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(1987). Hypothesising, circularity and neutrality revisited: an invitation to curiosity":"\"e627c21fef4cb304d942513d546c9f57\"","Challenge and Support in Therapeutic Relationships":"\"a626551b3105969d6093cbfcb240971c\"","Challenging techniques":"\"03c2e70beee3b7cba15e06209007f1ab\"","Charlie Sackey":"\"4e930f1b39e5e03f2423fd4af95e49e9\"","CheckLists":"\"22cd3fafb9d61d212e2166535b300dd5\"","Checking":"\"958ae36e144d9389f8f252b3ccd73de1\"","Child Protection":"\"d4e9f9e7725904f35906cd3f0f6dfbb6\"","Child Protection/Safeguarding Services":"\"0ef4b3b69f149fe4f9b7bf9be11abadb\"","Children in Care and Substance use":"\"b1286efb799b319a3fd6b06faf4fbcd1\"","Children of Substance Using Parents":"\"be6182a489eda360778ea060dba99ffe\"","Children with Mental Health/Behaviour problems who use substances":"\"14a227ee4a039de30237847db3012e6b\"","Choi-Kain, Gunderson (2008) Mentalization: ontogeny, assessment, and application":"\"a680e8b2a88fe42a738b380e6d72e47b\"","Choosing what to measure":"\"c374918b054753e90051f0f07fd97af4\"","Chorpita, Daleiden and Weisz (2005)":"\"ac18d8b2ce52e376a807d04e08c02230\"","Circular interviewing":"\"2200e5310f18adf4856e49e15f2f2b10\"","City Bridge Trust":"\"9e525ffe1eeb94d56460de99594ddc79\"","Client CASE REVIEW - CheckLists":"\"49cdba2a2357c1ca3c4fbefdc2f5652a\"","Client Case Review - Date and Agenda":"\"85a2ba2e0effd77f23ea91413f38bb28\"","Client's AMBIT Wheel":"\"01065a71c7000113d19491ed44c60eaf\"","ClientContents":"\"40c798af0b12d29921da27ba81e99e66\"","ClientWheelDoubleSided":"\"9f2ebc75e249253018a0c128efec4551\"","ClientWheelsingle":"\"d67724a4f18b3b2c8595c19d5e57da57\"","Clinical Global Impression (CGI)":"\"c201c96d1f978cc2e602df8e886e1921\"","ClinicalContactNotes":"\"830b1cf1f5251158775a3a21753926b4\"","ClinicalThemes":"\"f8c3b809a6f57f07099620cb04802305\"","Coaching":"\"6859cfa44795d9c246a46d8b6f7aa035\"","Cognitions":"\"8d0e1af6416dec4dfe0cbd07f7cfb928\"","Cognitive Behavioural":"\"e385cd923b88d791096e59c6018779e3\"","Cognitive Behavioural work - CheckLists":"\"0f523299debebc3c9f9c59295224a0b4\"","Cognitive approaches to SUD-Rx":"\"74e6f2ad3c00b95e52c5baa710f534dd\"","CognitiveBehavioural for SUD-Rx":"\"2354325878557eabbb61e0ff40fc6275\"","Cole, M (2009) Using Wiki technology to support student engagement: Lessons from the trenches":"\"699739a1ad75969488047e9985c8aeff\"","Colombo-style Curiosity":"\"1e53919868ca9da91846ad703f96427e\"","ColorPalette":"\"93cb1de29f5e011b68f0119c0359ea03\"","Comic Relief":"\"4c083f54121033325d7fc5d70d1f9e9b\"","Comment by 'dickon' on '+ Getting started'":"\"e5e8b296cd01c4f698e8158a96ff112f\"","Comment by 'dickon' on 'Comment by 'dickon' on 'Error messages' 1'":"\"e9b26a9c407680af96449469c1da420c\"","Comment by 'dickon' on 'Comment by 'dickon' on 'Error messages''":"\"3a7ca69273eeea7f46aa52a795a43438\"","Comment by 'dickon' on 'Commenting Function'":"\"850b30baa070c34a70a6167855dda945\"","Comment by 'dickon' on 'Commenting Function' 1":"\"6dd7dc51eb57b045a5bdf6ac6fb7ffbd\"","Comment by 'dickon' on 'Commenting Function' 2":"\"6793fc6f659a712fdb349ccf05b2e24d\"","Comment by 'dickon' on 'Error messages'":"\"32e3838befea00c378d8029c3598e9e8\"","Comment by 'dickon' on 'Error messages' 1":"\"2c76a3874e13a9c526f864a433f14adb\"","Comment by 'dickon' on 'Future AMBIT training intentions'":"\"6547e8580e2f2b23ddf6deb172511b6f\"","Comment by 'dickon' on 'JF'":"\"a457146de2d4bae373168ae539e4e1ab\"","Comment by 'dickon' on 'Logic models training exercise'":"\"4d48a5ec909acef1b0f00d4e91effad8\"","Comment by 'dickon' on 'iFrames'":"\"cb508a3ea7b03d87b8cefd4cb9736199\"","Comment by 'jamesfairbairn' on 'AMBIT Local Facilitators'":"\"b8579efc731deae706596e9be68719d5\"","Comment by 'jamesfairbairn' on 'Active Planning'":"\"619532b535610624e7f79f502f65aaae\"","CommentButtons.jpg":"\"058c20db0f1a878522b10d93128c3012\"","Commenting - Boundaries":"\"547b0f10f54e7dea8831611c2e02dcc3\"","Commenting - Content Moderation":"\"ba02ab78eea70520d9015bd1c6a7e2f7\"","Commenting Function":"\"bd77837d1d995ddf2070d357f4728f77\"","CommentingButton.jpg":"\"baa56f38036f4c5bd90c1870d3bb8ef7\"","Community":"\"0463216901e5ff9998fe008b32fc9ba3\"","Community of Practice":"\"adf9ccdc170ff09a04cd622ef268560d\"","Community of Practice (extended learning)":"\"d111cb0e5001e1ec04f5f13533cfa31a\"","Community of Practice core changes widget":"\"aebc7ed463f3fee04381380bbd373f9c\"","Community of Practice recent changes":"\"784b52573f50f900b0e561b3c9f86909\"","Community of practice pic.jpg":"\"8f3d2515f93e72996995f5c249328f52\"","Comorbidities":"\"b3f3f1a6bb1d3889b32b2b7312bddec4\"","Comparing Destinations":"\"7c1b161e479891898524ba8a123ae5e0\"","Comparing and Sharing functions":"\"4348bd4811d8137897647e3c3d7eb4c2\"","Competencies 29.08.2018":"\"e9146fe060ecfd76f5f5952673ad2a39\"","Competency use and importance ratings":"\"1ed7edd139cb45f039c80c1ccbfa847b\"","Complexity":"\"5cf7f3dcb7b4b6f5319a13d86804dac7\"","Concrete Mentalizing difficulties":"\"ae7ea1b76cbeadf675d36e9081d80f77\"","Conduct problems":"\"2e6b881155f955b8a7a0c9418c1b2ea8\"","Confidentiality":"\"0cd5427c713cd8aa37c74759ee94012a\"","Connecting Conversations":"\"a81f59bb1b9f75712536aac21e1a0f64\"","Consent to Treatment":"\"86c096d4ea02d60f241c2d4cb9c4351b\"","Consultation Day":"\"511d2cd282ad2fb5a1972ff45fa34e97\"","Contact us":"\"30b80df86d4b33ec657e93c3dc6eeab2\"","Contemplation":"\"7ff77dd49beab3144a6b19c8a8963c7b\"","Contextualising in time":"\"21f1f8cc8daee37e659bb990cde55c17\"","Contingencies":"\"e6e3d551143eef17827f1d2920c0ab98\"","Copyright matters":"\"0cc52ee8e83eff12368de8cebbf44098\"","Core Features of AMBIT":"\"78d9324a82bda036b5cae8bd1dc74dcd\"","Course of a session - some interventions in detail":"\"d08cb3aa03f1614edd5ad42bb57c5f97\"","Create specific \"TRAILS\" or \"STORYLINES\" for beginners":"\"f40484159bd90d27cfaa97b6eeae2f1d\"","Createnewpageicon.jpg":"\"1e203c5a22f111a25c7e130b0976f56c\"","Crisis Contingency Planning":"\"912bd059769b8ab8bf8bea4a5a2bd3b4\"","CrisisServices":"\"1a12bca916486f92a9e19536f2f1ec09\"","Criteria for inclusion/exclusion of CONTENT in AMBIT":"\"455334aa7ba0f09f82d3fbae53761929\"","Crossword":"\"12cbc14eac292493391ab2fe8db14bf8\"","Cultural Context":"\"46516015c6000d606706ca6a23551f33\"","Cultural consultation":"\"5009522990a5a5c2a74f904a7fb53620\"","CultureOfHospitality":"\"a15d982cccfb4f5247183c93d38e72a0\"","Curiosity.jpg":"\"788dac2c55c41c8f2e6198f8cdcd8034\"","Current Research and Outcome Evaluations in the AMBIT Community":"\"d3d8c5ed7fa466245a439b6e6e8e9530\"","DOMAINS and LEVELS of dis-integration":"\"4ca148e36b97ebc8d2db413a2c86a98c\"","DataSecurity":"\"04c4872f737c9ee591ab6c0d7d5dab68\"","Day 5 - sculpting the AMBIT wheel: a training exercise":"\"735e3c7bd9757e0cdc6f218acdf9eee5\"","Default \"Create New Here\" item in drop-down tag lists (Jer 7/10)":"\"2d78072e41a64fcd068778b9671eba0d\"","DefaultTiddlers":"\"901f1bfd57e4160b2c0c96af5be95bc8\"","Defining Mentalization":"\"ed1caee7d7c5aa5fc3ea237e07ac899b\"","Delirium Tremens":"\"45fe090ad237402ffd902b2be33364fc\"","Delivering tele-supervision: a guide for AMBIT Trainers":"\"e0fbdcd77e64c78771dfad993512c4cf\"","Delusions":"\"2ce066d256d38c652721afbbe8c7c8fa\"","Depression":"\"1c5ca47a9e9d79562d5479318ac1e2f9\"","Develop Discrepancy":"\"386fb904d10c607b0e57e075c7cd654e\"","Developing Team Learning Objectives":"\"8763fd649547e7d6fec1caa0169cab68\"","Developing learning organisations":"\"7119801995a1a62ebd2e0fea8ae9b008\"","Developing maintenance routines":"\"6f76ebf5bd24fc58b61f55627d9215de\"","Development of Mentalization":"\"cf34ce3932695f98202c4c48747f6df4\"","Developmental Considerations":"\"2cc59b019bfd05502d9adb47aabf20de\"","DevelopmentalHistory":"\"2d47ae36f390fc59645f6ca1e9a664c8\"","Dgrid.PNG":"\"0c26a6da5b925e760e073f8d6c93a44f\"","DickonBevington":"\"4d6b1a9aced49eaaf5a3ba08922a7999\"","Differences between MST and AMBIT":"\"a05b0eb05e6e300eff0eed262dcb556b\"","Difficulties Saving Pages":"\"ffe84916d477363ca6957171f33534d0\"","Dis-integration":"\"b39b164e7fb8bb73ef65da987a183eeb\"","Dis-integration Grid EXERCISE":"\"7d74ed1808358538b537fd5998df5058\"","Dis-integration grid":"\"28cf9b533de2a7d9811922f56c37dc77\"","Dis-integration grid - Local":"\"6c82b0a8071851560e8d3ef971ecb4ad\"","Dis-integration pic.jpg":"\"db5f00db047ee760b0e0f5bb57094e40\"","Dis-integrationGridPicture":"\"34f8a6816ae093f7002c43d7424f1a56\"","Dis-integrative processes in a Family/Systemic context":"\"192be63025f8890ca940b4c0afb4ffef\"","Dis-integrative processes in a Multi Disciplinary Team":"\"97b7d9d35ad3748b882470a66ac77aff\"","Dis-integrative processes in a Multi-Agency context":"\"edfd4ad8ed19a662c581c8841d695ba0\"","Dis-integrative processes in an Individual Clinician":"\"bf1d6270fd43721d4d89f655347c2540\"","Dis-integrativeProcesses":"\"0d17d935408ba190ba7e21cf6ab2df53\"","Disclaimer":"\"3934d53537cc8215498fbcb63b213e0c\"","Discussing outcomes (PF and DB)":"\"ba462b7c2b8d09becb6a991bdd64ce96\"","Disintegration in networks: respect for local practice and expertise?":"\"7a3634c2c5a3bacbb74e30d072f9077c\"","Dive Boat":"\"4b99f2139da03907fcac02371465decf\"","Does AMBIT work? (Unconference conversation 2016)":"\"77510f962ab14e101722cd6e18d0d1e3\"","Domains":"\"2118b7e36ee41c4aac4f68009b55046b\"","Domestic violence":"\"2811362d02529a94580933fe1586f272\"","Downloadable Resources from Training":"\"a46803e0f2da368f5b6a8e8502449014\"","Draft of 'Cognitive Behavioural'":"\"ccff47dcaec370d6e3be6ed7804190e2\"","Draft of 'Contact' by mariannemcgowan":"\"b9bd945f0227acf5c5f75f5607bf5aec\"","Draft of 'LEARNING at work' by jamesfairbairn":"\"c2f7b7c1ca3fbc4079eac31ca19f6d02\"","Draft of 'PsychoEducation' by mariannemcgowan":"\"5ac3e3ff9f11fafe542ebec949b45ee5\"","Draw my mind":"\"7721872a0051bb6401156e58a1c9a703\"","Drawing the AMBIT Wheel":"\"901a7d617533fc5e06632df7225e9c1c\"","Duncan Law and the IAPT CO-OP Group (2012).  Using Service User Feedback & Outcome Tools":"\"3e1ad81f5ba2ce50e4050b3cf7659e2f\"","ENDING PHASE":"\"3714764cd2f3e3fbae53d6dbc9bc103b\"","EXAMPLE of a local training session":"\"998575e022bdaec9478561df0fc4d810\"","Early phase of individual therapy - establishing trust and setting Guidelines":"\"8c159dab243af98dbd43cf5ca30dea66\"","EatingDisorders":"\"4c3309f777536eb7a9064344768db103\"","Edit 1.JPG":"\"7b57547098699edf050a841ff2c08069\"","Edit 2.JPG":"\"95ad07df7b8581a05fd24060dffc915d\"","Edit 3.JPG":"\"53dbeecc35d8bf696dc9871f14bcc5da\"","Edit 4.JPG":"\"0fbce2f55c2ae230c908a75504b3b24a\"","Education-Vocation Intervention phase - Example timetable and Flowchart":"\"e8575cc30d212926c65b78e2f440e3e1\"","EducationEmploymentTraining":"\"1654c271b75ff32121d4559acffeca96\"","Educational-Vocational Engagement Phase Flowchart":"\"997d88479493716dd03e6033f9b0ac7e\"","Educational-Vocational Training":"\"85b4d80e97fa4c64d34f8c064f1fed63\"","Educational-VocationalComponents":"\"26866001092365c1e34da2c96a802ce7\"","Educational-VocationalPrinciples":"\"1793dbe6e954c713574f2a7220578f70\"","Educational-VocationalStructure":"\"d14fe38b9575fe2dc5c8182f417f3de7\"","Educational/Vocational centre":"\"9847518b7ad77d2460e3e4d09faadeb8\"","Egg & Triangle - Local":"\"de18fa3a8f4c5c48a9ea2f88a4b79470\"","Egg and Triangle.pdf":"\"1505a609ff9be82a46bc8aa6ff2d3103\"","Egg and triangle (marked)":"\"e38bfd0fb7264a55f2a19832e845ea36\"","EiaAsen":"\"1401769c78e1094cacc8553525341951\"","Elevator Pitch":"\"5b4426f170d2a5013fb37c5d4456eaf3\"","EmergencyProcedures":"\"099b44975658a9325e6a3592b443d3d7\"","EmergencyResponse":"\"48aafc2e0473c9cb1d1a370fd0e3e27e\"","Enactments":"\"7bde5f92b6f06456c3ae8949b8a988a9\"","End Phase of Mentalization based work":"\"35bf11f5d4b574cd96dea30c86a85ce3\"","Endings - Parachute pack":"\"a85e53deadbaa9f8812ba0976594f9cb\"","Engagement":"\"10cfbe69e2555dd7cf7937237c970a4e\"","Engagement call":"\"0e1a2c0b8964e9e7ce0e7fa63d62110a\"","Engagement techniques":"\"d9aea18538ae062397ffae92379be39a\"","Engaging a team in Outcomes Measurement - Liz Cracknell and Carol Evans":"\"966b5dedfaa83f5059a23335ae796c52\"","Epistemic Trust":"\"3140d4457577b9cac34fe3b62589e4a7\"","Epistemic Trust image.jpg":"\"db407ff4a5dc4e65e97e9ac8f4aa5877\"","Error messages":"\"8a93953807f57fd03fbdd14ea49f348f\"","Evaluating AMBIT trainings":"\"d62b0dae1678ba1ffeaa827b7b0b988f\"","Evaluating outcomes":"\"d9363aa58fbeb9536363fc3ffd000c23\"","Even-handed attention":"\"fa0ebc842f39fdd80b216bc39fb69d3d\"","Evidence":"\"5236213d3ab6fb27565833d3371362b8\"","Example Google Doc Link":"\"909f5a511f3a085300868bdb5d9f3ab2\"","Example of Manualizing- Making a Cup of Tea":"\"e9bb03560663a7a65ab7f968d73f04f0\"","Example timetable during engagement phase":"\"63c50370c65e49543835858de5c9cb82\"","Examples of Mentalizing Formulations":"\"6adc49cb5f742b19ad28a015c1efb2f4\"","Existing cases":"\"1aff819ccc441714618c198d6be230da\"","Experts By Experience":"\"0229c20521db1382eaa9369c9250794d\"","Explicit mentalization":"\"60f8c021875dfaa70bd6cf5a0903f8a3\"","Exploitation and Substance use":"\"038d9ede7d546760a4fc4e49fa38e732\"","ExportAIMInstructions":"\"c016448a9a97e633f75e21be45efd1e2\"","Express Empathy":"\"49834644ab7e27f4a480af7618eb5440\"","Expressed Emotion":"\"bd773a3591d013de7c2114837cd42370\"","Extended learning":"\"972c23ab75b9791b906d1e54dacf414b\"","FINISHING (Closing) a case - CheckLists":"\"0496e3c1bf06657a9b21cf8ec13341da\"","Families and Engagement":"\"996c19d9311b043966cc1eee9818e442\"","Family":"\"be4df68b117a2cb38d6a72918d7599f9\"","Family Life Space (Genogram) Techniques":"\"a5e91a0f4fe93b9e144a2ee414a57d60\"","Family Sculpts":"\"6f4ab14f1d4fec58b07bc59f8cda0eda\"","Family System Mentalizing diagram 1":"\"edda21d138f82e7b10018f642eeb5016\"","Family System Mentalizing diagram 2":"\"4264a170a66d3bb8d7d87ed01567315c\"","Family-Aims and Principles":"\"a4785d22a534ee347be147b824554977\"","Family-Settings and Arrangements":"\"36726eb9c879c03fef9f81877d5be47d\"","FamilyHistory":"\"102764ec16adb0c1bb354c9223ec05d0\"","FamilyInformalNetworkMembers":"\"23cf1bd08505c4b97e9c8b56f148649d\"","FamilyWork":"\"fce12f6eacf2ef8b7926ec290235c12a\"","FamilyWork for SUD-Rx":"\"e4b206813d0e54c4fe87468bfba1deaf\"","Features of Successful Mentalizing":"\"7b44edb594a66344935a6cea0e39735e\"","Features of UNsuccessful Mentalizing":"\"da6fcf3f48b40cee0e8b66cefcfd6925\"","Feedback on AMBIT Training":"\"fd97020d7e372d8dd14b00e8ac5fd8ff\"","Feedback please!":"\"c3e2e4edbb7692f1998360c2d6e88183\"","Feeling":"\"ebb3fe6a43d16c78cf80472d9f09469b\"","Feeling Spinner":"\"4cdb0be6d4abbbdefd96234907c5ae15\"","Fillers":"\"a5b0a1eb3353a9d81b7cb6a7a66a7fb1\"","Find a falsehood":"\"d131a799e5e018f4bdf85f39a5362063\"","Fishbowl discussion":"\"9973a85a6d4abbffe97050892aec1a9d\"","Fishtank film clip":"\"08e3751b90232c0713813ef8717c0bde\"","Fitting AMBIT expertise to the expertise of others (Unconference 2016)":"\"1a2da8293656e6b2217c2560b7e83d59\"","Fitting what you ADD into what is ALREADY THERE in your manual":"\"71095741d81c9a163b48faeac47d4202\"","Fixsen's Stages of Implementation":"\"be83fa51153e64c467c5c1f9765e73a9\"","Fixsen, et al (2005) Implementation Research: A Synthesis of the Literature":"\"48f848439e197df67fc7496da61b7b25\"","Focussing on Functional difficulties and Distress":"\"ef564ffb955058b7c2c54dd521a9e490\"","Focussing on Strengths":"\"ead1d7f9b1eabe2c161ce2bda5248b5c\"","Follow-up after Mentalization based work":"\"aac07bb0fa434dcc8fff239427ab34a8\"","Follow-up training for established teams":"\"8f67d374e276ec93b35c351c78d38b14\"","Fonagy, Cottrell, Phillips, Bevington, Glaser and Allison (2014) What Works for Whom":"\"abda23877b7e7121019d886b185783cd\"","Formal supervision":"\"ab6e297c065b2d1ac9480e743815f14d\"","Formulation and Treatment Aims":"\"431238d0b4297b8af7cf99aa40def402\"","Four corners":"\"6020cb50ea573d83e2e65573c0b2159b\"","Fuggle et al (2014) The AMBIT approach to outcome evaluation and manualization: adopting a learning organization approach":"\"5c7e29c368a4dde29879380b690b8260\"","Future AMBIT training intentions":"\"646da5d6eaf9ec78d0068ccb8a421457\"","GHQ-12":"\"a5842aa958ae6e1fc47e7eeb86eb031e\"","GHQ12.pdf":"\"38d90dc7da5c9ed2b652f73b0d76994c\"","GUM":"\"ad9bf3ca0fba84ef12502aa0f8a05ae6\"","Gemma McKenzie":"\"cc979f5c645f66aeaead8b6a6398126d\"","General Features of Unsuccessful Mentalizing":"\"b971864193af42e105c5b861fc1f9695\"","General Systemic Techniques":"\"a6a320924a4cf85583c8480662721b25\"","General features of a \"Mentalizing Stance\"":"\"da9c3ead6d6f63e6a715bf9c3f381a5c\"","Generalize (and Consider Change)":"\"f183164cd30c8a57899cab561cc19538\"","Genogram picture":"\"d7a3f6951da3e45952c0ab489f6dcd6b\"","Gergely, G (2004) The social construction of the subjective self":"\"ca425fbf4f798603185b7903d5197c53\"","Getting started with CBT":"\"6ff15bd480cb610c3f7a2ec0a43bc67a\"","Getting started with the Strengths and Difficulties Questionnaire":"\"50fda1a11941f27d5c9296baf7c21890\"","GettingStarted":"\"b6af4c4a5bb6db504e4af9ed029e9379\"","Gilvarry et al (2012) Practice standards for young people with substance misuse problems":"\"3e999280b03c7608e453e0d27f89857c\"","Giving Advice":"\"da008459f05a7559d4604fc070880ea2\"","Global Assessment of Function (GAF)":"\"2a2ff7cae969d71897d2c5f2ead42837\"","Glossary":"\"dafb85c9d681127c523ad88a12f719a3\"","Goals-based outcome measures":"\"406248fb9e8d7e34bf664445c1cbc8b7\"","Governance":"\"a5a24c292f092682696a6185c6cda59a\"","Graded Exposure":"\"5caefa3d5a7ce1758bc6f93a676a3ab3\"","Graded assertiveness in challenging a team member":"\"c22821af2cc51e04bab4cdad93256dd9\"","Grid Pic.jpg":"\"2109be038a6291e70fb6ce39cad2e835\"","Griffiths et al (2016)":"\"4d0f60e3be0eeedcbb7306b628f1c383\"","Group Work":"\"7392e67e0ae477e3991b44e829be428e\"","GroupPrinciples":"\"eb55a638ca8f12bbba11e77230b7b24a\"","GroupSessionStructure":"\"dd863a22de74fcbef563d61acec27983\"","GroupworkTabs-661265199":"\"070fc7c5bd25cf44502d7ca53918364a\"","Guidance for Teams Considering Applying for Training":"\"e2d657f4ef17968a2a29f63870e77692\"","H-CAMA":"\"40bc7f0a1cff721364fdcf181dd8274a\"","Hallucinations":"\"4a845d5b50f8d3c8ffd31a7a010c3006\"","Hard to reach":"\"b6d95661c2aea86dca8534e7247e8016\"","Hidden, private or implicit theory":"\"198d1907bd32c2fcf8e71e035a26c41d\"","Hide/move blurb about tiddler under title (Jer 5/10)":"\"8deb63d973c9c619aa2ee58ed437c1fc\"","HierarchyOfNeed":"\"f27828836d52bc9f476b6329793a670e\"","Highlighting and reinforcing Positive Mentalizing":"\"91e8071ad3b2f600f31db6e694205d99\"","HoNOSCA":"\"50a998efadf821daf93751a048d92cad\"","Holding the Balance":"\"460b31ab70e536c933c04af5dac08f6d\"","Home":"\"d4013355d7915741b4499091011aed05\"","HomeContents":"\"cd53d0aa34b82a9896bce61018fbf927\"","Homework":"\"541d26ec9f68ade7bb3441eee7b594f8\"","HoverMenu":"\"1915a501f2f1d5028ab6034b830772a5\"","How do members of our team seek help from each other?":"\"64de1d87d71ffedade8c5ade7d42a8cd\"","How do members of our team support help seeking in others?":"\"4647aaa62e22e70c6bb56b0000a62a33\"","How do we as trainers keep ourselves on task?":"\"1657b65d8a94e70b90c8267b51d6d687\"","How do we help each other in this team?":"\"a099a7d287252bb4a6cff8dba70f1146\"","How do we measure whether our team is DOING this?":"\"1f775528664bb022268deabe1b5262d2\"","How does Mentalizing relate to children with Autism?":"\"d2da1d6ce7e9f99b542015a6eb9815de\"","How does the AMBIT approach fit with our Service Priorities":"\"422be773a8e6e8121bd895a3c4d81f51\"","How long should we run trainings for?":"\"4cea1d095abe8f16515edaafbac8a637\"","How motivated is my client?":"\"00810ba76cccdf58912fb261fdfb1f84\"","How teams support each other to mentalize - Unconference Conversation, 2016":"\"996bf8aabc3ca8be5f38158780faa093\"","How to Change the Manual Title/Icon":"\"0c2690cd955d09c90808723c13a10804\"","How to add a document or PDF":"\"4142cd241b0831085000f020d4560102\"","How to add a picture":"\"a6367a6fd0a59464e8b1f74e587b7bea\"","How to centre a title, phrase or image":"\"c6d27278b8420287de16af14214b26ff\"","How to decide who is the KeyWorker?":"\"dbb177cadb93c92c3432399eda7ca0a4\"","How to draw up a Care Plan":"\"989775859103717e027d82d96a8d9693\"","How to edit - Videos":"\"866edb6b654aa94efbcbfe2c97474cff\"","How to edit your teams manual":"\"7c01551999ab496ebc2dbf26f1834cbf\"","How to embed a video":"\"ed258cd661cefa81a11d3fe190d5036e\"","How to get the best out of Web-based seminars":"\"577c87710dbd7c3b0f426aaf5707b016\"","How to speak to a DOCTOR":"\"ea882d8298563894b1b6ce80c6bbc279\"","How to speak to a NURSE":"\"2258a2023d127ba9a902bc85d2d61730\"","How to speak to a SOCIAL WORKER":"\"0d124d0f38c3d5048f1c99c1a8276df6\"","How to speak to a...":"\"fb86d631b9c60d705f73ae018ba79a57\"","How we work together in the room":"\"3dc113ce110a63893a9535108935c95e\"","HyperLinks":"\"8da780898bff36d515badeb968fd7f6e\"","Hypothesizing":"\"ea24ee7564eb6ac6400a925a95f55e52\"","I cannot relinquish my statutory responsibilities to do this AMBIT stuff...":"\"c10dbe020b257e6bf6a1e054d0c0cee5\"","I haven't got time to do this!":"\"6f43a9336ac6e7c4d0b4bbaf7ff1ad98\"","I'm stuck: what next?":"\"fe8605b7347615d14e05f1e31f6d2d93\"","IMP":"\"159748fd4e6a4290cfc6ef2cd5845f57\"","INITIAL PHASE":"\"e3817025e05e0f509eafbf16d6c208ef\"","INTERVENTION PHASE":"\"504d132c9e362eb326c9358368ab0058\"","IPCimage3.PNG":"\"dee8d1811ac26316564d18680a6fa00d\"","IPPA-R (The Inventory of Parent and Peer Attachment—Revised)":"\"280e3ad2705a44980dd5683285059d30\"","IPT":"\"dc1c26bbec6e48ed033dd7cfd3f84305\"","IPT Ending Session 6 (30 mins)":"\"348b3157bec0f40abfcc7f3069023c06\"","IPT Session 1 (45 mins)":"\"10ba044a8a04258b03aaa416ba8bb17d\"","IPT Session 2 (30 mins)":"\"6b6fbcdeb0d14230021a8ac088fe771e\"","IPT Session by Session Guide":"\"02cd84c041a871a298771b0f2664a68f\"","IPT Sessions 3-5 (Middle Phase - 30 mins)":"\"67bb8bd9b4fdd4c9f04a906f323f25a2\"","IPT Worksheet 1.pdf":"\"0d9ccda5c88c1a14e19b05175b2daa10\"","IPT Worksheet 15.pdf":"\"8c29d0addb7294805203e807425c3bcf\"","IPT Worksheet 2.pdf":"\"36b75ce4ffddcf09526978e996f5f498\"","IPT Worksheet 3.pdf":"\"c1cdc7cd95330e074c08f734aa227e7e\"","IPT Worksheet 4.pdf":"\"1ff3b88a974ea2cb50a9f6d07fc494a5\"","IPT Worksheet 5.pdf":"\"205a290f143e986d10a51056aa322f20\"","IPT Worksheet 6.pdf":"\"b26f22cbfe2a1b88097a267ba665acca\"","IPT Worksheet 7.pdf":"\"71da5bbc49a7ee2c3c5bfe8841c6e365\"","IPT Worksheet 8.pdf":"\"64ca2af3ed9761152cc3b822da3127ea\"","IS.JPG":"\"4d6024bad11decb90e8157081635ce7b\"","Iceberg Analogy.JPG":"\"610bb584c0b8a52a5694db3798ae8401\"","If I am the KeyWorker, do I hold sole responsibility for everything?":"\"fa136489eec8fd3889a97b9ee6ab5d0e\"","Implementation Plan":"\"fea3c2417386d9c62dc156466944c7cd\"","Implementation Science":"\"c9e5e9db86f5b27b454620262aa9c8e7\"","Implementation Team":"\"98cbb02ca778510b7420c8711ac4746e\"","Implementation of the Evaluation Framework - Things to consider":"\"8f0787a22792b0eb7c17780f7aa656d5\"","Implementing social-ecological change":"\"2f9478d0a3c7127fc13e7077bd332368\"","Implicit Core Beliefs":"\"3a6588a306858fff4533c9f4c922782d\"","Implicit mentalization":"\"1ab793c8628f673e51f11bfaa708575e\"","Implicit psychoanalytic model":"\"052bbc66378c6d7c9e8a457f661b8789\"","In my beginning is my end":"\"50caff5ab1adb94fd6fb5d3166c8a9da\"","Increasing 'value' in services":"\"0261c1da7eb3f82e4bc49bd7816c6240\"","Increasing 'value': the work of Michael Porter":"\"fe2221d861b73d05ede9615ee302d0e7\"","Increasing service value: the work of John Seddon":"\"4347a0fc8dd600b0f4e4f9b6bf3f47ff\"","Individual Differences and Disagreements":"\"169eb68191834ba63bf545ee17c08110\"","Individual differences and AMBIT training":"\"0e3ebdd5d01c86ee13b17765683bbd25\"","Inducting new team members":"\"3278f7355a9ae077aa38218ab308fcf9\"","Information About AMBIT Training":"\"ed282e8251915813299585075a7453fd\"","Initial introductions at a Training event":"\"1b08387c3ed161d18a66c89aecd63eda\"","Injecting":"\"05e58f2ec1b4fee83223b176a126d942\"","Insight and Engagement":"\"57ff7f52817118488fd577de983f04d4\"","Integrative":"\"f8373cf7f1a4d895ea7766450b57a10b\"","Integrative Multimodal Practice":"\"b02e834c9378a203aa825f9dc194ffa2\"","IntegrativeContext":"\"138bbaa79a1c3251711c1b1bec7e36ca\"","Intention Broadcasting. Proceedings of I-KNOW ’09 and I-SEMANTICS ’09 - Von Kaufman, Richard (2009)":"\"acb0bb097f716ae336ec3d080e2ca506\"","Internal Working Model":"\"5bcf44fb9eae0df6f9284825f9f190a5\"","International Train the Trainer (TTT) Model":"\"398f4c34e6bceaca1642718dc7eab398\"","Interpersonal Therapy (IPT)":"\"a1c7e6ec4ab3ac76f98917191726a69a\"","Interprofessional Boundaries":"\"2c06dc721f837e1c648d1e5066fd058b\"","Intervention timeline":"\"f67ee35e76418596a07dcbbe88b5e581\"","Interventions (by target group)":"\"89d7795b94e6e76f319cb617c079dc09\"","Interventions for Groups":"\"98c053f1e331d8f87e9df1c5157f4413\"","Introducing Family Work":"\"252ae2d1724c2b7f5885930cd15393c3\"","Introducing Mentalization based work - addressing resistance":"\"4397f64fa3cb8c53db0eafb119c87d01\"","Introduction":"\"4c557339fb1d180a1c24389fcce516ee\"","Involving young people in designing outcomes":"\"e074064abe582fcc8f1220635e9da9c0\"","Is 'Thinking Together' a replacement or a change to Clinical Supervision?":"\"9367eea0a70009fc742fa94cef2b156e\"","Is AMBIT evidence based?":"\"2e84e62b79e402b66822c95a60ec075b\"","Is Mentalizing just Empathy?":"\"29b46636fc80fa47c0ec52523e8a8586\"","Is Mentalizing just Reflective thinking?":"\"02cfbd271ac11eafba0e14a4d862218f\"","Is Mentalizing just about working in the transference?":"\"fd2566a0b632be03fe37c4da0b20c37e\"","Is my client showing help-seeking behaviours towards me/the team?":"\"2b3e734a41befe291ee1dcc3065d9f8d\"","Is there any difference between Mentalizing and Mindfulness?":"\"e7cfe2a8d835b35bdd56ec308a080048\"","Is this relevant to me as a NON-specialist worker (not a therapist)?":"\"ba7dd1d501de9479a3a14546402857e8\"","Isn't mentalizing just being supportive?":"\"74c25afb81dff15697630a108c93fba9\"","Issues that can arise when training your own team":"\"48186a9cc767f61ed8fd46e86788c1fd\"","Iterative":"\"a8d12ec25887ebf1a32744ded95521f4\"","JF":"\"be14cb41830438515c657fd151105537\"","JF.PNG":"\"63b6a3c769602650a3e354d4c721f041\"","JW.PNG":"\"946d9e6438a3ac5354ea62e1da83a205\"","James Fairbairn":"\"e2043d75c5cbb5a03c9fdb40d560c262\"","James Wentworth Stanley Memorial Fund":"\"2a3e81be0ad93008dbba7a9799d0e6ae\"","James Wheeler":"\"847c752f034dda6e3626cb13a63d15d9\"","Jason Shaw (2013) Developing a Hypertext Educational Environment using TiddlySpace":"\"7604f018e94bed0175c7bab33299d5f4\"","JeremyRuston":"\"4174e14aaf4099cff5d16a83ed3acf57\"","John Lincoln":"\"d16e55f32103becaf4a7bda65eb755bc\"","Johnson, Baron-Cohen et al (2005) emergence of the social brain network":"\"051e42bdc12c121e831d908710c7c3ec\"","JonathanLister":"\"044a7a8cb16d4002c5c6c324f0d8cdd4\"","Just the facts":"\"ae5528786eae9e02edfe5c8ab94006be\"","Kaminski J, Pitsch A, Tomasello M (2012) Dogs steal in the dark":"\"8e56794ed0f9a2a3c82494fbee2a356a\"","Keeping secrets/different levels of disclosure within the family":"\"058649cfe8a0a9a3f32d6a2455c9d6b3\"","KeepingYourBearings":"\"ab39aa4a75a9a42c9befbc63dc298f4f\"","Key Problems":"\"b3018a48892e8b259592493de67aab2f\"","KeyProblemDefinitions":"\"ce76374f108c534c94dff2febd2192c3\"","KeyWorker":"\"2920203b214fdde85e71acb070956fac\"","Keyworker well-connected to wider team":"\"8591ba938f9da2faccee9b697a6c7fd6\"","Khan et al (2010) You just get on and do it: healthcare provision in Youth Offending Teams":"\"9340a6b674e392aca120bb82b357b91c\"","Kolb's Experiential Learning Model":"\"c4a2c52f88bf7e9af983de0194c3ae35\"","Krueger and Glass (2013) Integrative Psychotherapy for Children and Adolescents: A practice-oriented literature review":"\"a3839bb1e2da2b636dadd952c600e0de\"","Kyratsis Y, Ahmad R, Holmes A (2012) Technology adoption and implementation in organisations - BMJ":"\"2455dc7cb204bc4f7accd27c9bbd0578\"","LEARNING at work":"\"0fe2413c3ad85aaba45677c5dbcb1f8a\"","LEARNING exercises from AMBIT training":"\"a9b15bd3cc18167f9717fcc86c65be9a\"","LOCAL trainers FAQs":"\"f176f272d7e71d06c81f766450ab5667\"","Lack of insight":"\"86478bb91ec92d6a4b1ed1fb5a44d8ea\"","Laura Talbot":"\"b331f4d367623bad96bce48bcac15fb6\"","Lave and Wenger (1991). Situated Learning: Legitimate Peripheral Participation":"\"891ddc76e3449639d5ea7ff9acc7cd91\"","Lead Training Testimonials":"\"70d3916558076edc88fce9eb113baf11\"","Learning Difficulties and Substance use":"\"5e111001fc869f5318c46f209e0e6ae5\"","Learning Organisations (extended learning)":"\"cce4d1afd4eb5ef52b08aaccbe8d8318\"","Learning Organisations (further reading)":"\"2e0ebb7bb1c59bd5e3ec937efa6ed067\"","Learning about AMBIT":"\"74714d7b95f67f1edc51c9bed1492b77\"","Learning about Addressing Dis-integration":"\"75ee25264330a97542b36263d76ee946\"","Learning about Supervisory Structures":"\"ebe0a8ddc62053cef4ef7b57e7dc8f65\"","Learning about Team Learning - a discussion exercise":"\"dfb0bbc40294f7d7ee86f2833cd248ef\"","Learning about mentalizing":"\"343ff707008106b07d67e60abd76192c\"","Learning organisation - is the concept useful in AMBIT? - Peter Fuggle":"\"5a24ec39f30267179b8fffb5e1f08244\"","Learning through outcome measures":"\"f5ff2edb2e737593397852cb5d6754e5\"","LearningContents":"\"93488f7511c6b5393957ab406a73b788\"","Lecture and discussion on Evidence":"\"141cb18e88bd63cd998bd580bc2001e9\"","Level of intensity":"\"39bccfec041375c156776458c8ebd3e6\"","Licensed":"\"1728aadfc99f6c30310282c480545d31\"","Life practice":"\"37d362d00557740e21cd8b8a86e6d1d2\"","Line-ups - exploring individual differences":"\"50b9bfd50cbfe0cb7c9bd7fe420a62fa\"","Links":"\"e1021640537b3e7f2de858b7b34075ad\"","LivingSkills":"\"aa17c979ef429fe0c562d08a6fe4a6f8\"","Liz Cracknell":"\"071919f6bffcb29539cef3ddbef54b63\"","Liz's buttons test":"\"e2cf5691693e138c4df9d6ded1f88a3c\"","Lizpicture.jpg":"\"a6f19cda48bcfe2fe13de77e0ddc1c50\"","Local Facilitator Training (LFT)- training model":"\"337ed55ac5038f0dcd167daaa9030e1d\"","Local Facilitator Training: potential barriers to achieving training objectives":"\"7513f5585a5765d5d3dd5e96ec1f865f\"","Local Manualization Homework Tasks":"\"f35b2974c9082a96bce9844a6d50956b\"","Local