This is an edited digest from a post on the TiddlyWiki Google Group.
I am interested in the APPLIED side of TW's as opposed to (or alongside, rather) the technical developments that mostly leave me scratching my head at present (though I have hopes...)
I have been playing with the content of my TiddlyWiki manual for a long time now, but certainly would not claim any specific competencies (at all!) in the programming side of things; rather, it is the APPLICATION of this elegantly different writing format that fascinates me, and what it can bring to real life tasks, like running a team who are trying to do a complex set of tasks better, and in a more joined-up way.
I am fascinated in the way that TW works not just as an *analytical* tool (splitting a complex area up into branches/tags, much as a 'mind map' can do on paper) but that simultaneously it works as an *integrative* tool (linking distant branches/twigs) so that I sometimes envisage the web of information in a TW as being 3-dimensional: Tags spreading out over the surface of a sphere, Links diving through the core to their targets, though of course this is too simple in reality.
Hence I am very interested in rather abstract notions such as "What, precisely (semantically and pragmatically, that is), is a link, and a tag?" and "what does non-linearity offer to the reader and writer that more conventional linear text forms lack? - and what do we risk losing by not having a linear statement of an argument?" Clearly this is a Both-And rather than an Either-Or situation. No doubt others have thought long and hard about these questions already, and I would be most interested if there are any pointers to where I can connect up with this conversation.
There is a seminal paper (1959) in the field of psychoanalysis by a British analyst called Wilfred Bion titled "Attacks on Linking", and to summarise this very complex and dense piece of writing, he is saying that unconscious processes (which might be construed as having a "vested interest" in remaining unconscious) "conspire" to keep apart material that could and probably "should" be linked in the mind ("Don't bore me with the facts, I like my story the way it is!"). I think this goes for a great deal of the different schools of psychology and psychotherapy, as well as the neurosciences, which until recently have ploughed surprisingly separate furrows, without paying very much attention to links that are (or almost certainly should be) present. A generous understanding of this is that researchers have been focussed on their own skills and areas of interests, and that the branches of the "tree of knowledge" have extended out so quickly over the past 100years that common fruits on separate twigs have been easily overlooked, not least because the technology to suggest, explore and make links between, say, cognitive-behavioural theories and those of psychoanalysis, have been lacking. On the other hand, most of us would also recognise that (mainly unconscious) things like envy, empire-building and straightforward protectionism (academic and economic) have played their part, too.
This is very much the theoretical position that IMP (Integrative Multimodal Practice - the therapeutic stance that we are manualizing in TW) tries to take - that paying more conscious attention to the links between theories and practical applications is very powerful in terms of providing a better integrated (and thereby *integrative* for the poor client and family) service. In IMP we do that via two significant routes; firstly by training keyworkers in the basics of a whole range of evidence-based interventions (that have traditionally been "owned" by different professional groups), and secondly by using TW as the manualization allowing/promoting/sustaining this linking, and encouraging local team edits to the manual to create a marriage of "top-down" expert material with "bottom-up" local expertise.
To get back to the point of TiddlyWiki, there seem to be features embedded within TW that suit it quite uniquely for the job:
- its self-contained-ness, so that there can be clear editorial control over content, rather than a free-for-all.
- the ease of basic editing so that non-experts can adopt it ...even technophobes (perhaps a little way to go to fully realise this!)
- the lack of expensive additional (desk- or server-bound) software that any health service would baulk at paying for/maintaining.
- the size of a tiddler; by which I mean that a tiddler is "bite-sized" rather than a full essay, and this makes the document approachable from a user's perspective.
Saturday, 18 April 2009
Tuesday, 14 April 2009
This is a copy of my post to the TiddlyWiki Google Group, that gives a bit more detail on the project.
I am not a programming expert, but a consultant in child and adolescent psychiatry (I work in the NHS and at the Anna Freud Centre.) I am using tiddlywiki as the platform for a novel approach to "treatment manualization", which I call TiddlyManuals. If you will indulge me I'll first give a bit of background, and explain what this means and the basic idea that I am chasing. I am hoping that the expertise in this group (Google Groups - TiddlyWiki) may be helpful to the project which is about reaching and helping the most hard-to-reach and needy young people.
