and around the young person/their family/carers. We recommend the [[AIM]] assessment as one way to approach determining [[What's the problem?]] that you as a worker are being invited to help with.
!Consulting widely
The ''Treatment aims'' are drawn up ''in consultation with the young person and their'' FamilyInformalNetworkMembers; they represent the best attempt to reach a prioritised and achievable set of outcomes.
In order to understand ([[Mentalize]]) these desired changes accurately you will need to understand the young person's views, as well as those of other parts of the young person's system; the FamilyInformalNetworkMembers, and the ProfessionalNetworkMembers. Use the [[Dis-integration grid]] to help with this task. The use of SupervisoryStructures in your team is crucial in this stage of [[Active Planning]]
!Drawing up Aims
AMBIT is not a monolithic approach, with predefined treatment aims - although developing the young person's or their family's [[Relationship to help]] is likely to be one aim.
Consider //all// the major functional domains:
!@@color(red):Patient priorities@@
What does the young person most need to see changing in order for him or her to think "since seeing you, things have started to get better." (In the event of //disagreement// about the extent, or worrisomeness, of mental health symptoms, you can also make reference to professional observations/aims on mental state under "Health priorities" below.) Consider also the [[StrengthsResiliencies]] that might usefully be built upon.
!@@color(red):Family/carer priorities@@
Ditto for the family/carers. Include professional observations on family-functioning, and be clear //whose aims are whose// if there are differnt perspectives on what the problem(s) is (are).
!@@color(red):Health priorities@@
Are there significant health priorities, such as mental or physical health-related risks? Include the risk of deterioration, and bear in mind the developmental trajectory of the young person (in childhood and adolescent developmental terms, 'standing still is going backwards'.)
!@@color(red):Education + Vocation priorities@@
Are there requirements for new opportunities or support in order to maintain or recover trajectories into adulthood?
!@@color(red):Social-ecology and Cultural priorities@@
Is there a need to support culturally relevant integration into normative activities and contact with existing local community resources? Think of sports groups, youth resources, faith networks, groups serving specific cultural or ethnic populations...
!@@color(red):Professional network priorites@@
Are there examples of [[Dis-integrativeProcesses]] or [[Dis-integratedInterventions]]that require correction? In relation to the <<tag [[Care Plan]]>> consider what conversations may be required to achieve the desired integration/coordination... Use a [[Dis-integration grid]] to help clarify what you know and do not know about the different aims within the system, and to determine how best to reduce [[Dis-integration]] between these.
!Conflicting Aims:
Sometimes there are CONFLICTING treatment aims:
>//the family wants more control over their son who they see as behaving recklessly... the son wants more freedom for himself, from a family that he sees as overlooking his nearly-adult status, and treating like a younger child..//
In this case the task of the KeyWorker is to find a position to which all parties can sign up as the MINIMUM change that they could agree upon. (In the example given, they might not agree on practical details, but they might agree that they want to see the number of arguments at home reduce from twice daily to once weekly, and for them not to escalate to violence.
!Changing Aims
Sometimes aims need to be altered during the course of treatment (new information, changing circumstances, etc)
...then record these in a NEW Formulation (if you are using the manual in [[ICR]] mode, you can do this at [[Make or View Client Notes]]
!Once aims are agreed:
You should record these as the conclusion of your [[Formulation and Treatment Aims]] of the case.
!Aims and the Plan
Treatment Aims should shape the [[Care Plan]] - they are overarching targets, where the Care Plan is more specific and practically-oriented. See [[Active Planning]] for advice on how to do this.
!description
Obsessional ideas are recurrent, persistent thoughts, impulses, or images that enter the mind despite the person's efforts to exclude them, often recognized by the person as unrealistic. Compulsive behaviours are repetitive and purposeful behaviours associated with a subjective sense that they must be carried out, e.g. checking, washing.
!end of description
!breakdown
0 = No problem. No obsessive or compulsive symptoms, can tolerate changes in routine without anxiety.<br>
1 = Mild. Adherence to routines or habits, with some anxiety or anger when interfered with e.g. perfectionistic regarding homework and spends extra time each night checking and double-checking.<br>
2 = Moderate. Routines and fixed ideas impact functioning and cause conflict or require major adaptation by caregivers, e.g. family must rearrange schedule to accommodate hour-long showers twice a day, preoccupation with intrusive thoughts causes daily distress.<br>
3 = Severe. Obsessions or compulsions dominate daily functioning and interfere with social and cognitive development, e.g. compulsive counting/checking interferes with schoolwork, pervasive preoccupation with cleanliness leads to isolation and restriction of activities.<br>
4 = Very severe. Incapacitated by rituals or compulsions, e.g. refuses to leave home because of fears of contamination, cannot speak or move because of indecision
!end of breakdown
Having explicit goals with a young person is entirely consistent with the AMBIT approach. It is linked to encouraging focus on both the client and the practitioner's intentionality. The most common goal based measure used in the UK is the one adopted by the CAMHS Outcomes research Consortium (CORC).
!AMBIT and GBO's
This is also strongly in keeping with the AMBIT approach to developing and "attuning" plans about the work, described in [[Active Planning]] and especially in relationship to the ideas about [[Taking Aim]].
See also [[Advice on setting Treatment Aims and Goals]]
!!!AIM and GBO's
The [[AIM Form]] (AMBIT Adolescent Integrative Measure) the 40 – item multi-domain assessment adapted from the validated Hampstead Child Adaptation Measure and embedded in the AMBIT manual offers a version of "GBO's" (Goals based outcomes). In the AIM, up to 6 items can be identified as “[[Key Problems]]”, which can form key targets or treatment goals of a treatment [[Care Plan]]. Thus, insofar as such treatment goals cannot be created //"out of thin air"// by the clinician and client, post-treatment measurement of these “Key problems” acts as a "partially-constrained" version of “~Goals-Based Outcome Measures”
!Read more?
Forms and guidance for the CORC goals-based measures can be easily downloaded from the CORC website [[here|http://www.corc.uk.net/resources/measures/child/]].
See also p.74 of the UK's Child IAPT (Improving Access to Psychological Therapies) document: [[Duncan Law and the IAPT CO-OP Group (2012). Using Service User Feedback & Outcome Tools]] (this document is embedded in this page, below:
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An important influence on any family-based intervention (see [[SystemsTheory]]) arises from an understanding of the social context within which the family and its members function. Traditionally, environments are thought of as a set of concentric circles, each nested within another, the individual at its centre, surrounded by the nuclear family, extended family, friendship network, neighbourhood network, and community.
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It is self-evident, and very much at the core of our understanding of these families, that difficulties within one ecological context are never independent of what is happening in others, therefore effective intervention at the level of the family must entail attention to problems in the school or peer context, and even more broadly to cultural pressures, that can arise for example because of the minority status of the family. These pressures may be eased by helping the family to understand the way in which they interact with the more immediate tensions within the family, or - where the external social system (such as a school or social services) is serving the family poorly, this may be helped by enabling this aspect of the system to understand the family. [[Attachment]] processes also operate between the individual and social systems, and detachment from these systems, and the institutions representing them such as school or neighbourhood, is known to be a risk factor for mental health problems. Working towards a reattachment is highly desirable, and this can be begun within a crisis intervention.
!description
Difficulties with sleep and arousal, including insomnia (difficulty initiating sleep), excessive daytime sleepiness, nightmares, night terrors, sleep apnoea, sleepwalking, and narcolepsy. Rated on the basis of how much distress and functional disturbance is associated with the problem, regardless of whether sleep is the primary concern.
!end of description
!breakdown
0 = No problem. May sometimes wake during the night, but sleeps again without difficulty, no persistent problems.<br>
1 = Mild. For example, consistent difficulty in going to sleep (up to 1 hr.), nightmares, or night waking causing daytime fatigue.<br>
2 = Moderate. Major difficulties that disrupt functioning, e.g. complains consistently of initial insomnia of more than an hour's duration; sleeping excessively during the day, sleepwalking that causes family disruption OR reversed sleep-wake cycle.<br>
3 = Severe. For example, nightly difficulties sleeping that leave them exhausted during the day and interfere with personal and/or family functioning, sleeping excessively during the day, narcolepsy symptoms interfere with school or social functioning, mania causes person to sleep only 3 hours per night.<br>
4 = Very severe. Nightly difficulties that constitute an acute risk to safety or development, e.g. agitated sleepwalking or night terrors that lead to aggressive or uncontrollable behaviour, young person in psychotic break does not sleep for several days.
!end of breakdown
''FORMULATION and TREATMENT AIMS:''
<<tag [[Formulation and Treatment Aims]]>>
<<newJournal label:"Record new" focus:text text:"JUST START TYPING to overwrite these instructions.
!PRESENTING PROBLEMS
!UPSTREAM (BACKGROUND) factors
!TRIGGER factors
!MAINTAINING factors
!RESILIENCIES
!LIKELY BARRIERS to TREATMENT
!TREATMENT AIMS" title:"YYYY-0MM-0DD 0hh:0mm - Current case FORMULATION" tag:ClientNotes:Formulation>>
!
''CARE PLAN:''
<<tag [[Care Plan]]>>
<<newJournal label:"Record New" focus:text text:"JUST START TYPING to overwrite these instructions. Refer to [[Formulation and Treatment Aims]] and the [[RiskAssessment]].
!LIKELY (CRISIS) CONTINGENCIES:
Add content here....
!PLANNED CARE/TREATMENTS:
Add content here....
." title:"YYYY-0MM-0DD 0hh:0mm:0ss - Current CARE PLAN" tag:ClientNotes:[[Care Plan]]>>
!Definitions
This is a particular and important aspect of human relationships. Between a KeyWorker and young person, it does not mean that they are 'attached' in a //sentimental// way. It refers to the way that a person responds to another at a time of stress. Do they seek proximity (the reassurance of being close, that allows them space to think ([[Mentalization]]), or do they push away, etc? The different (increasingly ingrained and automatic) responses to distress and to caregiving/authority figures, are what is described by the different [[Attachment Definitions]]
The tag <<tag [[Attachment]]>> gathers together other material relating to this.
!Development of Mentalizing within an attachment relationship.
[[Mentalization]] develops in children within their [[Attachment Relationship]]s: if a mother is able to respond "contingently" (i.e. according to the demands of the baby's condition; see [[Contingencies]] for how this is carried into [[Cognitive Behavioural]] approaches) and to apply [[Marked mirroring]] of her baby's mental state-
!Inexact Science:
Remember that the stage of change is not a static thing, and like [[Mentalization]] it is in a constant state of flux - you are looking for a broad estimate of where the young person is //at this point in time...//
!!Ask the following questions:
To help clarify which of the [[Stages of Change]] your client is in...
!1. How important?
How important does it feel for you to change now?
* Scale 0 - 100
* Where 0 is completely unimportant and 100 is the Most Important thing.
!2. How confident?
How confident are you about making those changes?
* Scale 0 - 100
* Where 0 is no confidence and 100 is complete confidence.
!3. How far?
How far have you got in the journey towards making those changes?
* Scale 0 - 100
* Where 0 is "haven't started any planning yet" and 100 is "job done".
!Record your findings:
This should be recorded in your notes.
>//If you are using this manual as an [[ICR]], then you can record this in the [[Formulation and Treatment Aims]] (you do this via [[Make or View Client Notes]]) to record your estimation of this.//
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Here we address issues that relate to working with the common problems that arise in working with the professional networks around a young person and their family. Click the [[Show references and info]] panel to see the sub-topics under this heading.
!Reframing expectations
In AMBIT we are not //suprised// or //disappointed// by [[Dis-integrated|Dis-integrativeProcesses]] practice, but instead we //expect it// - addressing this is one of the [[Core Features of AMBIT]], which we call [[Taking Responsibility for integration]].
!Note on definition
Although the [[Family]] is often the most important part of a young person's network, we locate issues to do with Family under [[Manage CLINICAL PROBLEM]] - this is because the 'Family-as-a-whole' can in many respects be seen as the client.
MBIO is an earlier name given to the practice of [[AMBIT]].
MBIO (''~Mentalization-Based Integrative Outreach''), and ''Integrative Multimodal Practice'' [[IMP]] described early workings of this approach.
See [[AMBIT: an overview]] for more detail in what this refers to.