Protocols":"\"faf08a583238f54473ad3f2de5c6687b\"","Local Session 01: What is AMBIT?":"\"479709534e7bc0a269f32a2a9f28d813\"","Local Session 02: What is AMBIT training for?":"\"2f6beeb4cd3f8e3f6acdc409606711f9\"","Local Session 03: Mentalization":"\"a974240b3b3f51636c46b77c95774028\"","Local Session 04: Working with your Team":"\"54f88c35a0e744fe97f7451a18a54629\"","Local Session 05: Working with your Networks":"\"231a9949814d0d6afd596ab8e718441e\"","Local Session 06: Working with your Client pt. 1 (Mentalizing stance)":"\"0cbee80332258d1ef03fdffaaec96513\"","Local Session 07: Working with your Client pt.2 (Hard to reach)":"\"5dd129b356424e644146e3c09e17bac6\"","Local Session 08: Review (1) and Auditing Team Practices":"\"c182326a8552d4c935a4e65bd23b59b7\"","Local Session 09: Working with your Client pt.3 (Outcomes)":"\"f88b5739c49cd7289468232e47e7edf9\"","Local Session 10: Review (2) and Top-up plans":"\"14f8433f4fcb5034f53b80a7edfc7dbf\"","Local Session 11: Making a real difference - Implementation Science":"\"45aad715a5230cd16ba0e256fdf5cc03\"","Local TTT Session 8.0":"\"84a9946182edcbc69bca2ed5b5a22f44\"","Local TTT Session 8.1":"\"36eaa290240229c383c60e0327234e9e\"","Local TTT Session 8.2":"\"56ef49ccbb1ed91177224999bd01ac6e\"","Local TTT Videos":"\"518da8a130c38547ed5d569b8786a7ff\"","Local Training Sessions: some core ideas and structure":"\"0bc0ec9bd9e62631153cc7f508285983\"","Logic Models":"\"00c9c47efa87f0c923baa240b3e42a17\"","Logic model for AMBIT services":"\"a88ad7d4200218a2d07fedb0d24b8e6c\"","Logic model for AMBIT training":"\"7f6b21928856a87363571fe30fa04d64\"","Logic model.JPG":"\"7acd20f48c2681e2178401a2183ffbf4\"","Logic models training exercise":"\"eadc109a0d161e7164c897844bc67234\"","LoneClimber.jpg":"\"ecfa60bf71ec2061bd54a6cd442908a6\"","Long-tail of gradually diminishing contact":"\"8f5386ccd2925ddb20e1bce3a4133a89\"","M-BIO":"\"8a489026e3d3269c2dc168eb4f5e0f84\"","MAINTENANCE PHASE":"\"c61300c176ca615a70a0ef4a6ef0b2ce\"","MB-Principles":"\"b05a26beda85f0e7a5911683212ccb84\"","MBT":"\"445c629929b2209c0745f68a49225dae\"","MBT-A":"\"3ab02097ba24fdb0484aa1feb2422b21\"","MBT-F":"\"6bb23024d74eeef27ef7fb8e8c5b5604\"","MP3's are like thoughts":"\"2adb7eb1525204e2869a99628def940a\"","MPTW":"\"6dec8a646fd15b81678a102b8127025a\"","MS.JPG":"\"c32ab8e42bf44e71829d6887f22eae32\"","Maintaining Mind-mindedness":"\"0fb64e688a83f76c00c6d746a5f92ab2\"","Maintaining factors for problems":"\"a3575cd14cb20a9d057efb84a4344b43\"","Maintenance":"\"0ad75199aed9f12cfb72957373ceb77d\"","Maintenance and the Recovery Model":"\"f4db4d4bffb8caf559d1a244745cecf2\"","Make or View Take Home Messages for other team members":"\"e0fc6c7e3396c8d36d741c97c89d9dce\"","Make or View notes on a Session, other Contact or Medication":"\"38e5dde43fb38ed4f6533b92e77e43e9\"","Making Manuals easier to use (Unconference 2016)":"\"d44d988411c96cd9ed1db78d425e5a67\"","Making plans for change":"\"b046616877dddbc3faaf8327cbe942af\"","MalalaQuote":"\"b495148c04975928c23d1904d03c18e5\"","Manage CLIENT RELATIONSHIP":"\"cbeb07b6582cc984edfbd8e706d6a903\"","Manage CLINICAL PROBLEM":"\"fcf80ea5c49e07d918a4acb13bc79e32\"","Manage Parental Mental Illness":"\"85d7aecf4c20fc3562527c76e7135ec7\"","Manage Violence":"\"9774bfa8f5e768d17c23d30b3b084914\"","Manage an Out of Control child":"\"52979f11b0a9fdabfc1c61b2f7253eb4\"","Managing NETWORK PROBLEMS":"\"be7a874671263bd6a20cbe6244f39279\"","Managing Risk":"\"d70df3c2d1a01cc5ce274eff3f452911\"","Managing a case from referral to discharge":"\"3ddec8d76b067a3e3b640f701e38dd20\"","Mania":"\"f8856dea48f7d3330972b172a2be6050\"","Manual Features":"\"7ec56c71ccc48216447fac60dc750ba4\"","Manual Treasure Hunt Quiz":"\"92872ab539834ba453bef25a3e4a484a\"","Manualised framework":"\"8417c7f0d5ffc4d4727722d23f467212\"","Manualization":"\"ad409253d6ea99067102638455b72712\"","Manualization Boundaries":"\"6690c87be611f3f73e884505b8f57601\"","Manualizing a live issue - Garry Richardson and Heather Tovey":"\"531e7f4817bde3f78155938d22da4009\"","Manualizing exercise":"\"d2771229ef5debe494dddbe0983bab43\"","MapFrontDoor":"\"6796ad8f2eed14c91e6b14eb894025f0\"","MapFrontDoor-v3":"\"48c704357f5dc746047e7e3ea02516c5\"","MapWheel":"\"75c87199595bcad3539192463b799439\"","MapWheel_2014":"\"5c76f71734fc1a6420de95b6ee21f67d\"","Mapping cultural and language resources":"\"c8b05b1e2dce96d76cf86a4367af715b\"","Mapping social-ecological needs and goals":"\"78a9661c2f0439dd8ddfc513ebef2605\"","Mapping social-ecological resources":"\"af96f65462f928273015fcaf3d04a293\"","Marianne McGowan":"\"0be7eb8927fac76f400afc161f0ba04d\"","Mark Dangerfield":"\"9799d769d9274aaa63b006a9fb56ad11\"","MarkLocalEdits.jpg":"\"145e0a3ab9795e893c0d9c68d9e7710e\"","Marked mirroring":"\"1dc032d3bc681cc4275d9be6c6581ade\"","Marking the Task":"\"2a9e8d32c6a4379f4e42b7b50ee040c7\"","MarkupPostHead":"\"1c29537fbb6a635876458923a2fb6f74\"","MarkupPreHead":"\"932e08545d48e9cccf406ea7f36a823e\"","MaryTarget":"\"887646b8067eba0a2f7407123d58da6e\"","Mason, B (1993) Towards positions of Safe Uncertainty":"\"27d35094663a2d36f17fea5f68403307\"","Measures used by AMBIT Teams":"\"5271b1223bc10be7c0c72a1ea3862ebb\"","Measuring Reliable Change":"\"28c1bcc44772eeff354dd00ae4d1e35f\"","Measuring progress against objectives":"\"75963e5da374b993edb5df06d2e6bfdb\"","Measuring recovery and reliable recovery":"\"eb97fd9a565bd1e8589b70294b9c6e18\"","Measuring reliable change":"\"95f1ed06f40a2d10eddefa2b94f88502\"","Measuring the Impact of AMBIT Training":"\"ed9c26a2ee0b02145b7ce702d378fcfd\"","MedicalEmergencies":"\"384e23f97e05c167ff24aa1c9c842e6e\"","Ment_Table_Stance_pic":"\"d78db04deaa6f73b4158fc89e31be4b4\"","Mental Health Assessment - Emergency Duty Team":"\"451865de928d8f8863bdfc99945c0ada\"","Mentalization":"\"8d2321bda126158ba7bd5308d76bb592\"","Mentalization, the work of Daniel Kahneman and the value of doubt":"\"98f9e0599c420d79614baf618b6b3356\"","MentalizationBasedTabs-525376893":"\"e1962a92567224965f991a4d90b661ba\"","MentalizationBasedWork":"\"2572ed33b06958dc2cc3db2dacb5f858\"","Mentalize":"\"e6bc6a7b2b81fcdc96bba28f1f219458\"","Mentalize that!":"\"46fef3cd725a5ba320c94a93971a3df8\"","Mentalize the Moment":"\"1b782bf73abd5b5c6c373594a272175e\"","Mentalize us, your trainers...":"\"ba3372c3000cb2b228388d4ea5c87173\"","Mentalizing":"\"9825f1cdccc1f05cd3704fea3e51501e\"","Mentalizing Levels":"\"0fae27ceaa2b34f7b98f77576bff1edd\"","Mentalizing Loop":"\"017d7f3461edb6d62faac741f0c577ec\"","Mentalizing Quotes":"\"d5d4ff9a8260968b420ad3eae3756286\"","Mentalizing Stance in Family Work":"\"5b1827586a2b81aa133d40e788eac29b\"","Mentalizing Therapy Techniques":"\"a56177ce59585050a55cab2c79dc80ba\"","Mentalizing service barriers":"\"4532815d186efc85d45876ed7098844e\"","Mentalizing stance- local":"\"5881cf2060c56f1a88b4e60fb98aa9b9\"","Mentalizing the Moment (in Thinking Together)":"\"8381a7088c1f10336d376f7ea44b2110\"","Mentalizing the Moment (in the Mentalizing Loop)":"\"b3c21c9bef0f3a20ae8b66ca3d59fd2a\"","Mentalizing your colleagues":"\"24ccfaffd2bca2d5144c23e38b5b351b\"","MentalizingLoop.jpg":"\"4aff984da5b5c316512fda98a7e29178\"","MentalizingWorkCourse":"\"f897da2331486bd0e85b8f9732796eaf\"","MetaTeam":"\"a2b8018fa37af9540013a007b1e77e64\"","Middle Phase of Mentalization based Work":"\"e1423cbfec0ba6731987812653a56ba9\"","Mind-Scanning":"\"d176fb522d3ed81fc062a1a6ba5cf961\"","Mini-PREACHY":"\"4a011b19a652e9e208e869a6e03ad937\"","Mirza and Mirza (2008) Adolescent Substance Use":"\"629e2d49442579d07ed78dbfa9c894f9\"","Misuse of Mentalization":"\"7fe1a1ff85d0bed8e02939fd7c81f0e0\"","Modified training plans":"\"0e91bea62cf5940fcb1e1d7eaf17063b\"","Monitoring mental health":"\"9364c32467d87eb43159b0bb8b09d552\"","More Actions pic.jpg":"\"b473ea498e1198e3ba2e8ef896f808b2\"","Motivational Training exercises":"\"75ab3dbdff3a198fec142a3f38e4f4c2\"","Motivational Work":"\"c13c59d32f7f66425bb07e35bb7a3d06\"","Motivational Work - Checklists":"\"18a1750d38cd0df74bf47986bded73a9\"","MotivationalAdapting":"\"40bf464499de4e8502a911fbc3b49111\"","MotivationalDefinitions":"\"c531fcf18899bd4803ca85bad975610a\"","MotivationalTabs--1940090237":"\"04fe317efbe92eb28abe3a62b5d70401\"","MotivationalWorkCore":"\"b47febf116e2984a629aa3977382a3c4\"","MtM.PNG":"\"b7e1ff56c739fc4efeec94e562129074\"","Multi-Disciplinary Team":"\"0b874d4c5b52fb8571d478b3a6501022\"","Multi-Domain Assessment":"\"9d5a91eeb4b4f018420134b93e671913\"","MultiFamilyPrinciples":"\"43bd604755c202d99aa62ce52ae25e19\"","MultiFamilyStructure":"\"de2a761496e07000e3ff65b0fc59e8be\"","MultiFamilyTabs-235621063":"\"60d4602dd7e67d49a72f10924d1fe572\"","MultiFamilyTabs-820552911":"\"af7639bc3c6d7ad1dadc01675a06fde4\"","MultiFamilyTechniques":"\"97d1b64c88402436efe79e424782a527\"","MultiFamilyWork":"\"90bc09f275bacf58eae4832f3e21e99c\"","MultiSystemicTherapy":"\"ba0e18cce16505e87e79beabc4e2c1b2\"","Multimodal":"\"7f2e0065179065b1d432837ac6922956\"","Multiple interacting aetiologies":"\"c0711c2f4ca2f816275ca6562b354485\"","Mz.PNG":"\"d2589c5a5519bba0a65b97c2dff21c01\"","NET-Aim-Q":"\"7533936cffc446dc912d2ccc5d43e653\"","NET-Stat-Q":"\"312cf1c81179bb09f49cd6c79cc5b276\"","NETWORK exercises from AMBIT training":"\"c054f18e7ed2e3a83f45ca69b721e28c\"","NICE - Depression":"\"26d393ad1a4eb77236d7a681eac7acb5\"","NICE - Sexual Health Guidelines for Youth":"\"7deaea0ac5ffad4821ac2d5f0f8a2efc\"","NICE ADHD Guidelines":"\"c572a9a5a7c9108456960e9ac0e84aac\"","NICE Bipolar guidelines":"\"9b92b90e4e4ea0428bff20a3009047ad\"","NICE Guidance on Parent training for conduct disorder":"\"4cabb7a47d914d929ffb51f4812748d9\"","NICE Guideline - Eating Disorders":"\"cc8722484f47279d94a96376d97de894\"","NICE Guideline - Schizophrenia (over 18yrs)":"\"f7a8914ec727d3b6b7beec1541c72549\"","NICE Guidelines":"\"46e1c604a71180ca65b7641adcd0da32\"","NICE Guidelines for PTSD":"\"ee60ba89aaf63c22efdccd21c7dc2ba2\"","NICE OCD guidelines":"\"2b7f63a8aab989d7aff6cb9f414c1bc7\"","NICE guidelines on Self Injury":"\"2ec83c388c012262039166e57ec761de\"","NTA - Assessing Young People for Substance Use":"\"d3011cdf6c682650c0a6ef585058e231\"","Narrative Continuity.jpg":"\"e2469247934eefa3b27bbcd51ec01fef\"","Narrative History":"\"1b33cdc13629f51c596a842a1b4f4e28\"","Needs video":"\"19238df20ba1c6ebc87e047b9bab1b7f\"","NeilDawson":"\"78ca334300da05848885cf0ce3fbb186\"","NetworksContents":"\"5b025048c4ad14fbdf4a0f766513d8df\"","NeuroDevelopmental":"\"dc59bfefd1a6228cf0ab9eebaf12575e\"","Neutrality towards ideas":"\"bdcb91ba7b88774e82fb0d0af77dc80c\"","New referrals":"\"73b672ede1cbed7c6aaec076147249f2\"","Non MZ.JPG":"\"36ce022cbcfe6316c2490e8605dac6d9\"","Non mentalizing states - Local":"\"b37ed47143217f0849b2b720e5c9fed1\"","Non-contingent":"\"4e58193c28343ef9cd564116d6cd8691\"","Non-mentalizing Bingo!":"\"d070e7694d34b0bf6e9d0578b616f3ce\"","Non-mentalizing, positioning and network problems":"\"a9b2864c844a9ca1394ea70be32efbea\"","NonSequentialProcess":"\"90539da42e4c3060827c8455c9a1079a\"","None of the above!":"\"e5abe87565f8c13308f705fb0ea255e2\"","Normalising":"\"a1307b429a9a9d3264c8048c0e433f3a\"","Notice and Name":"\"28d694ecaf5fc6775a9c74839bc05c05\"","OUR LOCAL Resources and Practice":"\"12e921fdc53922826268714dbbfa1831\"","OUR LOCAL Teamwork and Governance":"\"39518a4c2d5c18de826b369f390627e6\"","OUR Team":"\"ab25520eeabb7bbcc334186d75899ce8\"","Obsessional compulsive disorder":"\"98086196d034114d27d0c6163034258b\"","Opacity of other minds.jpg":"\"837d19511c4335ab741f18718dc173d0\"","Open Questions":"\"5647ee14f56069f6800e4ec281d7714d\"","Open book pic (2).jpg":"\"56f2933c4a1790e0f665aec2508edf3b\"","OpenPagesPic.jpg":"\"89781034b7156dd61510c8f1bdba0c45\"","OpenSource":"\"510a14d640499018ab3fc97c1826d915\"","Ordinary conversation":"\"ec9c93798655addbab8bf0a42d433537\"","Organisational support for the technology to run TiddlyManuals":"\"c99b58201282fbee28a5cb371b200b00\"","Ostensive communication":"\"6fd86a3e40010297b77172eb43917e1d\"","Other Symptoms of Psychosis and Engagement":"\"85112a930b67c1321b9d20cdbe8f8a11\"","Other key aspects of AMBIT in a little more detail":"\"2fc7a99d89da88dacbca44853c30c6c2\"","Other team's AMBIT manuals":"\"02910cb59950f1a729b9bffb40a2e474\"","Our Resources":"\"c9e32665234a38ad9288c0c712fff127\"","Our team and CLIENT work":"\"775c7502751083010c44fd86a38a5658\"","Our team and LEARNING":"\"970463bdd3687934da3b9b92dae7340f\"","Our team and NETWORKS":"\"cd86c40a002765c0e53d2a9697ce418a\"","Our team and TEAMWORKING":"\"29e28fce5796df877518b203e54db0ba\"","Our team's core expertise":"\"4db5b311eff0ea83114cb92adab22ed6\"","Outcome measures (T2, 3 months)":"\"47dccd6e1acc9380d4429ce52b3ce3dc\"","Outcome measures (Unconference 2016)":"\"9574c61e42aff58dbebd5c82cf452a75\"","Outcomes from the Family Intervention Programme":"\"1149394e3488e83a5da0dd4575bb1955\"","Overview: LEARNING at work":"\"9af2005fbc017d6cf971062f31b4e86e\"","Overview: Working with your CLIENT":"\"f43ffed22fc9ed13c66b916b54ba55fd\"","Overview: Working with your NETWORKS":"\"0d5c2ab233c80418e357c27142062b37\"","Overview: Working with your TEAM":"\"d8dfab622d454df0ee60c0f42018ff39\"","POD":"\"9d5407bd2b5fd7d522749c344243edec\"","POD - a web based outcome measurement system":"\"fcd1ee1e68e81060afebe3e59362907e\"","PREACHY":"\"1a2ca33b95e06ceb947e4bd9c12d483c\"","PREP day: Overview":"\"295ce73f41ae5c67c70e63d37359f670\"","PREP day: meeting the whole team":"\"4606b2fdb6a81d5f6574d424f88fb5f7\"","PREP day: meeting with senior management and commissioners":"\"c7f96faf4d6439186aa9f3aa3abde214\"","PREP day: meeting with team managers and senior staff":"\"5b82768d8344c90bfc240434149863ef\"","PREP sessions/exercises":"\"3114bcc18e7fa3f1d27b87a666867ada\"","PREP: Questionnaire feedback for senior management and commissioners":"\"54b2d91456c09616d2c1fc20fb92cea4\"","PREP: Setting objectives exercise":"\"2204cc1a8898599d598d518152980d99\"","Panic Attacks":"\"d1e92df610bbb357ae9f2f079e8d80c6\"","Paranoid":"\"91ab62e827cbedeecb682d35fac48a74\"","Passed-outwards Discussion":"\"13bfbb4d9f5eefe2e2306698ad77f7a3\"","PastMedicalHistory":"\"5b0e1f8e39cf758b7caf86d76579ebc7\"","PastPsychHistory":"\"b9ae36702d52a36a3564b2872857dea1\"","Patient-Worker Boundaries":"\"0b32f36c7f64332b31fe360aa032e3ae\"","Pause and Review":"\"74f0c33ced81409a13eef92aa9984324\"","Perception of ones OWN MENTAL FUNCTIONING":"\"d2d14115182f0f24e54d7e92e75daa7e\"","Permission to practice - team learning":"\"dab2d2f7e970d920192b6a0481065f89\"","Person Specifications for an AMBIT Keyworker":"\"9b571d47e0c19a827bbbaa4c712b8ec0\"","Personal safety":"\"fb63d8794be5aabc98701b2a3ee51bce\"","Perspective-taking.jpg":"\"2757609ffc51ebfbb5e5d99a3a161253\"","Peter Fuggle":"\"31f6fde8aeafd2ad9b091733893ddab6\"","PeterFonagy":"\"20b3878d173e2b10d6ffbdfa169a393d\"","Pharmacological":"\"aec33b118fbb7f8d096bf977dc919580\"","Phases of AMBIT work":"\"ff8cc2f76f64ef2b8e8edef9eafb35a4\"","Physical Health matters":"\"727d147b40bd2ea6ebf3bdc63b6734dd\"","Pic_WellConnected":"\"446c39e489664ff09977f4002c04a4b7\"","Picture Uploader":"\"8a9351b92d4ff940eda6cc647ae0f259\"","Picture1.jpg":"\"d3a63f9b21d10dab26392a6c8ad89892\"","Picture1.png":"\"3273d70695d001071babe39c31b375e9\"","Picture2.png":"\"60ff8eb831cc7fd9bea5e88b05063c70\"","Planning a training event in your team":"\"1b2e90c2d9bc0a681cbcf0ddb2104d8a\"","Police":"\"651545d0a45deb290720592f78d9e54c\"","Positioning Theory":"\"3f35267b974a5bfde6476080b038e9ef\"","Positive and Negative Syndrome Scale (PANSS)":"\"64670929cd34dea6c66a2181cb98a9fb\"","Post Traumatic Stress":"\"242e66f3abe2ca9e0632d8a7db0ff130\"","Post-Prep passed-outwards discussion":"\"b11eca3bb628290f6038d2a97b467c76\"","Post-training outcome goals":"\"4e59e58028992f81068132fa6ac912de\"","Practical examples of sustaining the AMBIT approach - 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pic":"\"b53e611387ece156886a979945635df6\"","Ripples in a Pond":"\"4228773766da42eaee4cbdc998484662\"","Ripples_picture":"\"c601c3b8e41d3ec7592240ca2af7de14\"","Risk Assessment":"\"8b32780fc769238a510703fa910a5852\"","Risk Assessment - paper form":"\"2e294412132490b807b3fda6b487b92c\"","Risk Management- Challenge and Support":"\"8ef1f5b42b31873218dceb8f68e1a3b5\"","Risk of suicide":"\"ceb089704fc70f46192d64b2401b9572\"","RiskAssessment":"\"7afe7e6d104d6db5f94c2ac3f86875a3\"","Rituals and Disciplines":"\"9e9d1a80e3a432c82b384c349d7e74e3\"","Role of the Chair":"\"8f5bb0c0eeeb39eebda9dbb055c873b8\"","Role of the Team Learning Support Worker":"\"897c7550bb3611422728381d0c6ce0dd\"","Roles and Responsibilities in an AMBIT team":"\"382f29c29311bc8309c05055e89656a2\"","Roles in the AMBIT Community of Practice":"\"447379c9dd92acee485d8749cec8ab3c\"","Roll with Resistance":"\"a2b733cca625ac142926169c3a6ece9d\"","Rossouw, Fonagy (2012) Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial":"\"f8da4ec6cc4d3efee3d75635e016c1a9\"","Royal College of Psychiatrists - Standards for Crisis/Outreach services":"\"acee31cdf4db7feee33e6ec10c7e6884\"","Rx":"\"a1807de06e704ab33a230d6123c7b1f1\"","SD":"\"bb977d6d23b2ee4d988908e68e2a2d37\"","SELF REPRESENTATION":"\"09cfbad9afa6a9b2e13af5109dc2c93b\"","SMART goals":"\"65720d4754d9e7a9e3bb6fbe9a64d0d8\"","SNAPSHOT":"\"095b9fa51c8067e655c0b9ec4448c007\"","SNAPSHOT.PNG":"\"bda21598284eeb7d176902fda59f3d26\"","SPECIFIC INTERVENTIONS - CheckLists":"\"7271bada4a554c2c5e0f8a9749748d0c\"","STIs":"\"f8988ce30c8b144ee261ad63d1b558ef\"","SUD":"\"f7ea67694f71e0c958e9ac15f028c745\"","SUD-Rx":"\"23926e0b26c66a759d4de09ca361efa1\"","SUD-Rx - Who should be present at sessions?":"\"75f0d56c503d9a728040ad4145dcebb1\"","SUD-Rx Session 1 - 2":"\"38b1dc83420eae5c0229a0a4e96a88f6\"","SUD-Rx Session 3":"\"8fcc014f4a09a00d2d1b08b4cc4ecafd\"","SUD-Rx Session 4":"\"42bde80bcebd785457d72b72a894e170\"","SUD-Rx Session 5":"\"1b20d51d7c364e9564234cb57a471ab8\"","SUD-Rx Session 6 - FINAL":"\"b4425d5ae1bd0baf8782f50045d22de1\"","SUD-Rx Sessions - CheckLists":"\"a51632cb798c0ee1c3c3625801371ede\"","SUD-Rx Techniques":"\"147d29ac268ebb365eb60f8a266e5a16\"","SUD-Rx principles":"\"a2761c7ce45e935a18c93eabba714fff\"","SUSTAIN best practice":"\"a5fbae5cd00849b5aed5f43740b23962\"","SUSTAINING best practice - CheckLists":"\"9f5c68e90674dc1ab55bffc83594ff3c\"","Safeguarding Children and Young People from Sexual Exploitation":"\"de5b4f9400792d3dd917e1c9f6d69592\"","Safety and sex for youth":"\"5dcba5b40628c1d94b05c8db67a94576\"","Sample supervision notes":"\"6d87e4bf089b1e54e0cd3ea4afc7be8f\"","Save tick.jpg":"\"601ae3c5b560fe6e02fd28d7076d3722\"","Scaffolding existing relationships":"\"2d9c0c7c722074fa493b0431a7acbd08\"","Scaffolding existing relationships: developing a tool":"\"69cc6408fb37bca325ca11c897aeaf85\"","Score 15 - Family functioning":"\"d774efb6cbe0f0c970c58592363f9565\"","Screening Tool for Sexual Exploitation by Brook":"\"85b8073c11c8c687ac6bff1e5fc83b6d\"","Screening for biological illness":"\"76e83b98821facb5c5a8c1f69cc6c8f8\"","Screenshot_20180323-002957-01.jpeg":"\"b7c18971e143b5930cb1c0042c9bb9ec\"","Sculpting a network":"\"b07eeae22d53e620f6114754ac25f06c\"","Secure Base":"\"7724d572ce6a5b06b7d6fa72d78156a1\"","Security and Authorization":"\"69bbac2cb63212f2fe5f877a96750fce\"","Seddon, J. 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treatment":"\"b89d3b5e69a63b3e8c1344855d41b13a\"","SubstanceUseDisorder":"\"cd0e1039e663770a5d190bd837bd36f8\"","Suggested Team Training Sessions":"\"29e99b0266c2c44f8f7437f34133ab4b\"","Suggested structure for an (internal) AMBIT Supervision session":"\"df7b85099bfaa08504203d82ef15b870\"","Suicide Attempt":"\"732d24d5cd817fb20d223921413cbdfa\"","Suicide Warnings":"\"d50dd152967b104f0d0f9da443c80795\"","Summarising":"\"3b19af235a827a606f3f1ca788c99a0c\"","Supervision Notes":"\"060919ed03d6d76abc93d2c9e38a2544\"","SupervisoryStructures":"\"9eee1478281a008f08b7006387a8a201\"","Support for the AMBIT Community of Practice":"\"9eb3abba5ba8a5342021367cea30a7de\"","Sustaining AMBIT practice after training: lessons from a group of front line teams":"\"203a6a0c052ca81d4a13676d3611ba59\"","Sustaining an AMBIT approach in an acute adolescent in-patient setting - Whittick, Morrell, Fairbairn, Thulbourn and Millard":"\"afc64224d5578d2a52152bff3ee041df\"","Sutcliffe et al, 2004 - Communication failures: an insidious contributor to medical mishaps":"\"4a6e883647446f5b88cb079645dac2f1\"","Syed, 2016 Black Box Thinking":"\"3edf2b549d456d41de326dbde905115f\"","SystemsTheory":"\"d2f65185e5d82a6ee4e11b6841853038\"","TEAM exercises from AMBIT training":"\"49059a98eedb1becee7aba6ac35cce63\"","TOP - Drug and Alcohol Outcomes":"\"6fd32ea57eaa851a275a2e09d0219cd9\"","TS Eliot - \"East Coker\" from the \"Four Quartets\"":"\"1cd3fc7e4204ba6ca9343b53dab8db73\"","TTT May 2018 reflections on what we could use from Day 3":"\"18af33fb3b63315ef8207ad0260f3ee5\"","TTT May 2018: Reflections on how to use network learning in our teams":"\"e90ce3311871a50eab080e8dfc5f397b\"","TTT-One Year Review and Consultation Meeting":"\"8bb034231853310b033e17cc68b74ac7\"","TV phone-in or Documentary games":"\"759b21516da48c29753bb39e042f1ab4\"","TabAllTags":"\"72e14cbdfafdf2b4baa40822287254f6\"","TabMore":"\"b633efd1f1e69dc6832a0d8bee584e60\"","TabTags":"\"6c13f37180ac1b6bdb6941187b8e95be\"","Tags":"\"2599e6a49e459721b6f8f4dc58e33a99\"","TakeHomeMessages":"\"50c1c5f34ed639be7b506fdf3d3be4d9\"","Taking Aim":"\"236d38231bd668eac4080e9108d2765e\"","Taking Responsibility for integration":"\"bc8a7d4b31fe320f7def03df58f65b91\"","Taking a break":"\"1778f8dc3c842d903ee7024140f10bb7\"","Tasks & Problems to manage":"\"d03a2d57ce9e4e9f3063664b7941fcb3\"","Team Meetings":"\"7f63e9a8379a97b9bc44133365c37dbd\"","Team around the Worker":"\"bfe82f2162d6e948f595c7ac20acd85d\"","Team around the Worker - pic":"\"86b62b3a0d4fbeaa146fd54793cf0603\"","Team training session: deciding on the intervention":"\"8194115e3c925c13c1a35379ec367f5e\"","Team training session: what interventions do we do?":"\"07955ee6578bbb38c9f8341cec651c60\"","TeamContacts":"\"08150fd7be2fedec971c19a6af13b7e1\"","TeamContents":"\"6c88702d27ba9a7a55ecc4255a76c5ae\"","Teleological thinking":"\"4db1886afafde84d504b7a10ace1cc93\"","Terminating non-mentalizing interactions":"\"7b407954bc8599e62f72aa75a6c86886\"","Test save 06.01.19":"\"5d214ec37962d05f2992cb6633e98a89\"","The 'What's it like to be...' exercise":"\"f67c02447294a79def5ecbe11a365ca9\"","The AIM questionnaire":"\"e2b36cc56617e3e2382d89c19b96f4e6\"","The AMBIT Lead - role and responsibilities":"\"ead42f84d239847cbc86dfdee6fe2c87\"","The AMBIT Pro-Gram":"\"ca89f009befd75c1d2f0844004d6d61d\"","The AMBIT Pro-Gram: an example":"\"23520c2d66c63939618bfb432ce368b2\"","The AMBIT Study Group":"\"545fbf28615c0efe378f817d61bbbdb6\"","The Common Core of skills and knowledge":"\"a75eb0b3c3bc6fd8fba1026dad93e8ab\"","The Coping With Stress Course - Gregory Clarke":"\"69b04db14d478022db965da063f4b0d2\"","The Development and Properties of the AIM":"\"4cff8b6f9c969bc66f4be540e166dc3a\"","The Inquisitive Stance":"\"7f1359492b6c7a12cd65b12e6846838b\"","The Therapist's Mentalizing Stance":"\"3d713ea60a3a3fc2040290c926def19e\"","The Troubled Families Programme: an overview":"\"9f059a6d26eb66261850031681faab4a\"","The Troubled Families Programme: the intervention model":"\"2057af1e7002c57e7c1ba531e1ea22aa\"","The World Health Organisation Quality of Life– BREF questionnaire (WHOQOL-BREF)":"\"2ca505afb685cc231dba401a36cc7b73\"","Theoretical foundations of Family Work":"\"01d092988993a4cd703e8a9542275273\"","Theoretical/Explanatory Frameworks":"\"25d27b5ea0e2e5a1c6e183c34c8f81c0\"","Theories: LEARNING at work":"\"1c12a8b527c4c7d7719d8b703560a456\"","Theories: Working with your CLIENT":"\"7ca99b71767bef2041ca1125edf09835\"","Theories: Working with your NETWORKS":"\"c9407d2184303fb0e795878f9d3290eb\"","Theories: Working with your TEAM":"\"10630c651c425b5683ce34a7a065fc99\"","Theory":"\"fb582c1547bed16c3e4aa55948bfd3d4\"","Theory behind the Individual key-worker relationship model":"\"4c0520fa1ac7e9290ba26d2d518389aa\"","Theory in Practice":"\"1d8f192d74d0f99155973f4fce3f2544\"","Therapeutic Bargain":"\"5533890942a65c66e38dd5107a62a428\"","Therapeutic relationship":"\"767f0bccd648eb771ac70cd2648c8ff1\"","Therapist's use of Self":"\"2d6d97cbbac4bf08d8f929b36dd00f0b\"","Thinking":"\"4950dc39f9118a20b10dec09759d5274\"","Thinking Together":"\"f0cdaa0ac32dbc27ee9218f59e0d04c8\"","Thinking Together - 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Sarah Harmon":"\"14424ea01eaee03bd969670f0d04c9ae\"","Using Tele-supervision: a guide for participants":"\"8ac77fad5572d63554125cc1afb95193\"","Using the AIM":"\"aa84b386004368141a8eeaf1c94b8a69\"","Using1.JPG":"\"f7212ad3e3847c28aaa35c94e5d780c8\"","Using2.JPG":"\"83d1b59df2d5f95a790ff2420e9a3c0a\"","Using3.JPG":"\"9b67d2b31dfafc9b224f8e9ee07e9554\"","Using4.JPG":"\"918e4168682930ce79a31a35cd2e876e\"","Using5.JPG":"\"d0549d1975c9288acde403578f105013\"","Using6.JPG":"\"19ef40299c5479622ec57ca9e6b1a8ff\"","UsingTheManualContents":"\"8a11a406c255a782468ee9caa05fca7f\"","VB.PNG":"\"1d0263b9d38df5aabf97baf1731bfcba\"","Verity Beehan":"\"43eb21adea45cf1ca21b7de4dec2f18c\"","Video feedback":"\"8a535de79f608c166cdc2b21b001ecc9\"","Video introduction to Thinking Together":"\"7235c173ef160414d44d60d8597abea6\"","Video introduction to disintegration":"\"1591ebe9cdd3b31306dc57f29ad68032\"","Videos":"\"77a33599227c43a553d2971b0368c2a4\"","ViewTemplate":"\"2a61d67c08fb80cf44d55a68f536371e\"","Violence":"\"ecf1be0a6242ba098b7347c972eb84fa\"","We do most of this AMBIT stuff already - what is DIFFERENT in what you are teaching?":"\"657d838af315944992073c7b5bba895d\"","We want a hospital bed, not a home visit!":"\"bc2674ba07cd2671b3a9ba561b315032\"","Wearing different hats":"\"d13950cc8cd58866c36e203b1f340f7d\"","Wearing different hats.jpg":"\"f42d89553aee47b2df051784963974d9\"","Wearing different hats2.jpg":"\"bcddaaac32c6facb68600f873318df63\"","Web-based AMBIT Lead seminars":"\"cd9c6a4541898a8e9a121a87988848f9\"","Weighing Pros and Cons":"\"7fed0c20902ae13a9149553ee886bca1\"","Weisz, Jensen-Doss, Hawley (2006) Evidence-based youth psychotherapies versus Usual Care":"\"db87c68f065b826bae7241d97677623f\"","Weisz, Simpson-Gray (2008) Evidence-Based Psychotherapy for Children and Adolescents":"\"c85fa4e9d62959dcf4804cd1c3f17426\"","Welcome to the Pause Southwark Manual":"\"63f243af0914d55509b82e8abebb7681\"","Welcome to the space 'ambit-content'":"\"348810fd0b5a63cea005f27d57572540\"","What I would to like to learn and what should be preserved?":"\"804e4493817d21d8fddf16c7e00ef837\"","What dish would you most prefer to cook?":"\"8a8f3af1ae45355d60298be01bbbf99d\"","What do we mean when we say \"That's (not) very AMBIT!\" - Dickon Bevington":"\"f2b1b2edbf524b0eb5c05a88a67e56a1\"","What do workers here need in order to do their job well?":"\"c7de638e98c53a9e9d5c23a4f7843831\"","What does AMBIT stand for?":"\"2c8b6c4923a9e0961c5d0164909f0724\"","What helps a team to learn?":"\"2ece3820359b000118bc88d502166ec9\"","What if people just hate the word \"mentalization\"?":"\"d71746e9e30a33d8b66238d6ec56676e\"","What if workers don't want to mentalize?":"\"1863bc4c690caf3fe330eadddc845156\"","What is your AMBIT? (blank AMBIT wheel)":"\"1605327c6f5157e13de7a5da5cdc59a7\"","What makes me me?":"\"af6ff091ab555a721a952d6d51757d0a\"","What makes the work with clients hard?":"\"1dfd62a1f286934cb198e0ad83d498bd\"","What negative feelings does the work bring up for workers?":"\"fecfcf2c87db3a772f2108b96c00d36d\"","What positive feelings does the work bring up for workers?":"\"e90735a8536c81056d645c7385bdf9cb\"","What to cover in the Care Plan":"\"673e73b80d088e2e735683ed1a3db668\"","What's the problem?":"\"5ab4677fdc8c1d41bd22d55f839ca7ab\"","WhatInfluencesPractice_pic":"\"e8a81450025f6ef9f7211d66df28b33e\"","Wheel and probs.jpeg":"\"77fcaf23ce1d6ab9f82441e718505009\"","Wheel with client highlighted.jpg":"\"e79c5708dde137643a02f65e165ab035\"","WheelMapMaker":"\"1e669576aa5932908bbac40dd09e99aa\"","When (how quickly) are we meant to implement this material?":"\"c8dabbca03eda0b583052b9db8519bab\"","When to suspect maltreatment - NICE guideline":"\"e103d4173aef8da044c78242013bd5c0\"","Where are we in the therapeutic journey?":"\"878888313c4d8a2e6239a30a30d801dc\"","WhichInterventionWhen":"\"103ff91f5645f50a1624c226c3be5476\"","Who does what?":"\"0ed92570b800fbecdf376966dedc7f48\"","Who has your rope pic.jpg":"\"e5efe801caa2d1a629a7456aeda09c9e\"","Who is this manual for?":"\"76c8298ccf05e37bdb75ac83aed44428\"","Why intervene simultaneously in multiple domains?":"\"3d05fad2d54d89e733ad6dc53872d6fc\"","Wilson, G. T. (1998). 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(1).jpg":"\"8b2d16d3fa9714e2ba239283f282e0e8\"","nicole-honeywill-dGxOgeXAXm8-unsplash.jpg":"\"d19c2be31009e95cc55d8f568a6141b1\"","nn.PNG":"\"4f552020576f107a715217482bd514ac\"","outcome pic.jpg":"\"421ea5cd54509cbf0e86e33edea7f178\"","page-background.svg":"\"9ca4624ac0594b9363e08808d07b4b31\"","patrick-perkins-8VurHsVsls4-unsplash (1).jpg":"\"addeae80f46f7a548904ffac26562366\"","patrick-tomasso-Oaqk7qqNh_c-unsplash.jpg":"\"f04cd3a245f615bec6e32cc86f1a2e52\"","pavan-trikutam-71CjSSB83Wo-unsplash.jpg":"\"5479b4ac6da12ab610a95cb718afcbd4\"","peterpicture.jpg":"\"59b00e0b527d4e6b02569da7d1ae41e0\"","pre-conditions for learning.jpg":"\"a184c7fbe45072a3123da56f3be61e9c\"","ratchet":"\"b4e7c5fd97a537c893190609c61a9c5b\"","session 2 page 1":"\"bbc7cb08f23bb27265a7671d52f27f97\"","siora-photography-cixohzDpNIo-unsplash (1).jpg":"\"aef0de2b77536c6315ea1afa0980568c\"","stance tension client.jpg":"\"c9472e177da6dfda6e3eccfbc39657b1\"","stance tension learning.jpg":"\"193a96ccef92b5f6d3c56292982918b4\"","stance tension networks.jpg":"\"1e94d1135eea14ed0c1b284f367758ab\"","stance tension team.jpg":"\"8835a42d1d1206eb5bbfcd29b6188829\"","studying together image.jpg":"\"2180330f309aa508895f99912f7cac31\"","sympt.PNG":"\"aca8f4ce910119b1b44755e9576ef821\"","tile motif.png":"\"62cf9842297d58ad2ee659576dd35f9d\"","togimg.PNG":"\"494cacc7f331dec74a021c643ef5cf52\"","what to measure pic (2).jpg":"\"7df1824401c18acc7712158d26f46961\"","what to measure pic.jpg":"\"a79d84c4eff8d35bcf9264a011147dbd\"","working together image.jpg":"\"93492a212e4b0c54bdd634cc08a0c17b\"","world.PNG":"\"eaf4cd6e2076c4a25b36c3c357b776d5\""}

