Using the AIM assessment in the AMBIT manual

The AIM assessment is an adaptation of the validated HCAM (Hampstead Child Adaptation Measure) and is itself due to get validation following its use as one of the measures in the large multi-centre IMPACT study of adolescent depression. The AIM was adapted in order that it could be integrated within the AMBIT manual; there, through simple algorithms, it can generate ranked lists of links to manualized material that offer evidence-based responses to the variety of problems that young people present with, and results can be exported direct to an Excel or SPSS database. Here is a short video about its use:

The Community of Practice

I haven't been writing much here recently, as increasingly the AMBIT TiddlyManual IS the blog (see http://ambit.tiddlyspace.com). We have been working hard to increase the "surface area" of the community of teams who are using this material (there are nearly 60 versions of the AMBIT manual - accessible from http://www.tiddlymanuals.com) and here is a video about part of this work:

An AMBIT Conference - May 10th

Moving on - training across a city

The pace of trainings in AMBIT is quickening, and we are glad that we have five fantastic Associate trainers now, who will be running trainings increasingly independently soon. Most recently, we have trained an in-patient unit and an Intensive Support outreach team in Cambridgeshire, and we are in the middle of training 160 (yes, 160!) workers from across the whole of Belfast - psychologists, family therapists, psychiatrists, social workers, youth offending officers, nurses, OT's, etc, all drawn from multiple teams in a citywide network of CAMHS and aligned provision. This strikes us as extremely exciting, and not a little scary, but the opening day seemed to receive a warm welcome and to offer a reasonably good fit with perceived training needs. It does seem that the web-based manual that presents (increasingly clearly I think) "what you are getting into" has played a part in helping to support this major dissemination. This exciting Belfast project is encouraging us to address very seriously the whole notion of an evaluation framework for assessing the impact of such a training exercise, and of course some of this will involve examining what is working and what is not in respect of the web-based wiki manuals. One of the key points about a TiddlyManual wiki approach to 'treatment manual' is that it is fantastically flexible - and we (Dohhh, only recently!) have realised that there is masses of stuff that we can put up there to support trainings - like video of the key chunks of didactic material so that a less confident public speaker can watch pre-prepared video and then run exercises that we know have proven helpful in previous trainings. Equally, we are putting up a lot of training exercises for local teams to run "internally" to support and embed implementation of new methods of working. See the training materials in the AMBIT manual here

San Francisco to Norwich - dissemination

The AMBIT project is increasingly busy, which is a Good Thing, but carries its own challenges.

The thinking behind developing a really good internet-based manual/training resource is about developing ways to disseminate the guts of good-ideas-that-help cheaply and widely (Jeremy Ruston, inventor or TiddlyWiki, describes how a web based manual offers up a "large surface area" for minimal cost)...

So it seems to me that any other model of dissemination of effective practice needs to justify itself against these criteria, but for our part the challenge is to find ways to disseminate practice that is (and remains) demonstrably effective. The circle that needs squaring is how to deliver sufficient oversight and supervision to provide some assurance of qualitative positive and sustainable change, without making the whole operation so expensive that only populations with sufficient wealth can access it.

Part of our approach (in keeping with the AMBIT principle of "Respect for Local Practice and Expertise") is to emphasise the empowerment of local supervisory structures, and to encourage these to engage in the act of "auto-manualization" - documenting their own sense of "what we do well" and measuring outcomes ("Respect for Evidence") to validate this. This is why we avoid the idea of an "AMBIT team" - but prefer to think of local teams developing local excellence, influenced by, or building over the foundations in AMBIT. The AMBIT project is quite happy to be the ditch-digger and drain-layer for the development by local teams of dwelling places that offer excellent, culturally-attuned and effective service!

Another part of our approach is to try to develop webinar/online supervision resources that can be accessed from afar by AMBIT Leads in local teams - this is a work in progress and we hope to get it going early in 2013.