Jon Lister and Jeremy Ruston and their colleagues at BT-Osmosoft (www.osmosoft.com) have been helping me (thanks is in no way an adequate expression here), and they have also been encouraging me to join this group for a long while. One of my main concerns is that most of my TiddyWiki'ing is done late at night as I have a fairly busy day job ...so if I am slow in replying please do not take that as rudeness!
My main area of interest is in getting the most evidence-based approaches to young people in crisis OUT of clinics (which the young people who most need help are least likely to get to) and instead to get them applied in the home, or in youth-friendly settings, by flexible, skilled practitioners who are trained in a whole variety of techniques that are drawn from various different professional groups who have previously (perhaps somewhat jealously) guarded these as "their own". Many of the young people I work with are approached by large numbers of concerned professionals (Psychiatrists, psychotherapists, social workers, youth offending workers, community nurses, special educationalists, etc etc) and one of our key aims is to reduce the sheer number of different people who swarm around these hard-to-reach youngsters, often succeeding only in confusing or otherwise repulsing them! I have been lucky enough to work with a group of nationally and internationally renowned clinicians and academics - most based around the Anna Freud Centre (www.annafreud.org) in London in developing this approach which goes by the name of "Integrative Multimodal Practice" (or IMP for short).
TREATMENT MANUALIZATION refers to what psychiatrists, psychologists and psychotherapists try to do when they think they have a reasonably effective treatment model (that could be ways of assessing, talking with, and intervening on behalf of a young person and their family who have arrived at some kind of crisis) which needs to be evaluated (does it work?) and then (assuming it does work) to allow this to be disseminated.
Unlike drug treatments (which are comparatively easy to evaluate, using what's known as a 'randomised controlled trial' - giving half of your patients the drug, and the other half an inert dummy medicine) psychological and social interventions are much more difficult to evaluate. For a start it is difficult to be sure that what Practitioner A says she is doing is REALLY the same as what Practitioner B is doing. A good manual gives a balance of the theoretical foundations of what you are trying to do, alongside an operationalized step-by-step account of what-to-do-when. So if A and B are both following the same manual there's a chance that what goes on in their separate sessions will have things in common...
So far so tedious. The main problem with treatment manuals (and there are many problems with treatment manuals) is that most practitioners hate using them, and it is always a moot point as to how much they really change practice (most humans like doing what they know, rather than what they are told to do.)
They are long, they are dull, it is hard to find the bits that you really need, and they often don't quite cover the 'real-life' situations that arise in chaotic clinical situations (think about a family with multiple problems - parental poverty and substance misuse, interactions that verge on physical abuse, a child with ADHD who is smoking vast quantities of dope and is developing early signs of an emerging psychosis, and who is getting into crime...)
From the practitioner's point of view, too, they often read like a 'ticking off' from some distant academic who sits in an ivory tower and tells hard-pressed therapists that "you don't want to do it like that... you want to do it like THIS.." which can be undermining of the skills and competencies that these guys already have.
Manuals also have an annoying habit of being out-of-date by the time they are published (evidence moves on), and they tend to be expensive (vested interests abound) and thus don't get disseminated as widely as they might in an ideal world.
Finally, manuals also have an uncanny knack of sitting on practitioners' desks (where they look impressive) but not actually getting referred to after the initial training is over.
Using TiddlyWiki as a platform for a manual offers all kinds of advantages:
1. The primary one is that it is possible to incorporate and integrate a whole range of other clinical functions into them, so that they become much more likely to be read by practitioners and thus to influence practice - hopefully for the benefit of our clients. The key example of this is by incorporating a diary function so that the notes a practitioner makes about her client can be recorded within the manual itself - so that it functions as workbook, rather than a separate manual. All practitioners make notes (this is one of the most reliable things that we all do!) - so if this becomes the place where they are first made, the practitioner and manual are likely to
come face to face on an almost daily basis.
2. An assessment tool (basically a questionnaire validated by testing it on various populations) that is incorporated in the manual means that specific information about a client can interact with relevant manualized content via a simple set of algorithms (tagging.)