https://8y1wh49hn1.execute-api.eu-west-2.amazonaws.com/prod/

4s50tg1b4toisc43c4q42gsceq

eu-west-2:2756d3cb-8b8b-47a9-8248-595a9d254d91

ambit-pausesouthwark_public

eu-west-2

eu-west-2_3lsaUbCyk

[list[DefaultTiddlers!!text]]

yes

no

no

<$transclude tiddler="SiteSubtitle">A place for thinking</$transclude>

[img width=150 [SiteIcon]]<br/>{{SiteTitle}}

<div style="margin-bottom:2em;margin-top:2em;">
[img width=160 [$:/_AFC/grey-wordmark.svg]]
</div>

\rules only filteredtranscludeinline transcludeinline macrodef macrocallinline

@font-face {
  font-family: "Effra";
  font-style: light;
  font-weight: 200;
  src: url('https://manuals.annafreud.org/fonts/$:/_fonts/Effra Light.woff') format("woff");
}

@font-face {
  font-family: "Effra";
  font-style: bold;
  font-weight: 600;
  src: url('https://manuals.annafreud.org/fonts/$:/_fonts/Effra Bold.woff') format("woff");
}

@font-face {
  font-family: "Verdana";
  font-style: normal;
  font-weight: 400;
  src: url('https://manuals.annafreud.org/fonts/$:/_fonts/Verdana.woff') format("woff");
}

html {
font-family: "Verdana";
}

.tc-top-menu,
.tc-site-title,
.tc-site-subtitle,
h1, h2, h3, h4, h5, h6 {
font-family: "Effra";
font-weight: 600;
text-align: left;
}

.tc-site-title {
font-weight: bold;
}

body .tc-titlebar h2 {
font-weight: 700;
}

afc-white: #ffffff
afc-black: #222222
afc-green: #209377
afc-pale-green: #6cbeaf
afc-blue: #155dac
afc-purple: #925195
afc-orange: #eb7837
afc-brown: #786e65
afc-light-grey: #e2e2e2
afc-very-light-grey: #f2f2f2

afc-mid: rgba(232, 232, 232, 0.84)

top-menu-background: <<colour afc-green>>
top-menu-foreground: <<colour afc-white>>

page-footer-background: <<colour afc-green>>
page-footer-foreground: <<colour afc-white>>

alert-background: <<color afc-white>>
alert-border: #b99e2f
alert-highlight: #881122
alert-muted-foreground: #b99e2f
background: #fff
blockquote-bar: <<colour muted-foreground>>
button-background:
button-foreground:
button-border:
code-background: #f7f7f9
code-border: #e1e1e8
code-foreground: #dd1144
dirty-indicator: #ff0000
download-background: #34c734
download-foreground: <<colour background>>
dragger-background: <<colour foreground>>
dragger-foreground: <<colour background>>
dropdown-background: <<colour background>>
dropdown-border: <<colour muted-foreground>>
dropdown-tab-background-selected: #fff
dropdown-tab-background: #ececec
dropzone-background: rgba(0,200,0,0.7)
external-link-background-hover: inherit
external-link-background-visited: inherit
external-link-background: inherit
external-link-foreground-hover: inherit
external-link-foreground-visited: #0000aa
external-link-foreground: #0000ee
foreground: <<color afc-black>>
message-background: #ecf2ff
message-border: #cfd6e6
message-foreground: #547599
modal-backdrop: <<colour foreground>>
modal-background: <<colour background>>
modal-border: #999999
modal-footer-background: #f5f5f5
modal-footer-border: #dddddd
modal-header-border: #eeeeee
muted-foreground: #bbb
notification-background: #ffffdd
notification-border: #999999
page-background: <<color afc-light-grey>>
pre-background: #f5f5f5
pre-border: #cccccc
primary: <<colour afc-purple>>
sidebar-button-foreground: <<colour foreground>>
sidebar-controls-foreground-hover: #000000
sidebar-controls-foreground: #aaaaaa
sidebar-foreground-shadow: rgba(255,255,255, 0.8)
sidebar-foreground: #acacac
sidebar-muted-foreground-hover: #444444
sidebar-muted-foreground: #c0c0c0
sidebar-tab-background-selected: #f4f4f4
sidebar-tab-background: #e0e0e0
sidebar-tab-border-selected: <<colour tab-border-selected>>
sidebar-tab-border: <<colour tab-border>>
sidebar-tab-divider: #e4e4e4
sidebar-tab-foreground-selected:
sidebar-tab-foreground: <<colour tab-foreground>>
sidebar-tiddler-link-foreground-hover: #444444
sidebar-tiddler-link-foreground: #999999
site-title-foreground: <<colour tiddler-title-foreground>>
static-alert-foreground: #aaaaaa
tab-background-selected: #ffffff
tab-background: #d8d8d8
tab-border-selected: #d8d8d8
tab-border: #cccccc
tab-divider: #d8d8d8
tab-foreground-selected: <<colour tab-foreground>>
tab-foreground: #666666
table-border: #dddddd
table-footer-background: #a8a8a8
table-header-background: #f0f0f0
tag-background: #ec6
tag-foreground: #ffffff
tiddler-background: <<colour background>>
tiddler-border: <<colour background>>
tiddler-controls-foreground-hover: #888888
tiddler-controls-foreground-selected: #444444
tiddler-controls-foreground: #cccccc
tiddler-editor-background: #f8f8f8
tiddler-editor-border-image: #ffffff
tiddler-editor-border: #cccccc
tiddler-editor-fields-even: #e0e8e0
tiddler-editor-fields-odd: #f0f4f0
tiddler-info-background: #f8f8f8
tiddler-info-border: #dddddd
tiddler-info-tab-background: #f8f8f8
tiddler-link-background: <<colour background>>
tiddler-link-foreground: <<colour primary>>
tiddler-subtitle-foreground: #c0c0c0
tiddler-title-foreground: #182955
toolbar-new-button:
toolbar-options-button:
toolbar-save-button:
toolbar-info-button:
toolbar-edit-button:
toolbar-close-button:
toolbar-delete-button:
toolbar-cancel-button:
toolbar-done-button:
untagged-background: #999999
very-muted-foreground: #888888

\define timeline-title()
<$view field="title"/>  <$list filter="[all[current]frombag{$:/plugins/federatial/xememex/config/recipe}]" variable="listItem"><span style="display:inline-block;background:#ff4;border:1px solid #cc0;color:black;padding:0 2px;border-radius:4px;font-size:0.8em;line-height:1.3;">local</span></$list>
\end
<$macrocall $name="timeline" format={{$:/language/RecentChanges/DateFormat}}/>

<$macrocall $name="timeline" format={{$:/language/RecentChanges/DateFormat}} subfilter="frombag{$:/plugins/federatial/xememex/config/recipe}"/>

<$list filter="[<currentTiddler>!is[tiddler]]" variable="ignore"> 
<div class="tc-sidebuttons">
<a href="mailto:marianne.mcgowan@annafreud.org?subject=Feedback%20on%20the%20manuals" target="__blank">
{{$:/core/images/plugin-generic-language}} Give Feedback
</a>
</div>
</$list>

\rules only filteredtranscludeinline transcludeinline macrodef macrocallinline

.tc-sidebuttons {
position: fixed;
right: 0;
top: 50%;
width: 8em;
}


.tc-sidebuttons svg {
fill: <<colour background>>;
float: left;
width: 2em;
height: 2em;
margin-right: 4px;
}

.tc-sidebuttons a {
display: block;
background: <<colour afc-green>>;
padding: 4px;
border-top-left-radius: 8px;
border-bottom-left-radius: 8px;
font-weight: bold;
text-decoration: none;
color: <<colour background>>;
}

.tc-sidebuttons a:hover {
background: <<colour afc-pale-green>>;
}

/* ------------------------------------------
PURE CSS SPEECH BUBBLES
by Nicolas Gallagher
- http://nicolasgallagher.com/pure-css-speech-bubbles/

http://nicolasgallagher.com
http://twitter.com/necolas

Created: 02 March 2010
Version: 1.2 (03 March 2011)

Dual licensed under MIT and GNU GPLv2 Nicolas Gallagher
------------------------------------------ */

/* NOTE: Some declarations use longhand notation so that it can be clearly
explained what specific properties or values do and what their relationship
is to other properties or values in creating the effect */

/* ============================================================================================================================
== BUBBLE WITH AN ISOCELES TRIANGLE
** ============================================================================================================================ */

/* THE SPEECH BUBBLE
------------------------------------------------------------------------------------------------------------------------------- */

.bubbles-triangle-isosceles {
  position:relative;
  padding:15px;
  margin:1em 0 3em;
  color:#000;
  background:#f3961c; /* default background for browsers without gradient support */
  /* css3 */
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#f9d835), to(#f3961c));
  background:-moz-linear-gradient(#f9d835, #f3961c);
  background:-o-linear-gradient(#f9d835, #f3961c);
  background:linear-gradient(#f9d835, #f3961c);
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* Variant : for top positioned triangle
------------------------------------------ */

.bubbles-triangle-isosceles.bubbles-top {
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#f3961c), to(#f9d835));
  background:-moz-linear-gradient(#f3961c, #f9d835);
  background:-o-linear-gradient(#f3961c, #f9d835);
  background:linear-gradient(#f3961c, #f9d835);
}

/* Variant : for left/right positioned triangle
------------------------------------------ */

.bubbles-triangle-isosceles.bubbles-left {
  margin-left:50px;
  background:#f3961c;
}

/* Variant : for right positioned triangle
------------------------------------------ */

.bubbles-triangle-isosceles.bubbles-right {
  margin-right:50px;
  background:#f3961c;
}

/* THE TRIANGLE
------------------------------------------------------------------------------------------------------------------------------- */

/* creates triangle */
.bubbles-triangle-isosceles:after {
  content:"";
  position:absolute;
  bottom:-15px; /* value = - border-top-width - border-bottom-width */
  left:50px; /* controls horizontal position */
  border-width:15px 15px 0; /* vary these values to change the angle of the vertex */
  border-style:solid;
  border-color:#f3961c transparent;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* Variant : top
------------------------------------------ */

.bubbles-triangle-isosceles.bubbles-top:after {
  top:-15px; /* value = - border-top-width - border-bottom-width */
  right:50px; /* controls horizontal position */
  bottom:auto;
  left:auto;
  border-width:0 15px 15px; /* vary these values to change the angle of the vertex */
  border-color:#f3961c transparent;
}

/* Variant : left
------------------------------------------ */

.bubbles-triangle-isosceles.bubbles-left:after {
  top:16px; /* controls vertical position */
  left:-50px; /* value = - border-left-width - border-right-width */
  bottom:auto;
  border-width:10px 50px 10px 0;
  border-color:transparent #f3961c;
}

/* Variant : right
------------------------------------------ */

.bubbles-triangle-isosceles.bubbles-right:after {
  top:16px; /* controls vertical position */
  right:-50px; /* value = - border-left-width - border-right-width */
  bottom:auto;
  left:auto;
  border-width:10px 0 10px 50px;
  border-color:transparent #f3961c;
}


/* ============================================================================================================================
== BUBBLE WITH A RIGHT-ANGLED TRIANGLE
** ============================================================================================================================ */

/* THE SPEECH BUBBLE
------------------------------------------------------------------------------------------------------------------------------- */

.bubbles-triangle-right {
  position:relative;
  padding:15px;
  margin:1em 0 3em;
  color:#fff;
  background:#075698; /* default background for browsers without gradient support */
  /* css3 */
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#2e88c4), to(#075698));
  background:-moz-linear-gradient(#2e88c4, #075698);
  background:-o-linear-gradient(#2e88c4, #075698);
  background:linear-gradient(#2e88c4, #075698);
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* Variant : for top positioned triangle
------------------------------------------ */

.bubbles-triangle-right.bubbles-top {
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#075698), to(#2e88c4));
  background:-moz-linear-gradient(#075698, #2e88c4);
  background:-o-linear-gradient(#075698, #2e88c4);
  background:linear-gradient(#075698, #2e88c4);
}

/* Variant : for left positioned triangle
------------------------------------------ */

.bubbles-triangle-right.bubbles-left {
  margin-left:40px;
  background:#075698;
}

/* Variant : for right positioned triangle
------------------------------------------ */

.bubbles-triangle-right.bubbles-right {
  margin-right:40px;
  background:#075698;
}

/* THE TRIANGLE
------------------------------------------------------------------------------------------------------------------------------- */

.bubbles-triangle-right:after {
  content:"";
  position:absolute;
  bottom:-20px; /* value = - border-top-width - border-bottom-width */
  left:50px; /* controls horizontal position */
  border-width:20px 0 0 20px; /* vary these values to change the angle of the vertex */
  border-style:solid;
  border-color:#075698 transparent;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* Variant : top
------------------------------------------ */

.bubbles-triangle-right.bubbles-top:after {
  top:-20px; /* value = - border-top-width - border-bottom-width */
  right:50px; /* controls horizontal position */
  bottom:auto;
  left:auto;
  border-width:20px 20px 0 0; /* vary these values to change the angle of the vertex */
  border-color:transparent #075698;
}

/* Variant : left
------------------------------------------ */

.bubbles-triangle-right.bubbles-left:after {
  top:16px;
  left:-40px; /* value = - border-left-width - border-right-width */
  bottom:auto;
  border-width:15px 40px 0 0; /* vary these values to change the angle of the vertex */
  border-color:transparent #075698;
}

/* Variant : right
------------------------------------------ */

.bubbles-triangle-right.bubbles-right:after {
  top:16px;
  right:-40px; /* value = - border-left-width - border-right-width */
  bottom:auto;
  left:auto;
  border-width:15px 0 0 40px; /* vary these values to change the angle of the vertex */
  border-color:transparent #075698 ;
}


/* ============================================================================================================================
== BUBBLE WITH AN OBTUSE TRIANGLE
** ============================================================================================================================ */

/* THE SPEECH BUBBLE
------------------------------------------------------------------------------------------------------------------------------- */

.bubbles-triangle-obtuse {
  position:relative;
  padding:15px;
  margin:1em 0 3em;
  color:#fff;
  background:#c81e2b;
  /* css3 */
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#f04349), to(#c81e2b));
  background:-moz-linear-gradient(#f04349, #c81e2b);
  background:-o-linear-gradient(#f04349, #c81e2b);
  background:linear-gradient(#f04349, #c81e2b);
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* Variant : for top positioned triangle
------------------------------------------ */

.bubbles-triangle-obtuse.bubbles-top {
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#c81e2b), to(#f04349));
  background:-moz-linear-gradient(#c81e2b, #f04349);
  background:-o-linear-gradient(#c81e2b, #f04349);
  background:linear-gradient(#c81e2b, #f04349);
}

/* Variant : for left positioned triangle
------------------------------------------ */

.bubbles-triangle-obtuse.bubbles-left {
  margin-left:50px;
  background:#c81e2b;
}

/* Variant : for right positioned triangle
------------------------------------------ */

.bubbles-triangle-obtuse.bubbles-right {
  margin-right:50px;
  background:#c81e2b;
}

/* THE TRIANGLE
------------------------------------------------------------------------------------------------------------------------------- */

/* creates the wider right-angled triangle */
.bubbles-triangle-obtuse:before {
  content:"";
  position:absolute;
  bottom:-20px; /* value = - border-top-width - border-bottom-width */
  left:60px; /* controls horizontal position */
  border:0;
  border-right-width:30px; /* vary this value to change the angle of the vertex */
  border-bottom-width:20px; /* vary this value to change the height of the triangle. must be equal to the corresponding value in :after */
  border-style:solid;
  border-color:transparent #c81e2b;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* creates the narrower right-angled triangle */
.bubbles-triangle-obtuse:after {
  content:"";
  position:absolute;
  bottom:-20px; /* value = - border-top-width - border-bottom-width */
  left:80px; /* value = (:before's left) + (:before's border-right/left-width)  - (:after's border-right/left-width) */
  border:0;
  border-right-width:10px; /* vary this value to change the angle of the vertex */
  border-bottom-width:20px; /* vary this value to change the height of the triangle. must be equal to the corresponding value in :before */
  border-style:solid;
  border-color:transparent #fff;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* Variant : top
------------------------------------------ */