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This the //emotional state// (happy, sad, fearful, calm, etc).
Feelings in-the-here-and-now are referred to as the person's //"affect"//, while feelings "averaged out" over a period of time are also referred to as //"mood"//.
!Feeling influences [[Behaviour]]
For instance, if I am feeling depressed I am less likely to go out to meet my friends. If I am anxious I am more likely to 'snap' at friends, etc etc...
![[Behaviour]] influences Feelings
E.g. If I don't go out I am more likely to feel lonely... and more depressed. so far, so obvious...
![[Thinking]] influences Feeling
If I repeatedly think to myself "I am a failure" or "nobody wants me around" the very act of "running" such thoughts in my mind is likely to depress me.
An analogy that can be helpful in explaining this is [[MP3's are like thoughts]]
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<h2>OpenID</h2>
<h3>Why OpenID?</h3>
<a href="http://openid.net/"><img src="/bags/common/tiddlers/openid.png" alt="openid" ></a><br />
Use just one username and password across hundreds of OpenID-enabled sites.<br />
It's an open standard.<br />
<a href="http://openid.net/what/">learn more</a>
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|''TEAM MEMBERS ARE LISTED UNDER RELATED INFORMATION (above left)''|
This is a tag that gathers the names of all current team members together. [[Why name team members in an individual client record?]]
!Keeping Team members up to date:
When there are changes to the team, be sure to adjust this in the main TeamTemplate manualization, here:
<<newJournal label:"Add new team member" focus:title text:"The team member may wish to add a few BRIEF lines of autobiography here, i.e. 'I am a nurse, my area of special interest is..., when I'm not working I enjoy...' (NB do try to avoid un-boundaried self-disclosure.)" title:"Start typing to add your name as WikiWord" tag:[[Team members]]>>.
!If an existing team member leaves:
Remember to delete their name from the TeamTemplate.
This is for advanced users and is not required for day to day use of [[TiddlyManual]]s.
It involves starting an an entirely separate wiki - that you can use for lots of different things (see @dickon for an example) but which are separate from //this// wiki!
*Ensure you are [[Logged in|Log in]] as a user.
*Go to your [[User menu]]
*You will see a button saying ''"Create Space"'' and a box above to give your new space a name. If the name you choose is already taken then you'll need to choose a new one!
*If you want to work on the current space that you have opened //with someone else//, but you //don't want to make them a member// (which would give them completely equal rights over the content with you) then check the box that says ''"Include the current space in the new space"'' - this will make a new space that [[includes|Including spaces]] the original - you can then make your colleague a member of that space and while your original material remains untouched, the two of you can hack away at the new version to your heart's content.
!Welcome to the AIM
This is a highly interactive assessment, that can be filled in on your computer. ''ALTHOUGH THE ASSESSMENT IS ONLINE, NO PATIENT DETAILS THAT YOU ENTER LEAVE YOUR LOCAL COMPUTER'' (this is because the whole website is effectively downloaded and runs from within your local computer when you open the site.)
A 'paper' version of the AIM is also available to download [[Here|https://docs.google.com/Doc?docid=0AZh_CVBdhJPYZDZoMmdiNF80OTRnaHIzdDdnNA&hl=en_GB]].
You can see [[Topics covered by the AIM - a checklist]] to help guide the assessment interview.
!What to do:
!! Please fill in these details:
|Name / Unique ID: |<<option txtAIM_ID>> |
|Date of assessment: |<<option txtAIM_date>> |
|Name of assessor: |<<option txtAIM_assessor>> |
#The PRACTITIONER SCORES this questionnaire, not the young person, though it can be done collaboratively. (A self-report version (playing cards) is under development - contact AFC for details.)
##During the initial assessment, score all 40 items.
##You may need to go back to the young person to gather more information.
##Aim to complete this within one week of first contact.
#"KEY PROBLEMS": Limit these to a maximum of SIX - this may require careful consideration.
##Key problems are those that appear to be the most important TARGETS for intervention.
##They will act as your ~GOALS-BASED OUTCOME MEASURES.
##These are things that the young person and family should help you identify. Ultimately it is the practitioner's decision (a young person with psychosis may not agree that this is the case, for instance - which does not mean that treating this is not an important treatment goal to measure your outcomes against.)
#ONCE COMPLETED:
##At the bottom of this form there are instructions on how to:
###Export the results to a database
###List and rank ''//suggested interventions//'' according to the results of the specific AIM assessment (useful to help you develop your [[Care Plan]].) This function only works if your AIM is embedded in a treatment manual, not if you are accessing the AIM site as a separate resource.
#Use for OUTCOMES
##When you start a specific intervention directed at a specific problem, use the relevant item(s) on the AIM to measure progress with the problem(s).
##When you end a complete treatment episode, re-score the KEY PROBLEMS to act as [[Goals-based outcome measures]].
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This is linked to [[Cognitive Behavioural]] work, and refers to [[Implicit Core Beliefs]] about oneself; particularly a person's (or group's) belief in their ability to cope and achieve - by //their own// ability, strength and resourcefulness.
FamilyWork is often directed at increasing the Self-efficacy of the [[Family]] as a whole, which may "lose confidence" that it could ever manage the behaviours displayed by a young person without external/professional support.
[[Motivational Work]] stresses the need to "Support Self-efficacy" - this involves taking the client's [[Autonomy]] very seriously - allowing THEM to be the author of any change in their lives, //not// the KeyWorker or therapist. Sometimes this will mean accepting that a person is choosing //not// to stop a damaging behaviour at this time.
In adulthood this is relatively simple - the adult is generally considered responsible for his or her choices. However, with young people, //and in particular where there are [[Child Protection]] concerns//, supporting self-efficacy is sometimes more an ideal that shapes practice than the sole reality at play.
!Purpose
Explain why risk assessment is important and provide a downloadable assessment.
!Why assess risk
Risk Assessment is a key part of good clinical practice and [[Clinical Governance]] (which is one of the [[Core Features of AMBIT]]. A clear framework for enquiring about risk - especially those risk factors that research has proven to be significantly associated with poor, even fatal, outcomes guards against mised opportunities to prevent preventable harms. //There is no evidence to suggest that asking about risky behaviours or other risk factors actually increases these risks.//
An integrated version of this same assessment (RiskAssessment) is provided for those using the full [[ICR]] version of the manual.
You can go to the site directly by clicking [[Here|https://docs.google.com/open?id=0B5h_CVBdhJPYYWFjYjYxZjEtMzg3Mi00ZjAzLWEzZTEtNjI2MDlhZDVhZDYz]] or see a preview of it below:
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This is found on what is called the [[Top menu bar]], and it is hidden unless you go into the [[Advanced mode]].
!MENU CONTENTS
!!!Your Identity
You can link your TiddlySpace username and password to other verified web identities such as Open ID
!!!Your Spaces
This is where you can [[Make a new space]] or select and open other spaces (wikis) that you already curate - if you have other spaces they will be listed out here. For instance, some people use TiddlyWiki's in TiddlySpace to organise notes, project-manage, etc...
!!!Your password
This is where you can opt to change your password to a new one.
!To GET OUT of the menu
Click anywhere OFF the drop-down box, on the dark background.
Before seeing a family for the first time, and before, during and after subsequent sessions, the key workers formulate and test working hypotheses. These are preliminary attempts to explain the YP's presenting symptoms in terms of the contexts within which they occur. As more information emerges during the course of therapy, they develop to include all the significant participants and known events and relationships in an interactive pattern that offers both an explanation and possible solutions.
!!Reasons for making hypothesizing an overt and formal part of the key worker’s role.
#Firstly, it openly acknowledges the worker's assumptions, prejudices, values and ‘hunches’.
#Secondly, hypothesizing allows key workers to keep track of their organizing ideas, which can then be viewed and modified in the light of the feedback from the family.
#In this way the continuous formulation (and refutation) of hypotheses keeps the key workers alert to the active part //they are playing in the shaping of the therapeutic reality//. The key worker’s hypothesizing, resulting questions and other actions are part of what elicits the particular account the family will tell.
!!Working guidelines
Hypotheses are working guidelines for organizing the KW's work; thus two or three hypotheses are being entertained simultaneously to guard against the temptation to regard a hypothesis as a factual statement. In this way the KW's interest and curiosity will be kept alive, thereby warding off excessive certainty as well as reducing the risk of engaging in stereotyped and routine work. The following are generic hypotheses which have to be amplified in the light of unique data of the specific family. Many of these hypotheses are overlapping.
!!Hypotheses address:
#The social/cultural contexts (the social and gender factors that may precipitate and maintain the presenting problems).
#The family context (predictable life cycle issues, e.g. adolescence, birth of child, retirement; unexpected life cycle issues, e.g. sudden death, chronic illness; impact of external events, e.g. redundancy.
#The 'function' the presenting problem has: e.g.
##'glue' for family relationships
##'punishment for past sins'
##regulating distance between family members
##protecting family members
##controlling family members
##keeping family of origin involved
##giving a job to seemingly 'retired' parent(s)
!![[Mentalizing]] associations with hypothesizing
Hypothesising tends to be //tentative// in style (see [[The Therapist's Mentalizing Stance]]) so that it can invite alternative views or elaborations from family members. An example of hypothesising would be
>//‘We were wondering in what way A’s mother’s recent hospital admission had affected everyone in the family? Is it possible that it affected A differently from others?’//
Or:
>//‘we wondered who in the family tends to try to make things better if there has been a argument between Dad and the oldest son? Is this something that A tries to do?’//
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!Welcome to the AIM - Instructions
Welcome to the AMBIT AIM (Adolescent Integrative Measure), which is a [[Licensed|AIM Creative Commons Licence]] resource, freely available for general use subject to the terms of its Creative Commons License. [stuff on Authors, etc, here]
!How to use this:
Instructions for completing the assessment are included at the top of the [[AIM Form]]. Once you have completed the [[AIM Form]] you can [[Export data from the AIM]] so that it can easily be pasted into a local database.
!@@color(red):Confidentiality:@@
Please note that filling in an AIM questionnaire @@color(red):WILL NOT SAVE ANY DETAILS ABOUT YOUR CLIENT ONLINE@@ - all of the data that you input is only //ever// held on your local computer - this is because of the way that the software that this runs on ([[Tiddlywiki|www.tiddlywiki.com]]) works.
!Additional functions:
*''__Exporting data__'' - Using the AIM in the:{{{http://ambit-aim.tiddlyspace.com}}} space will give you scores that can be [[exported|Export data from the AIM]] to your local database.
*''__Ranking suggested interventions:__'' You will also see a link to generate a list of [[AIM suggested interventions]], but this will ''not'' generate any suggestions //''unless you are viewing the AIM when it is included as part of a __treatment manual__''//.
**Because of the way that TiddlySpace works, the whole AIM questionnaire can very easily be [[included]] within another 'space' (or wiki);
**indeed, it is //designed to be included// as part of wiki-based TREATMENT MANUALS (see @tiddlymanuals or {{{www.tiddlymanuals.com}}}) such as the @ambit manual, or its local adaptations.
**If you visit, say, the @ambit manual, you will find this same AIM questionnaire embedded within a rich mentalization-based framework for managing high risk, multi-problem, complex youth.
**In these treatment manual(s), the individual items in the AIM are each '[[tagged|Tags]]' with what the AMBIT project's authorial team has considered to be the best evidence-based approach(es) to work in that specific problem area.
**Clicking on [[AIM suggested interventions]] ''in a tiddlymanual'' once you have completed an AIM ''will generate ranked lists of these suggested interventions, as direct links to manualized content''.
**These ranked lists are not "therapy by numbers" - they can be sorted in different ways, for instance according to whether you want to address the MOST SEVERE PROBLEMS as a priority, or focus on the intervention(s) that are the MOST FREQUENTLY INDICATED across the range of difficulties that you have just mapped out. You can limit your suggestions to just those problems identified as "Key Problems". The idea is to offer a more or less objective prompt for the practitioner along the lines of ''"Are you offering the interventions that this set of problems requires, or your //favourite ones//?"''
!!Developing new evidence and new treatments
Because @tiddlymanuals are designed to be flexible, and adaptable to different settings and to the developing evidence base, new treatments (or adaptations of the core AMBIT content) are invited to include the {{{@ambit-AIM}}} space, and to edit the tags on individual AIM items, to suit the range of treatments that they are offering.