Another part of the dissemination quest is obviously talking about the model, and we seem to have been doing a lot of that recently. In the last three months of 2012 AMBIT and tiddlymanuals will have been presented at AACAP in San Francisco, London, Peterborough, Norwich, Oslo, Stockholm, Geneva. We are training teams at full capacity, too. Most recently 3 new teams in Norwich which are novel, multiagency (statutory and voluntary sector) teams that will purposefully span an extended age-range of teens to mid twenties, a service development that Norfolk should be congratulated for embracing in such a bold innovative way. We have a cluster of other statutory and non-statutory teams for training in London in the coming fortnight, then large numbers of practitioners in Belfast in the New Year... bookings stretching out into summer 2013, in fact!

So AMBIT has become very much more of a "thing", even though it is not really trying to be a thing, but a broad approach that supports local teams to develop and innovate in ways that combine and build upon something that approaches (we hope) closer and closer to the ideal of "evidence-based practice". These are exciting times, and the AMBIT project is having to address internal challenges relating to the expansion of its administrative, training and supervisory capacities. We are growing up, I guess.

MBT-F catches up, and the theme moves on

Well, at last we have found the time to make the switch for the MBT-F manual so that it has finally adopted the much improved new (v.3) AMBIT manual "theme".

Thank you to Jon Lister and Joshua Bradley from JandJ for their expertise in helping us do this.

A theme in TiddlySpace-speak is just a set of instructions that tell the browser (that you are using to "read" the site) how to behave - effectively it sets the look of the thing, and the interface. In terms of the theory at the basis of AMBIT and MBT-F, "mentalization", the design of the theme is where the authors must attempt to mentalize their readership - have their minds, their intentions and predicaments, in mind so that something contingent can be offered.

Why Wikis?

We are trying to balance palliation of the nostalgia for the simplicity, predictability and aesthetics of a book (titles, chapter headings, pages on a wooden desk, more?!) with the many other layers of possibility that the wiki-based format adds:

* gathered multimedia content
* non-linearity of content that can be re-organised in an infinity of ways
* inter-connectivity that encourages meaningful linking of content
* searchability
* cross-comparisons between geographically dispersed practitioners.

The more things improve in the manual (incrementally, incredibly slowly, but I think perceptibly) the more I am interested in the way this feeds into, even directly influences, the way that AMBIT is maturing as a model, and has been spreading in terms of uptake by teams. Manualizing and mentalizing are not so far apart.

We are now heavily booked for trainings right out into summer 2013, with a good mix of statutory and voluntary sector teams. We have a significant trial funded and in the planning stage in Cambridgeshire, which will be carried out over the next 3 years.

Better SEARCHING supports a COMMUNITY of PRACTICE

Here is a short video clip that shows how the SEARCH function in the AMBIT manual works, and where it is... as well as demonstrating how you can use it to peek at OTHER teams' working practices, and compare, contrast and share best practice. We do not promote the idea of "AMBIT teams", but rather locally expert teams that use AMBIT as a framework or a stepping stone to develop and share their own local excellence. The search bar is one way we are trying to foster this "Community of Practice". The ideas of Community of Practice are particularly articulated by Etienne Wenger and colleagues - it is a really neat way of seeing what the AMBIT project is using the manual to support.

We Won!

We won the Guardian and Virgin Innovation Nation award! Wow... Really wasn't daring to hope for THAT!

Voting is open - PLEEEEEASE vote!

Get the vote out! The prestigious Guardian Innovation Nation Awards are decided on a combination of judge's points and public vote... Here is the link to the Guardian InnovationNation Voting page - please use it as soon as possible, and tell your friends! It would be a great boost to the project to win this.

Shortlisted for Guardian Award!

Great news - the AMBIT collaboration (represented by the most active "tiddly-manualers") has just been told that we are shortlisted for the Guardian and Virgin Business Media "Innovation Nation" award under the category for "Collaboration". See the website here.

You can see our introduction to the project at TiddlyManuals.

We have to provide a 100 word "pitch" for the project to go on the Guardian website, which is to canvas for the votes that will ultimately decide the winner...