.bubbles-triangle-obtuse.bubbles-top:before {
  top:-20px; /* value = - border-top-width - border-bottom-width */
  bottom:auto;
  left:auto;
  right:60px; /* controls horizontal position */
  border:0;
  border-left-width:30px; /* vary this value to change the width of the triangle */
  border-top-width:20px; /* vary this value to change the height of the triangle. must be equal to the corresponding value in :after */
  border-color:transparent #c81e2b;
}

.bubbles-triangle-obtuse.bubbles-top:after {
  top:-20px; /* value = - border-top-width - border-bottom-width */
  bottom:auto;
  left:auto;
  right:80px; /* value = (:before's right) + (:before's border-right/left-width)  - (:after's border-right/left-width) */
  border-width:0;
  border-left-width:10px; /* vary this value to change the width of the triangle */
  border-top-width:20px; /* vary this value to change the height of the triangle. must be equal to the corresponding value in :before */
  border-color:transparent #fff;
}

/* Variant : left
------------------------------------------ */

.bubbles-triangle-obtuse.bubbles-left:before {
  top:15px; /* controls vertical position */
  bottom:auto;
  left:-50px; /* value = - border-left-width - border-right-width */
  border:0;
  border-bottom-width:30px; /* vary this value to change the height of the triangle */
  border-left-width:50px; /* vary this value to change the width of the triangle. must be equal to the corresponding value in :after */
  border-color:#c81e2b transparent;
}

.bubbles-triangle-obtuse.bubbles-left:after {
  top:35px; /* value = (:before's top) + (:before's border-top/bottom-width)  - (:after's border-top/bottom-width) */
  bottom:auto;
  left:-50px; /* value = - border-left-width - border-right-width */
  border:0;
  border-bottom-width:10px; /* vary this value to change the height of the triangle */
  border-left-width:50px; /* vary this value to change the width of the triangle. must be equal to the corresponding value in :before */
  border-color:#fff transparent;
}

/* Variant : right
------------------------------------------ */

.bubbles-triangle-obtuse.bubbles-right:before {
  top:15px; /* controls vertical position */
  bottom:auto;
  left:auto;
  right:-50px; /* value = - border-left-width - border-right-width */
  border:0;
  border-bottom-width:30px; /* vary this value to change the height of the triangle */
  border-right-width:50px; /* vary this value to change the width of the triangle. must be equal to the corresponding value in :after */
  border-color:#c81e2b transparent;
}

.bubbles-triangle-obtuse.bubbles-right:after {
  top:35px; /* value = (:before's top) + (:before's border-top/bottom-width)  - (:after's border-top/bottom-width) */
  bottom:auto;
  right:-50px; /* value = - border-left-width - border-right-width */
  left:auto;
  border:0;
  border-bottom-width:10px; /* vary this value to change the height of the triangle */
  border-right-width:50px; /* vary this value to change the width of the triangle. must be equal to the corresponding value in :before */
  border-color:#fff transparent;
}


/* ============================================================================================================================
== BUBBLE WITH A BORDER AND TRIANGLE
** ============================================================================================================================ */

/* THE SPEECH BUBBLE
------------------------------------------------------------------------------------------------------------------------------- */

.bubbles-triangle-border {
  position:relative;
  padding:15px;
  margin:1em 0 3em;
  border:5px solid #5a8f00;
  color:#333;
  background:#fff;
  /* css3 */
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* Variant : for left positioned triangle
------------------------------------------ */

.bubbles-triangle-border.bubbles-left {
  margin-left:30px;
}

/* Variant : for right positioned triangle
------------------------------------------ */

.bubbles-triangle-border.bubbles-right {
  margin-right:30px;
}

/* THE TRIANGLE
------------------------------------------------------------------------------------------------------------------------------- */

.bubbles-triangle-border:before {
  content:"";
  position:absolute;
  bottom:-20px; /* value = - border-top-width - border-bottom-width */
  left:40px; /* controls horizontal position */
  border-width:20px 20px 0;
  border-style:solid;
  border-color:#5a8f00 transparent;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* creates the smaller  triangle */
.bubbles-triangle-border:after {
  content:"";
  position:absolute;
  bottom:-13px; /* value = - border-top-width - border-bottom-width */
  left:47px; /* value = (:before left) + (:before border-left) - (:after border-left) */
  border-width:13px 13px 0;
  border-style:solid;
  border-color:#fff transparent;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* Variant : top
------------------------------------------ */

/* creates the larger triangle */
.bubbles-triangle-border.bubbles-top:before {
  top:-20px; /* value = - border-top-width - border-bottom-width */
  bottom:auto;
  left:auto;
  right:40px; /* controls horizontal position */
  border-width:0 20px 20px;
}

/* creates the smaller  triangle */
.bubbles-triangle-border.bubbles-top:after {
  top:-13px; /* value = - border-top-width - border-bottom-width */
  bottom:auto;
  left:auto;
  right:47px; /* value = (:before right) + (:before border-right) - (:after border-right) */
  border-width:0 13px 13px;
}

/* Variant : left
------------------------------------------ */

/* creates the larger triangle */
.bubbles-triangle-border.bubbles-left:before {
  top:10px; /* controls vertical position */
  bottom:auto;
  left:-30px; /* value = - border-left-width - border-right-width */
  border-width:15px 30px 15px 0;
  border-color:transparent #5a8f00;
}

/* creates the smaller  triangle */
.bubbles-triangle-border.bubbles-left:after {
  top:16px; /* value = (:before top) + (:before border-top) - (:after border-top) */
  bottom:auto;
  left:-21px; /* value = - border-left-width - border-right-width */
  border-width:9px 21px 9px 0;
  border-color:transparent #fff;
}

/* Variant : right
------------------------------------------ */

/* creates the larger triangle */
.bubbles-triangle-border.bubbles-right:before {
  top:10px; /* controls vertical position */
  bottom:auto;
  left:auto;
  right:-30px; /* value = - border-left-width - border-right-width */
  border-width:15px 0 15px 30px;
  border-color:transparent #5a8f00;
}

/* creates the smaller  triangle */
.bubbles-triangle-border.bubbles-right:after {
  top:16px; /* value = (:before top) + (:before border-top) - (:after border-top) */
  bottom:auto;
  left:auto;
  right:-21px; /* value = - border-left-width - border-right-width */
  border-width:9px 0 9px 21px;
  border-color:transparent #fff;
}


/* ============================================================================================================================
== SPEECH BUBBLE ICON
** ============================================================================================================================ */

.bubbles-example-commentheading {
  position:relative;
  padding:0;
  color:#b513af;
}

/* creates the rectangle */
.bubbles-example-commentheading:before {
  content:"";
  position:absolute;
  top:9px;
  left:-25px;
  width:15px;
  height:10px;
  background:#b513af;
  /* css3 */
  -webkit-border-radius:3px;
  -moz-border-radius:3px;
  border-radius:3px;
}

/* creates the triangle */
.bubbles-example-commentheading:after {
  content:"";
  position:absolute;
  top:15px;
  left:-19px;
  border:4px solid transparent;
  border-left-color:#b513af;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}


/* ============================================================================================================================
== BLOCKQUOTE WITH RIGHT-ANGLED TRIANGLE
** ============================================================================================================================ */

.bubbles-example-right {
  position:relative;
  padding:15px 30px;
  margin:0;
  color:#fff;
  background:#5a8f00; /* default background for browsers without gradient support */
  /* css3 */
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#b8db29), to(#5a8f00));
  background:-moz-linear-gradient(#b8db29, #5a8f00);
  background:-o-linear-gradient(#b8db29, #5a8f00);
  background:linear-gradient(#b8db29, #5a8f00);
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* display of quote author (alternatively use a class on the element following the blockquote) */
.example-right + p {margin:15px 0 2em 85px; font-style:italic;}

/* creates the triangle */
.bubbles-example-right:after {
  content:"";
  position:absolute;
  bottom:-50px;
  left:50px;
  border-width:0 20px 50px 0px;
  border-style:solid;
  border-color:transparent #5a8f00;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}


/* ============================================================================================================================
== BLOCKQUOTE WITH OBTUSE TRIANGLE
** ============================================================================================================================ */

.bubbles-example-obtuse {
  position:relative;
  padding:15px 30px;
  margin:0;
  color:#000;
  background:#f3961c; /* default background for browsers without gradient support */
  /* css3 */
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#f9d835), to(#f3961c));
  background:-moz-linear-gradient(#f9d835, #f3961c);
  background:-o-linear-gradient(#f9d835, #f3961c);
  background:linear-gradient(#f9d835, #f3961c);
  /* Using longhand to avoid inconsistencies between Safari 4 and Chrome 4 */
  -webkit-border-top-left-radius:25px 50px;
  -webkit-border-top-right-radius:25px 50px;
  -webkit-border-bottom-right-radius:25px 50px;
  -webkit-border-bottom-left-radius:25px 50px;
  -moz-border-radius:25px / 50px;
  border-radius:25px / 50px;
}

/* display of quote author (alternatively use a class on the element following the blockquote) */
.example-obtuse + p {margin:10px 150px 2em 0; text-align:right; font-style:italic;}

/* creates the larger triangle */
.bubbles-example-obtuse:before {
  content:"";
  position:absolute;
  bottom:-30px;
  right:80px;
  border-width:0 0 30px 50px;
  border-style:solid;
  border-color:transparent #f3961c;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* creates the smaller triangle */
.bubbles-example-obtuse:after {
  content:"";
  position:absolute;
  bottom:-30px;
  right:110px;
  border-width:0 0 30px 20px;
  border-style:solid;
  border-color:transparent #fff;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}


/* ============================================================================================================================
== TWITTER
** ============================================================================================================================ */

.bubbles-example-twitter {
  position:relative;
  padding:15px;
  margin:100px 0 0.5em;
  color:#333;
  background:#eee;
  /* css3 */
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

.bubbles-example-twitter p {font-size:28px; line-height:1.25em;}

/* this isn't necessary, just saves me having to edit the HTML of the demo */
.bubbles-example-twitter:before {
  content:url(twitter-logo.gif);
  position:absolute;
  top:-60px;
  left:0;
  width:155px;
  height:36px;
  /* reduce the damage in FF3.0 */
  display:block;
}

/* creates the triangle */
.bubbles-example-twitter:after {
  content:"";
  position:absolute;
  top:-30px;
  left:50px;
  border:15px solid transparent;
  border-bottom-color:#eee;
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

/* display of quote author (alternatively use a class on the element following the blockquote) */
.bubbles-example-twitter + p {padding-left:15px; font:14px Arial, sans-serif;}


/* ============================================================================================================================
== NUMBER
** ============================================================================================================================ */

.bubbles-example-number {
  position:relative;
  width:200px;
  height:200px;
  margin:50px 0 200px;
  text-align:center;
  font:140px/200px Arial, sans-serif;
  color:#fff;
  background:#C91F2C;
}

/* creates the larger triangle */
.bubbles-example-number:before {
  content:"";
  position:absolute;
  bottom:-140px;
  right:0;
  border-width:0 0 140px 140px;
  border-style:solid;
  border-color:transparent #C91F2C;
}

/* creates the larger triangle */
.bubbles-example-number:after {
  content:"";
  position:absolute;
  bottom:-140px;
  right:85px;
  border-width:0 0 140px 55px;
  border-style:solid;
  border-color:transparent #fff;
}


/* ============================================================================================================================
== PINCHED SPEECH BUBBLE (more CSS3)
** ============================================================================================================================ */

.bubbles-pinched {
  position:relative;
  padding:15px;
  margin:50px 0 3em;
  text-align:center;
  color:#fff;
  background:#333;
  /* css3 */
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* creates a rectangle of the colour wanted for the pointy bit */
.bubbles-pinched:before {
  content:"";
  position:absolute;
  top:-20px;
  left:50%;
  width:100px;
  height:20px;
  margin:0 0 0 -50px;
  background:#333;
}

/* creates a rounded rectangle to cover part of the rectangle generated above */
.bubbles-pinched:after {
  content:"";
  position:absolute;
  top:-20px;
  left:0;
  width:50%;
  height:20px;
  background:#fff;
  /* css3 */
  -webkit-border-bottom-right-radius:15px;
  -moz-border-radius-bottomright:15px;
  border-bottom-right-radius:15px;
}

/* creates the other rounded rectangle */
.bubbles-pinched > :first-child:before {
  content:"";
  position:absolute;
  top:-20px;
  right:0;
  width:50%;
  height:20px;
  background:#fff;
  /* css3 */
  -webkit-border-bottom-left-radius:15px;
  -moz-border-radius-bottomleft:15px;
  border-bottom-left-radius:15px;
}


/* ============================================================================================================================
== OVAL SPEECH BUBBLE (more CSS3)
** ============================================================================================================================ */

.bubbles-oval-speech {
  position:relative;
  width:270px;
  padding:50px 40px;
  margin:1em auto 50px;
  text-align:center;
  color:#fff;
  background:#5a8f00;
  /* css3 */
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#b8db29), to(#5a8f00));
  background:-moz-linear-gradient(#b8db29, #5a8f00);
  background:-o-linear-gradient(#b8db29, #5a8f00);
  background:linear-gradient(#b8db29, #5a8f00);
  /*
  NOTES:
  -webkit-border-radius:220px 120px; // produces oval in safari 4 and chrome 4
  -webkit-border-radius:220px / 120px; // produces oval in chrome 4 (again!) but not supported in safari 4
  Not correct application of the current spec, therefore, using longhand to avoid future problems with webkit corrects this
  */
  -webkit-border-top-left-radius:220px 120px;
  -webkit-border-top-right-radius:220px 120px;
  -webkit-border-bottom-right-radius:220px 120px;
  -webkit-border-bottom-left-radius:220px 120px;
  -moz-border-radius:220px / 120px;
  border-radius:220px / 120px;
}

.bubbles-oval-speech p {font-size:1.25em;}

/* creates part of the curve */
.bubbles-oval-speech:before {
  content:"";
  position:absolute;
  z-index:-1;
  bottom:-30px;
  right:50%;
  height:30px;
  border-right:60px solid #5a8f00;
  background:#5a8f00; /* need this for webkit - bug in handling of border-radius */
  /* css3 */
  -webkit-border-bottom-right-radius:80px 50px;
  -moz-border-radius-bottomright:80px 50px;
  border-bottom-right-radius:80px 50px;
  /* using translate to avoid undesired appearance in CSS2.1-capabable but CSS3-incapable browsers */
  -webkit-transform:translate(0, -2px);
  -moz-transform:translate(0, -2px);
  -ms-transform:translate(0, -2px);
  -o-transform:translate(0, -2px);
  transform:translate(0, -2px);
}

/* creates part of the curved pointy bit */
.bubbles-oval-speech:after {
  content:"";
  position:absolute;
  z-index:-1;
  bottom:-30px;
  right:50%;
  width:60px;
  height:30px;
  background:#fff;
  /* css3 */
  -webkit-border-bottom-right-radius:40px 50px;
  -moz-border-radius-bottomright:40px 50px;
  border-bottom-right-radius:40px 50px;
  /* using translate to avoid undesired appearance in CSS2.1-capabable but CSS3-incapable browsers */
  -webkit-transform:translate(-30px, -2px);
  -moz-transform:translate(-30px, -2px);
  -ms-transform:translate(-30px, -2px);
  -o-transform:translate(-30px, -2px);
  transform:translate(-30px, -2px);
}


/* ============================================================================================================================
== OVAL THOUGHT BUBBLE (more CSS3)
** ============================================================================================================================ */

.bubbles-oval-thought {
  position:relative;
  width:270px;
  padding:50px 40px;
  margin:1em auto 80px;
  text-align:center;
  color:#fff;
  background:#075698;
  /* css3 */
  background:-webkit-gradient(linear, 0 0, 0 100%, from(#2e88c4), to(#075698));
  background:-moz-linear-gradient(#2e88c4, #075698);
  background:-o-linear-gradient(#2e88c4, #075698);
  background:linear-gradient(#2e88c4, #075698);
  /*
  NOTES:
  -webkit-border-radius:220px 120px; // produces oval in safari 4 and chrome 4
  -webkit-border-radius:220px / 120px; // produces oval in chrome 4 (again!) but not supported in safari 4
  Not correct application of the current spec, therefore, using longhand to avoid future problems with webkit corrects this
  */
  -webkit-border-top-left-radius:220px 120px;
  -webkit-border-top-right-radius:220px 120px;
  -webkit-border-bottom-right-radius:220px 120px;
  -webkit-border-bottom-left-radius:220px 120px;
  -moz-border-radius:220px / 120px;
  border-radius:220px / 120px;
}

.bubbles-oval-thought p {font-size:1.25em;}

/* creates the larger circle */
.bubbles-oval-thought:before {
  content:"";
  position:absolute;
  bottom:-20px;
  left:50px;
  width:30px;
  height:30px;
  background:#075698;
  /* css3 */
  -webkit-border-radius:30px;
  -moz-border-radius:30px;
  border-radius:30px;
}

/* creates the smaller circle */
.bubbles-oval-thought:after {
  content:"";
  position:absolute;
  bottom:-30px;
  left:30px;
  width:15px;
  height:15px;
  background:#075698;
  /* css3 */
  -webkit-border-radius:15px;
  -moz-border-radius:15px;
  border-radius:15px;
}

/* ============================================================================================================================
== OVAL SPEECH BUBBLE WITH QUOTATION MARKS (more CSS3)
** ============================================================================================================================ */

.bubbles-oval-quotes {
  position:relative;
  width:400px;
  height:350px;
  margin:2em auto 10px;
  color:#000;
  background:#ffed26;
  /* css3 */
  /*
  NOTES:
  -webkit-border-radius:Apx Bpx; // produces oval in safari 4 and chrome 4
  -webkit-border-radius:Apx / Bpx; // produces oval in chrome 4 (again!) but not supported in safari 4
  Not correct application of the current spec, therefore, using longhand to avoid future problems with webkit corrects this
  */
  -webkit-border-top-left-radius:400px 350px;
  -webkit-border-top-right-radius:400px 350px;
  -webkit-border-bottom-right-radius:400px 350px;
  -webkit-border-bottom-left-radius:400px 350px;
  -moz-border-radius:400px / 350px;
  border-radius:400px / 350px;
}

/* creates opening quotation mark */
.bubbles-oval-quotes:before {
  content:"\201C";
  position:absolute;
  z-index:1;
  top:20px;
  left:20px;
  font:80px/1 Georgia, serif;
  color:#ffed26;
}

/* creates closing quotation mark */
.bubbles-oval-quotes:after {
  content:"\201D";
  position:absolute;
  z-index:1;
  bottom:0;
  right:20px;
  font:80px/0.25 Georgia, serif;
  color:#ffed26;
}

.bubbles-oval-quotes p {
  width:250px;
  height:250px;
  padding:50px 0 0;
  margin:0 auto;
  text-align:center;
  font-size:35px;
}

/* creates smaller curve */
.bubbles-oval-quotes p:before {
  content:"";
  position:absolute;
  z-index:-1;
  bottom:-30px;
  right:55%;
  width:180px; /* wider than necessary to make it look a bit better in IE8 */
  height:60px;
  background:#fff; /* need this for webkit - bug in handling of border-radius */
  /* css3 */
  -webkit-border-bottom-right-radius:40px 50px;
  -moz-border-radius-bottomright:40px 50px;
  border-bottom-right-radius:40px 50px;
  /* using translate to avoid undesired appearance in CSS2.1-capabable but CSS3-incapable browsers */
  -webkit-transform:translate(-30px, -2px);
  -moz-transform:translate(-30px, -2px);
  -ms-transform:translate(-30px, -2px);
  -o-transform:translate(-30px, -2px);
  transform:translate(-30px, -2px);
}

/* creates larger curve */
.bubbles-oval-quotes p:after {
  content:"";
  position:absolute;
  z-index:-2;
  bottom:-30px;
  right:25%;
  height:80px;
  border-right:200px solid #ffed26;
  background:#ffed26; /* need this for webkit - bug in handling of border-radius */
  /* css3 */
  -webkit-border-bottom-right-radius:200px 100px;
  -moz-border-radius-bottomright:200px 100px;
  border-bottom-right-radius:200px 100px;
  /* using translate to avoid undesired appearance in CSS2.1-capabable but CSS3-incapable browsers */
  -webkit-transform:translate(0, -2px);
  -moz-transform:translate(0, -2px);
  -ms-transform:translate(0, -2px);
  -o-transform:translate(0, -2px);
  transform:translate(0, -2px);
  /* reduce the damage in FF3.0 */
  display:block;
  width:0;
}

.bubbles-oval-quotes + p {
  position:relative; /* part of the IE8 width compromise */
  width:150px;
  margin:0 0 2em;
  font-size:18px;
  font-weight:bold;
}


/* ============================================================================================================================
== RECTANGLE-BORDER STYLE WITH CURVE
** ============================================================================================================================ */

.bubbles-rectangle-speech-border {
  position:relative;
  padding:50px 15px;
  margin:1em 0 3em;
  border:10px solid #5a8f00;
  text-align:center;
  color:#333;
  background:#fff;
  /* css3 */
  -webkit-border-radius:20px;
  -moz-border-radius:20px;
  border-radius:20px;
}

/* creates larger curve */
.bubbles-rectangle-speech-border:before {
  content:"";
  position:absolute;
  z-index:10;
  bottom:-40px;
  left:50px;
  width:50px;
  height:30px;
  border-style:solid;
  border-width:0 10px 10px 0;
  border-color:#5a8f00;
  background:transparent;
  /* css3 */
  -webkit-border-bottom-right-radius:80px 50px;
  -moz-border-radius-bottomright:80px 50px;
  border-bottom-right-radius:80px 50px;
  /* reduce the damage in FF3.0 */
  display:block;
}

/* creates smaller curve */
.bubbles-rectangle-speech-border:after {
  content:"";
  position:absolute;
  z-index:10;
  bottom:-40px;
  left:50px;
  width:20px;
  height:30px;
  border-style:solid;
  border-width:0 10px 10px 0;
  border-color:#5a8f00;
  background:transparent;
  /* css3 */
  -webkit-border-bottom-right-radius:40px 50px;
  -moz-border-radius-bottomright:40px 50px;
  border-bottom-right-radius:40px 50px;
  /* reduce the damage in FF3.0 */
  display:block;
}

/* creates a small circle to produce a rounded point where the two curves meet */
.bubbles-rectangle-speech-border > :first-child:before {
  content:"";
  position:absolute;
  bottom:-40px;
  left:45px;
  width:10px;
  height:10px;
  background:#5a8f00;
  /* css3 */
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* creates a white rectangle to cover part of the oval border*/
.bubbles-rectangle-speech-border > :first-child:after {
  content:"";
  position:absolute;
  bottom:-10px;
  left:76px;
  width:24px;
  height:15px;
  background:#fff;
}

/* ============================================================================================================================
== OVER SPEECH BUBBLE, EMPTY, WITH BORDER (more CSS3)
** ============================================================================================================================ */

.bubbles-oval-speech-border {
  position:relative;
  padding:70px 30px;
  margin:1em auto 60px;
  border:10px solid #f3961c;
  text-align:center;
  color:#333;
  background:#fff;
  /* css3 */
  /*
  NOTES:
  -webkit-border-radius:240px 140px; // produces oval in safari 4 and chrome 4
  -webkit-border-radius:240px / 140px; // produces oval in chrome 4 (again!) but not supported in safari 4
  Not correct application of the current spec, therefore, using longhand to avoid future problems with webkit corrects this
  */
  -webkit-border-top-left-radius:240px 140px;
  -webkit-border-top-right-radius:240px 140px;
  -webkit-border-bottom-right-radius:240px 140px;
  -webkit-border-bottom-left-radius:240px 140px;
  -moz-border-radius:240px / 140px;
  border-radius:240px / 140px;
}

/* creates larger curve */
.bubbles-oval-speech-border:before {
  content:"";
  position:absolute;
  z-index:2;
  bottom:-40px;
  right:50%;
  width:50px;
  height:30px;
  border-style:solid;
  border-width:0 10px 10px 0;
  border-color:#f3961c;
  margin-right:-10px;
  background:transparent;
  /* css3 */
  -webkit-border-bottom-right-radius:80px 50px;
  -moz-border-radius-bottomright:80px 50px;
  border-bottom-right-radius:80px 50px;
  /* reduce the damage in FF3.0 */
  display:block;
}

/* creates smaller curve */
.bubbles-oval-speech-border:after {
  content:"";
  position:absolute;
  z-index:2;
  bottom:-40px;
  right:50%;
  width:20px;
  height:31px;
  border-style:solid;
  border-width:0 10px 10px 0;
  border-color:#f3961c;
  margin-right:20px;
  background:transparent;
  /* css3 */
  -webkit-border-bottom-right-radius:40px 50px;
  -moz-border-radius-bottomright:40px 50px;
  border-bottom-right-radius:40px 50px;
  /* reduce the damage in FF3.0 */
  display:block;
}

/* creates a small circle to produce a rounded point where the two curves meet */
.bubbles-oval-speech-border > :first-child:before {
  content:"";
  position:absolute;
  z-index:1;
  bottom:-40px;
  right:50%;
  width:10px;
  height:10px;
  margin-right:45px;
  background:#f3961c;
  /* css3 */
  -webkit-border-radius:10px;
  -moz-border-radius:10px;
  border-radius:10px;
}

/* creates a white rectangle to cover part of the oval border*/
.bubbles-oval-speech-border > :first-child:after {
  content:"";
  position:absolute;
  z-index:1;
  bottom:-10px;
  right:50%;
  width:30px;
  height:15px;
  background:#fff;
}

/* ============================================================================================================================
== OVER THOUGHT BUBBLE, EMPTY, WITH BORDER (more CSS3)
** ============================================================================================================================ */

.bubbles-oval-thought-border {
  position:relative;
  padding:70px 30px;
  margin:1em auto 80px;
  border:10px solid #c81e2b;
  text-align:center;
  color:#333;
  background:#fff;
  /* css3 */
  /*
  NOTES:
  -webkit-border-radius:240px 140px; // produces oval in safari 4 and chrome 4
  -webkit-border-radius:240px / 140px; // produces oval in chrome 4 (again!) but not supported in safari 4
  Not correct application of the current spec, therefore, using longhand to avoid future problems with webkit corrects this
  */
  -webkit-border-top-left-radius:240px 140px;
  -webkit-border-top-right-radius:240px 140px;
  -webkit-border-bottom-right-radius:240px 140px;
  -webkit-border-bottom-left-radius:240px 140px;
  -moz-border-radius:240px / 140px;
  border-radius:240px / 140px;
}

/* creates the larger circle */
.bubbles-oval-thought-border:before {
  content:"";
  position:absolute;
  z-index:10;
  bottom:-40px;
  right:100px;
  width:50px;
  height:50px;
  border:10px solid #c81e2b;
  background:#fff;
  /* css3 */
  -webkit-border-radius:50px;
  -moz-border-radius:50px;
  border-radius:50px;
  /* reduce the damage in FF3.0 */
  display:block;
}

/* creates the smaller circle */
.bubbles-oval-thought-border:after {
  content:"";
  position:absolute;
  z-index:10;
  bottom:-60px;
  right:50px;
  width:25px;
  height:25px;
  border:10px solid #c81e2b;
  background:#fff;
  /* css3 */
  -webkit-border-radius:25px;
  -moz-border-radius:25px;
  border-radius:25px;
  /* reduce the damage in FF3.0 */
  display:block;
}

\rules only filteredtranscludeinline transcludeinline macrodef macrocallinline

.tc-ext-doc-link {
color: <<color primary>>;
fill: <<color primary>>;
font-size: 1.2em;
font-weight: bold;
font-family: Effra;
text-decoration: none;
border-radius: 4px;
padding: 0.3em;
margin: 0.3em -0.3em 0.3em -0.3em;
border: 2px solid transparent;
}

.tc-ext-doc-link svg {
vertical-align: middle;
height: 0.75em;
}

.tc-ext-doc-link img {
vertical-align: middle;
height: 1.3em;
}

.tc-ext-doc-link:hover {
color: <<color background>>;
fill: <<color background>>;
background: <<color primary>>;
border: 2px solid rgba(0,0,0,0.5);
}

\rules only filteredtranscludeinline transcludeinline macrodef macrocallinline

@media (min-width: {{$:/themes/tiddlywiki/vanilla/metrics/sidebarbreakpoint}}) {

<<if-sidebar """

	.tc-sidebar-scrollable {
		background: linear-gradient(to right,rgba(255,255,255,0) 0%,rgba(255,255,255,0.85) 42px,rgba(255,255,255,0.85) 100%);
	}

""">>

}

@media (max-width: {{$:/themes/tiddlywiki/vanilla/metrics/sidebarbreakpoint}}) {

<<if-sidebar """

	.tc-sidebar-scrollable {
		background: linear-gradient(to right,rgba(255,255,255,0.85) 0%,rgba(255,255,255,0.85) 100%);
	}

""">>

}

/* Make links bolder */

button.tc-tiddlylink, a.tc-tiddlylink {
    font-weight: bold;
}

\rules only filteredtranscludeinline transcludeinline macrodef macrocallinline

.tc-topbar-right {
	top: 0;
	right: 0;
}

.tc-topbar-left {
	display: inline-block;
	top: 0;
	left: 0;
	width: 100%;
}

nav.tc-top-menu p {
	margin: 0;
}

nav.tc-top-menu > ul {
	position: relative;
	list-style-type: none;
	margin: 0;
    padding: 0 0 0 42px;
	text-transform: uppercase;
	background: <<colour top-menu-background>>;
	<<box-shadow "1px 1px 5px rgba(0, 0, 0, 0.3)">>
}

nav.tc-top-menu > ul > li {
	display: inline-block;
	margin: 0;
	padding: 0;
}

nav.tc-top-menu > ul > li > a,
nav.tc-top-menu > ul > li > button {
	display: block;
	font-weight: 700;
	color: <<colour top-menu-foreground>>;
	fill: <<colour top-menu-foreground>>;
	text-decoration: none;
	padding: 0.5em;
	margin: 0;
	background: none;
	border: none;
    cursor: pointer;
    text-transform: inherit;
    border-radius: 0;
    text-decoration: none;
}

nav.tc-top-menu > ul > li > a.tc-selected,
nav.tc-top-menu > ul > li > button.tc-selected {
	background: <<colour top-menu-foreground>>;
	color: <<colour top-menu-background>>;
	fill: <<colour top-menu-background>>;
}

nav.tc-top-menu > ul > li svg {
	width: 1em;
	height: 1em;
	fill: <<colour top-menu-foreground>>;
}

nav.tc-top-menu > ul > li > a:hover,
nav.tc-top-menu > ul > li > button:hover {
	background: rgba(0,0,0,0.25);
    border-radius: 0;
    text-decoration: none;
}

nav.tc-top-menu .tc-drop-down {
	max-height: 70vh;
	overflow: auto;
}

nav.tc-top-menu .tc-drop-down a {
	text-decoration: none;
}

nav.tc-top-menu .tc-drop-down button {
	display: inline-block;
	width: auto;
}

nav.tc-top-menu .tc-drop-down ol {
	margin: 0;
}

<hr/>
<$button class="tc-btn-invisible">
<$set name="tags" filter="[<currentTiddler>]">
<$action-sendmessage $message="tm-new-tiddler" tags=<<tags>>/>
Create new tiddler tagged '<$text text=<<currentTiddler>>/>'
</$set>
</$button>

<textarea readonly="readonly" style="width:100%;height:10em;"><$text text={{!!text}}/></textarea>

<$list filter="[all[shadows+tiddlers]tag[$:/tags/TopMenu]!has[draft.of]limit[1]]" variable="listItem">

<nav class="tc-top-menu">

<ul>

<$list filter="[all[shadows+tiddlers]tag[$:/tags/TopMenu]!has[draft.of]]">

<li style={{!!custom-menu-styles}}>

<$list filter="[<currentTiddler>!has[dropdown]]" variable="listItem" emptyMessage="""

<$set name="dropdown-state" value=<<qualify "$:/state/topmenu/dropdown/">>>

<$set name="dropdown-state" value={{{ [<dropdown-state>addsuffix<currentTiddler>] }}}>

<$button popup=<<dropdown-state>> selectedClass="tc-selected">

<$transclude field="caption"/>

</$button>

</$set>

</$set>

""">

<$list filter="[<currentTiddler>has[custom-menu-content]]" variable="listItem" emptyMessage="""
<$link to={{!!target}}>

<$transclude field="caption"/>

</$link>
""">

<$transclude field="custom-menu-content" mode="inline"/>

</$list>


</$list>

</li>

</$list>

</ul>

<$list filter="[all[shadows+tiddlers]tag[$:/tags/TopMenu]!has[draft.of]]">

<$list filter="[<currentTiddler>has[dropdown]]" variable="listItem">

<$set name="dropdown-state" value=<<qualify "$:/state/topmenu/dropdown/">>>

<$set name="dropdown-state" value={{{ [<dropdown-state>addsuffix<currentTiddler>] }}}>