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|Date:|$Date: 2008-03-08 10:53:09 +1000 (Sat, 08 Mar 2008) $|
|Source:|http://mptw.tiddlyspot.com/#ExtendTagButtonPlugin|
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This tag gathers together a collection of checklists for the KeyWorker to use to ensure that specific pieces of work are organised and important things are not missed.
See the Related Information for sub-topics that have checklists...
If you are using the manual in its fully interactive ([[ICR]]) mode, you can easily [[Add CheckLists to your ToDo list]].
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!!Noticing
A statement about an interaction (preferably in the ‘here and now’, but it can also be a reported event or sequence) between two or more family members (if there is family present), or between the client and therapist, is the starting point.
Here the therapist focuses on ''an emerging pattern of how family members relate to each other'' or how this young person relates to others (or me). Keeping in mind that it is possible to make many different observations of what might seem just one event and that therefore any observational statement is highly selective, the therapist voices this and immediately follows it up by ''checking for CONSENSUS'' between family members...
>//“I notice that when Sally does x (cry), David it looks as if you find it very hard to understand what exactly she is feeling and why, and without this understanding her behaviour doesn’t seem to make sense ''(Noticing)''. Have I got this right or am I totally off the mark? ([[Checking]]) Can you see what I am talking about? Well, let me continue… to me it looks that when Sally does x (cry), this makes you feel (or act) really y (confused), and so you do z (cut off) or respond in y (confused) way. Likewise, Sally, when David then does this (y), it seems like you find it hard to understand exactly what he is feeling that makes him behave like this. And then to me it looks that this makes you feel (or act) z (irritated) and it goes round in circles. ''(Noticing)'' I don’t think anyone is to blame here because everyone is finding it hard and doesn’t quite understand where everyone else is coming from…I’m not sure I’ve got this right ([[Checking]]) … what do you think Sally?”//
In this example the therapist first identifies and highlights an interaction which (to him) appears to be related to some mentalization difficulty ''(Noticing)''.
The therapist then offers more [[Checking]] of her observation by inviting the family and its individual members to connect with and perhaps share this observation, but also giving them the chance to dismiss it.
It is possible that some or all family members might, for example, state that they had ‘no idea what the therapist was going on about'. This would then lead the therapist to reflect (in his own mind, without necessarily sharing this with the family at this stage) on the validity of his observation in view of the feedback obtained and himself dismiss the observation as insignificant and / or speculate about the possibility of – and potential reasons for - family members defending themselves again what has been observed. In either case it is unwise to just keep repeating the same.
If the observation (''Noticing'') and related comments resonate with some (or all) of the family members ([[Checking]]) then the therapist goes on to ''question the problem''; in doing this, the therapist is looking for
*Shared experiences of how this pattern of relating to one another is a problem for family members
*A common language with which to name or label it.
>//“Do you feel all right about the way this is…this kind of ‘going round in circles’ (are you happy with that)? If not, why or how does it bother you? Is that the way you want it? Is that something you want to change? Does it ever cause you a problem? Do you sometimes get stuck? If you kept this going what might be the outcome?”//
This line of questioning aims to elicit whether the family and its individual members regard the highlighted interaction pattern as something that causes them dis-ease (is experienced as ‘dysfunctional’), or as something that they regard as a non-issue (however ‘pathological’ it may seem to the therapist).
!!!When to focus in on an identified issue:
It is only if or when at least one family member perceives the observed interaction as being problematic, that the therapist can focus on this issue.
!!Naming
Once a problematic interaction has been noticed and focussed upon, the family are invited to find ways to NAME it.
In order to maximise the phase of emotional brainstorming introduced in the second step ([[Mentalize the Moment]]) the family can use [[Pause and Review]] techniques, playing with images of a video or DVD of the "action" which can be paused to allow time and space for mentalization to be recovered.
Family members are encouraged to form a ‘working party’ to think about interactions, from a meta-level, as it were. They are also encouraged ''to find some buzz words to mark the interaction sequence and the associated feeling states.''
>//“So what word or sentence comes to mind when you think about this?”//
The aim is to find a word or phrase that becomes some form of ‘mantra’ which family members can recall after sessions, when similar stuck interactions evolve. Examples are ‘tango’, ‘malignant clinch’, ‘top-dog’, ‘door mat’, ‘playing first fiddle’, ‘the knight in shining armour’, ‘playing the fool’, 'hot potato', etc
Mentalization theory tends to emphasise the opacity of other people's minds and the value of adopting a tentative stance with respect to what we know about the mind states of others. This is one of the cornerstones of the [[The Therapist's Mentalizing Stance]].
Daniel Kahneman is a cognitive psychologist whose focus of work is on cognitive processes which underpin decision making. He is very influential, won a Nobel prize in 2002 for work relevant to economics. He recently wrote a popular summary of his work called 'Thinking, fast and slow'. (Penguim,2011). He is not particularly focused on therapeutic endeavour but his work emphasises themes that are very consistent with a mentalizing framework. A number of these are very striking. Readers interested in the details of this work are invited to look at the full text.
!Cognitively, doubt is much more hard work than certainty.
For example, he suggests that the brain is a machine for jumping to conclusions even when the data is highly inadequate to such conclusions. Although this quick decision making is generally good from an evolutionary point of view, it is not so good at finding out how the world works. We like narratives much more than we like data. However many such 'narrative' conclusions are flawed. On Page 114, he states that 'Sustaining doubt is harder work than sliding into certainty'. Kahneman's assertions are supported by a lifelong cognitive research programme. In this way, cognitive theory can be seen to support the value of a 'tentative' position by the AMBIT worker. This
The poet Yeats had something similar to say in his famous poem "The Second Coming", albeit rather more pessimistically!:
>//The best lack all conviction, while the worst//
>//Are full of passionate intensity.//
!The value of seeing things from the outside
Kahneman examined forecasting behaviour and found that people or teams looking at things from the inside were exposed to a range of decision making biases which were mitigated by inviting others to look at the same information from the outside. This would seem to be entirely consistent with the ripple analogy used in the Passed-out Discussion and [[Thinking Together]]
!The pressure to be expert
The following is a quote from page 263 of 'Thinking Fast and slow' where Kahneman is discussing the nature of over-confidence which he considers a form of cognitive bias.
'''Experts who acknowledge the full extent of their ignorance may expect to be replaced by more confident competitors, who are better able to gain the trust of their clients. An unbiased appreciation of uncertainty is a cornerstone of rationality - but it is not what people and organisations want. Extreme uncertainty is paralysing under dangerous circumstances, and the admission that one is merely guessing is especially unacceptable when the stakes are high. Acting on pretended knowledge is often the preferred solution'''.
This quote raises a number of important issues for the AMBIT approach and may benefit from being the starting point for some team discussion.
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Using scales (0 to 100, for instance) is a helpful way of measuring progress or testing the notion that //"Nothing will change"//, and fostering [[Self-efficacy]] in that small changes are marked and even a small change implies some control, where perhaps none had previously been believed possible.
The use of a rating scale encourages externalisation of the problem, or reflection upon it in a way that fosters [[Mentalization]].
When using rating scales it is important to RECORD the scores - ideally in a visual way such as a graph, but alternatively on a table. This can be positively reinforcing if a young person begins to see change 'in black and white'. It also emphasises the [[Cognitive Behavioural]] stance of therapist and client acting as joint enquirers/scientists, rather than expert and patient.
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This is one of three [[Pre-mentalistic stances]] - and the person in Psychic Equivalence assumes that mental events (thoughts, beliefs or wishes), while recognised as internal, ''have the same status as physical reality''. In other words the person is "Living in the cognition" rather than the cognition living in their mind. Another way of describing this state of mind, then, is ''~INSIDE-OUT THINKING''.
To give an example of this; if I think //"the world is rubbish"// then I can either mentalize about that (reflecting, perhaps, that //"it is curious that such a thought has come into my mind today, but perhaps understandable as I smoked and drank too much last night and am hung over now, with lots of work piling up in front of me"//) or I can assume that //"I am living in a rubbish world."//
Anger is a good example of this state of mind. When a person is functioning in Psychic Equivalence there is little point in directly challenging their utterances, as this is more likely to escalate things and leave them with an experience of you as someone who very clearly does NOT mentalize their dilemma clearly. A client who enters the room shouting about a traffic warden who has persecuted him does not want, and is not able, to hear reasonable justifications of the traffic warden's job. A more effective reply might be first to acknowledge the mental state that they are sharing with you:
>//"That sounds absolutely infuriating; I can see you've been really upset by the way the warden put a ticket on your car, and if you were only //just// on the edge of the no-parking zone, and the warden seemed to you to be //pleased// to be doing this, that would be even more annoying."//
Only after the client exeriences you as having some empathy with his dilemma, may he be able to start to think [[Mentalize]] about the experience in a different way. This is not un-connected to the instruction to [[Express Empathy]] found in [[Motivational Work]].
This an exercise in just getting a bit more familiar and confident with the manual. The questions can be answered by finding the answers in the manual, so it is a bit like a manual treasure hunt. This may be helpful for AMBIT leads to help colleagues get familiar with the manual. Inventing new and better quizzes very welcome. Answers on separate page.
1. Getting started: what gender is in the middle of the AMBIT wheel?
2. How long (in time) is the video tour of the manual?
3. What browser is mentioned near the beginning of the video tour?
4. Why are there lots of planes flying around in the page on clinical governance? How many planes can you find on the page?
5. What is the second heading in ‘Training principles’. When writing new material what does it suggest you should do first?
6. When you click on a link, where can you find the new page that you have called up?
7. What does the manual advise that you do with your hands if faced with a young person carrying a firearm?
8. In the video on Simmering Down, what colour top is the daughter in the role play wearing?
9. What is the sixth item on the AIM form?
10. You are going to send a copy of a page of the manual to a colleague. The page is the page on Managing Violence. In the Link address that gets generated by using snapshot, how many percentage signs are there in the address?
[[Treasure Hunt Quiz -answers]]
This is one of a number of [[Comparing and Sharing functions]] in the AMBIT manual.
You can see a list of the current versions of the AMBIT manual by leaving this version and going to the ''@@color(red):www.tiddlymanuals.com@@'' signposting site. The list of current AMBIT manuals will open automatically in a separate window if you click [[Here|http://tiddlymanuals.tiddlyspace.com/#"AMBIT"]] or see the web frame below.
See also material explaining this, and other [[TiddlyManual]]s, and more general introductions to [[Using the Manual]].
<html><div align="center"><iframe src="http://tiddlymanuals.tiddlyspace.com/#AMBIT" frameborder="0" width="100%" height="600"></iframe></div></html>
!Why am I here?
* Your team has identified an area of your work that is not covered adequately in the manual.
* You want to [[Edit]] brand new content for your team's local version. (If you want to improve or adapt an existing page see the advice on [[Edit]]ing.)
!What to do
* Directly below this sentence, you should see a set of buttons (''if you don't see them, follow the instructions below at'' @@color(purple): __''WHERE ARE THE BUTTONS?!''__ @@...)
* Select the broad category for the area of work that you want to "[[manualize|Manualization]]", then click that button to open a "blank page", and start writing - there is advice on how to [[Edit]]!
!Manualizing buttons:
|New <<newJournal label:"Manage RISK item" focus:title text:"Add your content here. Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"Manage RISK""Local Protocols">>|New <<newJournal label:"Manage CLIENT RELATIONSHIP item" focus:title text:"Add your content here. Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"Manage CLIENT RELATIONSHIP""Local Protocols">>|
|New <<newJournal label:"Manage CLINICAL PROBLEM item" focus:title text:"Add your content here. Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"Manage CLINICAL PROBLEM""Local Protocols">>|New <<newJournal label:"Manage NETWORK PROBLEM item" focus:title text:"Add your content here. Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"Manage NETWORK PROBLEM""Local Protocols">>|
|New <<newJournal label:"LOCAL RESOURCE record" focus:title text:"Add your content here. Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"Our Resources">>|New <<newJournal label:"LOCAL Teamwork & Governance item" focus:title text:"Add your content here. Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"Local Protocols""OUR LOCAL Teamwork and Governance">>|
|New <<newJournal label:"SUSTAIN best practice item" focus:title text:"Add your content here. Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"SUSTAIN best practice""Local Protocols">>|New <<newJournal label:"Blank Page" focus:title text:"Add your content here. THINK HOW YOU WANT TO TAG THIS PAGE TO LINK IT TO EXISTING CONTENT! Check you are not duplicating content; search for existing pages with your intended title!" title:"Type brief title here" tag:"Local Protocols">>|
!@@color(purple):WHERE ARE MY BUTTONS?!@@
>You must be both [[logged in|Log in]] as a ''MEMBER of this space'', __and__ the manual must be switched to ''EDITING MODE'' (see the [[Mode and Login panel]] top right), in order to see any of the content editing buttons displayed above!