After a lot of to-ing and fro-ing, this is where we have got to:

AMBIT's innovative open source approach radically improves knowledge sharing across NHS and voluntary sector teams working with highly vulnerable, disadvantaged, disillusioned UK youth. AMBIT offers "how-to-do-it" instructions which each team adapts, refines and improves, based on their local expertise (street level workers, local youth). Any improvements are shared, compared and integrated with other ideas from teams around the country, and existing evidence, constantly improving the effectiveness of the work. Supported by open source programmers, the AMBIT project fosters co-ownership of professional knowledge and multi-stakeholder participation through sharing, remixing and evolving text, diagrams, pictures and video content for professional ‘manuals’.

Not that this site sees more than the odd passing seagull, but if you are here, and you fancy supporting us (before May 30th this year!) do slip along to the Guardian website and vote for us!

Thanks, Dickon.

Netherlands love Mentalizing

Great conference at the end of last week in lovely Haarlem, outside Amsterdam, hosted by the newly launched MBT Netherlands organsation.

The conference was in the most beautiful concert hall venue; two stages, one radically modern, all swirling wood galleries, curving so they gave you the feeling of being inside a whale (but in a nice way.) The other was strict and classical with huge windows that poured in light and framed the medieval market place below - felt very honoured to be there.

AMBIT got a very positive welcome, for which I am most grateful, and the notion of TiddlyManuals seemed to interest people. The day afterwards a group of MBT treatment developers met to think specifically about MBT and Adolescence. What was so encouraging was the strong sense that two parallel processes were occurring.

First, there was increasing clarity and confidence that there is a shared common core of what underpins mentalizing therapies... that is both respectful of other branches of therapeutic endeavour, but also quite distinctive.

Second, there is a rich variety of implementations and variants, that seems entirely in keeping with the fact that Mentalizing is above all an imaginative activity, that must respond contingently to its setting if it is to be "what it says on the tin". So there are settings where MBT is using groups and individual work, and settings where it is using Family and Individual work, and settings where it is using all three. In Geneva (with Martin Debbane and colleagues) it works with youth mandated into treatment by courts, in London (Trudie Rossouw and colleagues) it has been deployed in CAMHS outpatient clinics and a "tier 4" specialist in-patient unit. AMBIT is just another (though even more heavily adapted, and actively adapting) variant in this sense...

What comes out of this (at least in my mind, and others seem interested in ways that may simply reflect their kind and polite manner in keeping with their mentalizing excellence, but I dare to hope is more!) is the goodness of fit with a Tiddlymanuals-type approach to the manualization of such an approach. Tiddlymanuals and their "amoeba-like" capacity to include content from multiple other wikis allow layers of core manual ("what is mentalizing, how it arises, the neuroscience, and how we translate all that into a basic mentalizing stance") along with sort "epi-" or "meta-manualizations" of the kinds of local tweaks, adjustments, responses and delivery systems that fit this to the specifics of a local social ecology... so all roads lead to tiddlyspace, tiddlywiki and the use of co-constructed wiki manuals n'est ce que pas?!

Implementing change, sustaining change and sustaining fidelity

Thinking a lot about the nature of the task (and it is a paradoxical one) of standing in front of a team (that usually already has a great deal of expertise) and suggesting to them ways that they may wish to change their understanding and practice... so as to get better.

We bang on about the need to support self efficacy in teams (as in our patients), but tell 'em what to do... well, not quite: part of our method is to avoid trying to generate teams that are badged as "AMBIT teams" - but instead to offer AMBIT as a platform upon which local teams can find space to develop and share their own locally-developed and locally-tested expertise, in a "fecund mix" of evidence based practice, and their own hard-won practice-based evidence. This might be seen as a bit tricksy in one way, as our manual "template" (upon which we hope they'll write and show their improvements and tricks and techniques)is pretty big, even overwhelming...

Part of it requires a shift towards an outcomes-focused approach - does this stuff make a difference in the direction I want it to (or more importantly that my patients want)? So then the challenge is not just to show a team some neat and satisfying ideas and tricks, but to make a difference to their outcomes, and more than that, to establish patterns of behaviour that are sustainable. That last sentence is a double-entendre - but not in a saucy way. The behaviour change made by a team can be sustainable or not (i.e. does the team keep doing it?) but also, the method of working can make a team sustainable or not (i.e. do the workers burn out, get sick, get bored?)