<$reveal type="popup" state=<<dropdown-state>>>

<div class="tc-drop-down">

<$transclude tiddler={{!!dropdown}}/>

</div>

</$reveal>

</$set>

</$set>

</$list>

</$list>

</nav>

</$list>

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ambit-white: #ffffff
ambit-black: #222222
ambit-green: #209377
ambit-pale-green: #6cbeaf
ambit-blue: #155dac
ambit-purple: #925195
ambit-orange: #eb7837
ambit-brown: #786e65
ambit-light-grey: #e2e2e2
ambit-very-light-grey: #f2f2f2

ambit-mid: rgba(232, 232, 232, 0.84)

top-menu-background: <<colour ambit-purple>>
top-menu-foreground: <<colour ambit-white>>

page-footer-background: <<colour ambit-green>>
page-footer-foreground: <<colour ambit-white>>

alert-background: <<colour ambit-white>>
alert-border: #b99e2f
alert-highlight: #881122
alert-muted-foreground: #b99e2f
background: #fff
blockquote-bar: <<colour muted-foreground>>
button-background:
button-foreground:
button-border:
code-background: #f7f7f9
code-border: #e1e1e8
code-foreground: #dd1144
dirty-indicator: #ff0000
download-background: #34c734
download-foreground: <<colour background>>
dragger-background: <<colour foreground>>
dragger-foreground: <<colour background>>
dropdown-background: <<colour background>>
dropdown-border: <<colour muted-foreground>>
dropdown-tab-background-selected: #fff
dropdown-tab-background: #ececec
dropzone-background: rgba(0,200,0,0.7)
external-link-background-hover: inherit
external-link-background-visited: inherit
external-link-background: inherit
external-link-foreground-hover: inherit
external-link-foreground-visited: #0000aa
external-link-foreground: #0000ee
foreground: <<colour ambit-black>>
message-background: #ecf2ff
message-border: #cfd6e6
message-foreground: #547599
modal-backdrop: <<colour foreground>>
modal-background: <<colour background>>
modal-border: #999999
modal-footer-background: #f5f5f5
modal-footer-border: #dddddd
modal-header-border: #eeeeee
muted-foreground: <<colour ambit-green>>
notification-background: #ffffdd
notification-border: #999999
page-background: <<colour ambit-light-grey>>
pre-background: #f5f5f5
pre-border: #cccccc
primary: <<colour ambit-blue>>
sidebar-button-foreground: <<colour foreground>>
sidebar-controls-foreground-hover: #000000
sidebar-controls-foreground: <<colour ambit-green>>
sidebar-foreground-shadow: rgba(255,255,255, 0.8)
sidebar-foreground: #acacac
sidebar-muted-foreground-hover: #444444
sidebar-muted-foreground: #c0c0c0
sidebar-tab-background-selected: #f4f4f4
sidebar-tab-background: #e0e0e0
sidebar-tab-border-selected: <<colour tab-border-selected>>
sidebar-tab-border: <<colour tab-border>>
sidebar-tab-divider: #e4e4e4
sidebar-tab-foreground-selected:
sidebar-tab-foreground: <<colour tab-foreground>>
sidebar-tiddler-link-foreground-hover: #444444
sidebar-tiddler-link-foreground: #999999
site-title-foreground: <<colour tiddler-title-foreground>>
static-alert-foreground: #aaaaaa
tab-background-selected: #ffffff
tab-background: #d8d8d8
tab-border-selected: #d8d8d8
tab-border: #cccccc
tab-divider: #d8d8d8
tab-foreground-selected: <<colour tab-foreground>>
tab-foreground: #666666
table-border: #dddddd
table-footer-background: #a8a8a8
table-header-background: #f0f0f0
tag-background: #ec6
tag-foreground: #ffffff
tiddler-background: <<colour background>>
tiddler-border: <<colour background>>
tiddler-controls-foreground-hover: #888888
tiddler-controls-foreground-selected: #444444
tiddler-controls-foreground: <<colour ambit-green>>
tiddler-editor-background: #f8f8f8
tiddler-editor-border-image: #ffffff
tiddler-editor-border: #cccccc
tiddler-editor-fields-even: #e0e8e0
tiddler-editor-fields-odd: #f0f4f0
tiddler-info-background: #f8f8f8
tiddler-info-border: #dddddd
tiddler-info-tab-background: #f8f8f8
tiddler-link-background: <<colour background>>
tiddler-link-foreground: <<colour primary>>
tiddler-subtitle-foreground: #c0c0c0
tiddler-title-foreground: #182955
toolbar-new-button:
toolbar-options-button:
toolbar-save-button:
toolbar-info-button:
toolbar-edit-button:
toolbar-close-button:
toolbar-delete-button:
toolbar-cancel-button:
toolbar-done-button:
untagged-background: #999999
very-muted-foreground: #888888

\define image-link-body(image,caption,width,height,color,background-color,icon)
<div class="tc-thumbnail-wrapper" style="width:$width$px;height:$height$px;">
<div class="tc-thumbnail-image">[img[$image$]]</div><div class="tc-thumbnail-icon" style="fill:$color$;color:$color$;">
$icon$
</div><div class="tc-thumbnail-caption">
$caption$
</div>
</div>
\end

\define image-link(link,image,caption,width,height,color,background-color,icon)
<$link to="""$link$"""><$macrocall $name="image-link-body" icon=<<__icon__>> color=<<__color__>> background-color=<<__background-color__>> image=<<__image__>> caption=<<__caption__>> width=<<__width__>> height=<<__height__>>/></$link>
\end

\define image-link-ext(link,image,caption,width,height,color,background-color,icon)
<a href="""$link$""" target="_blank" rel="noopener noreferrer"><$macrocall $name="image-link-body" icon=<<__icon__>> color=<<__color__>> background-color=<<__background-color__>> image=<<__image__>> caption=<<__caption__>> width=<<__width__>> height=<<__height__>>/></a>
\end

\define link-doc(caption,url,type:"docs")
<a href="""$url$""" class="tc-ext-doc-link" style="" target="_blank" rel="noopener noreferrer" title="Open in Google Docs">
{{$:/core/images/chevron-right}}<$image source={{{ [tag[$:/_GoogleDocsIcon]caption<__type__>] }}}/> $caption$
</a>
\end

\define link-pdf(caption,url,colour:"#55c6a7")
<a href="""$url$""" class="tc-btn-big-green" style="background-color:$colour$;" target="_blank" rel="noopener noreferrer">
{{$:/core/images/file}} $caption$
</a>
\end

\define embed-video(code)
<iframe width="560" height="315" src="https://www.youtube.com/embed/$code$" frameborder="0" allow="autoplay; encrypted-media" allowfullscreen></iframe>
\end

<div class="tc-table-of-contents">
<<toc-selective-expandable 'AboutContents'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'ClientContents'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'HomeContents'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'LearningContents'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'NetworksContents'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'AMBIT'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'TeamContents'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'TrainingContents'>>
</div>

<div class="tc-table-of-contents">
<<toc-selective-expandable 'UsingTheManualContents'>>
</div>

tags

title

hide

hide

hide

show

show

hide

show

show

hide

hide

hide

yes

auto

sticky

no

hide

hide

show

hide

restored

no

no

no

<div class="tc-more-sidebar">
<$macrocall $name="tabs" tabsList="[all[shadows+tiddlers]tag[$:/tags/Recent]!has[draft.of]]" default="$:/_AFC/Recent/All" state="$:/state/tab/recentsidebar" class="tc-vertical" />
</div>

\define lingo-base() $:/language/ControlPanel/
\define config-title()
$:/config/PageControlButtons/Visibility/$(listItem)$
\end

<<lingo Basics/Version/Prompt>> <<version>>

<$set name="tv-config-toolbar-icons" value="yes">

<$set name="tv-config-toolbar-text" value="yes">

<$set name="tv-config-toolbar-class" value="">

<$list filter="[all[shadows+tiddlers]tag[$:/tags/PageControls]!has[draft.of]]" variable="listItem">

<div style="position:relative;" class={{{ [<listItem>encodeuricomponent[]addprefix[tc-btn-]] }}}>

<$checkbox tiddler=<<config-title>> field="text" checked="show" unchecked="hide" default="show"/> <$transclude tiddler=<<listItem>>/> <i class="tc-muted"><$transclude tiddler=<<listItem>> field="description"/></i>

</div>

</$list>

</$set>

</$set>

</$set>

<$transclude tiddler="$:/core" subtiddler="$:/core/ui/ViewTemplate/subtitle"/>

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

Open Pages

Recent changes

$:/_AFC/Palette

\whitespace trim
\define print-button()
<$button tooltip="print" aria-label="print" class=<<tv-config-toolbar-class>>>
<$action-sendmessage $message="tm-open-window" template="$:/plugins/federatial/print/window" windowTitle={{$:/config/plugins/federatial/print/window-title}}/>
<$list filter="[<tv-config-toolbar-icons>prefix[yes]]">
{{$:/core/images/print-button}}
</$list>
<$list filter="[<tv-config-toolbar-text>prefix[yes]]">
<span class="tc-btn-text">
<$text text="print"/>
</span>
</$list>
</$button>
\end
<$list filter="[<currentTiddler>tagging[]role[heading]limit[1]]" variable="ignore" emptyMessage=<<print-button>>>
<$text text=""/>
</$list>

\rules only filteredtranscludeinline transcludeinline macrodef macrocallinline

.tc-export-controls {
	background: #dfddf9;
	margin: -1em -1em 0 -1em;
	padding: 1em;
	border-bottom: 2px solid black;
}

.tc-export-controls textarea {
	width: 100%;
}

.tc-export-header {
	margin-top: 1em;
	padding: 1em;
	border: 1px solid black;
}

@media print {

	.tc-unprintable {
		display: none;
	}

}

<$transclude tiddler="$:/plugins/federatial/print/template/inner" mode="block"/>

! <$view field="title"/>

{{!!text}}

\whitespace trim

<$set name="themeTitle" value={{$:/view}}>

<$set name="tempCurrentTiddler" value=<<currentTiddler>>>

<$set name="currentTiddler" value={{$:/language}}>

<$set name="languageTitle" value={{!!name}}>

<$set name="currentTiddler" value=<<tempCurrentTiddler>>>

<$importvariables filter="[[$:/core/ui/PageMacros]] [all[shadows+tiddlers]tag[$:/tags/Macro]!has[draft.of]]">

<div class="tc-unprintable tc-export-controls">

<$button message="tm-print" tooltip="Print this page">
Print
</$button>

</div>

<$transclude tiddler="$:/plugins/federatial/print/template" mode="block"/>

</$importvariables>

</$set>

</$set>

</$set>

</$set>

</$set>

{
    "tiddlers": {
        "$:/config/Comments/EnableFilter": {
            "title": "$:/config/Comments/EnableFilter",
            "text": "[all[current]!is[system]]\n"
        },
        "$:/plugins/tiddlywiki/comments/above-story": {
            "title": "$:/plugins/tiddlywiki/comments/above-story",
            "tags": "$:/tags/AboveStory",
            "text": "<$reveal state=\"$:/config/Comments/EnableWikiComments\" type=\"match\" text=\"yes\" default=\"no\">\n\n<$tiddler tiddler=\"$:/SiteTitle\">\n\n<$transclude tiddler=\"$:/plugins/tiddlywiki/comments/comments-template\" mode=\"inline\"/>\n\n</$tiddler>\n\n</$reveal>\n"
        },
        "$:/plugins/tiddlywiki/comments/add-comment-button-actions": {
            "title": "$:/plugins/tiddlywiki/comments/add-comment-button-actions",
            "text": "<$set name=\"username\" value={{$:/status/UserName}} emptyValue=\"(anonymous)\">\n<$set name=\"target\" filter=\"[<currentTiddler>]\">\n<$action-createtiddler $basetitle={{{ [[Comment by ']addsuffix<username>addsuffix[' on ']addsuffix<currentTiddler>addsuffix[']] }}} role=\"comment\" list=<<target>> text=\"\" edit-mode=\"yes\"/>\n</$set>\n</$set>\n"
        },
        "$:/plugins/tiddlywiki/comments/add-comment-button": {
            "title": "$:/plugins/tiddlywiki/comments/add-comment-button",
            "text": "<$reveal state=\"$:/status/IsReadOnly\" type=\"match\" text=\"no\" default=\"no\" tag=\"div\" class=\"tc-comment-button\">\n<$button class=\"tc-btn-invisible\" actions={{$:/plugins/tiddlywiki/comments/add-comment-button-actions}}>\nadd comment {{$:/core/images/add-comment}}\n</$button>\n</$reveal>\n"
        },
        "$:/plugins/tiddlywiki/comments/comments-template": {
            "title": "$:/plugins/tiddlywiki/comments/comments-template",
            "text": "<div class=\"tc-comments\">\n<ol class=\"tc-comment-list\">\n<$list filter=\"[all[tiddlers+shadows]role[comment]contains<currentTiddler>sort[created]!has[draft.of]]\">\n<li>\n<div class=\"tc-comment-entry\">\n<div class=\"tc-comment-entry-heading\">\n<$link>{{!!creator}} at <$view field=\"modified\" format=\"date\" template=\"0hh:0mm:0ss DDD DDth MMM YYYY\"/></$link>\n<$list filter=\"[all[shadows+tiddlers]tag[$:/tags/CommentToolbarButton]!has[draft.of]]\" variable=\"listItem\">\n<$transclude tiddler=<<listItem>> mode=\"inline\"/>\n</$list>\n</div>\n<div class=\"tc-comment-entry-body\">\n<$reveal type=\"match\" state=\"!!edit-mode\" text=\"yes\">\n<$edit-text tiddler=<<currentTiddler>> tag=\"textarea\" focus=\"true\"/>\n</$reveal>\n<$reveal type=\"nomatch\" state=\"!!edit-mode\" text=\"yes\">\n<$transclude tiddler=<<currentTiddler>> mode=\"block\"/>\n<$transclude tiddler=\"$:/plugins/tiddlywiki/comments/add-comment-button\" mode=\"inline\"/>\n</$reveal>\n</div>\n</div>\n<$transclude tiddler=\"$:/plugins/tiddlywiki/comments/comments-template\" mode=\"inline\"/>\n</li>\n</$list>\n</ol>\n</div>\n"
        },
        "$:/plugins/tiddlywiki/comments/config": {
            "title": "$:/plugins/tiddlywiki/comments/config",
            "text": "\\define select(description,filter)\n<$button>\n<$action-setfield $tiddler=\"$:/config/Comments/EnableFilter\" $value=<<__filter__>>/>\n$description$\n</$button>\n\\end\n\n! Wiki Comments\n\n<$checkbox tiddler=\"$:/config/Comments/EnableWikiComments\" field=\"text\" checked=\"yes\" unchecked=\"no\" default=\"no\"> <$link to=\"$:/config/Comments/EnableWikiComments\">Allow wiki-level comments as well as tiddler comments</$link> </$checkbox>\n\n! Tiddler Comments\n\nThis filter expression determines which tiddlers will have commenting enabled:\n\n<$edit-text tiddler=\"$:/config/Comments/EnableFilter\" tag=\"input\"/>\n\nOr you can choose a preselected filter:\n\n* <<select \"All tiddlers except system tiddlers\" \"[all[current]!is[system]]\">>\n* <<select \"Only tiddlers tagged 'commentable'\" \"[all[current]tag[commentable]]\">>\n* <<select \"Disable all commenting\" \"\">>\n"
        },
        "$:/plugins/tiddlywiki/comments/filter-all-comments": {
            "title": "$:/plugins/tiddlywiki/comments/filter-all-comments",
            "tags": "$:/tags/Filter",
            "filter": "[role[comment]!sort[modified]]",
            "description": "All comments",
            "text": ""
        },
        "$:/plugins/tiddlywiki/comments/footer-view-template-segment": {
            "title": "$:/plugins/tiddlywiki/comments/footer-view-template-segment",
            "tags": "$:/tags/ViewTemplate",
            "list-after": "$:/core/ui/ViewTemplate/body",
            "text": "<$list filter={{$:/config/Comments/EnableFilter}} variable=\"ignore\">\n<div class=\"tc-comments-segment\">\n<$transclude tiddler=\"$:/plugins/tiddlywiki/comments/add-comment-button\" mode=\"inline\"/>\n<$transclude tiddler=\"$:/plugins/tiddlywiki/comments/comments-template\" mode=\"inline\"/>\n</div>\n</$list>"
        },
        "$:/plugins/tiddlywiki/comments/header-view-template-segment": {
            "title": "$:/plugins/tiddlywiki/comments/header-view-template-segment",
            "tags": "$:/tags/ViewTemplate",
            "list-before": "$:/core/ui/ViewTemplate/body",
            "text": "\\define display-original-comment()\n<$link><$text text=<<currentTiddler>>/></$link>\n\\end\n\n\\define find-original-comment(exclude)\n<$list filter=\"[<currentTiddler>role[comment]]\" emptyMessage=<<display-original-comment>> variable=\"ignore\">\n<$list filter=\"[list<currentTiddler>sort[title]] -[enlist<__exclude__>]\">\n<$set name=\"newExclude\" filter=\"[enlist<__exclude__>] [<currentTiddler>]\">\n<$macrocall $name=\"find-original-comment\" exclude=<<newExclude>>/>\n</$set>\n</$list>\n</$list>\n\\end\n\n<$list filter=\"[all[current]role[comment]]\" variable=\"ignore\">\n<div class=\"tc-is-comment-header\">\n<p>\nThis tiddler is a comment on\n<$list filter=\"[list<currentTiddler>sort[title]]\">\n<<find-original-comment>>&nbsp;\n</$list>\n</p>\n<$list filter=\"[list<currentTiddler>role[comment]sort[title]limit[1]]\" variable=\"ignore\">\n<p>\nParent comments:\n</p>\n<ul>\n<$list filter=\"[list<currentTiddler>role[comment]sort[title]]\">\n<li>\n<$link to=<<currentTiddler>>><$text text=<<currentTiddler>>/></$link>\n</li>\n</$list>\n</ul>\n</$list>\n</div>\n</$list>\n"
        },
        "$:/plugins/tiddlywiki/comments/readme": {
            "title": "$:/plugins/tiddlywiki/comments/readme",
            "text": "This plugin provides a simple means for adding threaded comments to tiddlers.\n\n* Click the \"add comment\" button to make a new comment, and then click the \"save\" button to save it\n* You can comment on a tiddler itself, or add a comment to an existing comment\n* The sidebar tab ''Comments'' lists a timeline of all comments\n* Comments are attributed to the username stored in the system tiddler [[$:/status/UserName]]\n* By default, comments are available on all non-system tiddlers. The ''config'' tab lets you customise which tiddlers can accept comments by specifying a filter extension\n* The buttons for adding and editing comments are only available if the system tiddler [[$:/status/IsReadOnly]] is not set to `yes`\n* Use the \"All comments\" option in the $:/AdvancedSearch ''Filter'' tab to see or export all comments\n\n!! Data Model\n\nThe data model employed by the comments plugin is very simple:\n\n* Comment tiddlers are identified by the `role` field being set to `comment`\n* The `list` field of comment tiddlers lists the tiddlers to which this comment applies\n** It is thus possible for a comment to be applied to multiple tiddlers at once\n** The links between comments can be preserved when renaming them by using the relink checkbox in the edit template\n* The `edit-mode` field of comment tiddlers is set to `yes` to display it in edit mode, or `no` to display it in view mode\n* The `saved-text` field is updated when switching to edit mode so that it can be restored if the user cancels\n\n"
        },
        "$:/plugins/tiddlywiki/comments/sidebar-segment": {
            "title": "$:/plugins/tiddlywiki/comments/sidebar-segment",
            "tags": "$:/tags/SideBarSegment",
            "list-after": "$:/core/ui/SideBarSegments/site-subtitle",
            "text": "<$reveal state=\"$:/config/Comments/EnableWikiComments\" type=\"match\" text=\"yes\" default=\"no\">\n<$tiddler tiddler=\"$:/SiteTitle\">\n<$transclude tiddler=\"$:/plugins/tiddlywiki/comments/add-comment-button\" mode=\"inline\"/>\n</$tiddler>\n</$reveal>\n"
        },
        "$:/plugins/tiddlywiki/comments/sidebar": {
            "title": "$:/plugins/tiddlywiki/comments/sidebar",
            "tags": "$:/tags/SideBar",
            "caption": "Comments",
            "text": "<div class=\"tc-timeline\">\n<$list filter=\"[all[tiddlers+shadows]role[comment]has[modified]!sort[modified]eachday[modified]]\">\n<div class=\"tc-menu-list-item\">\n<$view field=\"modified\" format=\"date\" template=\"DDth MMM YYYY\"/>\n<$list filter=\"[all[tiddlers+shadows]role[comment]sameday:modified{!!modified}!sort[modified]]\">\n<div class=\"tc-menu-list-subitem\">\n<$link>Comment by '<$view field=\"modifier\">(anonymous)</$view>'</$link> on\n<$list filter=\"[list<currentTiddler>sort[title]]\">\n<$link to=<<currentTiddler>>><$text text=<<currentTiddler>>/></$link>\n</$list>\n</div>\n</$list>\n</div>\n</$list>\n</div>\n"
        },
        "$:/plugins/tiddlywiki/comments/styles": {
            "title": "$:/plugins/tiddlywiki/comments/styles",
            "tags": "[[$:/tags/Stylesheet]]",
            "text": "\\rules only filteredtranscludeinline transcludeinline macrodef macrocallinline\n\n.tc-is-comment-header {\n\tpadding: 0.25em;\n\tborder: 2px solid #c1e1ea;\n\tborder-radius: 4px;\n\tbackground: #f1fcff;\n}\n\n.tc-comments-segment {\n\tborder-top: 2px solid #d7eef4;\n}\n\n.tc-comment-button button {\n\twidth: 100%;\n\ttext-align: right;\n}\n\n.tc-sidebar-scrollable .tc-comment-button button {\n\twidth: auto;\n\ttext-align: right;\n}\n\n.tc-comment-button button svg {\n\tfill: #26cb56;\n\theight: 2em;\n\twidth: 2em;\n}\n\n.tc-comments {\n}\n\n.tc-comment-list {\n\tlist-style: none;\n     padding-left: 0;\n}\n\n.tc-comment-list .tc-comments {\n\tpadding-left: 1em;\n}\n\n.tc-comment-entry {\n\tposition: relative;\n\tborder: 2px solid #c1e1ea;\n\tborder-radius: 4px;\n\tmargin: 0.5em 0 0 0;\n\tbackground: #f1fcff;\n}\n\n.tc-comment-entry-heading {\n\tfont-size: 0.7em;\n\tfont-weight: bold;\n\ttext-transform: uppercase;\n\tbackground: #d7eef4;\n\tcolor: #5B6D80;\n\tpadding: 0 0.5em;\n}\n\n.tc-comment-entry-body {\n\tfont-size: 0.8em;\n\tpadding: 0 0.5em;\n}\n\n.tc-comment-entry-body textarea {\n\tfont-size: 1.1em;\n\twidth: 100%\n}\n"
        },
        "$:/tags/CommentToolbarButton": {
            "title": "$:/tags/CommentToolbarButton",
            "list": "[[$:/plugins/tiddlywiki/comments/toolbar-button-cancel]] [[$:/plugins/tiddlywiki/comments/toolbar-button-delete]] [[$:/plugins/tiddlywiki/comments/toolbar-button-save]] [[$:/plugins/tiddlywiki/comments/toolbar-button-edit]]"
        },
        "$:/plugins/tiddlywiki/comments/toolbar-button-cancel": {
            "title": "$:/plugins/tiddlywiki/comments/toolbar-button-cancel",
            "tags": "$:/tags/CommentToolbarButton",
            "text": "<$reveal state=\"$:/status/IsReadOnly\" type=\"match\" text=\"no\" default=\"no\" tag=\"span\">\n<$reveal type=\"match\" state=\"!!edit-mode\" text=\"yes\">\n<$button>\n<$action-setfield $tiddler=<<currentTiddler>> $field=\"edit-mode\" $value=\"no\"/>\n<$action-setfield $tiddler=<<currentTiddler>> $field=\"text\" $value={{!!saved-text}}/>\ncancel\n</$button>\n</$reveal>\n</$reveal>\n"
        },
        "$:/plugins/tiddlywiki/comments/toolbar-button-delete": {
            "title": "$:/plugins/tiddlywiki/comments/toolbar-button-delete",
            "tags": "$:/tags/CommentToolbarButton",
            "text": "<$reveal state=\"$:/status/IsReadOnly\" type=\"match\" text=\"no\" default=\"no\" tag=\"span\">\n<$reveal type=\"match\" state=\"!!edit-mode\" text=\"yes\">\n<$button>\n<$action-deletetiddler $tiddler=<<currentTiddler>>/>\ndelete\n</$button>\n</$reveal>\n</$reveal>\n"
        },
        "$:/plugins/tiddlywiki/comments/toolbar-button-edit": {
            "title": "$:/plugins/tiddlywiki/comments/toolbar-button-edit",
            "tags": "$:/tags/CommentToolbarButton",
            "text": "<$reveal state=\"$:/status/IsReadOnly\" type=\"match\" text=\"no\" default=\"no\" tag=\"span\">\n<$reveal type=\"nomatch\" state=\"!!edit-mode\" text=\"yes\">\n<$button>\n<$action-setfield $tiddler=<<currentTiddler>> $field=\"edit-mode\" $value=\"yes\"/>\n<$action-setfield $tiddler=<<currentTiddler>> $field=\"saved-text\" $value={{!!text}}/>\nedit\n</$button>\n</$reveal>\n</$reveal>\n"
        },
        "$:/plugins/tiddlywiki/comments/toolbar-button-save": {
            "title": "$:/plugins/tiddlywiki/comments/toolbar-button-save",
            "tags": "$:/tags/CommentToolbarButton",
            "text": "<$reveal state=\"$:/status/IsReadOnly\" type=\"match\" text=\"no\" default=\"no\" tag=\"span\">\n<$reveal type=\"match\" state=\"!!edit-mode\" text=\"yes\">\n<$button>\n<$action-setfield $tiddler=<<currentTiddler>> $field=\"edit-mode\" $value=\"no\"/>\nsave\n</$button>\n</$reveal>\n</$reveal>\n"
        }
    }
}

<div class="tc-timeline">
<$list filter="[all[tiddlers+shadows]role[comment]has[modified]!sort[modified]eachday[modified]]">
<div class="tc-menu-list-item">
<$view field="modified" format="date" template="DDth MMM YYYY"/>
<$list filter="[all[tiddlers+shadows]role[comment]sameday:modified{!!modified}!sort[modified]]">
<div class="tc-menu-list-subitem">
<$link>Comment by '<$view field="modifier">(anonymous)</$view>'</$link> on
<$list filter="[list<currentTiddler>sort[title]]">
<$link to=<<currentTiddler>>><$text text=<<currentTiddler>>/></$link>
</$list>
</div>
</$list>
</div>
</$list>
</div>

$:/themes/tiddlywiki/snowwhite

450px

0px

770px

770px

fluid-fixed

tile motif.png

classic

Create a drop-down list of all recent : <<tag [[(a) Work in Progress - Major change]]>>

* ''We do not track extremely minor content changes'', such as fixing broken links, correcting typos, or improving the layout - members of the [[AMBIT Editorial Group]] work independently on these "housekeeping" tasks.
* ''Major changes'' require more "sign-off" than ''Minor changes''

!!(a) Work in Progress - Major change
This is used to [[tag|Tags]] changes flowing from group discussions in the [[AMBIT Editorial Group]] and in order to be posted in the AMBIT manual they require a minimum of three members to agree, but to be properly accepted they require sign off from at the very least the significantly more for the highest level changes proposed.

The highest level of major changes mark a response to new evidence drawn from wider theoretical/experimental advances.  They generally mark a //significant change in direction// (the removal of one of the [[Specific interventions]], or addition of a new one, for instance; or a change to the [[Core Features of AMBIT]] represented in the [[AMBIT Wheel]].)

!!(b) Work in Progress - Minor change
This [[tags|Tags]] changes that are generally new pages that introduce some small element of new theory of practice, or which are formed to better elaborate an existing area, but which do not represent any kind of fundamental shift in direction or practice - but are rather "clarifications" or "embellishments" on existing content.

For example:

* The response to a local outcomes evaluation by a local AMBIT-influenced team that demonstrates wide applicability for other teams, but comes without the assurance of a randomized controlled trial.  
* These changes are more likely to be smaller //components of practice//, or examples of stylistic approaches to a problem.
* The practice recommendation or "example" will be judged as marking a subtle shift in the direction of the "steer" that has previously been offered by the manual, although not one that - if all other things remaining unchanged - would be likely to have a significant impact on outcomes.
** For instance, the addition of video illustrating a technique for introducing the use of playing cards developed as a young persons' version of the [[AIM Cards]] - this (new) approach to the use of the cards (themselves an innovation from the AFC, building on the Clinician-rated [[AIM form]]) was developed locally and evaluated locally in the AMASS team in Islington.  It was agreed in the Editorial Group that this approach, while without formal validation evidence, was worth sharing as by doing so there may be scope for a formal validation exercise.) 

Drop down list of all recent : <<tag [[(b) Work in Progress - Minor change]]>>

* ''We do not track extremely minor content changes'', such as fixing broken links, correcting typos, or improving the layout - members of the [[AMBIT Editorial Group]] work independently on these "housekeeping" tasks.
* ''Major changes'' require more "sign-off" than ''Minor changes''

!!(a) Work in Progress - Major change
This is used to [[tag|Tags]] changes flowing from group discussions in the [[AMBIT Editorial Group]] and in order to be posted in the AMBIT manual they require a minimum of three members to agree, but to be properly accepted they require sign off from at the very least the significantly more for the highest level changes proposed.

The highest level of major changes mark a response to new evidence drawn from wider theoretical/experimental advances.  They generally mark a //significant change in direction// (the removal of one of the [[Specific interventions]], or addition of a new one, for instance; or a change to the [[Core Features of AMBIT]] represented in the [[AMBIT Wheel]].)

!!(b) Work in Progress - Minor change
This [[tags|Tags]] changes that are generally new pages that introduce some small element of new theory of practice, or which are formed to better elaborate an existing area, but which do not represent any kind of fundamental shift in direction or practice - but are rather "clarifications" or "embellishments" on existing content.

For example:
* The response to a local outcomes evaluation by a local AMBIT-influenced team that demonstrates wide applicability for other teams, but comes without the assurance of a randomized controlled trial.  
* These changes are more likely to be smaller //components of practice//, or examples of stylistic approaches to a problem.
* The practice recommendation or "example" will be judged as marking a subtle shift in the direction of the "steer" that has previously been offered by the manual, although not one that - if all other things remaining unchanged - would be likely to have a significant impact on outcomes.
** For instance, the addition of video illustrating a technique for introducing the use of playing cards developed as a young persons' version of the [[AIM Cards]] - this (new) approach to the use of the cards (themselves an innovation from the AFC, building on the Clinician-rated [[AIM form]]) was developed locally and evaluated locally in the AMASS team in Islington.  It was agreed in the Editorial Group that this approach, while without formal validation evidence, was worth sharing as by doing so there may be scope for a formal validation exercise.) 

!!Purpose
This page provides an overview of where to start if you are planning to manualize in your team. This can include editing existing pages in the manual and adding your own completely new pages. 

!!1. Start work on pre-defined topics
You can edit pages which the AMBIT team have created but that act as a template for you to add content to.

*Click on the tag <<tag [[Local Manualization Homework Tasks]]>> to see a dropdown list of these pre populated pages. 
*''Create a NEW manualizing homework task'' by selecting the option  //"Create New Tiddler tagged ..."// in the drop-down list that appears when you click on the button.

!!2. Create new content 
Instead of editing pages that are already in the manual you can create your own content and add your own topics.  

* Click on the  ''+'' icon just above the search engine. 
* Consider the Title you give your new page 
* Consider which topic(s) this new page might be a sub-topic of, or if it might have sub-topics of it's own - use [[Tags]] to organise this
* See [[How to edit - Videos]]

[img[Createnewpageicon.jpg]] <br><br> 

!!3. Improve existing content
If you and your team have identified an area of your work that is not covered adequately in the manual, and want to...

* describe it in better terms
* adapt it to fit your local culture, service ecology, etc.
You can go to the page you've found that needs improving and [[Edit|How to edit - Videos]] that page directly or click the ''More Actions''  button (top right corner of the page (tiddler) - see picture below) and select ''clone'' to create another version of the page.
[img[More Actions pic.jpg]] 

!!4. Start a new 'Sub topic'
In order to create a new sub topic you will need to understand how the [[Tagging|Tags]] system works. I.e that tags act as topic heads hierarchically above the page that it is tagged with. Therefore if you want to add a subtopic to the page 'Manualization' for example, you would tag your new page with Manualization. 