3. More radical is the idea that, via a set of social rituals and disciplines a local team using such a manual can be given permission to adapt it - authoring additional material to fit its own specific
setting. A particular area may have a problem with, say, knife crime. Now, there is nothing specific in the manual about what to do if a young person brings a knife to a session, but there are plenty of relevant sections that could be linked to from a new 'problem-tiddler' that a team has agreed would be relevant to their own area of practice. We are experimenting with using a TiddlyWiki manual to record team discussions and add 'local tweaks' in real time in this way. Thus over time, incrementally, a single team's manual comes to represent more and more closely what they are ACTUALLY doing, and to be increasingly "attuned" to the specific circumstances that pertain in their region and the population that they serve.
4. Once a team has worked out its own 'attuned' version of the manual, it can generate outcome measures. (These are simple scaled ratings of severity, which are applied before and after treatment to get a measure of what - if anything - has changed. They tend to get forgotten in the heat of the moment because they rely on the right form being present at the right time, etc; in the Tiddly Manual they are built in - ultimately I plan that they will function as diaried 'pop-ups' that the clinician cannot ignore.) If the outcome measures are encouraging, then this attuned manual can be posted in a "Manual library" alongside its outcome data, and a description of the
essential demographic and geographic details about the setting it has been used in, to allow much faster dissemination of effective practice.
In order to achieve this, I have been helped by the introduction of TiddlyWeb, which is a server-side version of TW, that allows for much greater control over individual tiddlers - who has ownership/editorial rights etc. Jon and Jeremy are obviously much more articulate about
this than I, but essentially I understand the TiddlyWeb as a mass of tiddlers that all live in different "Bags" (some would be in the "Anna Freud Bag" and these would be the absolute core 'nuts and bolts' of the interventions that would need proper trials-based evidence to change, others would be in a local team's bag, and others in an individual practitioner's bag, etc... The form of a specific TW is then determined according to a "recipe" so that certain Tiddlers are
pulled out of certain bags according to what the recipe determines.
This sense of "valves" that limit the editing of different parts of the TW according to a form of hierarchy is important, because the RISK of using a Wiki-based manualization is that it could descend into a kind of "therapeutic anarchy" whereby a team member just makes up a new therapeutic approach without there necessarily being a shred of evidence to support it - not how I'd want any child of mine treated!
WHERE WE ARE NOW:
So, we have a prototype manual now; it is a bit clunky, and there is a fair bit of detail to add, but we think we are getting towards a core skeleton that will be useful to clinicians in the field. We are also hoping to try versions of it out very soon in a number of challenging clinical settings in London, N. Ireland, Cambridgeshire, and hopefully elsewhere in the UK. I am already using one version (not a TiddlyWeb version) with a small team in the Anna Freud Centre - partly to work
on defining the kind of social disciplines and rituals that a team needs to "sign up to" to work in this way, and to see if therapists (who are not known for their adoration of technology) can develop a sense that 'their' version of the manual may start to represent their team's thinking and identity - rather than remaining as a necessary irritant. I see the Manual in this sense as the maypole around which the team all dance - and learning the right steps is pretty key.
At present the Manual contains a lot of copyrighted material by the authors, and is released under a strict licence (Creative Commons), so that it cannot be used in clinical settings without separate agreement from the core group based at the Anna Freud Centre.
Jon Lister from BT-Osmosoft filmed me speaking about this stuff at a recent conference on "Computers in Psychology" and this is available on his Vimeo account:
Intro - http://vimeo.com/3922545
Main event - http://vimeo.com/3922602
Q&A - http://vimeo.com/3922712
So far so good. I have written far too much, I suspect, so thank you to anyone who has
read this far!
I am not a programming expert, but a consultant in child and adolescent psychiatry (I work in the NHS and at the Anna Freud Centre.) I am using tiddlywiki as the platform for a novel approach to "treatment manualization", which I call TiddlyManuals. If you will indulge me I'll first give a bit of background, and explain what this means and the basic idea that I am chasing. I am hoping that the expertise in this group (Google Groups - TiddlyWiki) may be helpful to the project which is about reaching and helping the most hard-to-reach and needy young people.
Jon Lister and Jeremy Ruston and their colleagues at BT-Osmosoft (www.osmosoft.com) have been helping me (thanks is in no way an adequate expression here), and they have also been encouraging me to join this group for a long while. One of my main concerns is that most of my TiddyWiki'ing is done late at night as I have a fairly busy day job ...so if I am slow in replying please do not take that as rudeness!