We figure that the people that WRITE the manuals are generally the best at FOLLOWING them, too, but that there is also this stuff called evidence out there, that is better than benign eclecticism and safer than the lonely visionary; hence the different layers of content in tiddlymanuals or tiddlyspace - the capacity for one person's (or team's) wiki to include the content of another one's, and then to overwrite pages written by others - to create my own local version, without in any way affecting the pages that the original author wrote, and still curates.

We have recently been invited to write a paper for the journal Attachment and Human Development and we are thinking about help-seeking behaviours a lot, and how might a treatment manual act as a kind of place to turn to for help. Look at how Google have managed it! A locally-adapted tiddlymanual might act a bit like that - a place that people turn to, if a better "secure base" isn't available. Our developing hypothesis is not to suggest that a bit of wikification can or should ever replace a great supervisor or experienced colleague, but that in the absence of that person, people might turn to a great looking manual that "delivers the goods" predictably... but in the same way that we are able to "scribble" over our parents and other attachment figures (in the privacy of our own minds we can, and usually do, hold our own ideas about what our parents reveal of themselves) we can also "scribble " over the core manual - hold our own ideas about it, if you like... and just as this makes our parent/attachment figure recognisable, familiar, safe to us, so - we hope - our wiki-adaptations help to make the manual feel recgnisable, familiar and safe.

MindTech UnConference

An interesting "UnConference" today at MindTech in South London (theory being that the really useful things that happen in conferences tend to happen in the gaps between presentations, so an UnConference is mostly gaps, and little formal presentation.)

Follow it on twitter #mindtech

TIDDLYNOTES

One of the conversations was about designing a radically new approach to client notes - that could place the client at the centre of the system, rather than the current NHS IT systems - that are almost entirely top-down, functioning for the larger system first, the doctor second, and the patient hardly at all...

Now, I am not saying that it would be a cinch but go with me on this...

Think about TiddlySpace and all it does. Say I have a problem, and I go to my GP. Say I have a "MyHealthJournal" - a TiddlySpace-like wiki, and I have already included my GP's Space-about-me (what used be called my medical notes), so I have access to all my notes; and although the original content is curated by my GP, if I have different views or feel stuff has been left out, I can annotate my own version of my GP's notes within my Space. My version and my GP's version are clearly separate, comparable, and transparently useful as each note (tiddler in the Tiddlyspace vernacular) is taggable, searchable, link -able etc.

Now, because my problems are a bit complicated, I am referred to a social worker, and a psychotherapist too. I choose to include their spaces about me in my space too.

I can set access so that my psychotherapist can read my GPs notes, but my Social worker can't. My space also includes a Safety Space that all included spaces have reading and editing rights...

As far as I can see most of this is already feasible in a tiddlyweb environment like Tiddlyspace...

OK, we're talking about a few tweaks for security, for setting access levels to included spaces from other visitors to your space, then Bob's your uncle and the job's a good 'un... No but seriously, it is doable. The more interesting question is of course how the people using this system would learn to USE it...

Hard pressed health staff would I am sure worry about the additional demands that might be placed on them if they were expected to read all of this new material, as they could end up having no time to see and speak to clients or patients if they were trying to keep up with additional posts... But this like most things if thinkable is probably also manageable...

How might this fit with existing TiddlyManuals? Well, the functionality to use a downloaded copy of the manual as a set of notes is already built in, if a little clunky. Look in the AMBIT manual under the tag ICR (interactive case recording). We have placed this on hold, as we felt we needed to focus on the browsing and team editing functions first, but comes a time...

Finally! New AMBIT theme arrives

Blimey, it's here. At last!

So, the feedback has always been that all that information is "just too like a jack-in-a-box that can leap out and overwhelm the poor venturer into AMBIT" Jonathan Lister and Joshua Bradley (funded thanks to Comic Relief) have worked away with us to shape it into something that is (I hope; we shall see) rather gentler. The video above gives a flavour of the thing, but I guess the proof of the pudding is in the hit rates - whcih are running at about 500 per month at present. Do please go and have a browse and send us some feedback.