Additionally, if you come across a tag that you wish to create a new page under  you can:

* Choose the option  //"Create New Tiddler tagged ..."// in the drop-down list that appears when you click on buttons below 
* This creates a new page as a new sub topic under that topic heading
** Check you are not DUPLICATING content (use [[Search]] or [[Tags]] to help)
* Some examples are provided below:
** <<tag [[Managing Risk]]>> - material related to managing risks in work with clients
** <<tag [[Manage CLIENT RELATIONSHIP]]>> - material on engagement or challenges in the relationship with your client
** <<tag [[Manage CLINICAL PROBLEM]]>> - material on challenges in the face to face work with clients
** <<tag [[Working with your NETWORKS]]>> - material on challenges in working across professional and informal helping networks
** <<tag [[Local AMBIT training session plans]]>> - material on local training updates, refreshers, or exercises that the team wants or needs to practice at a forthcoming [[AMBIT training|Information About AMBIT Training]] refresher.
** <<tag [[Supervision Notes]]>> - use this tag to create notes on a team supervision if there are learning points that are of value (remember not to post any confidential information, just learning points on practice!)

!!''5. Review Our Existing Local Pages'' 
If you are looking for what your team has //already manualized// you are in the wrong place... just look at the Sidebar and click the ''Recent Changes'' tab - all local titles are labelled:
[img[MarkLocalEdits.jpg]] 

!!''6. Help!''
* See [[Manualization Boundaries]]: __''NB this is a TEAM TASK''__, not an individual team member's choice...
* See [[How to edit - Videos]] to learn how to edit your teams manual  
* Tips on //what// to manualize? See existing <<tag [[Local Manualization Homework Tasks]]>> where outstanding manualization tasks for a local team are listed.
* ''Feedback'': we rely on hearing from you if stuff doesn't work or is not clear.  Contact ambit@annafreud.org or use the [[Feedback please!]] form to give technical reports of glitches, or other suggestions for improvements, please!

----

<center><<image-link "How to edit your teams manual" "luciano-de-sa-ObwMZBdEWdI-unsplash (1).jpg" "How to edit your teams manual" "250">><<image-link "Preconditions for Team Learning" "john-schnobrich-2FPjlAyMQTA-unsplash (1).jpg" "Preconditions for Team Learning" "250">>
</center>

<center><<image-link "Your Manual" "free-to-use-sounds-W_FHuUQKNP0-unsplash (1).jpg" "Your Manual" "310">></center> 

Adaptive Mentalization-Based Integrative Treatment (AMBIT) is one of a number of emerging adaptations of MBT. The AMBIT approach provides tools for putting mentalization to use in work with clients, team colleagues and wider inter-agency networks, and is designed to support the development of both local excellence and evidence-based practice. It is as much a framework for local improvement and learning as it is a unitary and fixed method of therapy.

AMBIT stresses the need for local adaptation, and the sharing of emerging evidence and best practice, using its award-winning wiki-based approach to treatment manualization - AMBIT Manual). 

You may find it helpful to read two recent papers and a book chapter written about AMBIT: 

*[[Fuggle et al (2014) The AMBIT approach to outcome evaluation and manualization: adopting a learning organization approach]]
*[[Bevington et al (2012) Adolescent Mentalization-Based Integrative Therapy (AMBIT)]]
 *[[Bevington D, Fuggle P (2012) Supporting and enhancing mentalization in community outreach teams...]] 

It may also be helpful for you to read the following pages in the manual: [[AMBIT: an overview]] and [[Core Features of AMBIT]].

There are two main training options available for your consideration:

!!Training your whole team together
Multi-team trainings are aimed at small teams (of 5-16 members) from either the voluntary or statutory sector, and will be based at the [[Anna Freud National Centre for Children and Families]]. Small teams are trained together with other teams of roughly the same size. The course is delivered in two blocks of two consecutive days (four days in total). We allow a month or so between the two parts to allow teams time to put what they have learned into practice. 


Bespoke training dates can be organised for larger teams (>16 members). Prices vary depending on the size of the team and the location of the training (at the [[Anna Freud National Centre for Children and Families]] or at a venue of your choice). 

*Please see the [[Centre's website|http://www.annafreud.org/training-research/training-and-conferences-overview/training-at-the-anna-freud-national-centre-for-children-and-families/ambit-multi-team-training/]] or contact [[Amy Rozwod|mailto:amy.rozwod@annafreud.org]] for upcoming dates or more information. 

!!Training two or more local facilitators to train their colleagues in turn
The [[Local Facilitator Training AMBIT model|Local Facilitator Training (LFT)- training model]] is designed to make training more sustainable and affordable for teams; two or more members in a team are given an extensive five day AMBIT training which includes training on how to run trainings for the rest of their team. These local trainers are then supported in implementing the approach in their team through supervision sessions for twelve months following training. 

Please see the [[Centre's website|http://www.annafreud.org/training-research/training-and-conferences-overview/training-at-the-anna-freud-national-centre-for-children-and-families/ambit-multi-team-training/]] or contact [[Amy Rozwod|mailto:amy.rozwod@annafreud.org]] for upcoming dates or more information. 

* See [[AMBIT training|Information About AMBIT Training]] for all the details.

One of the first stages of either training option is to organise a meeting or telephone conversation between an AMBIT Trainer from the Anna Freud National Centre for Children and Families, and your Team and Service Manager(s) to discuss your training needs further. After being introduced to the model, our hope is that Managers will then be able to continue on to engage their team members in a discussion about learning objectives before any training commences, with the aim of shaping the training content to the needs of the team. 

For more information see the [[AMBIT Training Application Process]]. 

Please contact [[Amy Rozwod|mailto:Amy.Rozwod@annafreud.org]] to go ahead with organising such a meeting.

AMBIT training can be delivered at your location. This is generally more suitable for larger teams (>16). Please note that as well as paying for the training itself, your team must also cover trainer expenses including travel and accommodation, and you must provide the training venue. 

Prices start from £6,900 for up to 16 people. Please contact [[Amy Rozwod|mailto:Amy.Rozwod@annafreud.org]] for a quote.

We do not routinely run AMBIT trainings outside of the UK, but we are sometimes commissioned by overseas teams to run bespoke trainings for them.

Depending on the number of staff to be trained in your service, it may be possible for us to run a bespoke overseas training. However, there is a £500 surcharge on overseas trainings, and as well as paying for the training itself, your team must also cover trainer expenses including travel and accommodation. 

Another option is for two members of your team to attend the an International Train the Trainer Event, at the Anna Freud National Centre for Children and Families, London. See the [[Centre's website|http://www.annafreud.org/courses.php/113/ambit-train-the-trainer-for-international-teams]] or contact [[Amy Rozwod|mailto:Amy.Rozwod@annafreud.org]] for upcoming dates for this type of training.

The Train the Trainer model is designed to make training more sustainable and affordable for teams; two or more members in a team are given an extensive five day AMBIT training which includes training on how to run trainings for the rest of their team. These local trainers are then supported in implementing the approach in their team through supervision led by the AMBIT project for twelve months following training.

The training price for the 5 day training, plus monthly supervision for 12 months is £2,000 per person (a mininum of 2 team members per team must attend the training). 

Contact [[Amy Rozwod|mailto:Amy.rozwod@annafreud.org]] if you are interested in attending.

See [[International Train the Trainer (TTT) Model]] for the curriculum.

We only train teams that we believe will benefit from AMBIT training, and be able to translate the training experience into sustainable and effective changes in practice. One of the ways that we determine, together with you, whether AMBIT is right for your team is to organise a telephone conversation or meeting between an AMBIT Trainer from the Anna Freud National Centre for Children and Families, and your Team and Service Manager(s) to introduce you to the model, and to discuss your training needs further. We then ask teams to take part in a [[team audit|Pre-training team audit]] together, to discover what your learning objectives are.

*[[Guidance for Teams Considering Applying for Training]] can be found on the manual. 

Contact [[ambit@annafreud.org|mailto:ambit@annafreud.org]] if you have any further queries.

Where MBT is a very specific therapy, AMBIT is a much broader therapeutic approach.  Some people have described AMBIT as "pretherapy" - but contained within AMBIT are manualized versions of a wide range of evidence-based approaches, including simple CBT, simple versions of MBT, MBT-F, Motivational work etc.  The core training is for TEAMS and allows them to adapt how they use the materials in their own clinical setting.

To find out the difference between the different mentalization based courses that are offered at the Anna Freud National Centre for Children and Families there is more information the [[Centre's website|https://www.annafreud.org/training/mentalization-based-treatment-training/]]

If you decide after reading the documents that the MBT training may be more suitable for you and you wish to find out more about this course or any other course that the [[Centre runs|https://www.annafreud.org/training/]] then please contact [[Amy Rozwod|mailto:amy.rozwod@annafreud.org]].

//To be completed//

!Keeping assessment integrated:
''NB Section A below is the least necessary information gathering activity that a KeyWorker will need to undertake in situations where an Education/Vocational Centre provision does //not// exist.'' 

The intention is always to integrate as much of the young person’s education/vocational realities into the overall treatment package to avoid the splitting that commonly exists between education and mental health services.

There is an [[Educational-Vocational Engagement Phase Flowchart]].
!SECTION A
''Preliminary information gathering and arrangements for attendance:''
!!!If young person is School Age (<16yrs):
(a) ''If attending school'':
Gather information from the YP and/or their family about their current education situation:
##Which school? Address? Phone number? Email address?
##What year?
##Name of tutor/head of year/SENCO?
##Position in relation to public examinations?
##Status of any course work/ deadlines missed or pending?
(b) ''If not attending school'':
##Who in the education service is, or should be, responsible for their education provision? 
##Education Welfare Officer? 
##Educational Psychologist involved? 
##Learning mentor?
##Extend information by contacting relevant education professionals in the young person's school or college. Potentially the tutor, head of year, or SENCO (Special Educational Needs Cooordinator), in the first instance.
##Education history from records and teacher knowledge.
##Any Statement of Special Educational Needs? 
###Current? 
###In the past? 
###Being applied for? 
##Academic performance? 
###Any pattern of deterioration?
##Knowledge about family circumstances? Any significant events/crises?
##Siblings/relatives in school?
##Peer group relationships? Friendship group? Isolation? History and any recent changes? Bullying? Drugs? 
##Relationships with teaching staff?
##Relationships with ancillary staff? 
##Public examination status? 
##Course work situation, deadlines missed or pending?
##Other professionals or agencies known to be involved?
(d) ''School-age but not currently attending school:''
Information can be gathered from main school teachers, particularly the SENCO, as well as from Education Welfare Officers, Educational Psychologists, Learning Mentors or Connexions Personal Advisors (responsible for working with 13 to 19 year olds).
##How long out of school? 
##Any legal action current or being contemplated?
## attempts to reengage YP in school? Who involved? What happened? Family participation/support?
##Current alternative education provision or attempt at provision?
##Other professionals or agencies known to be involved? Social Services, G.P.?
##Is there information about any previous exclusions and reports written for school governors?
!!!If above School Age:
##What educational level achieved? 
###Exam results
###Basic literacy/numeracy skills
##Current employment status?
##Vocational Schemes, training, higher educational training?
##Aspirations regarding career and further educational opportunities?
!Engagement
Negotiation will need to take place between the KeyWorker and the young person, to get to (or be brought to) the Education/Vocational Centre.  
##See [[Motivational Work]]
##See [[Engagement techniques]] for further detail.
##If the initial information gathering/liaison exercise turns up a significant professional or family member for the young person, they may be persuaded to accompany the young person on the first one or two occasions to the Education/Vocational Centre.
!SECTION B
''Key tasks and activities during first two weeks of actual attendance.'' - see an [[Example timetable during engagement phase]]
(a) ''Educational Assessment''
Educational tasks and activities to be given to the young person during teaching sessions to complement information already obtained from teachers and other education professionals. Because of individual or small group context the information gained will be both current and potentially more detailed than may have been available before.
National Curriculum levels in Literacy and Numeracy could be obtained, as well as getting a basic Reading Age.
A whole range of educational or psychometric tests could be used as deemed necessary for more detailed assessment profile.
(b) ''Social Assessment''
This is carried out by observing the YP in a range of contexts and activities in the education centre.
**Relationship with peers - observed in formal, semi-structured and informal contexts.
**Formal - observation of relationships in small group tightly structured teaching situations
**Semi-structured - observation in less formal activities drama, art, cooking etc.
**Informal - observation in breaks and free time around the education centre.
**Relationships with authority figures - observations made in similar contexts to above and in addition, during one-to-one conversations.
**Relationship to learning - observations made in teaching situations.
It is important to note that much information that will contribute to both the educational and social assessment will be derived from the "routine" teaching context. Everything that the young person does during this assessment phase shouldn't look only like assessment.
(c) ''Family Assessment'' 
As appropriate, relevant family members will be encouraged to participate in elements of the education programme. This will provide opportunities to observe relationships between the young person and their family in a range of contexts not normally available either on home visits or in mainly structured family interviews. The contexts will be based on both individual family as well as multi family activities. The information obtained will be additional to that gained in regular family interviews.
(d) ''Individual Assessment''
The young person will be withdrawn from the education programme group for individual interviews as necessary.

A lively conversation, sharing knowledge of AMBIT-influenced ways to engage with young people:

*Sharing a bit of ''me''. Purposeful self-disclosure. Balancing risk.
*Engaging young people "where they're at"
**physically - meeting in a place that is right for the young person - McDonalds and parks vs clinics and offices. Perhaps with a plan to gradually transition to a more conventional clinical or helping space.
**Psychologically - "Getting it"
*Finding ways to "step out of chaos", to reduce affect: 
**activity (e.g. talking whilst playing pool)
**speaking in the car (reduced expectation of eye contact)
*Language that encourages mentalizing, e.g. "I'm interested to hear..."
*Language to share - tentatively - our own thoughts (see [[Broadcasting Intentions]]) e.g. "I guess my perspective is.... what's yours?"
*Importance of worker being "thick skinned"
**After further discussion it was considered that what was being referred to here was a maintenance of mentalizing capacity in the worker - in the sense of the worker being able to remain curious about the mental states underlying what might feel like difficult behaviours in a young person, not taking this behaviour "personally".
 

Unconferencers concluded that there were several strategies here which are rather different to traditional therapy or helping, and coined the term "Untherapy" to describe this!

As AMBIT is a constantly developing model, we are always interested in new research possibilities, and our emphasis on [[Respect for Evidence]] means that we encourage [[Evaluating outcomes]] and would be keen to pool results fro across teams. 

We are currently (2019) running an AMBIT Evaluation Project, which is a pilot project aimed at helping AMBIT influenced teams measure the outcomes of their client work using the AIM form (AMBIT Integrative Measure); a multi-dimensional measure of a client’s current state. 

Please contact [[ambit@annafreud.org|mailto:ambit@annafreud.org]] if you are interested in taking part or with your research suggestions, so that we can see how this project could fit into our current ongoing research projects.

!!No!

AMBIT is a team approach, therefore the training is only available to teams and not individuals. As an individual, you may be interested [[in other short courses|https://www.annafreud.org/training/]] that the Anna Freud National Centre for Children and Families runs. 

To find out more please contact [[Amy Rozwod|mailto:amy.rozwod@annafreud.org]].

AMBIT is a developing model of practice, and as such the evidence-base for its effectiveness is far from robust, even though early signs are encouraging. 

For more information, see manual pages on:

*[[Evidence]]
*[[Is AMBIT evidence based?]]
*[[Academic references]] 

We see attending conferences to speak about AMBIT, as a good way to advertise the approach to others, therefore we may be able to provide speakers, and we don’t aim to make a profit from such events. However, we do need to cover our costs so usually charge the raw cost of the speaker’s time, plus any travel and accommodation costs involved. 

Please contact [[Amy Rozwod|mailto:amy.rozwod@annafreud.org]] with speaker requests.

Although the AMBIT course was originally created for teams working with complex adolescents, it has now broadened to teams working with complex cases in general - and we have trained those working with families, early years, and young adults as well as adolescents. The material on the manual is sometimes more geared towards working with adolescents, however, the idea of the manual is for it to be customised by local teams so that the material works for their own client population.

AMBIT is really a set of Core Principles (the [[Core Features of AMBIT]]) which, integrated via the theory of [[Mentalization]] and other major [[theories|Theory]], offers a platform for local teams to develop evidence-based, or at least evidence-oriented practice.

We have a pricing structure that is designed to keep prices to an absolute minimum, as we know that access to training budgets for whole teams is imited.  The pricing structure does get updated fairly regularly - not least because we are constantly updating and adapting the ways that we deliver training to get maximum value for money, so please check with [[ambit@annafreud.org|mailto:ambit@annafreud.org]] for the most up to date pricing structure.


If you are part of a large team and it is too costly to send the whole team to a training, then our  [[Local Facilitator Training|Local Facilitator Training (LFT)- training model]] details of which can be found on the [[AFNCCF website|https://www.annafreud.org/training/training-and-conferences-overview/training-at-the-anna-freud-national-centre-for-children-and-families/ambit-local-facilitator-training-previously-known-as-ambit-train-the-trainer/]]. 

We are happy to consider top up training requests, but would also like to think with you about whether the AMBIT Leads from your service could assist in the delivery of top up trainings.  

An example curriculum is provided here [[Follow-up training for established teams]] but this is highly adaptable to suit the needs of the team.

We are very keen to encourage conversations between teams, as AMBIT seeks to promote and support a vital [[Community of Practice]] - so we encourage relations between teams to continue once training has been completed. The AMBIT manual is just one of the ways that we encourage teams to share their local knowledge and practice with each other.

Contact the AMBIT project officer, [[Amy Rozwod|mailto:Amy.Rozwod@annafreud.org]] who will contact a team similar to yours to see if they would be happy for their contact details to be passed on. 

!Intervention
As the educational assessment becomes completed there is an increased capacity to tailor the academic/vocational element of the programme more specifically to meet the needs of the young person. 

There is an [[Education-Vocation Intervention phase - Example timetable and Flowchart]].

This may involve more public exam work or support for course work. Alternatively, it may become clear that more sophisticated teaching delivery is required in relation to a YP's specific learning difficulty. This may entail intensive literacy or numeracy input.

Equally, as the social assessment information becomes available, the individual and family targets and objectives will become clearer and the programme can be adjusted accordingly.

The basic structure of the sample timetable above will remain the same but with an increasing emphasis on making the necessary connections with the young person's future placement after leaving the Education/Vocational Centre. This may involve meetings with the school, further education college or work experience placement professionals. The Connexions Personal Advisers will be particularly useful in helping to facilitate this transition as they have the responsibility for working with young people to help them negotiate any of these moves.

The young person should reduce attendance at the Education/Vocational Centre to 3 sessions per week at some stage during the second phase. This is to support their reintegration back to school or their transition into college or work experience placement whilst they are still part of the Education/Vocational Centre programme and available to get the most support from it.

An unconferencer posed the challenging question "Do you mentalize at home?". This led to a conversation about the extent to which is it possible to sign up to ideas about the importance and helpfulness of efforts to maintain a mentalizing stance in one's work but not carry forward this philosophy in to one's personal life. This thinking about personal self opened up conversations about mentalizing that were rather different to those we often have. Participants shared their experiences of failures of mentalizing in conflict with loved ones, and of how the emotions involved in intimate relationships make inevitable such failures. The idea was put forward that a couple that does not ever argue might be in [[Pretend mode]], in failing to acknowledge and address differences and difficulties. There was acknowledgement of how much more //comfortable// non-mentalizing positions can be at times, leading us to avoid mentalized positions even when we have become aware that is likely that we are in a non-mentalizing frame of mind:
*Sometimes we just want to be RIGHT, so certainty, or [[Psychic equivalence]] is the ideal position
*Sometimes we don't want to acknowledge things: [[Pretend mode]] works nicely
*Sometimes [[Teleological thinking]] is easiest and quickest (at least in the short term!)

The group thought about biological, neurodevelopmental and social factors impacting states of mind in adolescents:

*Neurodevelopment - mentalizing capacity is fragile, fight or flight is strong
*Importance of transition: am I an adult yet? does this society view me as an adult? Loss of childhood? Mismatch between expectations and responsibilities and level of freedom/agency - mixed messages given
*Tendency to view young people as //bad// not //sad//
*Development of sexuality and implicit message that this is bad
*Uncertainty around multiple changes occurring, changing expectations
*Importance of understanding individual differences
*Difficulties and differences in help seeking and response to offers of "help"
*Do all adult workers understand these issues?
*Exams, decisions, stress!

!Background to Referring Crisis
Sixteen year old Darren was referred to the team by his family and friends, who had become extremely anxious and frightened by his abnormal behaviour during the past six hours. 

He was a member of the local youth theatre and was performing in a production they were putting on at a local theatre. He had turned up for the show late and clearly under the influence of cannabis and alcohol. He was in an agitated state but insisted that he was all right to go on. Very quickly it became clear that he was not fit to continue as he was standing on the stage staring blankly around him disrupting the whole performance. He resisted attempts to persuade him to leave and had to be physically carried off. He did not calm down and had to be restrained when he started to bang his head repeatedly against the dressing room wall. He said he could hear voices telling him to kill himself. His family was called but neither his mother nor father was willing to come. However, his younger brother turned up to take him home. It took the two youth theatre leaders, one of Darren's friends and his brother to chaperone him back to his house. When his condition continued to deteriorate into the night the KW was called.
 
Because Darren was so agitated and a danger to himself and threatening violence particularly to his brother, in consultation with the psychiatrist the Keyworker decided to medicate him.
!Education Liaison - 
During the next three days whilst the KW was doing intense work with Darren and his family in the home, the Education/Vocational Centre teacher/therapist contacted the SENCO of his school. She found out that Darren had a long history of disaffection and truancy since his transfer from primary school. However when he was at school he had been very good at drama and music and was said to be a talented drummer. He had poor relationships with most of the school staff but was well liked by one drama teacher who had encouraged him to join the youth theatre. He was in the middle of his GCSE final year but was way behind in virtually all of his course work and was in danger of not being entered for any of his exams. He was said to have no real friends at school and was described as a loner and a bit of an "oddball". In contrast, the SENCO said that Darren's younger brother was a high achiever, sporty and popular. The SENCO had only met Darren's mother but had been alarmed by her highly critical manner of talking about him.

On the fourth day, the KW felt confident enough that Darren's condition had stabilised sufficiently for him to be brought to the Education/Vocational Centre.

!Education/Vocational Centre Attendance: Phase One
(See [[1. Educational-Vocational Engagement and Assessment]])
During the first two-week assessment period the following key observations were gathered:
*Educational Assessment
Darren was initially very reluctant to participate in any areas of the educational programme. However once he did start to engage it was possible to carry out a reading test which showed that he had a reading age of 9.5. This clearly showed why he would have difficulties accessing the secondary school curriculum. Further testing showed that he had some word recognition difficulties consistent with a mild form of dyslexia. His numeracy skills were average for his age. He talked about his liking for drama but mainly focused on his ambition to be a professional drummer.
*Social Assessment
At first he would only stay in the Education/Vocational Centre if the KW promised to stay with him. He would not join in any activities at all for the first three days but stayed on the fringes covertly observing what was going on. He was surly but not aggressive in his manner towards the staff. He kept his hood up during this phase.
In the break periods he was gradually encouraged to talk by one of the other young people in the group. After day four he slowly started to participate in the education programme. Once his hood came down it became increasingly easy to sustain a conversation with him for short periods.

He could not be taught in a group with anyone else because he would "wind up" others to the point that violence would either happen or be threatened.
After initial reluctance he would agree to be taught one-to-one and would be relatively co-operative. He would quickly become discouraged if he could not be successful with a piece of work straight away and would frequently tear something up if it was less than perfect in his eyes.
*Family Assessment 
The KW persuaded Darren's mother to attend some of the multi family group meetings. She was consistently critical of him and blamed him for all the trouble that he had caused the family. Darren became totally withdrawn and silent during these meetings. His younger brother came to one meeting. He was also critical of Darren and complained about how embarrassed he felt about having an older brother who showed him up at school.
In the individual family meetings which were attended by all the family including Darren's father, it appeared that Darren's breakdown or illness had had the effect of bringing together what had formerly been a fairly disconnected family. Harshness, criticism and mutual blame characterised the family communication patterns.
*Individual Assessment
Darren engaged well with his individual therapy and talked about his feelings of being a failure and about his anger towards everybody in his family. He said that he had felt suicidal in the past but currently had no such thoughts. He said that he wanted to get his life together and make a career for himself as a drummer.
!Education/Vocational Centre Attendance: Phase Two
(See [[2. Educational-Vocational Intervention and Transition]])

A literacy programme was devised to specifically help Darren with his reading difficulties.

Through connections with the school SENCO curriculum relevant to his GCSE subjects was brought to the Education/Vocational Centre for Darren to do. He was helped to organise himself so that he would be able to take four of the GCSEs that it was still possible for him to enter. The SENCO also arranged for him to slowly reintegrate into the school first of all via the drama lessons but with a plan to increase as his confidence and self esteem improved.

In the [[MultiFamilyWork]] meetings other members of the group started to challenge Darren's mother about the amount of criticism that she aimed in his direction. She began to talk about her feelings of guilt and frustration and how she had felt unable to help Darren. She had always known he had more problems with his schoolwork than his brother but hadn't been able to get anybody to offer any help.
 
She and Darren created targets for each other; significantly, she would try to be less critical and he would try to stop winding up his brother.

In YP group meetings the others in the programme were able to see behind Darren's "loner presentation" and were able to help him to face up to his avoidance behaviour as well as supporting him in his feelings of anger about his family's lack of understanding and support.

Peer group relationships around the Education/Vocational Centre improved significantly as Darren reduced his winding up behaviour towards others.

The family meetings also focused on the negative ways that everybody related to each other. Cross-generational patterns were relevant for both Darren's mother and father. Strains in the marital relationship were discussed in separate couple sessions. Darren and his brother were able to resolve some of their jealousies and rivalries to a limited extent.

In his individual sessions Darren switched between more pragmatic work in relation to his fears about drug and alcohol misuse and deeper issues related to his feelings of hopelessness and inadequacy.

Through links with the youth theatre leaders, Darren was encouraged to take up drumming lessons with a local musician.

At the end of the three months he had returned to school part time, was not misusing alcohol or cannabis and reported that he had not heard any voices since soon after the initial crisis.

A conversation about AMBIT-influenced approaches to working with young people who offend. Some keys thoughts emerging from this conversation:

*Remembering to "peel the banana" - What you see (the offending behaviour) is just the skin but what's underneath?
**how did young person get into this situation? What created the context where this behaviour made sense?
***remembering importance of trauma
**offender as victim
**grooming
**repeating experiences of being "let down" - a cycle: feeling let down -> offending -> response to offending -> feeling let down
*Encouraging young people to mz the victim? But, //first//, self
*mentalizing and gangs
**gangs as anxiety-infused systems
**risk of "us and them" thinking leading to dis-integration
**identifying the key figures in the system with whom to hold [[Connecting Conversations]]
**systemic interventions, helping gangs to make sense of - and navigate - helping services
**good ability to develop epistemic trust

Participants offered some favourite definitions of mentalizing:
*Seeing situations from another person's perspective
*understanding BEHAVIOUR - and the function of it - that of others and of ourselves
*seeing life through someone else's eyes - in order to understand behaviour

Then, participants shared some language they use to promote mentalizing in others:
*"What might it be like for your mum seeing you like this?"
*"If you were a fly on the wall/an alien/an outsider what you think/say about this?"
*Mirroring
*Modelling mentalizing - sharing our thoughts, sharing the experiences of others, pair work (modelling mentalizing conversations in the room), canine work

Thoughts on how to create the conditions for a young person to get their mentalizing going:
*change environment
*Wait until affect lowered before attempting. Time out. Choose your moments - you might want to have the conversation now, but it is going to be better in the long run to wait until a time when the young person is in a mental state 
*Change subject - to lower affect (have a contract in advance about managing this. Agreement about use of humour)
*sensitive attunement - giving the experience of being mentalized -> epistemic trust

!What's here, and what's elsewhere?
!!!This page covers:

* 1. Creating new pages
* 2. Editing existing content
* 3. Adding tags 
* 4. Adding links
* 5. Sharing your work

!!!Elsewhere:

* For a more ''basic guide'' see the [[User Guide]].
* For ''more detailed information'' about using the wiki-manuals that the [[Anna Freud National Centre for Children and Families]] use, including navigation and more complicated editing tasks (adding videos, recorded sound, formatting text to create headings, italics, bullet pint lists, etc, etc, etc), see the separate [[GUIDE FOR ANNA FREUD MANUALS|https://manuals.annafreud.org/guide/]].  

!!Help:
If you get into any difficulties with the manual or just have a question about the manual, or can give us feedback (we LOVE feedback positive or negative) please contact ambit@annafreud.org

!!''1. Creating a New Page''
 Once you are logged in, create a new page by clicking the + sign to the right of the homepage.  The new page will open in its 'editing view', with boxes where you can add text for the ''title'' (by default it is titled "New Tiddler" because in this software pages are known as "Tiddlers"... don't ask!), [[Tags]], and ''content'' (which can be simple text, or can include pictures, videos, sound recordings):

[img[AddNewPagePic.jpg]]                                                                


!!''2. Edit an Existing Page''
Find the page you wish to edit, click the //‘pen icon’// and the page will open in the same format as when you create a new page. 

[img[Edit 2.JPG]]
 

!!''3. Adding Tags''
[img[Edit 4.JPG]]

!!''4. Adding Links''
When editing or creating a new page, highlight a word or phrase that you wish to link, then click the ‘//link icon//’ (chain link) and search for the topic/page you wish to link this to. When selected, this will create a link from the chosen word or phrase to the relevant page.

[img[Edit 5.JPG]]

!! 5. Sharing your work (or any interesting content) with colleagues
{{ht.JPG}}

Create an instant address link ("URL") that you can email or text to colleagues - that will open a copy of the manual with specific chosen page(s) pre-opened.

* Get the page(s) you want to share opened in your manual.
* Use the crazy looking hashtag just above the search engine to copy the URL of all the current pages you have open to your clipboard.
{{URL.JPG}}
* Open your text or email programme, and 'paste' the URL address in, press send and share the link with your colleagues.
* This function means that you can direct your colleagues to specific pages, so if you wanted to share the page that was created at the last team meeting for everyone to review, or something that came up in supervision , etc, you can link them directly to that single page.
* ''This function effectively turns the whole manual into a big filing cabinet of individual shareable worksheets!''


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!!!Useful Links
* ''Basic guide'' to navigating/usage - [[User Guide]]
* ''More detailed guide'' (external link) for more detailed editing tips (formatting text, adding videos, pictures, PDFs, sound, etc): [[Anna Freud Manuals General Guide|https://manuals.annafreud.org/guide]])
* ''Advice to enthusiastic manualizers'' about [[Fitting what you ADD into what is ALREADY THERE in your manual]] (not reinventing too many wheels, or duplicating content)

This is a common example of a [[Training Challenge]] (a less off-putting term for 'homework') set in a [[Cognitive Behavioural]] approach.

''THE PURPOSE OF DIARY KEEPING IN CBT''
Sometimes diary keeping is carried out without being clear what the purpose of diary keeping is. As an approach CBT is concerned with trying to enable the young person to make changes in their daily life and is less focussed on changes that take place in the therapy itself. Diary keeping is a method of trying to connect the therapy sessions with real events in the young person's life. One of the ways that the young person's life is kept at a distance from the therapy is by the young person providng vague, general statements about themselves and the events of their week. For example atypical enquiry can go as follows. 'How are you?' 'Okay'. 'How has your week been? 'Okay'. 'Been out much?' 'A bit' 'Had any good days?' 'Not sure'. etc Such general evaluative statemetns are of little value in CBT. It can be similar when the statements are negative e.g 'How has your week been?' 'Shit'. The purpose of diary keeping is rarely to obtain a comprehensive picture of the whole week's events but more to locate one specific event that can then be explored in more detail as a way of getting these general statements.  

Most young people find keeping a diary record of what happens during the week very hard to do. Do not be discouraged by this but be extremely practical about how to encourage young person to begin to keep very simple records of what has happened in between sessions. 

''Start with a simple frequency diary''. This simply asks the young person to notice whether a certain thing happneded on a particular day. For example, having a row with a parent. Getting the young person to notice if this happened each day. In practice, at the following session, the young person may turn up without any record etc and you may need to go through the week asking for each day. What may be very helpful is to get interested in the days that NO ROWS took place.

Nowadays, young people can ''use mobile phones'' or other IT equipment to keep records of things. For some young people I have suggested they write a quick text message to themselves as a reminder of something that happened. There may be circumstances that it is appropriate to have an arrangement for the young person to text the therapist as a record keeping task. This can be excellent but needs to be set up with very clear task boundaries so that young people do not expect a therapist response to all such messages.  

if you have suggested a diary task, it is ''CRUCIAL'' that you are very interested in what the young person has done around this at the following session. If you minimise or forget, you model the very behaviour which you are trying to change. 