My main area of interest is in getting the most evidence-based approaches to young people in crisis OUT of clinics (which the young people who most need help are least likely to get to) and instead to get them applied in the home, or in youth-friendly settings, by flexible, skilled practitioners who are trained in a whole variety of techniques that are drawn from various different professional groups who have previously (perhaps somewhat jealously) guarded these as "their own". Many of the young people I work with are approached by large numbers of concerned professionals (Psychiatrists, psychotherapists, social workers, youth offending workers, community nurses, special educationalists, etc etc) and one of our key aims is to reduce the sheer number of different people who swarm around these hard-to-reach youngsters, often succeeding only in confusing or otherwise repulsing them! I have been lucky enough to work with a group of nationally and internationally renowned clinicians and academics - most based around the Anna Freud Centre (www.annafreud.org) in London in developing this approach which goes by the name of "Integrative Multimodal Practice" (or IMP for short).
TREATMENT MANUALIZATION refers to what psychiatrists, psychologists and psychotherapists try to do when they think they have a reasonably effective treatment model (that could be ways of assessing, talking with, and intervening on behalf of a young person and their family who have arrived at some kind of crisis) which needs to be evaluated (does it work?) and then (assuming it does work) to allow this to be disseminated.
Unlike drug treatments (which are comparatively easy to evaluate, using what's known as a 'randomised controlled trial' - giving half of your patients the drug, and the other half an inert dummy medicine) psychological and social interventions are much more difficult to evaluate. For a start it is difficult to be sure that what Practitioner A says she is doing is REALLY the same as what Practitioner B is doing. A good manual gives a balance of the theoretical foundations of what you are trying to do, alongside an operationalized step-by-step account of what-to-do-when. So if A and B are both following the same manual there's a chance that what goes on in their separate sessions will have things in common...
So far so tedious. The main problem with treatment manuals (and there are many problems with treatment manuals) is that most practitioners hate using them, and it is always a moot point as to how much they really change practice (most humans like doing what they know, rather than what they are told to do.)
They are long, they are dull, it is hard to find the bits that you really need, and they often don't quite cover the 'real-life' situations that arise in chaotic clinical situations (think about a family with multiple problems - parental poverty and substance misuse, interactions that verge on physical abuse, a child with ADHD who is smoking vast quantities of dope and is developing early signs of an emerging psychosis, and who is getting into crime...)
From the practitioner's point of view, too, they often read like a 'ticking off' from some distant academic who sits in an ivory tower and tells hard-pressed therapists that "you don't want to do it like that... you want to do it like THIS.." which can be undermining of the skills and competencies that these guys already have.
Manuals also have an annoying habit of being out-of-date by the time they are published (evidence moves on), and they tend to be expensive (vested interests abound) and thus don't get disseminated as widely as they might in an ideal world.
Finally, manuals also have an uncanny knack of sitting on practitioners' desks (where they look impressive) but not actually getting referred to after the initial training is over.
Using TiddlyWiki as a platform for a manual offers all kinds of advantages:
1. The primary one is that it is possible to incorporate and integrate a whole range of other clinical functions into them, so that they become much more likely to be read by practitioners and thus to influence practice - hopefully for the benefit of our clients. The key example of this is by incorporating a diary function so that the notes a practitioner makes about her client can be recorded within the manual itself - so that it functions as workbook, rather than a separate manual. All practitioners make notes (this is one of the most reliable things that we all do!) - so if this becomes the place where they are first made, the practitioner and manual are likely to
come face to face on an almost daily basis.
2. An assessment tool (basically a questionnaire validated by testing it on various populations) that is incorporated in the manual means that specific information about a client can interact with relevant manualized content via a simple set of algorithms (tagging.)
3. More radical is the idea that, via a set of social rituals and disciplines a local team using such a manual can be given permission to adapt it - authoring additional material to fit its own specific
setting. A particular area may have a problem with, say, knife crime. Now, there is nothing specific in the manual about what to do if a young person brings a knife to a session, but there are plenty of relevant sections that could be linked to from a new 'problem-tiddler' that a team has agreed would be relevant to their own area of practice. We are experimenting with using a TiddlyWiki manual to record team discussions and add 'local tweaks' in real time in this way. Thus over time, incrementally, a single team's manual comes to represent more and more closely what they are ACTUALLY doing, and to be increasingly "attuned" to the specific circumstances that pertain in their region and the population that they serve.
