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,

More chance to learn about implementation

I am pleased with how things are going.

AMBIT manuals

The multiple versions of the Core content of the AMBIT manual are starting bit by bit (and it was always meant to be bit by bit!) to inch towards differentiated, customised forms, that begin to address local specifics - "how we do this stuff here, with these kids, in these streets". Far be it from me to introduce comptetition into this collaborative exercise, but Kids company and the MAC team are giving the CASUS team a run for their money in starting to introduce regular slots to MANUALIZE their own practice in their own local versions, inter-digitating their contributions alongside the pre-formed manualization content about AMBIT that is curated from the Anna Freud Centre.

MBT-F manual(s)

At last, I have managed to put the MBT-F manual into the new AMBIT-theme, so that it has the same (we think greatly improved, though FEEDBACK is still something we crave) user interface as the AMBIT manual.

This user interface is thanks to the generous support of COMIC RELIEF, which is funding improvements to the manual, as well as training for non-statutory teams (there are still a few slots for FREE TRAINING in AMBIT for non-statutory teams in the UK if you rush to the Anna Freud Centre)

Fellowship at the CLARHC

I am thrilled to have been given a one year Fellowship at the Cambridge-based CLARHC (Collaboration for Leadership and Applied Research for Health and Care), starting in September. As a CLARHC Fellow, I get to spend a day a week working with Cambridge University academics, the Judge Business School, and other experienced clinicians to look specifically at the implementation of a TiddlyManual in a clinical, "real world" setting.

We are currently looking at different ways to do this, and some of the opportunities are more than exciting, involving the possibility of formal cluster analysis of outcomes for multiple teams engaging in AMBIT and using tiddlymanuals to support themselves in this - watch this space.

New user interface goes live

It is not yet finished, and the content probably still requires a lot more shaping.. but the new user interface is now set as the default, and you can see it at:

ambit core content manual

the list of teams starting to edit ther own local versions of the manual is held at

Tiddlymanuals.com

Please have a look, and feedback if you can.

2nd Version of New Look - & how do we get more feedback?

As described in my last post, we are working hard on the user interface.

There is a working version of where we have got to here, but we are now working towards a second version, which is not yet working, though you can see a mock-up here - simpler still, I think, and loses the 'floating' sidebar, which I think will be easier.

Of course designing an interface is a little like trying to mentalize another person - making sense of their actions (clicking that link there, rather than this one here - NOW WHY WOULD THEY DO THAT?!) in terms of their intentional mental state at the time: their beliefs, their wishes, their worries - which collectively drive their actions. It is hard! As a user of the site, some of my intentional state in a particular moment is, of course, pre-conscious - not in my own awareness, let alone that of the guy struggling to predict how to make a website so self-evidently obvious as to make the 'interface' practically invisible to me... Interesting how it takes expertise (Jon Lister and Joshua Bradley, and our frineds at Osmosoft supplying this) and experience/feedback (me, and the others who I can squeeze feedback out of) to get this anything like 'right'...

Feedback is the gold-dust we require, and it is very hard to get others quite as fired up as those close to the project so as to increase our data from 'ordinary users... It takes a certain head of steam to go to the bother of letting a web-designer know what annoyed me about the website, where I got lost...

I guess what I am saying is that sometimes this whole tiddlymanuals project seems a very lonely task. People will look once, but if they don't like it they'll go away. However, what we are trying to do with the AMBIT intervention (for multi-problem, complex, and "hard to reach" young people) as a whole is what Weisz and Simpson-Gray (2008) describe as a "deployment-focussed" development of a new intervention, and I guess this is very similar to the methods of open source development on the web. I love the saying of open-source programmers "Release Early, and Release Often" - as this seems to capture something of the AMBIT developmental method, too - keep showing people your ideas, keep trying them out, keep tweaking, tinkering, improving, bit by bit. Build on what we know works for whom, and keep pruning out what doesn't work...

That pruning bit is the painful one - will we really manage to persuade enough teams to actually begin actively 'manualizing' their own practice in the kind of co-constructed wiki-manual that the TiddlySpace AMBIT manual promises? If we don't, then the basic premise of the Tiddlymanuals project is challenged, but it is hard for teams to do this before the technology easily and "invisibly" supports this. How long do we give it before we have to prune that idea?!

I take heart from parallels in neurodevelopment... neural development follows a line of early (pre-birth to young childhood) massive "efflorescence" of nerve connections, generating billions of synapses (links between branches of nerves). In mid-childhood, and accelerating in adolescence, this process then goes into reverse with what is called "synaptic pruning"... Structures, or more importantly functional pathways, that have adaptive value to the individual are preserved, and strengthened, whereas unused pathways (poor adaptive value) are gradually shed. BUT... certain areas of the brain - most notably, the highest executive bits such as the pre-frontal cortex (where mentalizing occurs) tend to lag behind in their development relative to more archaic structures that deal with, say, threat and attachment. This is not because the prefrontal cortex is less useful; on the contrary, it is just that it is doing such a compex job (working out why people are behaving the way they are on the basis of empathic and imaginative intuition of their intentional mental states) that it takes a while to come on-line... let's be hoping that tiddlymanuals are a bit like that, and not just another part of the massive pluripotentiality of the developing world of effective interventions that yet fails to show adaptive value. My hope is in the fact that it is the very qualities of flexibility and adaptability that tiddlymanuals are directed towards, my fear is that the technology will be too alien to facilitate easy adoption, or that teams struggling under the burden of surviving in the current harsh economic climate will baulk at "adding" the task of manualizing their practice (though I maintain that this can more or less be done in real time, or at least in "bite-sized chunks", so that the time burden should be minimal, and a reasonable investment.) We shall see.