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