If the young person is able to do some frequency diary work, it may be possible to move on to doing more complex diary work using an ABC format (see below). This allows for a close analysis of the possible [[Reinforcement]] of particular behvaiours, and the design of new [[Contingencies]] that might help to //reduce// the reinforcement of undesired behaviours, and //increase// the reinforcement of desired behaviours. The purpose of this is twofold. Firstly, it may provide some ideas about how negative behaviours are being encouraged by their consequences. Secondly, it may help the young person to see 'patterns of interactions' rather than just being dominated by own feelings and thoughts.  

*Ask the young person to keep a diary sheet, either simply recording daily drug/alcohol consumption (or any other behaviour that is targetted, such as self-injury) or, preferably, (as it gathers more information to work with) recording ''__A, B, C__'';

!A = Antecedents
What came ''just before'' the target behaviour (e.g. smoking the joint/the aggressive outburst/etc) - //"Where were you? Who else was there? What were you thinking? What do you remember feeling?/etc."// (It is easy to see that thinking about these things is getting close to [[Mentalizing]].)


!B = Behaviours
What ''actually happened''? (e.g. smoked 1, 2, 3 joints...)


!C = Consequences
What happened ''afterwards?''  Think of short term effects (fun? paranoia? fights? Police?) and longer term effects (parental arguments, trouble at school...) - see [[Weighing Pros and Cons]] for more ideas on this.

Attention Deficit Hyperactivity Disorder

This is a neurodevelopmental disorder - the common core features of ADHD are:

*Attention problems (distractibility, difficulty staying on task)
*Impulsivity (the opposite of looking before you leap)
*Hyperactivity (high levels of physical energy and movement - "like a motor always on the go")

!Comorbidities
ADHD is associated with a wide range of other difficulties (co-morbidities), including:
* [[Conduct problems]]
* Educational under-achievement
* Disorganisation
* Low self esteem
* [[SubstanceUseDisorder]]
* Family dysfunction

In adolescence (as opposed to younger childhood) it is not uncommon that the main difficulties expienced are related less to the "core deficits" (Attention, Activity, Impulse control) and more to the "satellite problems" that arise as co-morbidities.  

!Treatment

Prescribing medication is the mainstay of treatment at earlier ages, alongside work with the family, school, and young person to help manage behaviours and associated mood problems.   Treatment may take the form of ''controlled drugs'' such as methylphenidate (a "Stimulant" drug, that seems to preferentially stimulate the frontal area of the brain, boosting the "executive" part of the brain that controls decision-making, and reduces impulsivity.  This treatment may be difficult at older ages.  This is particularly so if it is those co-morbidities that are now the main problem, and in general starting treatment late is much less effective than starting it earlier in the life course, with a view to helping establish good peer and family relations, improved school performance, and better self esteem.  

If [[SubstanceUseDisorder]] is a problem this makes use of the "stimulant" medications such as methylphenidate even more difficult, because of perceived risks of misuse of this medication (slow release preparations do reduce this risk, and there are non-stimulant alternatives, but these are still often insufficient to impact on other patterned behaviours that have begun to become ingrained.)

There are well researched and evidenced protocols for managing ADHD, in the UK these are provided in the  [[NICE ADHD Guidelines]]

[[Anna Freud National Centre for Children and Families]]

!!!''This page explains what the AIM is, and how to use it.''

{{measuring pic 2.jpg}}

!!''What is it?''
AMBIT AIM stands for ''AMBIT Adolescent Integrative Measure''.

*This is a questionnaire that has been adapted by DickonBevington and [[Peter Fuggle]] from the Hampstead Child Adaptation Measure (H-CAM), which is an assessment interview originally authored by PeterFonagy and MaryTarget.

*The AIM is a multilevel/multidimensional assessment, which attempts to gather a 'holistic picture' of a clients' level of functioning. The areas that it measures are: Daily life-function, socio-economic factors, family relationships, social relationships, mental state, clients' response to their situation, and, the complexity of the difficulties. See [[AIM items]] for a list of the 40 items and which domain they are in.

*It can be used as a measure at the beginning and end of work with clients to track how the work has gone, whether the goals set have been met, and whether things have changed in a clients' life. At a service or team level it can provide a rich source of information about the clients that have been seen, and act as a resource for teams to learn about the work they do.

*It is available for download and use within this manual here [[AIM form]].

*The AIM is recommended by the AMBIT team as a [[Multi-Domain Assessment]]. But it does not have to be used by teams who have AMBIT training

*It has been used within a large research trial called the 'IMPACT study of adolescent depression' in the UK. During this research the properties of the AIM were studied further.


''Please see here if you would like to read more detail about the [[Development and properties of the AIM|The Development and Properties of the AIM]].''

The AIM links directly to The [[AIM cards|AIM Cards]]. These are an AMBIT tool to be used together with clients as a way of assessing, building relationships and developing an understanding of the client. 

They can also be used as a measure of change with clients. The AIM cards are adapted directly from the AIM and cover the same areas.

!!''How to use the AIM Questionnaire''
 
The assessment is designed to be completed by a practitioner at an early stage in work with a client. It can be completed over a period of time (e.g. 2 weeks). It covers a number of areas of life, so it may take a little while to find out about all of these. 


There are 40 questions with numerical measures for each, ranging from 0+ (a positive strength), through 0 (no problem), and up to 4 (very severe problem).  Each item has its own descriptions of the levels of severity to help in scoring.

Each item also offers the opportunity to label it as one of a small number (say 6 or less) of [[Key Problems]], which is a helpful way to focus on the most pressing problems in a complex situation.

In this page you can find a break down of the areas covered by the AIM [[Aim: What's in the questionnaire?|AIM: What's in the questionnaire ?]]. The page shows a summary of the questions within each of the areas assessed.

''There is a protocol for using the AIM measure which is currently being developed by a group of AMBIT influenced services alongside the AMBIT team at the AFNCCF. Please see here to find out more about this approach to using the AIM at [[The AMBIT Client Impact Project|AMBIT Client Impact Project (ACIP)]]''

!!Using the AIM within this manual

*We have developed an interactive version of the AIM which can be completed within the manual (results are not saved or uploaded online but can be downloaded to your own file using 'EXPORT').

*After entering scores, this gives a 'read-out' of the assessment and then links the results with suggested interventions based on the best evidence available.  [[AIM suggested interventions]], 

!!!This function is currently under development and is not available to use at this moment. Please return here for updates on this function.

The below video describes this interactive function which is currently under development.

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To read further ideas about carrying out an assessment across multiple areas of a clients' life please see [[Multi-Domain Assessment]]. 

This can be used as a guide to your assessment to make sure that the areas are covered.

Below is the AIM form paper version, which you can download from the manual. Please [[Contact us]] for information on scoring. 

 [[here|https://docs.google.com/open?id=0B5h_CVBdhJPYck41Y2p5d0g0N3c]]:
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<html><iframe src="https://docs.google.com/file/d/0B5h_CVBdhJPYck41Y2p5d0g0N3c/preview" width="640" height="480"></iframe></html>

! Using the AIM cards for Active Planning



<center>{{AIM cards pic1.jpg}}</center>


The AIM cards are an example of applying the [[Active Planning]] triangle in practice.They are used to ''sensitively attune'' to the clients' perspectives, to ''broadcast our intentions'' as the worker, and to begin developing a focus or structure for work together. The AIM cards can be used as a [[ Goal Based Outcome measure|Goals-based outcome measures]] to develop and measure specific goals based on what matters most to the client.

>//This is an example of a page that has been ''cloned and customised'' from the original work by the ''AMASS team in Islington'' - to whom we are immensely grateful.//






*This video produced by the AMASS team in Islington (@ambit-amass) shows an example of how the cards can be used in a session with a client:

<html><iframe width="420" height="315" src="//www.youtube.com/embed/wG9Of1PCHPI" frameborder="0" allowfullscreen></iframe></html>

The AMASS Team have developed a framework for using the AIM cards. Their suggested steps and learning points are set out below. Here we also highlight examples of the ''active planning triangle'' with the intention of showing how active planning may look in practice. 

''Please note this framework can be adapted according to the client and service context''.

''When to use the AIM cards''

The AIM cards are usually used fairly early on in the contact with the client, as part of efforts to build a relationship. It is usually helpful that the client has met the worker at least once before using the cards. Exactly when they're used will vary according to the degree to which the worker thinks that the client would find it ok to share a bit about how things are with someone who they don't know/yet trust and the extent to which they are actively help-seeking.

It can be helpful to hold in mind that using the cards can help build [[Epistemic Trust]], if the worker takes care to reflect back what they are learning about the clients' perspective from completing the cards ''(senisitive attunement)''


Similarly, a client does not have to be actively or explicitly help-seeking in order for the cards to be used. In fact, it can be more helpful for the worker not to assume any help-seeking on the part of the client when using the cards, instead holding in mind that their first priority is to understand how life is currently from the clients' perspective ''(sensitive attunement'') 

''1. Introducing the cards''-
the worker should explain to the client what the cards are and their purpose. This is an example ''[[Broadcasting Intentions]]''.

>//I've bought some cards along that I do with lots of young people when I'm trying to get to know them. These cards have got different topics on that relate to different areas of a young person’s life//

>// I'd like to try to understand a bit how life is for you at the moment, to see if there's anything I could be helpful with - how does that sound?//


>//If you're not sure, you can take a look at the cards and then decide if you'd like me to bring them again another time - that's totally fine too
''(sensitive attunement)''//

''2. Agree how to look through the cards'' - Would they prefer to read through the cards themselves? or if they would like them to be read out by the worker? Remind them they can always ask for help with reading and can ask you questions if there are any that they are not sure about.

''Agree on how to divide up the cards - as a first step, usually 3 piles:''

*Things that are difficult/a problem

*Things that are going well/are strengths, and

*It doesn't apply to me


''3. Client sorts through the cards''-
allow the client to take the lead.
The worker should try to notice how actively the client looks to involve the worker in the process, and attune to this. The worker should hold in mind that using the cards is about understanding the clients' ideas about their life ''(sensitive attunement)'' rather than the worker seeking to influence these.  

Quite often, some extra piles can develop (i.e. sometimes a problem; not sure etc).

Pay attention to how much the client seems able to tolerate naming something as a difficulty – some people will describe thngs in a high impact way “Really hard for me”; others will only be able to acknowledge something being difficult, but with minimal impact (i.e. sometimes a problem). Either way, we consider anything that is labelled as a bit of a difficulty as something that constitutes a “problem” and we don't talk it up or down in terms of severity or frequency - go with the clients' current description ''(sensitive attunement'').

Similarly, notice how easy the client finds it to identify strengths and attune to their level of comfort with this.

Check in on how they found the process of sorting and if it would be ok for you to ask a bit more about some of the cards.

''4.Exploring the strengths pile''-
start with the strengths – explore each of these in detail. The purpose is to show interest and build a bit of an understanding about areas of life that are going well.


It can be helpful to offer some summaries back about what you feel you are learning about them, their skills, strengths and abilities as you look through this pile ''(sensitive attunment)''.

In time, it can be helpful to support the client to think about how their strengths might help with some of the areas they are finding more difficult. Time spent focusing on strengths may also help them to feel comfortable in the session and potentially more open to move onto exploring aspects of their life that might feel more difficult.

''5. Exploring the difficulties pile''-
lay out the difficulties cards on the table. Ask them if they would be ok with talking you through why they chose these cards as difficulties. If so, ask where they would like to start.

Again, attune to how much exploration the client can tolerate, so that they are not feeling pressured into talking about things that are too uncomfortable or difficult ''(sensitive attunement)''.

Comment on the process in a sensitive manner - i.e. let them know how well they are doing about thinking about something that’s difficult; notice if they are finding it hard; check if they are ok to continue.

Follow the clients' lead in terms of how much they wish to share about these cards at this stage. Using the cards can help us learn how able the client is to think about themselves and their situation and how much they feel willing/able/ready to accept some help with these matters ''(sensitive attunment).''


''6. Exploring how the cards fit together''- it can be helpful to explore whether the client feels that there are any links between the cards that they have chosen. 

Ask them to arrange the cards around to reflect this – for example, difficulties at school or with family might go together with a series of other cards.

Let the client take the lead in this. Usually, this process results in the cards being sorted into a smaller number of groups, around particular themes (e.g. how things are at home or at school or with friends, for example). The worker can ask questions to gain an understanding of why the client feels that certain cards go together, supporting them in the process of trying to make some sense of how these areas of difficulty might fit together and be influencing each other.



''7. Explore whether there is anything that the client might want help with''-
 it is important that workers do not assume that a client wants to have help (from them) just because they have identified something as an area of difficulty.

With this in mind, it can be helpful for the worker to:

Ask the client whether there are any of the difficulty cards that they would like to see looking a bit different. Are there any areas that they would make a change to if they could? If they identify some, check in about whether its something that they think you could be useful for by meeting together. Which cards would be their priority to focus on (usually 2-4 cards is realistic).

Here is a point where we may ''broadcast intentions''

>// I’d really like to be helpful if I can, so if there were any of the cards here that you feel you would like some help with, then I would be happy to try to help if I can//

Attune to the degree to which the client seems comfortable with the idea of being in need – it may be more appropriate to position them as the expert.

>// You’ve got a lot of strengths/things you’re good at; maybe we can figure out a way that those could help with the things that are feeling more tricky at the moment//

''8.Contract what help might look like and where to start''-
think with the client about how to turn these cards into goals, decide which they would like to start with and think about how you might begin to work on these cards together ''(making a plan!)''.

!!Using AIM cards to measure outcomes:



*The client can rate the severity of the problem indicated on the card (or cards) that they feel are most important to change or to focus on. They are able to rate how much this affects them at the moment, using the numbers on the cards. This can then be used as a [[Goals-based outcome measure|Goals-based outcome measures]] and tracked over the course of the work together. This is a helpful way of checking 'how are things now?' in relation to what matters most to the client in comparison with the beginning of the work together.  If the clients' rating is not changing, or getting worse this is also really important, as it can open conversations about why this might be, what might need to change for the ratings to move from x to x. Ratings can be plotted on a graph showing progress or change over time. This can also be shared and reflected on with the client. 

*At the end of the intervention the AIM card session can be repeated and the ratings of the chosen cards can be compared from the pre-intervention AIM card session. 







 

Change this number below (keep "limit:") to alter the allowed maximum number of selected Key Problems on the AIM form.

limit:6

!!Purpose 
The purpose of this page is to provide you with an overview of the 40 items of the [[AIM form]] with their corresponding subscales.

!!Subscales
!!!Young person daily life

1. Social Activities

2. Attendance at Education, Employment or Training

3.  Attainment in Education, Employment or Training

4. Other talents or abilities 

5. Physical Health Condition

6. Self Care

7. Physical Impairment or Disability

8. Social Development

9. Social Skills and Interaction



!!!Socio-Economic
10. Provision of Stable Housing

11. Income and Provision of Material Resources

!!!Family 
12. Relationships

13. Conflict with Young Person

14. Parental Disapline

!!!Social 

15. Supportive adult relationship outside the family

16. Peer friendships

17. Prosocial and antisocial peer group

!!!Mental State 

18. Cognitive Ability

19. Anxiety

20. Obsessional Ideas and Complusive Behaviour

21. Post-traumatic intrusive experience

22. Attention and Concertration

23. Irritability

24. Sleep Disturbance

25. Depression

26. Deliberate Self-harm

27. Eating problems

28. Substance misuse	

29. Suicidaility

30. Defiance

31. Destruction of property

32. Physical harm to others

33. Problematic sexual behaviour

34. Psychotic experiences

35. Elated mood

36. Mentalizing capacity

!!!Response to situation 
37. Insight

38. Engagement with treatment and care

!!!Measure of Complexity
39. Chronicity

40. Pervasivness 

!Introduction
Many of the young people AMBIT is designed for have high levels of [[Complexity]] and [[Comorbidities]].  It can be difficult to decide [[which intervention|WhichInterventionWhen]] to use, when, and the AMBIT [[AIM]] assessment can help you in this task by analysing your results and generating suggested interventions in the form of ranked lists, which provide direct [[Links]] to the manualized interventions.

!How does it work?

At the end of the [[AIM form]] you will see a final page titled ''AIM Results''.  At the bottom of that page you will see the ''Suggested Interventions'' section.

The AIM questionnaire collects the severity scores you have entered across the 40 items in the questionnaire for your client, and then uses quite simple algorithms to rank potentially useful (evidence-based) interventions for the problems you have identified with your client.  These algorithms are explained below.

The fact that //''different lists''// of suggested interventions are generated is in itself designed to communicate to the KeyWorker that, because the lives and difficulties of young people we work with a generally marked by COMPLEXITY, ''there is NOT a simple mechanical relationship between "problem //a//" and "intervention //x//"''

Thus the KeyWorker is encouraged to use these lists as an additional layer of 'mentalized' oversight on a case; one that offers a more or less objective //perspective// on the options open to him or her, or to discuss them in [[supervision|SupervisoryStructures]]  The lists should be used to monitor whether or not what is being delivered is broadly in line with other thinking, and to stimulate questions if there is wide variance between what is suggested and what is actually being offered:

>''//"Am I offering my 'favourite' interventions, rather than the ones most suited to the needs of this person at this time and place?"//''  

See also WhichInterventionWhen for other advice on how to sequence what to do, or [[I'm stuck: what next?]] if you are at a more general impasse.

!How does it rank interventions?

In order to make it quite clear that this is not a "check-box" exercise, and that there must be flexibility for the worker in deciding what to do, there are different ways to sort these suggestions, depending on whether you want to look at addressing the whole spread of a young person's difficulties (''GLOBAL ranking''), or to focus on the most severe ones first (''FOCAL ranking''), and whether you want to limit your attention just to the [[KeyProblems]]. 

* ''GLOBAL RANKING'' - each suggested intervention is ranked according to //how many different problems// (that is, AIM items scoring greater than 2) the young person has //which that particular intervention has evidence for being effective in treating//. This is good for selecting interventions that will COVER THE WIDER SET OF PROBLEMS AND THEIR CAUSES, in particular for finding approaches that might address some of the [[Comorbidities]] that frequently act as //maintaining factors// for the young person's difficulties.

* ''FOCAL RANKING'' - each suggested intervention is ranked in order of how SEVERE the set of problems it has evidence for being effective in treating are (their averaged AIM scores). This is good for FOCUSING THE MOST EFFECTIVE INTERVENTIONS ON HELPING WITH THE MOST SEVERE PROBLEMS.

* ''LIMIT'', as the title suggests, this limits the suggested interventions that are ranked in both of the above sorting algorithms //only to those relevant for items identified as KEY PROBLEMS//.

!Purpose of this page

!!!This is a quick reference page for those wanting to see at a glance what is covered in the AIM measure. It shows the separate categories or 'domains' measured by the AIM. It  then shows each of the items (questions) that fit within each of the categories.

''There are 7 categories measured by the AIM. Some have more items in them than others.''

!!!The categories are shown in bold below and the questions are numbered as they appear in the AIM questionnaire:

!! Daily life
*1.Social Activities
*2.Attendance at Education/Employment or Training
*3.Attainment in Education/Employment or Training
*4.Other Talents and Abilities
*5.Physical Health Condition
*6.Self-Care
*7.Physical Impairment or Disability
*8.Social Development
*9.Social Skills and Interaction
!!Socio-Economic
*10.Provision of stable housing
*11.Income and Provision of Material Resource
!!Family
*12.Relationships
*13.Conflict with Young Person
*14.Discipline
!!Social
*15 Supportive Adult Relationships Outside the Family
*16.Peer Friendships
*17.Pro-social and Anti-Social Peer Group
!!Mental State
*18.Cognitive Ability
*19.Anxiety
*20. Obsessional Ideas and Compulsive Behaviour
*21.Post Traumatic Intrusive Experiences
*22.Attention and Concentration
*23. Irritability
*24.Sleep Disturbance
*25.Depression
*26.Deliberate Self-Harm
*27.Eating Problems
*28.Substance Misuse
*29. Suicidality
*30. Defiance
*31.Destruction of Property
*32.Physical Harm to Others
*33.Problematic Sexual Behaviour
*34.Psychotic Experiences
*35.Elated Mood
*36.Mentalizing Capacity
!!Response to Situation
*37.Insight
*38. Engagement with Treatment
!!Measure of Complexity
*39.Chronicity
*40.Pervasiveness

= [[AMBIT Local Facilitators]]

----
!!''What does AMBIT mean?''

*''__AMBIT__''  ///ˈæmbɪt/// 

**''Noun.''

***a. Scope or extent

***b. Limits, boundary, or circumference

***c. ''A sphere of action, expression, or influence''</center>
*''__Etymology:__'' 
**16th Century: from Latin //ambitus// a going round, from //ambīre// to go round, from //ambi-// + //īre// to go 

!!''AMBIT as a way of working?''
The word AMBIT itself is preferred as opposed to its use as an acronym A.M.B.I.T. (''@@color(red):A@@daptive @@color(red):M@@entalization-@@color(red):B@@ased @@color(red):I@@ntegrative @@color(red):T@@reatment'')

!!''From A.M.B.I.T. to AMBIT to //"ambit-"//''
Best of all, refer to ''ambit-'': this is the prefix that starts the address to the many local versions of the online wiki [[manuals|Manualization]].  There is little of ambit- without the //local expertise// that adopts, adapts and helps itself to shape the onwards development through its own contribution of outcomes from the work.

!!''Introductory material on AMBIT:''
1. See [[AMBIT: an overview]], or learn about [[Mentalization]] and how this can act as an [[Integrative]] framework for work in a multi-modal, multi-agency context. 

2. [[Core Features of AMBIT]] goes into more detail

3. The [[AMBIT Wheel]] provides a good reminder.

!!''Past versions...'' 
As this model of practice has developed over the past years it has been through various name changes - since 2001 it has been known as both [[IMP]] and [[M-BIO]], and originally AMBIT stood for ''Adolescent'' Mentalization Based Integrative Treatment, rather than ''Adaptive'', which was adopted when significant numbers of teams began working with clients outside the originally targeted adolescent age range.

Part 1:
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Part 2:
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We also employ a pool of AMBIT Assistant Trainers, each of whom is experienced in working in, leading, or commissioning  an [[AMBIT-influenced]] team or organisation.

We'd love to hear from you if you are interested in becoming an AMBIT Assistant Trainer. Send us an [[email|mailto:ambit@annafreud.org]]

!!Introduction 
This is the basic five day training - which consists of four days of training, and one //self-organised// practice day that is held locally.  The [[Anna Freud National Centre for Children and Families]] provides [[AMBIT training|Information About AMBIT Training]] for //whole teams rather than individuals//. See [[Training Testimonials]].

There are also <<tag [[Modified training plans]]>> for training trainers, etc.

See here for a [[Guidance for Teams Considering Applying for Training]]. 

We encourage ''as many people in a team as possible to attend the training days'' as this helps to create the local team culture that AMBIT is trying to support local teams to create for themselves. 

|!Stage 1.0|!The five-step [[AMBIT Training Application Process]], taking note of the [[Guidance for Teams Considering Applying for Training]]:|
|1.1 |Expression of interest|
|1.2 |Engagement meeting|
|1.3 |[[Pre-training team audit]]|
|1.4 |Application review|
|1.5 |''Acceptance''. Upon successful application (Stage 1), teams are invited to join:|
|!''Stage 2.0'' |![[AMBIT Basic Five Day Training]], developed to enable teams to get started with using an AMBIT-influenced approach.|
|2.1 |AMBIT Basic Training Day 1 - basic curriculum, whole team, external trainers |
|2.2 |AMBIT Basic Training Day 2 - basic curriculum, whole team, external trainers |
|2.3 |AMBIT Basic Training Day 3 (AMBIT Leads) - smaller group working with trainers for a subgroup of "ambiteers" who will act as [[AMBIT Lead]]s; the core of the [[Implementation Team]]. |
|2.4 |AMBIT Basic Training Day 4 (Local Practice Day) - Local learning/goalsetting, whole team (''LOCAL EVENT: no external trainers'') |
|2.5 |AMBIT Basic Training Day 5 (Review and Consultation) - onwards learning, whole team . Ideally 2 - 3 months after initial days' training - creating a coherent local [[Implementation Plan]]. |
|''Other'' |There are a number of <<tag [[Modified training plans]]>> for specific circumstances, and adaptation is "part of the model". |

!AMBIT Client Impact Project (ACIP) 

!!!!Source: Peter Fuggle


!!Introduction 
ACIP is a project being carried through a collaboration out between teams influenced by the AMBIT model.

Outcomes can be measured in a diverse number of ways, depending on whether the focus is the client, the worker, the team, the network and the service.  There is no single way of measuring outcomes in AMBIT. The basic stance is curiosity about whether the work is proving helpful to the client, worker, team or network. 

Outcomes work for AMBIT has been hugely influenced by outcomes work in other projects at the AFNCCF where principles of low burden and simplicity have been demonstrated to be critical to successful implementation.  

AMBIT encourages local diversification according to service and client needs so that any approach that is intended to be used as part of the core model needs to be able to accommodate to local variation so that additional ways of evaluating outcomes can be bolted on to this core framework. 
 
The criteria for being part of the collaboration is that the participating team has been trained in AMBIT and that they are willing to explore the value and benefit of this shared approach to outcome monitoring by testing the suggested framework in their service.   

!!Purpose of the project 

The primary aim of the project is to:

*Develop a low burden, simple outcomes system that could be used in multiple contexts to evaluate whether clients of AMBIT teams improve in life functioning during their contact with the service. 
The secondary aims of the project are to: 

*find out whether it is feasible to obtain outcomes from a variety of teams using a shared outcomes approach so that outcome data can be accumulated across multiple settings.
 
*develop a method that might become a routine component of the AMBIT approach. 

!!Stages of Project 
*Consult with academic and AMBIT community. This involved holding a study day in 2019 attended by teams from across the world to consider the problem of outcome measurement. This resulted in the setting up of[[ the AMBIT Study Group |The AMBIT Study Group]]which has begun in 2020.
*Complete data analysis on CASUS data. A substantial series of outcome data from the CASUS team has been used to explore ways of assessing outcome for an AMBIT trained team.  This work is nearing completion and will be submitted for publication in 2020. 
*Design of low burden outcomes framework The analysis of the CASUS data has provided an invaluable opportunity to test different outcome methods and the need to pay attention to important details of any agreed method. The conclusion of this preliminary work is to propose the following core method of evaluating impact of AMBIT trained teams on client functioning. 

The core components of this are: 

*''A single measure''. The approach involves the use of one measure, the AMBIT Integrative Measure ([[AIM]]). This involves 40 item ratings.  
*''Two time points''. The measure is completed by the worker on two time points. Time Point 1 is near the beginning of the work with the young person. Usually this will be after the worker has had a couple of contacts with the client. The exact details of this will vary for each team. Time Point 2 is when the active work with the client comes to an end. Some teams may have follow up arrangements but the intention is that the second time point is when active help has been concluded. 
*''The informant''. For this project, the AIM is completed by the allocated worker. It is completed from the worker’s perspective. As a mentalization based approach it is important to be clear about this. It is not completed as if the worker is imagining what the client might say. This is consistent with the process of Active Planning where their intention is to explicitly contrast the perspective of the worker with the perspective of the client. The use of the AIM here could be part of the workers understanding of the client that is shared with the client as part of active planning.  
*	''Relationship of outcome monitoring and mentalization based practice''. In the discussions about developing this method, there has been a lot of discussion about how outcome measures interface with therapeutic work in which the perspective of the client is central to the helping process. The use of a worker rated AIM is not intended to undermine this central tenet of practice. 

Many teams may wish to amplify this basic measure by also exploring the clients understanding of the issues raised in the AIM by:

*Use of the AIM cards with the client as a method of obtaining a client perspective on the AIM items. 
*Exploring key problems from young person’s perspective and contrasting these with perceived key problems by the worker. 

For this project, the intention is not to try to develop a ‘true’ rating for the AIM by engaging the client but to retain a clear understanding that this is based on the workers understanding. We recognise that there are many complexities to this as ratings by the worker will be influenced by how well the worker knows the client. In our wider experience of outcomes work, it is often a major mistake if an outcomes framework tries to capture such complexities as it leads to method that is potentially more sensitive but undeliverable as a core outcome method. 

!!AIM Scores. 

The AIM produces three levels of scores to be considered about a case or the work of a team as whole; a total score, seven domain scores and 40 item scores. 

For a team we would suggest that the total AIM score is the primary outcome score. The difference between the Total AIM score at Time 1 and Time 2 would be the primary outcome measure. In theory this could range for 160-0. From current data we would anticipate that total scores will range between 10-50. 

!!![[Reliable Change |Measuring reliable change]]
From the CASUS data, we have calculated the reliable change criteria. This is the degree of change between Time 1 and Time 2 that suggests that the change may be greater than chance variation. For the Total AIM score this is 12.91. This means that any case where there is a difference in total scores of more than 12.91 is a case that has achieved reliable change. 

!!!Domain scores 
In addition to total scores, the AIM will also have the ability to generate domain scores for the seven domains covered by the AIM and also to generate individual item scores. As domains have a wide variation in number of items, domain scores are best presented as mean item scores for each domain. These will range between 0-4. 

!!!Item scores 
Our experience so far is that individual item scores are very informative. Some of these item (e.g. anxiety) are frequently scored high in the vulnerable populations the teams will generally serve. 

The purpose of the project is to explore the degree of similarity and variation between teams on all three levels of analysis offered by the AIM. 

!!Project plan. 
At the core of this project is a collaboration between members of the AMBIT Study Group and the AMBIT Team at the Anna Freud Centre. All of the current proposal etc needs ot be discussed and considered by the AMBIT Study Group. 

The Project Plan has three parts,:

*1. develop an agreed core model of outcome evaluation 
*2. Collect data from a number of participating teams
*3. Collectively reflect on the learning from this  and revise framework from this.  

Teams participating in the Project need to be actively attempting to use this framework in their work with clients. There is no required number of cases for a participating team at this stage. The intention is to hold a meeting of the Study Group in March 2020 to review examples of actual outcome monitoring and to consolidate guidance and good practice.

At this initial stage, data will be shared through excel spreadsheets. The longer term plan is to explore the use of an on-line outcome monitoring system called POD for this work. This again can be considered at the March meeting of the Study Group.

The intention is that by the end of 2020 we will have a substantive data set based on data from a number of teams. This may provide the basis for fresh thinking about the AMBIT approach and what we learn from the outcomes of clients coming through AMBIT teams.

----
!!''Introduction'' 
Descriptions of competencies can be a bit daunting and dry but they are also very useful in being clear about the core aspects of the model and what practitioners should know and do. 

The AMBIT Project Group at the [[Anna Freud National Centre for Children and Families]] has been working on trying to define the core competencies for a practitioner working in an AMBIT trained  team.  We recognise that different teams will adopt some parts of the AMBIT approach more than others and that it is not a requirement that all practitioners are competent in all the 20 competencies outlined below. 

We would greatly welcome comments and suggestions from current AMBIT trained teams about whether the competencies outlined here represent their understanding of the core AMBIT approach. 

Adaptations of these competences for individual teams would be especially interesting and welcome.  

!!''The overall competency framework for AMBIT'' 
!!!Individual Competencies
AMBIT competencies for individual workers are organised into three parts;

* ''Part A: Basic knowledge for AMBIT'' 
* ''Part B: Basic practice for AMBIT''
** [[AMBIT Competencies covered in the Basic Training]] lists the ten most basic components (Part A and Part B). 
* ''Part C: Advanced knowledge and practice for AMBIT.''
** [[AMBIT Full Competency Framework]] adds ten further competencies (Part C) which are listed together with the ten covered in the Basic Training (Part A and Part B).  
*** Thus, ''overall, there are twenty competencies''.
*** There is a self-audit scoring scheme included in that list
*** Embrace the importance of [[Work on the Self]] and use this to direct AutoDidact activities as teams or individuals.
!!!Team Competencies
Because AMBIT is explicitly and exclusively a ~TEAM-BASED approach, there is also a list of team-based practices that require the kind of  [[Working with your TEAM]] that AMBIT promotes:

* [[AMBIT Team Competencies]]

 

!!What is this?
See [[AMBIT Competencies]] for a description this.  The list below is ''just the first half'' of the [[AMBIT Full Competency Framework]] - that is, just the core elements of practice that we hope trainees will achieve in their initial [[AMBIT training|Information About AMBIT Training]].
!~Self-AUDIT
A simple exercise in thinking about your skills is to rate yourself on each of the competencies. Rate yourself against each of the following 20 competencies according to the following scale:

__''Scoring:''__ ''0'' = Not confident, ''1'' = Becoming confident, ''2'' = Confident 

!!PART A: KNOWLEDGE FOR AMBIT

!!1.	Knowledge of the theory of [[Mentalization]]* 

*An ability to draw on knowledge about the nature of mentalizing (see [[Mentalization]])

*An ability to draw on knowledge about the developmental basis of processes of mentalization (see [[Secure Base]] and [[Marked mirroring]])

*An ability to recognise mentalizing and patterns of non-mentalizing in both self and others (see [[Implicit mentalization]]; [[Explicit mentalization]]; [[Teleological thinking]]; [[Pretend mode]] and [[Psychic equivalence]])

*An ability to draw on knowledge that the vulnerability to loss of mentalization leaves the young person exposed to more primitive modes of experiencing internal reality that, in turn, undermines the coherence of self-experience (see [[Concrete Mentalizing difficulties]])

!!2.	Knowledge of the AMBIT approach*  

*An ability to draw on knowledge of the basic AMBIT framework (“core features”) summarised in the AMBIT wheel (see [[AMBIT Wheel]] and [[Core Features of AMBIT]]).

