There is no such thing as a standard AMBIT team

The chapter offers accounts by seven different teams trained and working in AMBIT-influenced ways, illustrating a variety of settings, the ways in which AMBIT has helped to improve their practice, and the challenges they faced. The chapter starts with an analogy comparing AMBIT with the operating system of a computer, which may run multiple different types of programs to address specific issues. The seven teams are: (i) an intensive CAMHS adolescent outreach service in London, designed to reduce inpatient admissions, (ii) a Tier 4 specialist adolescent inpatient unit in East Anglia, managing high risk/highly challenging behaviors, (iii) a voluntary sector outreach team working in London with highly excluded and gang-related young people, (iv) a therapeutic residential community for children with severe disturbance in the USA, (v) an intensive CAMHS community treatment service in Scotland, (vi) a service for young people on the edge of care in London, and (vii) a young people’s substance use service in a mixed urban/rural setting in the UK.

Learning at work: Toward a learning stance in teams

Team learning, the focus of the fourth quadrant of the AMBIT wheel, is justified by strong evidence about the weak translation of evidence-based trainings into practice fidelity, and weak clinical outcomes from even the most powerfully evidenced practices. The need for strong leadership (and what this entails) to support development of a learning organization is described. Research findings on quality improvements and outcomes in health and social care settings lead to a framework of AMBIT competencies. The notion of local team “manualization” is introduced; this is the systematic effort of a team over time to reflect upon and record (mentalize) how the team works, and why. Discussion of treatment manuals and (as the AMBIT stance presents it) the tension between “Respect for evidence” and “Respect for local practice and expertise” lead to notions of co-construction. Technical aspects of AMBIT’s wiki manual are described, along with how these aspects support a community of practice and mirror “open-source” IT developments.

“It was somebody I could trust”: A descriptive case study of one young man’s experience with an AMBIT-influenced team

This chapter presents an interview by a keyworker of a client (pseudonym Thomas) recently discharged from an AMBIT-influenced team, reflecting on his experiences of that episode. A verbatim account is provided of Thomas describing memories of the therapeutic relationship, issues of trust, similarities and differences between his experience of this team and of others, his thoughts about other people who helped him, and what made the difference. A commentary by the worker follows, commenting on her experience of the work, framing Thomas’s comments in relation to AMBIT’s principled stance and core features, and discussing how an AMBIT framework and AMBIT-influenced team helped steady her in work that was, at times, unsettling and isolated.

Working with your team

Describing the second quadrant of its “wheel,” AMBIT advocates purposeful effort to create relational contexts within the team to support colleagues’ mentalizing, even under pressure. Strong, individual, “keyworking” relationships with clients (facilitating epistemic trust) are the primary delivery mechanism facilitating change. However, such work is stressful, which inevitably threatens workers’ ability to mentalize clients, other professionals, and themselves. The balancing of autonomy (creating authentic relationships) against healthy dependence (maintaining mentalizing) is related to research evidence on team/organizational climate and culture, and to ideas about learning in organizations, especially from aircraft “near misses.” Activities and techniques for sustaining this focus are described, including a disciplined technique for help-seeking peer-to-peer conversations called “Thinking Together,” and techniques of graded assertiveness in challenging a team member whose behavior is hard to make sense of. The chapter concludes with discussion of more formal supervision, and some of the challenges involved in working in this way.

Working with your client

The first quadrant of the AMBIT wheel is presented, focusing on mentalizing in face-to-face client work. The “therapist’s mentalizing stance” (first developed in mentalization-based treatment) is described—behavioral prompts promoting a “way of being with” the client to foster mentalizing. Next, the “Mentalizing Loop” is described: a sequence of activities providing structure for sessions. Common sources of “unbalance” in the work are explored that can make it stressful; this is particularly expressed in the common tension between “Scaffolding existing relationships” and “Managing risk,” two often apparently contradictory elements of AMBIT’s principled stance. Broadcasting intentions, and other explicit mentalizing techniques, are presented, leading on to a presentation of the AMBIT wheel from the client’s perspective, emphasizing parallel helping processes between worker and client. The place of other (non mentalization-based) specific evidence-based interventions within AMBIT frameworks is discussed. Risk assessment, and the tension between support and challenge, is described.