4. Once a team has worked out its own 'attuned' version of the manual, it can generate outcome measures. (These are simple scaled ratings of severity, which are applied before and after treatment to get a measure of what - if anything - has changed. They tend to get forgotten in the heat of the moment because they rely on the right form being present at the right time, etc; in the Tiddly Manual they are built in - ultimately I plan that they will function as diaried 'pop-ups' that the clinician cannot ignore.) If the outcome measures are encouraging, then this attuned manual can be posted in a "Manual library" alongside its outcome data, and a description of the
essential demographic and geographic details about the setting it has been used in, to allow much faster dissemination of effective practice.
In order to achieve this, I have been helped by the introduction of TiddlyWeb, which is a server-side version of TW, that allows for much greater control over individual tiddlers - who has ownership/editorial rights etc. Jon and Jeremy are obviously much more articulate about
this than I, but essentially I understand the TiddlyWeb as a mass of tiddlers that all live in different "Bags" (some would be in the "Anna Freud Bag" and these would be the absolute core 'nuts and bolts' of the interventions that would need proper trials-based evidence to change, others would be in a local team's bag, and others in an individual practitioner's bag, etc... The form of a specific TW is then determined according to a "recipe" so that certain Tiddlers are
pulled out of certain bags according to what the recipe determines.
This sense of "valves" that limit the editing of different parts of the TW according to a form of hierarchy is important, because the RISK of using a Wiki-based manualization is that it could descend into a kind of "therapeutic anarchy" whereby a team member just makes up a new therapeutic approach without there necessarily being a shred of evidence to support it - not how I'd want any child of mine treated!
WHERE WE ARE NOW:
So, we have a prototype manual now; it is a bit clunky, and there is a fair bit of detail to add, but we think we are getting towards a core skeleton that will be useful to clinicians in the field. We are also hoping to try versions of it out very soon in a number of challenging clinical settings in London, N. Ireland, Cambridgeshire, and hopefully elsewhere in the UK. I am already using one version (not a TiddlyWeb version) with a small team in the Anna Freud Centre - partly to work
on defining the kind of social disciplines and rituals that a team needs to "sign up to" to work in this way, and to see if therapists (who are not known for their adoration of technology) can develop a sense that 'their' version of the manual may start to represent their team's thinking and identity - rather than remaining as a necessary irritant. I see the Manual in this sense as the maypole around which the team all dance - and learning the right steps is pretty key.
At present the Manual contains a lot of copyrighted material by the authors, and is released under a strict licence (Creative Commons), so that it cannot be used in clinical settings without separate agreement from the core group based at the Anna Freud Centre.
Jon Lister from BT-Osmosoft filmed me speaking about this stuff at a recent conference on "Computers in Psychology" and this is available on his Vimeo account:
Intro - http://vimeo.com/3922545
Main event - http://vimeo.com/3922602
Q&A - http://vimeo.com/3922712
So far so good. I have written far too much, I suspect, so thank you to anyone who has
read this far!
Friday, 10 April 2009
IMP and TiddlyManuals
This blog is about Adolescent Psychiatry, and a novel way of working that uses new technology to support people in working together as teams, and in their face-to-face interactions with young people in crisis; particularly those who are conventionally seen as "hard-to-reach".
IMP (Integrative Multimodal Practice) is a framework for practice and a means of joining up existing (and more or less evidence-based) technologies/techniques for working with adolescents in psychiatric crisis. The original authors of a paper manualization of this approach are:
IMP (Integrative Multimodal Practice) is a framework for practice and a means of joining up existing (and more or less evidence-based) technologies/techniques for working with adolescents in psychiatric crisis. The original authors of a paper manualization of this approach are:
- Prof Peter Fonagy
- Dr Mary Target
- Dr Eia Asen
- Dr Peter Fuggle
- Dr Dickon Bevington
- Rabia Malik
- Neil Dawson
They are a group of clinicians and academics based around the Anna Freud Centre and in various NHS settings. The Anna Freud Centre is a charity whose aims are to develop innovative treatments for children and adolescents, to evaluate these, and to disseminate them by training.
The technological aspects of the project are based on my development and use of TiddlyWiki as a platform to deliver a radically new means of manualizing operationalized treatment interventions, which I call TiddlyManuals, and in a sense it is this that I am wanting to talk about in this blog.
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