>If you have switched to [[edit mode|Mode and Login panel]] //after this page was already opened//, then you will just need to //close and re-open this page// to reveal the editing buttons. (Hint, you can use the [[History recorder]] to find this page again!)
!Help!?
* See ManualizationBoundaries: __''NB this is a TEAM TASK''__, not an individual team member's choice...
* See [[Video introduction to editing a tiddlymanual]] which demonstrates how to do this.
!Tips on what to manualize?
* See also existing __''@@color(blue):|<<tag [[Local Manualization Homework Tasks]]>>|@@''__ where outstanding manualization tasks for a local team are listed.
!Technical fixes
Use the [[Feedback please!]] form to give technical reports of glitches, or other suggestions for improvements, please.
The title and subtitle of your space are visible to visitors and are also displayed in your browser's tabs. Click on the SiteTitle and SiteSubtitle tiddler links below to make changes.
* [[SiteTitle]]
* [[SiteSubtitle]]
!Introduction
Dis-integration is a key concept in AMBIT, and [[Addressing Dis-integration]] is one of the [[Core Features of AMBIT]] - which is to say that we see Dis-integration as a natural "given" in complex systems. Thus becoming "upset" or "disappointed" at instances of Dis-integration is counter-productive and liable only to produce stress and burnout in staff.
Having an understanding of what leads to dis-integrated care networks, particularly an explanation that avoids unhelpful //blame//, or the perpetuation of the common //myths// that exist about other agencies or workers in such networks, is helpful, as are simple tools that help workers to address these difficulties proactively.
!Learning Outcomes
(a) To understand the nature of [[Complexity]] in hard-to-reach young people, the multiple aetiologies that influence their lifecourses, and the necessity for multi-modal interventions to address their difficulties. Following this, to understand the inevitability of complex networks of care.
(b) To understand the nature of [[Dis-integration]] in complex networks; how it arises, and how it can affect the care delivered to young people and families.
(b) To learn and practice the use of the [[Dis-integration grid]] as a tool for addressing dis-integration in the working environment.
!Didactic Teaching
A brief recap on [[Complexity]] and [[Multiple interacting aetiologies]] in [[Hard to reach]] youth, including [[Developmental Considerations]] that mean that Adolescence is a period of unique vulnerability. This complexity leads to the inevitable involvement of multiple agencies, and in this context the nature of [[Dis-integration]] is described, including the different [[DOMAINS and LEVELS of dis-integration]] across which it occurs. The [[Dis-integration grid]] is then described.
There is a video lecture here:
!!!Part 1
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!!!Part 2
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!Training exercises
Practice using the [[Dis-integration grid]] - see the [[Dis-integration Grid EXERCISE]].
!Time allocation
45 minutes
Family members are invited to describe what they think they share with other members of the family and what differentiates them from other members of the family. Each person is invited to consider how such distinguishing characteristics developed over time in their life. Other family members are invited to comment on each other's perceptions of themselves.
Reinforcement describes how controlling particular [[Contingencies]] may affect the repetition of particular behaviours - what is confusing is that BOTH Positive and Negative Reinforcement //encourage// a behaviour.
''Positive Reinforcement'' is where the contingency (i.e. the response to a behaviour) is pleasant.
>//A simple example of this is one of the effects of drugs, which is of inducing euphoria.//
''Negative Reinforcement'', is where an unpleasant experience is removed as a result of the behaviour.
>//Staying with the same example as above, drugs may also remove pain, anxiety, and the unpleasant symptims of withdrawal. This is a powerful [[Reinforcement]] of the drug habit, although the "reward" is the removal of something unpleasant, rather than the delivery of something pleasant.//
!Using this:
The KeyWorker can use [[ABC Diary-keeping]] to analyze what might be the Reinforcers that are supporting a particular behaviour, and use this knowledge to plan simple behavioural interventions, which involve changing the Reinforcers, so that different [[Contingencies]] exist.
>//''For example:'' Anton has rages, when he is destructive and abusive. After this he becomes tearful, and he receives comfort and support from his mother who hugs him. If the hugs act as a Positive Reinforcement, then a change would be to ensure that anton's mother gives hugs when he is behaving well (not in a rage) and that she expresses her sympathy and a wish to be helpful without lengthy hugs directy after a rage...//
There are also lists and descriptions of <<tag [[Features of Successful Mentalizing]]>>
There are several ways in which mentalization may be impeded; this involves the activation of the stress/fight-flight systems, or the [[Attachment]] system. When these are activated, they overwhelm and suppress [[Mentalizing]], and ''primitive'' [[Pre-mentalistic stances]], described as features of the 'disorganised mind', are adopted - much as computers may "roll back" to rely on earlier less sophisticated software when there is a malfunction in higher-order functions.
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You can read more about the following [[Pre-mentalistic stances]], and how to address them if you spot them (careful [[Mentalizing]] of your client's mental state allows you to [[Adapt your Discourse]] to fit their prevailing mental state.)
>1. [[Psychic equivalence]]
>2. [[Pretend mode]]
>3. [[Teleological thinking]]
!Spotting ~UNsuccessful Mentalizing
These 'pre-mentalistic' states, in their turn, generate, maintain, reinforce or exacerbate a range of
*Emotional difficulties
*Behavioural difficulties
*Interpersonal difficulties.
Lists and descriptions of these are tagged at the bottom of this section:
!
Complexity refers to the number of different [[Domains]] that are affected, and also the number of different [[ProfessionalNetworkMembers]] that are involved with a young person or their carers. The multiplication or duplication of input from different workers or agencies is a key trigger for what we call [[Dis-integratedInterventions]].
Complexity has a lot to do with the [[Comorbidities]] that so often go together, and is one of the defining features of a group of young people that professionals might sometimes refer to as [[Hard to reach]]. There are important [[Developmental Considerations]] for young people whose difficulties are highly complex.
!Prof David Fowler - talking about early social disability
In thinking about early PSYCHOTIC symptoms, Prof Fowler's research shows very clearly that it is ''early social disability'', often a "mess of symptoms and social problems", that is the key warning sign and the poorest prognostic sign... what's required is a fully integrated service...
This is a talk from the [[MAP conference in Norwich, november 2012|http://www.map.uk.net/pages/2013/01/04/map-conference-working-with-young-people-neglect-and-abuse-watch-the-film-of-the-speakers/]] (see more at [[AMBIT: an overview]]) about ''Working with young people, neglect and abuse''. See in particular the section around 5mins 48 seconds for the significance of //social disability//.
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This tradition, emanating from social learning theory, concerned with the cognitive structures that govern behaviour, has been particularly helpful in suggesting strategies for changing behaviour by pinpointing and restructuring dysfunctional cognitions.
Elaborate packages of interventions have been developed to deal with many specific types of both emotional and behavioural problems, including [[Depression]], [[Anxiety]], [[Conduct problems]], symptoms of [[Psychosis]], and [[EatingDisorders]]. In the context of a crisis-intervention programme, it will often not be appropriate to deploy the full packages, either to the parent or to the YP. However, using this approach may help to resolve the immediate crisis, after which further work along the same lines could be continued as needed by the CAMHS team.
A social-cognitive framework is also very relevant to the Assessment (see [[What's the problem?]]), in terms of identifying ideas that distort either the interpersonal relationships within the family, or the relationship of the family to the community. Interventions in crises might not be aimed at modifying these cognitions, but rather modifying others' expectations and attitudes in relation to such distortions. One aim of cognitive therapy is to prevent the same problems causing a crisis in the future, by helping the YP, the family and the network to recognise early signs that the YP is again becoming overwhelmed by distorted thinking.
Type the text for 'MedicalEmergencies'
Contact your local CrisisServices
!Know where you are:
In Motivational work it is important to [[Adapt your Discourse]] to fit your assessment of the client, particularly where he or she stands according to the [[Stages of Change]]. This is a key skill, and may be seen as the response from a [[Mentalized|Mentalization]] understanding of a client's dilemma.
Assessment in general is covered at [[What's the problem?]], but there is a specific focus on the Stages of Change at [[Assess Stage of Change]].
!description
The extent to which the young person’s friendship group is identified as pro-social or antisocial.
!end of description
!breakdown
0+ = Good. Positive links to socially responsible group, engages exclusively in prosocial activities (sports, clubs, community projects, etc) with these.<br>
0 = No problem. Mixes with peers who are generally accepted as prosocial, may know antisocial peers, but is not unduly influenced by them, and does not engage in activities alongside them.<br>
1 = Mild. Has occasional contact with young people associated with antisocial groups/gangs, and occasionally witnesses antisocial activities carried out by these.<br>
2 = Moderate. Counts antisocial peers amongst friends. Has regular exposure to antisocial activities in their presence, and occasionally takes part in these.<br>
3 = Severe. Majority of friendship group could be classified as antisocial, and most leisure time is spent in their company. Regularly engaging in antisocial behaviours alongside this peergroup.<br>
4 = Very severe. Strongly and almost exclusively identifies self as gang member. Regularly engaged in gang-related activities including significant offending behaviours.
!end of breakdown
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Senge, P. (2006, 2nd Edition) The Fifth Discipline: The art and practice of the learning organization, Random House.
See [[Developing learning organisations: the work of Peter Senge]]
Type the text for 'MappingLocalResources'
This refers to the second stage of [[The Active Planning Process]], in which the KeyWorker exerts effort to make EXPLICIT his or her [[Intentional stance]] to the young person. It is a key aspect of [[Active Planning]], one of the [[Core Features of AMBIT]].
The point of making an explicit effort to broadcast our intentions is that we cannot assume that our clients' will have the kind of [[Relationship to help]] that would easily or implicitly assume that our approaches are well-intentioned. So the AMBIT KeyWorker is encouraged to verbalise his/her intentions: //in the anxiety of the therapeutic encounter it is often hard for young people to [[Mentalize|Mentalization]] their therapist accurately.//
This may occur in terms of their general aims of the intervention such as "being helpful" to the young person, or the specifics, such as to register for a college course.
!How to broadcast our intentions:
Intention can be expressed in moment to moment interactions, for instance:
>//"My intention here is just to try to understand more accurately what you are feeling, and why."//
or
>//"What I am trying to do here is to be helpful, or at least to think of some new ideas about this familiar problem, and definitely to to avoid being unhelpful!"//
Being clear about moment to moment interactions would be adopting an explicitly intentional stance.
>//"I may not have got things quite right yet, but these are the things that at the moment seem to me the most important ones for me to try to help you deal with... ...I would like to hear from you which bits you think I have got about right, and which bits I still need to work on so that you can recognise them more clearly..."//
!A tool to help this:
The important point is to __get to the sharing of your "first effort"__ - and to invite the young person to help you improve it. When you are sharing your first effort, ''that'' is Broadcasting Intentions!.
Go to [[this link|https://docs.google.com/file/d/0B5h_CVBdhJPYNkJNamFPVXhsYXM/edit?usp=sharing]] to download this in PDF format, or just use the back of an envelope!
[img[https://lh5.googleusercontent.com/-loMP5VnnI1Q/URG08pJR4OI/AAAAAAAAGpY/o21-QH6rBw0/s640/ActivePlanningSheet.jpg]]
[img[https://lh5.googleusercontent.com/-EXERk6bOad4/URG07sRVqzI/AAAAAAAAGpc/W6cVjCoCoHA/s640/ActivePlanningSheet_DEMO.jpg]]
!Theory - why do this?
* See one of the [[Videos]] - at [[Active Planning]] for a description of this.
* Making intentions explicit addresses the likelihood that the young person who is help-seeking may well //also// anticipate mixed, even hostile or manipulative intentions in the helper (see [[Relationship to help]] for more exploration of this.)