How the engine works: Trust and making sense of each other and ourselves

This chapter lays out AMBIT’s core integrating theory of mentalizing, and the developmental and experimental research evidence supporting it. Mentalizing is a specific (prefrontal cortical) activity of mind, directed at explaining an agent’s (one’s own or another’s) behavior on the grounds of presumed or imagined intentional mental states. The chapter covers evidence from developmental and attachment studies supporting this. The multidimensional nature (automatic–controlled, self–other, internal–external, cognitive–affective) and complexity of this activity is described, as well as the implications when it fails—as it frequently does, given its fragility in the face of anxiety or arousal. Finally, the role of mentalizing in allowing access to learning from another person is explored. It is a powerful ostensive cue, triggering epistemic trust (trust in the social value of information that a helping individual may have to offer). AMBIT is reframed as a systemic application of this theory of communication.

Setting the scene

This chapter begins with an analysis of the fraught organizational and economic circumstances of work with the target population, and the demands these place upon workers, illustrated with four extended case scenarios. After this, the chapter covers in broad terms the solutions that AMBIT seeks to offer, describing the coherent structure of AMBIT by means of its “wheel” diagram. Four main areas of activity to be held in balance make up the quadrants of the wheel: working with your client, your team, and your networks, and learning at work. These are surrounded by four sets of paired, and often mutually contradictory, elements of a principled stance for workers. Emphasis is placed on the inevitability of being out of balance, justifying attention to structures that support the restoration of balance, and longer-term sustainability. At the wheel’s center, the load-bearing “axle” is mentalizing, which Chapter 2 addresses.

Working with your networks

This chapter describes the third quadrant of the AMBIT wheel: efforts toward improving networks around clients. Typical networks around complex clients are described, emphasizing the diverse ways constituent parts are understood by each other (and understand themselves), and the reciprocal ways these influence function. Systemic and positioning theories explain the tendency of networks to organize around concrete understandings of roles, responsibilities, and accountabilities. The inevitability of “dis-integration” across such ‘industrially designed’ networks is described, alongside AMBIT’s intention to reduce blame and shame as primary drivers in networks. The AMBIT stance describes the paradoxical demand that workers must both address multiple domains in a client’s life (requiring large networks) and take responsibility for minimizing the harms of dis-integration that these networks entail. Rather than describing (teleological) reorganization as the only possible response, systematic practices and tools to increase mindfulness about the minds that make up systems are presented: the un-service-centric stance, Dis-Integration Grids, Pro-grams, and sculpting.

Future ambitions for the AMBIT project

The evidence for AMBIT is described, together with our intentions regarding future development and dissemination. Existing evidence, and its limits, is sketched out. Challenges for future data collection/analysis are highlighted in relation to a “model” that is, by design, broad and adaptable, rendering “fidelity” difficult to define in conventional terms. Opportunities for meaningful randomized trials are limited, but possible. A description of AMBIT’s strategy for future model development (referencing open-source computing, learning organizations, and quality improvement models) concludes with a summary of AMBIT’s “evidence-informed” approach. AMBIT’s role as a learning system is supported by innovative web-based collaborations (for instance POD, a pooled online data system). Diverse training methods and reflective self-audit questions for teams considering training are described. Skepticism about how conventional trainings could ever create the necessary “step change” in services is balanced by the opportunities for dissemination offered by web-based learning and devolved engagement of a community of practice.

Adopting the AMBIT approach to changing wider systems of help

AMBIT is now beginning to address larger whole systems of professional help, predicated on four assumptions: help is relational, contingent on trust, and requires collaboration, and processes are all underpinned by effective mentalizing. To illustrate this, problems in the UK’s existing service delivery model for children and young people are presented, followed by a description of a novel approach (the THRIVE model) organizing offers of help around service users’ needs, wishes, and help-seeking behaviors, rather than the technical specialisms that the system offers. AMBIT develops ways of delivering the offer described by THRIVE as “supportive risk management” for families not wanting or responding to advice-giving for self-management, or to specific forms of therapeutic help, or to more specialized/adapted evidence-based practices. Next, the systemic and organizational assumptions in AMBIT are described, especially the invitation for practitioners to relate to existing systems of help (formal and informal), which professional workers of any type must inevitably join (or disrupt).