V.3.0 is nearly here

The new look AMBIT manual should be available in the coming week (or two)... Keep an eye on the site (http://ambit.tiddlyspace.com)!

Lots of Trainings

We have been busy training a lot of new teams in AMBIT, and the use of the TiddlyManual. As part of our Comic Relief grant, seven voluntary sector organisations are in the middle of trainings, and we are also training two CAMH (statutory NHS Child and Adolescent Mental Health) Services.

This is exciting as we now have a wiki based manual that these teams will be able to start working on, adapting their OWN locally adapted version.

In addition, the core training is increasingly crystallising into the key components of the approach, and we have separated out an additional one day training which we call the AMBIT Leads training, focusing much more intensively on sharing an understanding of the MANUAL, and how to put the TiddlySpace 'machinery' that supports this to work:

- The ability to manualize relevant bits of team practice 'on the hoof'
- The ability to compare, share, and adapt other teams' content.
- The use of the 'Snapshot' function in supervision sessions (I can pull out a relevant page of content, and email a link to just that page to my supervisee during the session.)

AMBIT and branded therapies

Our emphasis is increasingly on trying to offer AMBIT as a supportive - yet highly structured - framework for excellent local adapatation, rather than trying to force it onto the market as another "branded" therapy. Local "use-instances" of AMBIT are already directed at a range of different sub-populations, in different cultural milieux - see the signposting TiddlyManuals.com site.

In many ways AMBIT (and tiddlymanuals) is about empowering local services to clarify and build the most effective possible "Treatment as Usual", marrying evidence based practice (provided by our slowly-developing 'core' manual (here) with practice based evidence via the growing number of locally-adapted wiki treatment manuals, where teams manualize their own practice transparently, sharing and refining best practice in a collaborative network of 'open source' practitioners.

There is much emphasis on ensuring ease of implementation for AMBIT, and adaptability; this is most obviously represented in the form of tiddlywiki manuals, but is of course also one of the distinguishing features of mentalization per se; mentalization is exactly that psychological function seen as offering 'steerage' and 'navigation' through the complicated social universe which we inhabit - it is absolutely about supplying adaptability for the mentalizer!

In contrast to some other more rigidly-manualized approaches (which I could unfairly caricature as promoting a rather non-mentalizing stance that "We Know Best"), this is an alternative approach to the insistence that the rest of a service ecology should bend itself to the will of the manual-as-a-thing-in-itself. Our hypothesis is that most (if not all) well-conducted therapeutic techniques act to stimulate mentalizing, and indeed this is probably the 'curative feature' of all successful therapy; that there are many different ways to stimulate and support this most human of functions is hardly surprising!

A potential criticism of the fluid, dynamic approach to manualization that is exemplified by tiddlymanuals is that "it is impossible to perform a trial on "it" as there is no fixed or stationary "it" to test!" - Not so! It is quite possible to "freeze" a tiddlymanual by removing all the team editing capabilities for the duration of the trial. I have envisaged a sort of audit cycle that would consist of a cyclical pattern of locked-down outcomes evaluation, followed by a period of team-driven manualization, during which the lessons of the past year, and resolutions for the next, would be 'written in' to the team's manual. At present those teams just starting to try out manualizing themselves are tending to do it in "real time" - manualizing those practice issues that arise in the course of day to day work, which I am happy about. It seems to me that in this way teams develop a stronger sense of connection between "their" manual and their daily working expertise, as well as ensuring that they manualize live (rather than irrelevant) material.

Another AMBIT training - Dec 1st

We are running another AMBIT training at the AnnaFreud Centre on Dec 1st - there are some spaces left.