* This also relates to the notion of [[Marked mirroring]] in which the carer's "marking" (accurate mentalizing of the predicament of this moment) opens the young person's mind to accept the communication that follows as being //interesting// or //important//.
** For those interested in the technical theory behind this, it is a good example of what is referred to as [[Ostensive communication]] - see work by Gyorgy Gergely in [[Academic references]].
* The broadcasting of our intentions is also a feature of the ''tentativeness'', and ''not-knowing'' that characterise [[The Therapist's Mentalizing Stance]]
!More examples of Broadcasting intentions:
>//“I need to get a picture in my head about the things that make you YOU, so that if you could look inside my head you might say… he’s just about got it!”//
>//“My job is to make sure that I have got a really ACCURATE idea of the sorts of things that make your life hard, or that help you get by…”//
>//“Some of the things I may ask you won’t have anything to do with you… but we find that if we don’t ask at all, often these things get left out - we miss stuff that might be important…”//
>//“I don’t know you at all well, so if I ask you anything you don’t want to talk about, will you please let me know? I don't want to upset you at all.”//
!Broadcasting intentions... other people's takes...
See [[Tomasello et al (2005) Understanding and sharing intentions: The origins of cultural cognition]] for an interesting account of this from the stand point of evolutionary anthropology.
Also, after writing about broadcasting intentions, we discovered a commercial site that, building on an I.T. Masters study, uses the idea of broadcasting intentions in a slightly different way but one which overlaps with our own ideas; that //this is about increasing the ''"hit rate"'' of effective communications//...
Von Kaufman's work doesn't really address the fact that in AMBIT we are particularly concerned with the idea that the OTHER PERSON (ie our client) may be having //particular difficulty in mentalizing ''us''// (the worker) accurately, but we put it here because it is quite interesting (the academic paper supporting this is quoted and linked to below):
<html><iframe src="http://player.vimeo.com/video/3992189" width="500" height="281" frameborder="0" webkitAllowFullScreen mozallowfullscreen allowFullScreen></iframe></html>
The academic thesis supporting this work is here: [[Intention Broadcasting. Proceedings of I-KNOW ’09 and I-SEMANTICS ’09 - Von Kaufman, Richard (2009)]]
!Moving towards the consideration and planning of change
This third step represents an attempt to move away from discussing a //specific interaction// that occurred during the session and to //'widen the lens’// towards:
#GENERALISING: Capturing more generalised understandings relating to this specific observation.
#INVITING VISION: Generating possible applications of these understandings, by "inviting vision" of alternative strategies.
#PLANNING: Planning the implementation of these changes.
!N.B. It may take a few "loops" to reach the point of considering and planning for CHANGE
<html><object width="480" height="385"><param name="movie" value="http://www.youtube.com/v/qFV9GUWpz3I?fs=1&hl=en_GB"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="http://www.youtube.com/v/qFV9GUWpz3I?fs=1&hl=en_GB" type="application/x-shockwave-flash" allowscriptaccess="always" allowfullscreen="true" width="480" height="385"></embed></object></html>
!!1. GENERALISING
Family members are encouraged to come up with some more general observations and reflections on:
#How similar interactional patterns tend to evolve spontaneously at home.
#What feeling states these elicit.
“So we saw that mum feels sad and Johnny feels bad about having triggered this sadness….. maybe this is the only time it ever happened, but maybe it is not…. Can you talk together about whether you recognize this as something that happens at home…or elsewhere”
The effect of this intervention is that what was observed in the ‘here and now’ of the session is ‘looped out’ into life outside the session, in an attempt to identify recurring patterns which are experienced as being ‘dysfunctional’ by family members.
!!!!Relating to overarching treatment goals
A major aim of MBFT is to engage in family discussions of problem-relevant situations, to elicit and highlight emerging feeling states and their importance, and to foster within the family experiences of (and confidence in) practicing the kind of "curious interogative stance" that this kind of activity involves.
The therapist may ask people to tentatively speculate about and label hidden feeling states of one of its family member, or may indeed do this at times him or herself. The therapist actively encourages family members to label their own feelings, to reflect on what that must be like for them. Metaphors or wordings like the following can help:
“you may want to find out how feeling leads to doing”
“how a few snowflakes can launch an avalanche”
“how a little feeling can get out of control”
!!2. INVITING VISION
The therapist requests each family member to identify different ways of overcoming stuck interactions and to think about alternative ways dealing with recurring problematic interactions:
//“Given that you think this is not working, how would you like things to be….. what would x need to do differently for you to feel y? What might you need to say or do for your mother not to have these sad feelings – or at least less of them”//
In an attempt to elicit solutions from within the family, each person is encouraged to talk about their specific alternative ‘vision’. Once this is achieved, the therapist may ask family members to discuss each other’s ideas:
//“Can you talk together about this….about how for example dad’s idea would help mum to feel less sad….”//
__''Note:''__
At each step it is possible that entrenched interaction patterns re-emerge.
For example, two or three people may talk at the same time. The therapist can loop back to step 1 [[Noticing and Naming]] and make an observational statement, asking family members whether they have //also// noticed //''this''// particular interaction, etc. etc...
!!3. PLANNING FOR ACTION
This phase is designed to ask family members to consider ''specific'' and ''concrete'' actions that they could apply in the light of their understandings.
This may require them, in the first instance, to negotiate which particular ‘vision’ should be translated into action.
//"So we have three ideas... which are you going to opt for...? Please discuss this..."//
...followed by:
//“you say you’d like things to be this way…what would be the first step you would need to take for you to be on the way to that goal…? Maybe you want to do it right here and now…”//
!!!It is important that the first action step is both specific and do-able.
It has to be a relatively a small step – definitely not a leap.
People have a tendency to ask for major changes in a minimum of time and, as this is generally highly unrealistic, the therapist’s task is to slow down individuals jumping into action (the technique of ‘pro and con’ is handy here).
It may be helpful to say:
//“What is it that is stopping you…what would you have to say or do to convince them that you mean business…. So, what is the first step you can make now to convince them…?”//
or:
//“You say you want to talk about all these things you never talked about and how this makes you feel now…and you have all agreed that you might take the risk… how about doing this now? Talk to each other in such a way that allows you not to shut down, but to open up about your feelings”.//
There are [[CheckLists]] relating to New Referrals.
*See [[Referral Criteria]], which will be included in your locally-edited protols ([[Local Protocols]]).
*New Referrals are discussed in the Team Meetings - this discussion MUST include a [[Reflective Quorum]] to reach shared agreement on the current understandings of the [[RiskAssessment]].
*An urgent referral may require action before a full team meeting occcurs, in which case the [[Reflective Quorum]] may be smaller.
*Go to [[Processing a New Referral]] for details on getting started from the point of first contact, and [[Setting up a first meeting]].
*There is a checklist for the practitioner who embarks on a new assessment at [[Starting a NEW CASE - CheckLists]]
*Any work with young people and families occurs in [[Phases of AMBIT work]].
**A New Referral is obviously located in the [[INITIAL PHASE]] of the [[Intervention timeline]].
/***
|''Name''|TiddlySpaceBackstage|
|''Version''|0.8.0|
|''Description''|Provides a TiddlySpace version of the backstage and a homeLink macro|
|''Status''|@@beta@@|
|''Contributors''|Jon Lister, Jon Robson, Colm Britton|
|''Source''|http://github.com/TiddlySpace/tiddlyspace/raw/master/src/plugins/TiddlySpaceBackstage.js|
|''Requires''|TiddlySpaceConfig ImageMacroPlugin TiddlySpaceViewTypes|
!StyleSheet
.tiddler .error.annotation .button{
display: inline-block;
}
#backstageArea {
z-index: 49;
color: white;
background-color: black;
background: -webkit-gradient(linear,left bottom,left top,color-stop(0, #222),color-stop(0.5, #333),color-stop(1, #555));
background: -moz-linear-gradient(center bottom,#222 0%, #333 50%, #555 100%);
filter: progid:DXImageTransform.Microsoft.gradient(startColorstr=#ff555555, endColorstr=#ff222222);
-ms-filter: "progid:DXImageTransform.Microsoft.gradient(startColorstr=#ff555555, endColorstr=#ff222222)";
height: 25px;
padding: 0;
}
#backstageButton {
overflow: hidden;
}
#backstageButton #backstageShow,
#backstageButton #backstageHide {
margin: 0px;
padding: 0px;
}
#backstageButton #backstageShow:hover,
#backstageButton #backstageHide:hover {
background: none;
color: none;
}
#backstageButton img,
#backstageButton svg {
width: 24px;
height: 24px;
}
#messageArea {
top: 50px;
}
#backstageToolbar {
position: relative;
}
#backstageArea a {
padding: 0px;
margin-left: 0px;
color: white;
background: none;
}
#backstageArea a:hover {
background-color: white;
}
#backstage ol,
#backstage ul {
padding: auto;
}
#backstageButton a {
margin: 0;
}
.backstagePanelBody ul {
padding: 5px;
margin: 5px;
}
#backstage #backstagePanel {
margin-left: 5%;
padding: 0em;
margin-right: 5%;
}
#backstageToolbar a {
position: relative;
}
#backstageArea a.backstageSelTab,
#backstageToolbar .backstageTask {
line-height: 25px;
color: #767676;
}
.backstageTask .externalImage,
.backstageTask .image {
display: inline;
}
#backstageToolbar a span {
z-index: 2;
}
a.backstageTask {
display: inline;
margin-left: 1em !important;
}
.backstagePanelBody .button {
display: inline-block;
margin-right: 10px;
}
.backstagePanelBody {
margin: 0 0 0 0.6em;
padding: 0.4em 0.5em 1px 0.5em;
}
#backstage table {
margin: auto;
}
#backstage .wizard table {
border: 0px;
margin: 0;
}
#backstage div li.listLink {
border: 0px;
width: 78%;
font-size: 0.7em;
}
#backstage div li.listTitle {
font-weight: bold;
text-decoration: underline;
font-size: 1em;
background: #ccc;
width: 100%;
}
#backstage fieldset {
border: solid 1px [[ColorPalette::Background]];
}
#backstage .viewer table,#backstage table.twtable {
border: 0px;
}
#backstageToolbar img {
padding: 0;
}
#backstage .wizard,
#backstage .wizardFooter {
background: none;
}
.viewer td, .viewer tr, .twtable td, .twtable tr {
border: 1px solid #eee;
}
#backstage .inlineList ul li {
background-color: [[ColorPalette::Background]];
border: solid 1px [[ColorPalette::TertiaryMid]];
display: block;
float: left;
list-style: none;
margin-right: 1em;
padding: 0.5em;
}
.backstageClear, .inlineList form {
clear: both;
display: block;
margin-top: 3em;
}
.tiddlyspaceMenu {
text-align: center;
}
span.chunkyButton {
display: inline-block;
padding: 0;
margin: 0;
border: solid 2px #000;
background-color: #04b;
}
span.chunkyButton a.button, span.chunkyButton a:active.button {
white-space: nowrap;
font-weight: bold;
font-size: 1.8em;
color: #fff;
text-align: center;
padding: 0.5em 0.5em;
margin: 0;
border-style: none;
display: block;
}
span.chunkyButton:hover {
background-color: #014;
}
span.chunkyButton a.button:hover {
border-style: none;
background: none;
color: #fff;
}
#backstage .unpluggedSpaceTab .wizard,
.unpluggedSpaceTab .wizard {
background: white;
border: 2px solid #CCC;
padding: 5px;
}
.syncKey .keyItem {
border: 1px solid black;
display: inline-block;
margin: 0.2em;
padding: 0.1em 0.1em 0.1em 0.1em;
}
.keyHeading {
font-size: 2em;
font-weight: bold;
margin: 0.4em 0em -0.2em;
}
.unpluggedSpaceTab .putToServer,
.unpluggedSpaceTab .notChanged {
display: none;
}
.tiddlyspaceMenu ul {
margin: 0;
padding: 0;
}
.tiddlyspaceMenu ul li {
list-style: none;
}
.unsyncedChanges .unsyncedList {
display: block;
}
.unsyncedList {
display: none;
}
!Code
***/
//{{{
(function($) {
var name = "StyleSheet" + tiddler.title;
config.shadowTiddlers[name] = "/*{{{*/\n%0\n/*}}}*/".
format(store.getTiddlerText(tiddler.title + "##StyleSheet")); // this accesses the StyleSheet section of the current tiddler (the plugin that contains it)
store.addNotification(name, refreshStyles);
if(!config.extensions.tiddlyweb.status.tiddlyspace_version) { // unplugged
config.extensions.tiddlyweb.status.tiddlyspace_version = "<unknown>";
config.extensions.tiddlyweb.status.server_host = {
url: config.extensions.tiddlyweb.host }; // TiddlySpaceLinkPlugin expects this
}
var disabled_tasks_for_nonmembers = ["tiddlers", "plugins", "batch", "sync"];
var tweb = config.extensions.tiddlyweb;
var tiddlyspace = config.extensions.tiddlyspace;
var currentSpace = tiddlyspace.currentSpace.name;
var imageMacro = config.macros.image;
if(config.options.chkBackstage === undefined) {
config.options.chkBackstage = false;
}
// Set up Backstage
config.tasks = {};
config.tasks.status = {
text: "status",
tooltip: "TiddlySpace Info",
content: "<<tiddler Backstage##Menu>>"
};
config.tasks.tiddlers = {
text: "tiddlers",
tooltip: "tiddlers control panel",
content: "<<tiddler Backstage##BackstageTiddlers>>"
};
config.tasks.plugins = {
text: "plugins",
tooltip: "Manage installed plugins",
content: "<<tiddler Backstage##Plugins>>"
};
config.tasks.batch = {
text: "batch",
tooltip: "Batch manage public/private tiddlers",
content: "<<tiddler Backstage##BatchOps>>"
};
config.tasks.tweaks = {
text: "tweaks",
tooltip: "Tweak TiddlyWiki behaviors",
content: "<<tiddler Backstage##Tweaks>>"
};
config.tasks.exportTiddlers = {
text: "import/export",
tooltip: "Import/export tiddlers from/to a TiddlyWiki",
content: "<<tiddler Backstage##ImportExport>>"
};
config.tasks.sync = {
text: "sync",
tooltip: "Check Sync status",
content: "<<tiddler Backstage##SpaceUnplugged>>"
};
if (window.location.protocol === "file:") {
config.unplugged = true;
}
config.backstageTasks = ["status", "tiddlers", "plugins",
"batch", "tweaks", "exportTiddlers", "sync"];
config.messages.backstage.prompt = "";
// initialize state
var _show = backstage.show;
backstage.show = function() {
// selectively hide backstage tasks and tabs based on user status
var tasks = $("#backstageToolbar .backstageTask").show();
var bs = backstage.tiddlyspace;
if(!config.unplugged) {
tweb.getUserInfo(function(user) {
if(user.anon) {
jQuery.each(disabled_tasks_for_nonmembers, function(i, task) {
var taskIndex = config.backstageTasks.indexOf(task);
if (taskIndex !== -1) {
config.backstageTasks.splice(taskIndex, 1);
}
});
config.messages.memberStatus = bs.locale.loggedout;
} else {
config.messages.memberStatus = readOnly ?
bs.locale.nonmember : bs.locale.member;
}
});
} else {
config.messages.memberStatus = bs.locale.unplugged;
}
// display backstage
return _show.apply(this, arguments);
};
if(readOnly) {
jQuery.each(disabled_tasks_for_nonmembers, function(i, task) {
var taskIndex = config.backstageTasks.indexOf(task);
if (taskIndex !== -1) {
config.backstageTasks.splice(taskIndex, 1);
}
});
}
var tasks = config.tasks;
var commonUrl = "/bags/common/tiddlers/%0";
backstage.tiddlyspace = {
locale: {
member: "You are a member of this space.",
nonmember: "You are not a member of this space.",
loggedout: "You are currently logged out of TiddlySpace.",
unplugged: "You are unplugged."
},
showButton: function() {
var showBtn = $("#backstageShow")[0];
var altText = $(showBtn).text();
$(showBtn).empty();
imageMacro.renderImage(showBtn, "backstage.svg",
{ altImage: commonUrl.format("backstage.png"), alt: altText});
},
hideButton: function() {
var hideBtn = $("#backstageHide")[0];
var altText = $(hideBtn).text();
$(hideBtn).empty();
imageMacro.renderImage(hideBtn, "close.svg",
{ altImage: commonUrl.format("close.png"), alt: altText, width: 24, height: 24 });
}
};
var _init = backstage.init;
backstage.init = function() {
_init.apply(this, arguments);
var init = function(user) {
var bs = backstage.tiddlyspace;
bs.showButton();
bs.hideButton();
};
tweb.getUserInfo(init);
};
var home = config.macros.homeLink = {
locale: {
linkText: "your home space"
},
handler: function(place) {
var container = $("<span />").appendTo(place)[0];
tweb.getUserInfo(function(user) {
if(!user.anon && user.name !== currentSpace) {
createSpaceLink(container, user.name, null, home.locale.linkText);
}
});
}
};
config.macros.exportSpace = {
handler: function(place, macroName, params) {
var filename = params[0] ||
"/tiddlers.wiki?download=%0.html".format(currentSpace);
$('<a class="button">download</a>'). // XXX: i18n
attr("href", filename).appendTo(place);
}
};
}(jQuery));
//}}}
|''THIS TEAM'S LOCAL RESOURCES ARE ALL LISTED AS ~SUB-TOPICS IN THE 'RELATED INFORMATION' SECTION (see above, left)''|
See [[ABOUT Our Resources]] to learn how to use this function in your TeamTemplate.
!Adding a new resource?
Check you are logged in as a member of the space, and that the manual is switch ed to "Edit Mode" (see the panel, top right of you screen).
Either look in the "Show References and Info" Section, and selct "create a new sub-topic" or alternatively, click on the tag list here: __''@@color(red):|<<tag [[Our Resources]]>>|@@''__ where you can review material already under this topic heading (or [[Tag]]) and select the "create new tiddler..." item at the bottom of this list to generate a new tiddler.
See also [[Local Protocols]]
[[outputFactorDescriptors]]
[[Go Again?]]
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
This is a tag which links together all the tiddlers (pages) relevant to the AMBIT lead role.
See the [[Show references and info]] panel on this page for lots of content related to this role.
See also:
* [[The AMBIT Lead - role and responsibilities]]
* [[AMBIT LEADS - useful training pages]]
The AMBIT approach does not prescribe on the organisational structure for a team using AMBIT. It assumes their will be a variety of leadership arrangements within different teams. However, AMBIT practice is unlikely to be sustained without one or preferably two people within the team taking on the role of sustaining the skills and practice of AMBIT - which we refer to as the [[AMBIT Lead]] and the [[Implementation Team]].
This approach derives from the work of W.R. Miller and S. Rollnick, and is widely used across a range of difficulties, and especially frequently in work with [[SubstanceUseDisorder]]. See [[Motivational Work - Checklists]] for a summary that will help order your delivery of this intervention.
Motivational work emphasises the //development of engagement//, and the importance of //sustaining the client relationship//. it may be delivered in a single session, or across a number of sessions, and it is acceptable for a practitioner to dip in and out of the techniques described under this heading as required. (In fact, to do so is in keeping with the advice contained within the core principle to [[Roll with Resistance]]!
!Motivation and Mentalizing
There is a great deal of overlap between the theory underpinning motivational work and [[Mentalization]], which is, of course, particularly focused on //intentional states//. In particular it is worth understanding the [[Stages of Change]] - the 'first' of these, [[Pre-contemplation]], is an example of how non-mentalizing can present (see [[Pre-mentalistic stances]].)
!What motivational work is NOT...
Crucially it is ''not'' about ''MAKING motivation'' in a person who does not wish to change, but about working with whatever motivation is present at that time (sometimes the skill is in helping a client to discover motivation to change that they had overlooked.) The moment it becomes a any kind of 'feat of strength' on the part of the KeyWorker, the work being done is not properly 'Motivational'.
!Objectives
# "Icebreaking"
# Stimulate interactions between trainees, and set expectations that this is not just didactic teaching
# Give a "first hand" experience of [[Mentalization]] and emphasise that we [[Respect local practice and expertise]]
!Exercise
# Warn participants that this is a "quickfire" exercise (speed-dating, rather than analysis) so they need to move fast!
# Look around you for //someone you know least well// in the room, and partner up.
# Spend 2-3 minutes each, saying:
## ''Who you are''
## ''What you do''
## ''Why you think you are here today''
# While one person is speaking the listener's job is to understand this (they can ask simple questions to clarify, etc) and think about how they would explain why this person is here to the larger group.
# When both have spoken, return to the large group.
## Trainers introduce each other to the group ([[Broadcasting Intentions]]).
## ''In a small training'', ask partners to introduce each //other// (NOT themselves) and particularly to try to explain why they have come today (this could be one of thousands of reasons - from "because my boss told me to" to "because I live and breathe mentalization-based practice..."
## ''In a large training'' ask individuals to call out themes that they picked up //from their partners// (NOT themselves)
# Invite reflection about what it is like to have one's thoughts and intentions "reflected back" or "relayed on"
# Emphasise that what they have all been doing is [[Mentalizing]] (of course)...
!Time allocation
20 minutes
!!About the AIM
>About the [[AIM]]
>[[Topics covered by the AIM - a checklist]]
!!Using the AIM
>Fill in an [[AIM Form]]
>Get ranked intervention suggestions from your [[AIM suggested interventions]]
The main theoretical basis of these approaches is in SocialCognitiveTheory.
Strongly held beliefs about Cannabis (//"It is harmless"// or //"Without it I am much more aggressive"//, etc) may take the form of [[Implicit Core Beliefs]] and threaten a young person's motivation or the application of planned change behaviours.
The [[Cognitive Behavioural]] approach is similar to [[Motivational Work]] in that direct confrontation is avoided ([[Roll with Resistance]]), but there is slightly more room for gentle challenge.
In keeping with the Cognitive therapist stance (see [[CognitiveBehavioural for SUD-Rx]]) the approach towards a particular cognition is:
!!Identify the cognitions:
Via a joint exploration of the young person's [[Thinking]] the client and therapist seek to uncover the [[Implicit Core Beliefs]] that underpin a young person's thinking and influence [[Feeling]] and [[Behaviour]].
!!Externalise the problem:
Consider a specific cognition (for instance //"Without drugs I am totally unlovable."//) as ''separate from the thinker''. Note this is dirently related to the ideas about [[Psychic equivalence]] from [[Mentalization]]-based approaches:
*//"What would an observer from a distance see as the effect on you when this particular thought comes into your mind?"//
*//"Would it seem to make it more or less likely that you would use cannabis in the hours after it had been in your mind?"//
!!Design experiments to test these (dysfunctional) ideas:
*//"How could we design a test to see if this thought is true all of the time, only some of the time, or none of the time?"//
*//"'TOTALLY' is a strong word - I mean if just one person still found you lovable then that wouldn't be TOTALLY, would it?"//
*//"Who might we ask, or what do we think the people closest to you would say, if we did ask them whether you are 'totally unlovable'?"//
!![[Weighing Pros and Cons]]
This is another version of a Cognitive approach to the notion that //"I don't want to change my cannabis habit."//
!Do you want to complete a TOP on your client right now?
Go to [[Treatment Outcomes Profile]]
!What is it?
The Treatment Outcomes Profile (TOP) is a new drug treatment outcome monitoring tool that has been developed by the NTA in partnership with drug treatment providers in over 70 sites across England. It is applicable for use in all of the structured treatment modalities as defined by Models of Care for Treatment of Adult Drug Misusers: Update 2006. (Reference: The Treatment Outcomes Profile (TOP): A Structured Interview for the Evaluation of Substance Misuse Treatment. Marsden J, Farrell M, Bradbury C, Dale-Perera A, Eastwood B, Roxburgh M & Taylor S (2008). Development of the treatment outcomes profile. //Addiction//, 2008; 103 (9): 1450 -1460)
For the first time, service users, clinicians, service managers and commissioners will be able to obtain objective and comparable data about real improvements in service users' lives that will be able to inform and improve practice on both an individual and strategic level.
The TOP is a simple set of questions that will improve clinical practice by enhancing assessment and care plan reviews for clients. The data it provides will improve performance monitoring. Data will be reported into the National Drug Treatment Monitoring System (NDTMS) from October 2007 and results fed back to providers and commissioners from March 2008.