This is an introductory training about the nature of Mentalization, it's application for child and adolescent mental health services, and particularly its application for hard to reach and socially excluded youth, for whom conventional services are often not accessible. And yes, we talk about the tiddlymanuals - AMBIT as an Open Source therapy.

http://www.annafreud.org/courses.php/14/an-introduction-to-ambit-as-a-mentalization-based-framework-for-camhs-practitioners

Toronto - and a forthcoming v.3 new look

In a blustery rainy Toronto, speaking at the joint Canadian and American Academies of Child and Adolescent Psychiatry annual meeting. First workshop we (Efrain Bleiberg, Trudie Rossouw and I) did on mentalizing approaches to affectively unstable adolescents seemed well received. A symposium on mentalizing approaches to treatment next, on Saturday, with Peter Fonagy, Efrain, Trudie and Carla Sharp. I will be talking about AMBIT, MBT-F (Mentalization based treatment for families) and will include material on the tiddlymanual. Increasingly I like the notion of AMBIT as an 'open source therapy'... This is very much true to the nature of mentalizing in practice... Just like the programmers who throw open their source code for others to examine and help improve upon, so the mentalizing therapist takes a chance on 'throwing open' his or her thoughts, all the while marking them tentatively as 'just my best theory about what is going on here'. I love the open source 'mantra' - "Release early. Release often"... Really good match to mentalizing work, and draws a marked contrast between the stance that a mentalizing therapist takes and those of more 'knowing' or 'expert' schools of therapy, who may be perceived as withholding, or secretive, by their patients in ways that arouse emotional responses that then paradoxically block mentalizing...

Anyway, the other news is that a third generation of the user interface for tiddlymanuals is in development thanks to Jon and Josh at Withjandj and funded through the Comic Relief grant - the effort is all directed at smoothing (and soothing!) the user experience (once you adopt the frame of mentalizing it is like a benign virus that infects everything - web design is of course all about mentalizing the user!)..

The new design will aim for a crisper typeface, and will further emphasize the notion of tiddlers as paper on a desk (think wood, like the beautiful walnut2 theme for Firefox!) but we are working to make the 'meta-data' attached to each tiddler note even more intuitive, and to make it clearer for the user whether she is browsing or editing...

Should be released in a couple of weeks or less.

Manualizing Practice

A manual is where people who know how to do something write it down so that others can copy what they do and get the same results.

In a team this could just mean keeping minutes of team discussions and filing them in a place where everyone else knows to find them - so that those moments of clarity when we have met a problem, discussed and agreed how we might better manage it if were to happen again... don't get consigned to the dustbin of institutional amnesia!

Tiddlymanuals are about giving a team the opportunity to record its own ever-changing 'best estimate' of what best practice is, and to do so in a way that encourages outside scrutiny - that is radically rejecting of notions of 'intellectual property' as far as how best to help vulnerable and deprived youth.

The radical bit about Tiddlymanuals is the way that they allow a blending of centrally-curated "evidence-based" material, with locally-authored "practice-based" expertise. although what the viewer sees is a single integrated wiki, different groups of people are managing these different pools of content.

In the last weeks in my wonderful team in Cambridgeshire (CASUS) we've really started to try this out...

We had a case discussion the other day, chaired by my excellent trainee Meinou, and under her guidance, after the therapeutic case discussions were over, we talked briefly about how team meetings like this could be improved. It was one of those conversations that we have had many times before, and it could so easily have been "just another" one; this time, though, we were able to minute our discussions live, as we agreed "these are the things that would help better to shape the way we use the precious time we do have available"

As the team talked, so I minuted and checked that what I was writing fitted with other people's understanding - this is made much easier as the tiddlymanual is projected on the wall in the little room where the CASUS team meets, so that everything is transparent and explicit.

You can see the rough draft of how we shaped this ten minute discussion here - it is rough and ready, but that-in-itself will propel us to work harder to "get it right". Why? Because over time the wiki manual becomes the 'flag under which we sail' - which as a team i hope we will come to take pride in. It is just this "nimbleness" (going from discussion to publication in about 10 minutes) that wakes us up, keeps us on our toes...

Early on in my learning about wikis and open source, I was told that one othe mantras of the open source programmer is "RELEASE EARLY, RELEASE OFTEN". Why? Because there is nothing like real world exposure to (a) cull real world FEEDBACK (see here) and (b) spur one on to do better in awareness that our present efforts are short of the mark! I couldn't agree more, and this goes for ways of working therapeutically, as much as for developing computer code that others might find helpful,