There will also be monthly exception reports from NDTMS on non-returns and multiple submissions.
!When to complete it?
The TOP should be completed at three key treatment stages:
!!Treatment Start
*The TOP should be completed within two weeks either side of the date that a client started structured drug treatment.
*If the TOP is completed in the two weeks after the treatment start date it is important to ensure that the recall period focuses on the 28-days before treatment start and NOT the 28-days from the date that the TOP is completed.
*The treatment start TOP provides important information about the clients drug use before treatment and acts as a baseline for comparison with subsequent Review and Exit TOP’s.
!!Review TOP (3 months)
*It is good practice to conduct regular care plan reviews that are usually completed in 12 week (3 month) cycles. It is recommended that the TOP is completed as part of this process.
*However, the TOP only needs reporting to the NDTMS every 26 weeks (6 months).
!!Treatment Exit
*TOP should be completed within two weeks either side of the date that the client exits structured treatment.
*If the client is referred on to another structured treatment provider a Treatment Exit TOP is not required.
!How to complete the TOP
!!!Start by entering
Name and identifiers of your client (date of birth and gender)
Your name
Date of assessment
The stage at which the TOP is being completed (Treatment Start, Review, Treatment Exit, or post Treatment Exit.)
!!!Types of responses:
''Timeline'' - Invite the client to recall the number of days in each of the past four weeks on which they did something; for example, the number of days they used heroin. You then add these to create a total for the past four weeks in the TOTAL box
''Yes and no'' - a simple tick for yes or no, then a "Y" or "N" in the blue NDTMS box
''Rating scale'' - a 20-point scale from 0=poor to 20=good. Together with the client, mark the scale in an appropriate place and then write the equivalent score in the box.
You should aim to ask and complete every question. Do not leave any of the blue boxes blank. Enter N/A if the client refuses to answer a question or, after prompting, cannot recall.
!Do you want to complete a TOP on your client right now?
Go to [[Treatment Outcomes Profile]]
!description
Includes all forms of eating disorders, whether restricting calories, binge eating with or without purging, pica etc. Increase or decrease in caloric intake as a result of depression or other problem is rated under Self Care (06). Includes not eating for reasons associated with delusional states e.g. belief that food is poisoned.
!end of description
!breakdown
0 = No problem. Normal eating habits for age.<br>
1 = Mild. Some concern with eating habits; e.g. restriction of eating to a few foods, chronic overeating in overweight person.<br>
2 = Moderate. Extreme restriction of type or quantity of food, or dramatic overeating (e.g. food must be locked up).<br>
3 = Severe. Food restriction or consumption constitutes a serious health problem e.g. over or under-weight so that physician recommends intervention, beyond dieting for overweight; binging and purging.<br>
4 = Very severe. Eating habits constitute an immediate threat to health, e.g. acute anorexia nervosa, purging from bulimia causes acute medical problems.
!end of breakdown
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gcbM8nZirgsGPZMgfWJGLdjY3gzBJmeWKo2XtwS8Mdwi2OTj+sRsuYhjHAzW0WkseBZwFfoUaJzpotmG+nXUVCUdfVRSE4KuhezyeuKip2pDw3ohg94flsJ20GL1QCAg5yq2FIeJRJTAl64WIh+XUUX7tminmv463O0SdciOHbTgaXggeJE4OFDIh7cTGSW8dOzzpCcI3w0v8hvF0xHl1G6uQGitwhAdFESFfEGFMcFY5RfpCVrFBrltoh30EhnKYpbiRdamDULEMguQTws1LxU1T3Gb9IjoiPcit01cBs0hTgbSGW8Qpu3lo4OjFrLLU07iRTm8SZdoXnYUaAy3cWIuLKTwBl3d18xuTH5KLnIFQWfmU9Je1TZzJQ1XEnNChvTN7raq8jRJN/kSxWVHgcY3CpMCfGQIOL2oBKWcs0VfzP5iq+DR0Zw4NuoJnAAnvhxD+1zoUfIkf7jT+PKIbFPpgahY7CnOKdCsAP8usgAuzHk/8vzWTpFuCoMl4HNnpyCXdr4T+UwOLo5Ow/Sxc8BLdQ/KPfKRTrlcxfbq1QVbrcRS575KcHULhvMaJHEfWmeTc+IWUdFaaSITvRWCuAeUS9CuzONhQR+KwxTWKErIl07aIsBLv77ZM1ki+SmskUjCi7UqLaidHtgXXeKMf0BCi5kMXLr8nZSv3GIekbljFyz9aofjUYuogjtsB0yuQHKU3a3mMmCaJj7xy3Lt4688GD0uB2qnBYNpb+CWPUL9sYk4NG/aKNheX5TY5/u3YC4xA8bURWDfLRRzE3lzCTWDecPyy+tlj+anZ5NAwIkwL3pHdEpfeKQ7af/gRzFk7ibuz27atuZ3RFqXwH78n88gn8crG8C832Td6AkrQx7NEmmcPYeN+Ilnzo7iYaPipJhfi6/R83EJGLAc91c7YFpf+bQEc+jh6FEs4b5OY/qlI+dG5dSatHOXvhV1vtJiY0YdHCpfeAVoEjDCsB+bU9RPYvijIspaENX0Tpz6WuUzuMv75BXLvr4raFEr5uwBFBQBm6o+tlqbXf8H69PN+/NjJ1RcxuzxZXzqw24LuIImQaqjaZYALs7oc2PjQB95OXUzdq08qlcfPX5S+TGef0NGO7xYyd6K6FEuuH8o9jvG+T+RL8JjQ3097Njejzec+nLRmsf0z8DpM2dFkX1Zmb/lD2tPVPtnwBM0GXvhndidlob/ApSuPJT4d20JAxXV6R5XK9HTmp69gO/KhCM6YTx+5tCeO0QQqGZzVaDJANVFDMt6E2vHdymDuEpbSzMLtbXBdRsbPS/EVMNIzCTx5Z5zghX/vbB7K/mwWq/UWTVoqXhgMPYoBs+D9v9eaI6qUuuDQUYXY7pn0o2DEnjKh9OLS0DJj0vKa2KE+DOFNbcoIdcsb2sGTQYGYjE9Nw33Y0l4L+NwZ7lRrzEumsTDeQjvL3+z1+i89OT8NYGWytQKt8HqFBV70FtuR1YXfsTNHluiJXwqcbpk4I88ooH2L92E/1KCVpz+iXz/D36BLy8VVzwEAAAAAElFTkSuQmCC
The primary task is to produce a reference document for the Team and the family network. This can act as a route map for the reintegration of the young person into social functioning. Equally, it provides both an opportunity to test hypotheses about the nature of the family's expectations as they are involved in its production, and, over time, functions as a measure of progress.
''The family and young person must be involved in this''. In the early stages of assessment and treatment it may be difficult for the young person to concentrate or contribute, and this highlights the fact that document produced is only ever a working draft and can, and should, be consistently updated. The process of involving the family is a useful tool for engaging them, encouraging a sense of agency and reinforcing their expertise in knowing what is needed, and what is available.
!Immediate Care needs
* These needs have been covered in the [[Multi-Domain Assessment]].
* The young person needs to be cared for, perhaps initially with constant attention, by responsible adults at home.
* Make a timetable (see the 'Contingency Planning' proforma).
* Look for gaps in availability of personnel that might need filling, perhaps by extended family, friends, or other community-based resources, or by the Team.
* List the goals.
!Therapy needs
* See [[Care Plan]] produced as a result of the [[Multi-Domain Assessment]].
!Health needs
* The young person needs access to a GP and other primary care services, and to emergency services based at the local A&E.
* Some families - especially recent arrivals from minority ethnic groups, may find it hard to identify and enlist such services, and they may need help in negotiating the task of registering with a GP, etc.
* There may be local agencies specifically set up to provide such services, to which the family need directions for making contact.
* In addition, the young person may need dietary advice, or have special dietary needs (for instance if there is comorbid diabetes.)
* Access to health pursuits such as exercise may be an issue:
**if this is identified, does the young person or the family know where to find local sports centres, parks, etc.?
**Are there any impediments to accessing these services that need to be negotiated?
*List the goals.
!Family needs
This refers to:
* The young person's needs of the family, and
* The family's needs
** The young person may need the family to put aside intra-family or inter-family conflicts during the period of acute management of the situation (a systemic understanding of the illness behaviour may be helpful in such a context: is the disturbed behaviour a way of signalling for and enlisting outside support, of resolving some impasse?)
**There may be issues of separation, autonomy, etc that need to be worked through.
* From the family's point of view there may be a need for respite from the struggle and anxiety.
**Are there ways in which individual family members can get this (staying with relatives or friends for a night or so?)
*There may be needs not directly connected to the young person's mental health (Housing, finance (or Benefits advice), Employment, parental mental health, whether they tell other people in their community or how they explain the difficulties to them...etc.)
** It is important not to allow the process of mapping these needs to be hijacked into conflict resolution or family therapy work, but simply to record these needs as the young person, family and keyworkers see them.
* List the goals.
!Social activity needs
* This gives a chance to explore what the young person's and the family's ideas about normative social activities might be. Culture is likely to play a significant part in these expectations (See section on sensitivity to the [[Cultural Context]]).
* In exploring these needs, ask what other young people in the family, or known to the family, would //ordinarily be expected to be doing// socially, at this stage in their lives.
** What would the young person have to be doing for him/her and their family to think they are "back to normal again."
** What sort of contact with friends would be appropriate?
* The issue of the ''__young person's safety__'' may be raised.
** This is often a source of conflict in families, highlighting inter-generational differences. Again, it is important to list the different needs but avoid being drawn into family therapy at this stage.
**Reframing conflicts as "both/and" statements rather than "either/or" may be helpful; for instance noting that the young person needs contact to maintain links with his or her peer group and the family needs to feel that their concerns for safety are being addressed.
*//''"Is one of the goals to arrive at an appropriate compromise between different members of the family?"''//
* Likewise, there may be significant differences of opinion in the family regarding the ''__cultural acceptability__'' of certain social activities (e.g. dating).
** A similar approach to that outlined for safety needs to be adopted, holding in mind the primary task at this stage which is to document, rather than to solve, these dilemmas.
* Re-integrating a young person who has had a serious mental health problem into a social milieu is very challenging. The young person and the family might identify a need to do some pre-emptive planning in respect of likely difficulties. Examples of particular difficulties that can be addressed in this way include:
** Answering questions: A common concern is how the young person should respond to questions from peers about where he/she has been, what are the scars on his/her arm, etc? A need to rehearse a range of appropriate answers to such questions may be identified. Talking through strategies, making lists of possible responses, or role-playing can be useful in planning for such eventualities.
** (Re)-Entering a group: The thought of actually walking into a social group after an absence caused by mental health problems is highly anxiety provoking, and may lead to avoidance strategies. Is there a need to rehearse this, or is there a need for an appropriate chaperone (a sibling, a cousin, a close friend who can be made a confidant ahead of other friends and acquaintances?) to facilitate this?
* List the goals.
!Educational activity needs
This is covered in the section dealing with [[Educational-Vocational Training]].
!Language/Communication needs
* If English is not the first language then interpreters may be required.
**Sensitivity to a family's concerns about issues such as confidentiality in respect of interpreters is required.
**If at all possible the family should have access to the same interpreter, rather than having to meet a series of different individuals.
* List any needs and goals.
!Cultural/Religious needs
* This is also covered in the section addressing Sensitivity to [[Cultural Context]].
* It is helpful to make use of [[Cultural consultation]] when working with families from very different cultural backgrounds from one's own.
* Equally, an open, respectful curiosity (see [[Careful and concerned CURIOSITY]]) about the culture and customs of the family can facilitate engagement.
* The keyworker should consider whether their formulation and interventions are meaningful to the family and fit with their cultural and religious beliefs.
* Explore the communities’ expectations of the family and the young person.
** If there are differences in opinion within the community and family about these matters, be sensitive to the issue of shame, which parents may feel acutely if their children are seen as breaking traditional taboos.
** Likewise, if appropriate, ask about attitudes to mental illness in the family's culture.
** Ask about how other families manage such difficulties.
** Are there community resources that could help to mediate in such matters?
** Is one of the goals the arrival at an appropriate compromise between different members of the family?
* List the goals.
* Explore the ''__family's expectations__'' regarding the duties of children, attendance and involvement at a place of worship, and major ceremonies such as rites of initiation (Confirmation, Bar Mitzvah, etc), Marriages, etc.
** Are there any such events, or important feast days or fasts, approaching, that might alter the family's availability, or be placing additional stress upon family members?
** Ask about what the religious teaching is in respect of adherence to particular rules in the context of illness (for instance there are special allowances for pregnant women, the elderly and the sick during Ramadan.)
** Is there a need for professional guidance in the form of a priest/Imam/Rabbi? See [[Cultural consultation]].
* ''Accessing Services''
** Are there particular days (e.g. Sabbath) that would make visiting more difficult?
** Are there specific rules regarding pollution (eg removing shoes indoors) that the family need to inform visitors about?
The purpose of this session is to name all the different methods and techniques that team members use to work with young people and their families. The intention is to be as inclusive as possible.
! List all the different interventions that you do (20 minutes)
* Put all the different techniques you use on post-it notes.
**Aim to get coverage of the wide range of different conversations and activities that the team does...
**''__Include everything!__'' (''@@color(blue):we want a MINIMUM of 50 post-it notes!@@'') from the highly specialised "clinical" work (such as Cognitive Behavioural therapy) to non-specialist activities (//"Going for a cup of tea in the local cafe as a way of engaging a young person", "texting somebody in the week to see how they are doing", "Reviewing someone's suicide risk", "Arranging a family outing", "Taking a young person to meet with a teacher."//)
* Post them under headings (stick notices up around the room) for all the different domains in which we work
** Main domain: ''Individual'', ''Family'', ''Social ecology'', ''Systems-network of care''
!Look at your manual (20 minutes)
*Look at the [[Domains]] and [[Interventions]] in the manual to see what is there...
** Are all your methods and techniques represented? (10 minutes)
* Are there things that we do NOT do? Why is this? (10 minutes)
!Manualize one local method of working that the team use (20 minutes)
*Are there things that we DO that are NOT reflected at all (or are poorly represented) in the manual?
**Make a sub-topic of one of these in the manual
/***
|''Name''|ImageMacroPlugin|
|''Version''|0.9.4|
|''Description''|Allows the rendering of svg images in a TiddlyWiki|
|''Author''|Osmosoft|
|''License''|[[BSD|http://www.opensource.org/licenses/bsd-license.php]]|
|''Notes''|Currently only works in modern browsers (not IE)|
|''Requires''|BinaryTiddlersPlugin|
!Usage
{{{<<image SVG>>}}} will render the text of the tiddler with title SVG as an SVG image (but not in ie where it will fail silently)
!!Parameters
width/height: specify width/height parameters
link: make the image link to a given location
tiddlyLink: link to a tiddler
!Notes
Binary tiddlers in TiddlyWeb when passed through the wikifier will be shown as images.
eg. {{{<<view text wikified>>}}} on a binary tiddler will show the image.
{{{<<view fieldname image>>}}}
will render the value of the tiddler field 'fieldname' as an image. This field can contain a tid
{{{<<image SiteIcon>>}}}
will create an image tag where the tiddler has content type beginning image and not ending +xml
will attempt to create svg object in other scenarios
{{{<<image /photos/x.jpg>>}}}
will create an image tag with src /photos/x.jpg as long as there is not a tiddler called /photos/x.jpg in
which case it will render that tiddler as an image. Note for the case of svg files it will attempt to render as an svg if possible via the image
tag. It doesn't embed the svg in the dom for security reasons as svg code can contain javascript.
!Code
***/
//{{{
(function($) {
var macro = config.macros.image = {
shim: "/bags/common/tiddlers/shim",
ieVersion: config.browser.isIE ? parseInt(config.browser.ieVersion[1], 10) : false,
svgns: "http://www.w3.org/2000/svg",
xlinkns: "http://www.w3.org/1999/xlink",
svgAvailable: document.implementation.hasFeature("http://www.w3.org/TR/SVG11/feature#BasicStructure", "1.1"),
_fixPrefix: 1,
_external_cache: {},
_image_tag_cache: {},
_image_dimensions: {},
locale: {
badImage: "This image cannot be displayed."
},
handler: function(place, macroName, params, wikifier, paramString, tiddler){
var imageSource = params[0];
// collect named arguments
var args = macro.getArguments(paramString, params);
this.renderImage(place, imageSource, args);
},
init: function() {
var startupImages = store.getTaggedTiddlers("systemImage");
var place = $("<div />").attr("id", "systemImageArea").appendTo("body").hide()[0];
for(var i = 0; i < startupImages.length; i++) {
var image = startupImages[i];
macro.renderImage(place, image.title, { idPrefix: "" });
}
var data = new Image();
data.onload = function() {
// note ie 8 only supports data uris up to 32k so cannot be relied on
macro.supportsDataUris = this.width != 1 || this.height != 1 ? false : true;
macro.supportsDataUris = macro.ieVersion && macro.ieVersion < 9 ? false : macro.supportsDataUris;
};
data.onerror = data.onload;
data.src = "data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///ywAAAAAAQABAAACAUwAOw==";
},
refreshImage: function(src) {
var elements = macro._image_tag_cache[src] ? macro._image_tag_cache[src] : [];
if(macro._image_dimensions[src]) {
macro._image_dimensions[src] = false;
}
for(var i = 0; i < elements.length; i++) {
var el = $(elements[i]);
var newSrc = "%0?nocache=%1".format(src, Math.random());
el.attr("src", newSrc); // force reload
}
},
isBinaryImageType: function(contentType) {
return (contentType && contentType.indexOf("image") === 0 &&
contentType.indexOf("+xml") != contentType.length - 4) ? true : false;
},
isImageTiddler: function(tiddler) {
return macro.isSVGTiddler(tiddler) || macro.isBinaryImageTiddler(tiddler);
},
isSVGTiddler: function(tiddler) {
var type = tiddler ? tiddler.fields['server.content-type'] : false;
return type == "image/svg+xml";
},
isBinaryImageTiddler: function(tiddler) {
return macro.isBinaryImageType(tiddler.fields['server.content-type']);
},
renderImage: function(place, imageSource, options) {
var imageTiddler = store.getTiddler(imageSource);
var container;
var classes = ["image"];
if(options.link) {
classes = classes.concat(["imageLink", "externalLink"]);
container = $("<a />").attr("href", options.link).appendTo(place)[0];
} else if(options.tiddlyLink) {
classes.push("imageLink");
container = createTiddlyLink(place, options.tiddlyLink, false);
} else {
container = $("<span />").appendTo(place)[0];
}
$(container).addClass(classes.join(" "));
options = options ? options : {};
if(imageTiddler && macro.isBinaryImageTiddler(imageTiddler)) { // handle the case where we have an image url
return macro._renderBinaryImageTiddler(container, imageTiddler, options);
} else if(imageTiddler){ // handle the case where we have a tiddler
return macro._renderSVGTiddler(container, imageTiddler, options);
} else { // we have a string representing a url
return macro._renderBinaryImageUrl(container, imageSource, options);
}
},
_renderAlternateText: function(container, options) {
var img;
var src = options.src || "";
if(options.width && options.height) {
img = $("<img />").attr("src", src).addClass("svgImageText").attr("width", options.width).
attr("height", options.height).appendTo(container);
}
var alt = options.alt;
if(img && alt) {
img.attr("alt", alt).attr("title", alt);
} else if(alt) {
$(container).addClass("svgImageText").text(alt);
}
macro._image_tag_cache[src] = img;
},
_renderSVGTiddler: function(place, tiddler, options) {
if(!options) {
options = {};
}
merge(options, { tiddler: tiddler, fix: true});
if(macro.svgAvailable) {
this._importSVG(place, options); // display the svg
} else if(options.altImage) {
var image = options.altImage;
delete options.altImage;
this._renderBinaryImageUrl(place, image, options);
} else {
this._renderAlternateText(place, options); // instead of showing the image show the alternate text.
}
},
_renderBinaryImageTiddler: function(place, tiddler, options) {
var resourceURI;
var fields = tiddler.fields;
if(fields["server.type"] == "tiddlyweb") { // construct an accurate url for the resource
resourceURI = "%0/%1/tiddlers/%2".format(config.defaultCustomFields["server.host"],
fields["server.workspace"], encodeURI(fields["server.title"]));
} else { // guess the url for the resource
resourceURI = tiddler.title;
}
var ctype = fields["server.content-type"] || tiddler.type;
var text = tiddler.text;
if(macro.supportsDataUris && ctype && text.indexOf("<html") == -1) {
var uri = "data:%0;base64,%1".format(ctype, text);
options.src = resourceURI;
return macro._renderBinaryImageUrl(place, uri, options);
} else if(options.src) {
return macro._renderBinaryImageUrl(place, options.src, options);
} else {
return macro._renderBinaryImageUrl(place, resourceURI, options);
}
},
_renderImageTag: function(container, src, width, height, options) {
var img;
img = $("<img />").appendTo(container);
if(height) {
img.attr("height", height);
}
if(width) {
img.attr("width", width);
}
if(macro.ieVersion && macro.ieVersion < 7 && macro.shim && options.ie6png) {
$(img).css({width: userW, height: userH,
filter: "progid:DXImageTransform.Microsoft.AlphaImageLoader(src='%0', sizingMethod='scale')".format(src)
}).attr("src", macro.shim);
} else {
img.attr("src", src);
}
if(!macro._image_tag_cache[options.srcUrl]) {
macro._image_tag_cache[options.srcUrl] = [];
}
img = $(img).addClass(options.imageClass)[0];
macro._image_tag_cache[options.srcUrl].push(img);
return img;
},
_getDimensions: function(realDimensions, reqDimensions, preserve) {
var w = realDimensions.width;
var h = realDimensions.height;
var reqh = reqDimensions.height;
var reqw = reqDimensions.width;
var finalw = w, finalh = h;
var ratiow = reqw / w, ratioh = reqh / h;
var scaledw = ratioh * w;
var scaledh = ratiow * h;
if(!reqw && reqh) {
finalw = scaledw;
finalh = reqh;
} else if(reqw && !reqh) {
finalw = reqw;
finalh = scaledh;
} else if(reqh && reqw) {
var preserveWidth = w > h ? true : false;
if(preserve) {
if(preserveWidth && scaledh < reqh) {
finalh = scaledh;
finalw = reqw;
} else {
finalh = reqh;
finalw = scaledw;
}
} else {
finalw = reqw;
finalh = reqh;
}
}
return { width: parseInt(finalw, 10), height: parseInt(finalh, 10) };
},
_renderBinaryImageUrl: function(container, src, options) {
var srcUrl = options.src ? options.src : src;
srcUrl = srcUrl.indexOf("/") === -1 ? "/%0".format(srcUrl) : srcUrl; // for IE.
var image_dimensions = macro._image_dimensions[srcUrl];
var image = new Image(); // due to weird scaling issues where you use just a width or just a height
var createImageTag = function(dimensions, error) {
if(error) {
var altImage = options.altImage;
if(altImage) {
delete options.altImage;
macro._renderBinaryImageUrl(container, altImage, options);
} else {
options.src = src;
macro._renderAlternateText(container, options);
}
} else {
var dim = macro._getDimensions(dimensions, {
width: options.width, height: options.height }, options.preserveAspectRatio);
options.srcUrl = srcUrl;
macro._renderImageTag(container, src, dim.width, dim.height, options);
}
};
if(!image_dimensions) {
image.onload = function() {
var dimensions = { width: image.width, height: image.height};
macro._image_dimensions[srcUrl] = dimensions;
createImageTag(dimensions);
};
image.onerror = function() {
createImageTag(null, true);
};
image.src = src;
} else {
createImageTag(image_dimensions);
}
},
_generateIdPrefix: function(){
return "twsvgfix_" + (this._fixPrefix++).toString() + "_";
},
_fixSVG: function(childNodes, idPrefix) {
var urlPattern = /url\(\#([^\)]*)\)*/ig;
var fixes = [
{ attr: "id", pattern: /^(.*)$/ig },
{ attr: "href", namespace: macro.xlinkns, pattern: /^#(.*)$/ig }
];
var url_fixes =