*An ability to describe the AMBIT stance and the principle of holding the balance between competing dilemmas that are represented in it (see [[The Therapist's Mentalizing Stance]] and [[General features of a "Mentalizing Stance"]]). 

*An ability to describe the four key practices in the AMBIT approach and to understand the relationship between the four practices as part of an integrated approach to effective intervention (see [[Working with your CLIENT]]; [[Working with your TEAM]];[[Working with your NETWORKS]];[[LEARNING at work]]).  
 
*An ability to recognise the limitations of the relative lack of evidence for the AMBIT approach for hard to reach young people (see [[Respect for Evidence]] and [[Is AMBIT evidence based?]]).


!!PART B: AMBIT PRACTICE 

!!3.	Ability to use mentalization in their work with young people and their carers* 
 
*An ability to draw on knowledge that the intervention aims at increasing the young person’s capacity to mentalize (see [[Highlighting and reinforcing Positive Mentalizing]]).

*An ability to draw on knowledge that AMBIT formulates some of the mental vulnerabilities associated with hard to reach young people as resulting from the fragility of mentalization in the context of attachment relationships (see [[Formulation and Treatment Aims]]).

*An ability to draw on knowledge of the developmental factors and experiences that are typically associated with a vulnerability to loss of mentalization (see [[Developmental Considerations]]).  

*An ability to adopt the mentalizing stance in working with young people (see [[The Therapist's Mentalizing Stance]] and [[General features of a "Mentalizing Stance"]]).  

*An ability to use the mentalizing loop in working with young people and their carers (see [[Mentalizing Loop]]). 


!!4.	Ability to apply mentalization to work with colleagues*  

*An ability to draw on knowledge of mentalization to recognise that the mentalizing capacity of colleagues within a team (including oneself) is likely to fluctuate in response to anxiety, stress and other expected aspects of work with hard to reach young people (see [[Ripples in a Pond]] and [[Dive Boat]]). 

*An ability to draw on knowledge of attachment and mentalization to work towards creating a sense of safety within a team in order to facilitate mentalizing in oneself and others (see [[Secure Base]]). 

*An ability to draw on knowledge of attachment theory to recognise the value of availability and responsiveness in work between colleagues in a team (see [[Attachment theory]]). 


!!5.	Ability to apply mentalization to work across agencies and see problems from multiple institutional standpoints*    

*An ability to make sense of the behaviour of staff from other agencies in terms of understandable  mental states and intentions of agents in that organisation (see [[Addressing Dis-integration]]).

*An ability to recognise that beliefs about the practice of other agencies is likely to be influenced by unbalanced feedback patterns about such agencies (see [[Dis-integrative processes in a Multi-Agency context]]).

*An ability to adopt a position of respect towards staff from other agencies and to demonstrate this by positive curiosity about their work with the young person (see [[Non-mentalizing, positioning and network problems]]).  

*An ability to accept that different agencies may be required to prioritise different aspects of a young person’s needs and that these different priorities may create tensions within a network around a young person (see [[Mentalizing service barriers]]).  


!!6.	Ability to intervene in multiple domains*

*An ability to make sense of a young person's difficulties by considering the impact of these problems on many areas of his/her life and to recognise the way that these difficulties are likely to interact together (see [[Working in multiple domains]]).  

*An ability to work with both individual and systemic difficulties in trying to improve the life chances of the young person (see [[SystemsTheory]]). 

*An ability to engage with the wider community such as schools, colleges and youth services in working with the young person (see [[Working with the Social Ecology]]). 

* An ability to apply basic systemic ideas and techniques to intervening in relationship problems both within the family and between the family members and people in the wider community (see [[FamilyWork]]). 

*An ability to consider how wider systems, commissioning arrangements, service procedures and local policies impact on the work with young people and to aim to support such systems to operate in a more coherent way (see [[Addressing Dis-integration]]).  

  
!!7.	Ability to scaffold existing relationships to provide help.

*An ability to explore with the young person their experience of relationships with others in their network and to facilitate the young person in mentalizing both their own and others’ experiences of such relationships (see [[Relationship to help]]). 

*An ability to be guided by the young person about who may be most helpful to them about their key problems independent of the person’s professional status or background training (see [[The AMBIT Pro-Gram]]). 

*An ability to focus work on building capacity and availability in existing (and potentially long lasting) resiliencies identified in the young person’s social ecology (see [[Focussing on Strengths]]).

*An ability to actively support (by joining them at meetings etc) a young person’s engagement with more mainstream therapeutic, educational or social care/youth agencies (see [[Working in multiple domains]]).

*An ability and willingness (temporarily, and with due attention to professional boundaries) to step outside of formally defined roles in order to support the work of another agency - if doing so supports the establishment of improved working and more effective intervention in another functional domain (see [[KeyWorker]] and [[Why intervene simultaneously in multiple domains?]]).


!!8.	 Ability to think together with colleagues* 

*An ability to draw on knowledge about the high likelihood and impact of episodes of non-mentalizing in the worker doing work of this kind (see [[Features of UNsuccessful Mentalizing]] and [[Keyworker well-connected to wider team]]).

*An ability to apply mentalization in one’s interactions between colleagues within the team (see [[Work on the Self]] and [[Is Mentalizing just Reflective thinking?]]). 

*An ability to use the ‘thinking together’ approach to consulting with a colleague in a team, as a way of ensuring that sense is made of the worker’s own feelings about a particular young person or clinical situation, and the possible impact of this upon the work. (see [[Thinking Together]]).

*An ability to respond to colleagues who seek help around a particular case in helping them to think together about the dilemmas around a particular young person or clinical situation (see [[Thinking Together]]).

*An ability to challenge colleagues where evidence of a non-mentalizing approach to the work is present, and to support them to regain their own mentalized explanations for the behaviours that they are working with (see [[Local Session 04: Working with your Team]]).


!!9.	Ability to assess network functioning using a disintegration grid.*

*An ability to identify all key participants from the youth’s professional network who have an investment in the youth’s outcomes, including family members where appropriate and other formal and informal key stakeholders (see [[The AMBIT Pro-Gram]]). 

*An ability to make sense of the behaviour of others in the network in terms of intentional mental states (e.g. to apply the same insistence upon mentalized explanations for behaviour in working with professional colleagues as in working with young people and their families) (see [[Addressing Dis-integration]]). 

*An ability to work proactively to identify gaps (or dis-integrations) in the work of the multi-agency network, that might (mostly inadvertently) either diminish the effectiveness of the interventions by some parts of of the network, or damage the young person or family’s experience of contact with these various facets of “help” from the wider system by presenting them with conflicting or overwhelming demands (see [[Dis-integration grid]]).

*An ability to facilitate collaboration between professionals at all levels of the service system that takes into account professional beliefs about the nature of the young person’s difficulties, what may be helpful in addressing these problems, and beliefs about role responsibilities in a multi-agency system (see [[Addressing Dis-integration|Addressing Dis-integration]]). 

*An ability to help each of the key agencies to identify desired outcomes or initial goals, and to use this information to set overall treatment goals (see [[Advice on setting Treatment Aims and Goals]]). 


!!10.	Ability to manualize specific local practice.*

*An ability to use the local web based version of the AMBIT manual in a fluent and confident way: 
**To locate the manual via a browser (www.tiddlymanuals.com) 
**To open it and orient oneself to the sections of the screen desktop
**To navigate it and find specific material via the search function, via the indexes, or by following links, references and topics/sub-topics in the “Show related information” panel.
**To use the “Snapshot” function in the manual in order to share a specific page or set of pages with a colleague 

*An ability to draw on basic knowledge as to how the manual has been constructed and how a local version of it may be adapted to describe and develop solutions to local service challenges (see [[User Guide]]). 

*An ability to engage in team discussion about important areas of practice with young people in order to develop a shared approach to a particular difficulty or situation that commonly arises with this client group (see [[Manualization]]). 

*An ability to contribute into achieving a consensus approach to common clinical dilemmas based on team reflection and discussion and to manualize practice guidance from this (see [[Respect local practice and expertise]]). 
 
*An ability to reflect with team colleagues on interactions with young people and/or professionals in the network and in a systematic way agreed within the team (e.g. discussion in a team meeting) in order to enable collective learning about effective practice (see [[Team Meetings]]).  

*An ability to make use of the team wiki manual in order to ensure that clinical decision making is consistent with evidence based practice and the AMBIT model as applied to the specific local team (see [[Using the Manual]]).

----
See [[AMBIT Full Competency Framework]] for the extended list of competencies, and [[AMBIT Team Competencies]] for competencies relating to whole teams rather tan individuals.
----

!!DEVELOPING EVIDENCE ABOUT THESE COMPETENCIES
!!!!Relative Importance and Use of these competencies:
We asked 41 AMBIT practitioners at the AMBIT conference 2014 to give each competency a relative rating of its ''importance'' and its ''use in current practice''. 

High scores indicate more importance/use (see [[Competency use and importance ratings]]). 

!2016
See [[AMBIT Unconference 2016]]
!2015
Not videoed
!2014
[[AMBIT in an Adolescent MH team: struggles and successes - Griffiths, Duffy, Kennedy]]
[[Sustaining an AMBIT approach in an acute adolescent in-patient setting - Whittick, Morrell, Fairbairn, Thulbourn and Millard]]
[[Practical examples of sustaining the AMBIT approach - Jones, Jones and Schofield]]
[[What do we mean when we say "That's (not) very AMBIT!" - Dickon Bevington]]
!2013
[[Building a Community of Practice - Dickon Bevington]]
[[Learning organisation - is the concept useful in AMBIT? - Peter Fuggle]]
[[Using AMBIT to Reduce In Patient Admissions - Sarah Harmon]]
[[Manualizing a live issue - Garry Richardson and Heather Tovey|Example of Manualizing a live issue - Garry Richardson and Heather Tovey]]
[[AMBIT Across a Complex Array of CAMHS services - Gavin Cullen and Fiona Duffy]]
[[Engaging a team in Outcomes Measurement - Liz Cracknell and Carol Evans]]

!!''Introduction''
As AMBIT grows and its core content is shared by many teams, a more formal structure is under development to review and approve new material.
The original material in the manual was written by the listed [[Authors]], but as any reading of AMBIT will show, the nature of AMBIT is to //adapt// and develop to keep in touch with changing knowledge, evidence and experience, using access to the evidence base (eg [[Fonagy, Cottrell, Phillips, Bevington, Glaser and Allison (2014) What Works for Whom]]) as well as feedback from teams using the material in real world settings.  Local versions of the AMBIT manual are developing a great deal of new content, and the authorship of this content is held by the local teams.

<<tag [[AMBIT Editorial Group - current manualizing tasks]]>>

!!''The AMBIT Editorial Group''
* As a pilot we have convened a small group of AMBIT trainers to review changes to the manual more systematically.
* The group meets regularly to review all changes to the core content of the AMBIT manual, accepting or rejecting proposed changes, and passing more substantial adaptations to the [[AMBIT training|Information About AMBIT Training]] curriculum on for agreement by the wider AMBIT project team at their meetings.
* A ''minimum'' number of 3 members of the group needs to be present for editing to proceed (see [[Reflective Quorum]]). 
** There will be a review of the work of this group in 6 months
** This will include the technical methods for recording their work.
* ''We invite expressions of interest from others (especially outside of the AMBIT 'community') to join this group.''

!!''Tasks for the Editorial Group''
1. Setting the processes, rules and criteria The AMBIT Editorial Group, with oversight from an [[AMBIT Expert Reference Group]], sets the processes up for managing content in the manual, the rules by which content is admitted to the core AMBIT platform, and the criteria by which such content is judged.

2.Tracking and approving/rejecting NEW material 

*PROCESS: We track new material that is added in the manual under two headings
**<<tag [[(a) Work in Progress - Major change]]>>
**<<tag [[(b) Work in Progress - Minor change]]>>
*RULES
**"Very minor edits'" (correcting typos, repairing links, improving presentation) are not tracked at all.
** "Major and Minor changes" to content can be made if this fulfills the [[Criteria for inclusion/exclusion of CONTENT in AMBIT]].
**REMOVAL of the "Work in Progress" tags signifies that approval of the changes have been made.
3.  Identifying and resolving duplications/contradictions in EXISTING content

*PROCESS: We are systematically screening for material that has been written in different ways and under different headings.
*RULES:
Rules for how to label and integrate new material - see [[Fitting what you ADD into what is ALREADY THERE in your manual]]

''To Do Lists:''
This tag lists material that NEEDS EDITORING/AUTHORING WORK from the editorial group <<tag [[AMBIT Editorial Group - current manualizing tasks]]>>
These tags gather changes that need review and sign off:
<<tag [[(a) Work in Progress - Major change]]>>
<<tag [[(b) Work in Progress - Minor change]]>>

!!''Work in progress requiring sign-off by the AMBIT Project Group''
!!!(a) Standing item for sign-off by wider AMBIT Project Group:
(list pages below as [[Links]], that are currently being worked on that involve a change to the training curriculum/model)

* [list pages as links here]
* etc
* etc
!!!(b) Early drafting:
See the [[ambit-afc|https://manuals.annafreud.org/ambit-afc/index.html]] ambit-afc (local version of the manual for members of the AMBIT project at [[AFC|Anna Freud National Centre for Children and Families]]) for content that is being worked prior to inclusion in the core content.

!!''Current Editorial Group membership:''
* [[DickonBevington]] - Chair
* [[Peter Fuggle]]
* [[Suzanne Hare]]
* [[Liz Cracknell]]
* [[John Lincoln]]
* [[Garry Richardson]]
* [[Sally Zlotowicz]]
* [[Katie Partridge]]
* [[Nick Jones]]
* [[Olive Moloney]]

!!''What is this for?''
This tag lists material that has been identified as needing further/new content authoring by the [[AMBIT Editorial Group]] and original [[Authors]] - you can see content gathered under this tag here:
<<tag [[AMBIT Editorial Group - current manualizing tasks]]>>

!!''NOT for technical development priorities''
Please use this tag to label ''technical developmental tasks'': <<tag [[Tasks to improve manual]]>>

!!''Rules for editing and authoring''
Please tag all new edits and authored pages with either
[[(a) Work in Progress - Major change]] or [[(b) Work in Progress - Minor change]].  If you are just correcting minor typos or layout then no tagging is required.

The Editorial team is responsible for core content in the AMBIT manual 

DickonBevington (Lead Editor)
[[Peter Fuggle]]

The proposed AMBIT expert reference group will consist of recognised experts who have agreed to provide occasional oversight of the AMBIT content.  Suggestions or volunteers for these roles are welcomed (add comments at the bottom of this page or email us: ambit@annafreud.org) 

Using the yellow tags below you can find links to a whole series of Frequently Asked Questions about AMBIT in general, that have arisen in trainings or conferences over the past years.  Below you will see that there are also FAQ's about the Training, and for Local Trainers.

This is a resource that will be built upon and we invite users of the manual to offer further suggestions using the [[Feedback please!]] form.

Click the button below to select a question you are interested in:

*<<tag [[AMBIT FAQs]]>> 
*<<tag [[Training FAQs]]>> 
*<<tag [[LOCAL trainers FAQs]]>> 

This is a tag that collects all the Tiddlers that include downloadable forms that can be used in the general process of assessment, formulation and care planning.

!!Introduction
The [[AMBIT training|Information About AMBIT Training]] aims to provide team members with [[AMBIT Competencies covered in the Basic Training]], but as AMBIT is a framework for [[LEARNING at work]], so the full range of competencies is wider.  Listed below is the full range of competencies that team's should aim to cover.  See also [[AMBIT Team Competencies]] that cover the [[Core Features of AMBIT]]. 

!!~Self-AUDIT
A self-audit exercise is suggested with these competencies. 

Rate yourself against each of the following 20 competencies according to the following scale, in order to direct further training: 

__''Scoring:''__ ''0'' = Not confident, ''1'' = Becoming confident, ''2'' = Confident  


!!PART A: KNOWLEDGE FOR AMBIT

!!!1.	Knowledge of the theory of [[Mentalization]]* 

*An ability to draw on knowledge about the nature of mentalizing (see [[Mentalization]])
*An ability to draw on knowledge about the developmental basis of processes of mentalization (see [[Secure Base]] and [[Marked mirroring]])
*An ability to recognise mentalizing and patterns of non-mentalizing in both self and others (see [[Implicit mentalization]]; [[Explicit mentalization]]; [[Teleological thinking]]; [[Pretend mode]] and [[Psychic equivalence]])

*An ability to draw on knowledge that the vulnerability to loss of mentalization leaves the young person exposed to more primitive modes of experiencing internal reality that, in turn, undermines the coherence of self-experience (see [[Concrete Mentalizing difficulties]])

!!!2.	Knowledge of the AMBIT approach*  

*An ability to draw on knowledge of the basic AMBIT framework (“core features”) summarised in the AMBIT wheel (see [[AMBIT Wheel]] and [[Core Features of AMBIT]]).

*An ability to describe the AMBIT stance and the principle of holding the balance between competing dilemmas that are represented in it (see [[The Therapist's Mentalizing Stance]] and [[General features of a "Mentalizing Stance"]]). 

*An ability to describe the four key practices in the AMBIT approach and to understand the relationship between the four practices as part of an integrated approach to effective intervention (see [[Working with your CLIENT]]; [[Working with your TEAM]];[[Working with your NETWORKS]];[[LEARNING at work]]).  
 
*An ability to recognise the limitations of the relative lack of evidence for the AMBIT approach for hard to reach young people (see [[Respect for Evidence]] and [[Is AMBIT evidence based?]]).


!!PART B: AMBIT PRACTICE 

!!!3.	Ability to use mentalization in their work with young people and their carers* 
 
*An ability to draw on knowledge that the intervention aims at increasing the young person’s capacity to mentalize (see [[Highlighting and reinforcing Positive Mentalizing]]).

*An ability to draw on knowledge that AMBIT formulates some of the mental vulnerabilities associated with hard to reach young people as resulting from the fragility of mentalization in the context of attachment relationships (see [[Formulation and Treatment Aims]]).

*An ability to draw on knowledge of the developmental factors and experiences that are typically associated with a vulnerability to loss of mentalization (see [[Developmental Considerations]]).  

*An ability to adopt the mentalizing stance in working with young people (see [[The Therapist's Mentalizing Stance]] and [[General features of a "Mentalizing Stance"]]).  

*An ability to use the mentalizing loop in working with young people and their carers (see [[Mentalizing Loop]]). 


!!!4.	Ability to apply mentalization to work with colleagues*  

*An ability to draw on knowledge of mentalization to recognise that the mentalizing capacity of colleagues within a team (including oneself) is likely to fluctuate in response to anxiety, stress and other expected aspects of work with hard to reach young people (see [[Ripples in a Pond]] and [[Dive Boat]]). 

*An ability to draw on knowledge of attachment and mentalization to work towards creating a sense of safety within a team in order to facilitate mentalizing in oneself and others (see [[Secure Base]]). 

*An ability to draw on knowledge of attachment theory to recognise the value of availability and responsiveness in work between colleagues in a team (see [[Attachment theory]]). 


!!!5.	Ability to apply mentalization to work across agencies and see problems from multiple institutional standpoints*    

*An ability to make sense of the behaviour of staff from other agencies in terms of understandable  mental states and intentions of agents in that organisation (see [[Addressing Dis-integration]]).

*An ability to recognise that beliefs about the practice of other agencies is likely to be influenced by unbalanced feedback patterns about such agencies (see [[Dis-integrative processes in a Multi-Agency context]]).

*An ability to adopt a position of respect towards staff from other agencies and to demonstrate this by positive curiosity about their work with the young person (see [[Non-mentalizing, positioning and network problems]]).  

*An ability to accept that different agencies may be required to prioritise different aspects of a young person’s needs and that these different priorities may create tensions within a network around a young person (see [[Mentalizing service barriers]]).  


!!!6.	Ability to intervene in multiple domains*

*An ability to make sense of a young person's difficulties by considering the impact of these problems on many areas of his/her life and to recognise the way that these difficulties are likely to interact together (see [[Working in multiple domains]]).  

*An ability to work with both individual and systemic difficulties in trying to improve the life chances of the young person (see [[SystemsTheory]]). 

*An ability to engage with the wider community such as schools, colleges and youth services in working with the young person (see [[Working with the Social Ecology]]). 

* An ability to apply basic systemic ideas and techniques to intervening in relationship problems both within the family and between the family members and people in the wider community (see [[FamilyWork]]). 

*An ability to consider how wider systems, commissioning arrangements, service procedures and local policies impact on the work with young people and to aim to support such systems to operate in a more coherent way (see [[Addressing Dis-integration]]).  

  
!!!7.	Ability to scaffold existing relationships to provide help.

*An ability to explore with the young person their experience of relationships with others in their network and to facilitate the young person in mentalizing both their own and others’ experiences of such relationships (see [[Relationship to help]]). 

*An ability to be guided by the young person about who may be most helpful to them about their key problems independent of the person’s professional status or background training (see [[The AMBIT Pro-Gram]]). 

*An ability to focus work on building capacity and availability in existing (and potentially long lasting) resiliencies identified in the young person’s social ecology (see [[Focussing on Strengths]]).

*An ability to actively support (by joining them at meetings etc) a young person’s engagement with more mainstream therapeutic, educational or social care/youth agencies (see [[Working in multiple domains]]).

*An ability and willingness (temporarily, and with due attention to professional boundaries) to step outside of formally defined roles in order to support the work of another agency - if doing so supports the establishment of improved working and more effective intervention in another functional domain (see [[KeyWorker]] and [[Why intervene simultaneously in multiple domains?]]).


!!!8.	 Ability to think together with colleagues* 

*An ability to draw on knowledge about the high likelihood and impact of episodes of non-mentalizing in the worker doing work of this kind (see [[Features of UNsuccessful Mentalizing]] and [[Keyworker well-connected to wider team]]).

*An ability to apply mentalization in one’s interactions between colleagues within the team (see [[Work on the Self]] and [[Is Mentalizing just Reflective thinking?]]). 

*An ability to use the ‘thinking together’ approach to consulting with a colleague in a team, as a way of ensuring that sense is made of the worker’s own feelings about a particular young person or clinical situation, and the possible impact of this upon the work. (see [[Thinking Together]]).

*An ability to respond to colleagues who seek help around a particular case in helping them to think together about the dilemmas around a particular young person or clinical situation (see [[Thinking Together]]).

*An ability to challenge colleagues where evidence of a non-mentalizing approach to the work is present, and to support them to regain their own mentalized explanations for the behaviours that they are working with (see [[Local Session 04: Working with your Team]]).


!!!9.	Ability to assess network functioning using a disintegration grid.*

*An ability to identify all key participants from the youth’s professional network who have an investment in the youth’s outcomes, including family members where appropriate and other formal and informal key stakeholders (see [[The AMBIT Pro-Gram]]). 

*An ability to make sense of the behaviour of others in the network in terms of intentional mental states (e.g. to apply the same insistence upon mentalized explanations for behaviour in working with professional colleagues as in working with young people and their families) (see [[Addressing Dis-integration]]). 

*An ability to work proactively to identify gaps (or dis-integrations) in the work of the multi-agency network, that might (mostly inadvertently) either diminish the effectiveness of the interventions by some parts of of the network, or damage the young person or family’s experience of contact with these various facets of “help” from the wider system by presenting them with conflicting or overwhelming demands (see [[Dis-integration grid]]).

*An ability to facilitate collaboration between professionals at all levels of the service system that takes into account professional beliefs about the nature of the young person’s difficulties, what may be helpful in addressing these problems, and beliefs about role responsibilities in a multi-agency system (see [[Addressing Dis-integration]]). 

*An ability to help each of the key agencies to identify desired outcomes or initial goals, and to use this information to set overall treatment goals (see [[Advice on setting Treatment Aims and Goals]]). 


!!!10.	Ability to manualize specific local practice.*

*An ability to use the local web based version of the AMBIT manual in a fluent and confident way: 
**To locate the manual via a browser (www.tiddlymanuals.com) 
**To open it and orient oneself to the sections of the screen desktop
**To navigate it and find specific material via the search function, via the indexes, or by following links, references and topics/sub-topics in the “Show related information” panel.
**To use the “Snapshot” function in the manual in order to share a specific page or set of pages with a colleague.

*An ability to draw on basic knowledge as to how the manual has been constructed and how a local version of it may be adapted to describe and develop solutions to local service challenges. 

*An ability to engage in team discussion about important areas of practice with young people in order to develop a shared approach to a particular difficulty or situation that commonly arises with this client group (see [[Manualization]]). 

*An ability to contribute into achieving a consensus approach to common clinical dilemmas based on team reflection and discussion and to manualize practice guidance from this (see [[Respect local practice and expertise]]). 
 
*An ability to reflect with team colleagues on interactions with young people and/or professionals in the network and in a systematic way agreed within the team (e.g. discussion in a team meeting) in order to enable collective learning about effective practice (see [[Team Meetings]]).  

*An ability to make use of the team wiki manual in order to ensure that clinical decision making is consistent with evidence based practice and the AMBIT model as applied to the specific local team (see [[User Guide]]).  

!!PART C: ADVANCED COMPETENCIES

!!!11.	Knowledge of the common difficulties of under-served, (or ‘hard to reach’) young people and their families/carers across [[multiple domains|Working in multiple domains]].

*An ability to draw on knowledge of the psychological and interpersonal difficulties experienced by young people and family members/carers with multiple mental health, educational and social needs who are not seeking help for such problems (‘[[Hard to reach]]’ or [[Under-Served]]). 

*An ability to draw on knowledge of the multiple risks factors ([[Complexity]]) that influence hard to reach young people (e.g. at the level of the individual, family/carers, peer, school and community). 

*An ability to draw on knowledge of [[Family]] phenomena commonly associated with the multiple mental health needs of a ‘hard to reach’ young person (e.g. disorganised [[Attachment]] patterns, inconsistent parenting style, negative marital interactions, psychiatric disorders (Diagnoses), [[Physical Health matters]]), Educational needs (see [[Educational-Vocational Training]]), the [[SocialEcology]] (such as social service entitlements and economic factors (e.g. poverty) in a young person’s life - see [[Social-Ecological Work]] and [[SubsistenceSupport]].  

*An ability to reflect on the lack of [[Evidence]] associated with psychological therapies associated with this complex and often co morbid group

*An ability to draw on knowledge of the long term psychological, social and economic  consequences of social exclusion such dropping-out of school, college and work and/or a history of offending (e.g. reduced wages, limited career opportunities and housing restrictions) and its links to [[Complexity]] and the nature of [[Hard to reach]] populations.  

*An ability to draw on knowledge about the general (and specific local) approach to provision of services for such young people – and the psychological impact of multi-agency involvement in “complex” or “multi-problem” cases.  See [[Addressing Dis-integration]].


!!!12.	Knowledge of Attachment theory and help seeking as a way of making sense of 'Hard to reach' young people.  

*An ability to draw on knowledge of [[Attachment theory]] and the processes involved in help seeking, as well as the implications of lack of help seeking (or atypical forms of help-seeking) for young people whose [[Relationship to help]] may contribute to them being described as [[Hard to reach]].

*An ability to draw on knowledge that a [[Mentalization]] based approach is grounded in [[Attachment theory]]. 

*An ability to adapt methods of practice to take into account the young person’s previous experiences of seeking help from adults (see [[Contingencies]], as opposed to [[Non-contingent]] responses). 


!!!13.	Knowledge of systemic principles that inform the AMBIT approach 

*An ability to draw on knowledge of [[SystemsTheory]] - that whatever affects one member of a system (e.g. a family, school or multi-agency network) may affect all other members. 

*An ability to draw on knowledge that patterns of interaction within and outside a group may affect each member of that group (see [[Positioning Theory]]). 

*An ability to draw on knowledge that patterns of interaction between professionals working with a young person may affect each member of such a network Dis-integration. 


!!!14.	Ability to engage with young people and their social context 

*An ability to recognise the factors that inhibit [[Engagement]]  with help for young people and to adapt the intervention to accommodate to these factors (see [[Relationship to help]] and the [[Therapeutic Bargain]]). 

*An ability to identify trusted adults in the network around the young person (either family or professionals) and, where appropriate, to work through such adults in order to enhance the young person’s capacity to develop trust in others around key issues in his/her life (see StrengthsResiliencies and [[Scaffolding existing relationships]].) 

*An ability to carry out a process of gradual [[Engagement]] with a young person through the use of persistence that takes into account a formulation of the young person’s difficulty in responding to offers of help. 

*An ability to promote engagement by employing core clinical skills ([[Engagement techniques]] including ordinary skills such as empathy, warmth, reflective listening, reframing, flexibility and instilling hope for change). 

*An ability to draw on knowledge that engagement is a process over time rather than a single event  and that a young person’s behaviour (e.g. contacting the service when upset or angry) may indicate (through the lens of [[Attachment theory]]) positive shifts in [[Engagement]] as much as what they say about the relationship (e.g. you’re all rubbish). 


!!!15.	 Ability to complete an AIM assessment.*

*An ability to draw on knowledge about the value of carrying an assessment of different [[Domains]] of a young person’s life (see [[Working in multiple domains]]).

*An ability to complete an [[AIM]] assessment of a young person either with a member of the network who knows the young person well or a family member as part of an initial assessment of the young person’s needs. 

*An ability to complete an [[AIM]] assessment with the young person either using an on-screen ([[AIM form]]) or paper version ([[AIM - paper version]]) or by using the [[AIM Cards]] as a method of understanding the young person’s perspective on his life and problems. 

*An ability to score the AIM assessment and to use the [[AIM form]] in the AMBIT manual to generate suggested interventions for that specific range of presenting problems indicated from that assessment. 

*An ability to share the results of an AIM assessment with the young person and to construct a shared understanding of its meaning. 


!!!16.	Ability to develop a mentalized formulation of the young person’s difficulties  

*An ability to summarise information about a young person from a range of different sources in a concise and coherent manner.  See [[Formulation and Treatment Aims]].  This builds on the idea of providing //narrative continuity// (one of the [[Features of Successful Mentalizing]]). 

*An ability to reflect on the [[Formulation and Treatment Aims]] and to develop a description of the young person that takes account of their likely mental states and intentionality. 

*An ability to share this mentalized [[Formulation and Treatment Aims]] with the young person in a manner which supports the capacity of the young person’s mentalizing and does not raise anxiety and/or affect (for instance see [[Assessment for SUD-Rx - Giving Feedback]])


!!!17.	Ability to develop a shared care plan with the young person 

*An ability to be curious about the young person’s ideas as to what would make his/her life better and, where possible, develop these into goals for the work together (see [[The Inquisitive Stance]] as part of [[The Therapist's Mentalizing Stance]])

*An ability to process information gleaned from, and about, the young person and their network, using peer/supervisory support where indicated, and to draw up a preliminary ‘roadmap’ for the therapeutic work that might be possible or necessary (see [[Active Planning]]).

*An ability to broadcast one’s own therapeutic intentions ([[Broadcasting Intentions]]), concerns, non-negotiables, hopes, etc, tentatively, as a “work in progress”, inviting authentic collaboration to develop a care plan that takes account of the young person’s beliefs’ about what will be helpful. 

*An ability to communicate  ideas about  evidence based interventions (see [[Respect for Evidence]]) in ordinary language to a young person in order to discuss what is likely to be helpful , and why. 

*An ability to liaise with the young person about how the agreed care plan is communicated with family members and/or the professional network - see [[Active Planning]].

!!!18.	Ability to support the measurement of individual and team clinical outcomes

*An ability to recognise the importance of remaining curious as to whether a particular method of work with a young person is be experienced as helpful to them - see 
[[Evaluating outcomes]] and [[Respect for Evidence]]

*An ability to support and contribute to the development of systematic methods within a team to evaluating whether young people are experiencing the service as beneficial to their problems. 

*An ability to focus on continued evaluation of outcome from multiple perspectives, ensuring that both the young person and the AMBIT worker communicate their respective viewpoints and consider the viewpoint of the other. 


!!!19.	Ability to identify with, and access support from, the wider AMBIT Community of Practice.

*An understanding of the ideas behind the [[Community of Practice]] that AMBIT seeks to develop and support.

* An understanding of the way that the AMBIT tiddlymanual has “layers of authorship” – with all local versions sharing a common core, but being empowered to add to or overwrite this content in their own local version (see [[User Guide]]).

*An ability to locate links to other local versions of the AMBIT manual via the [[www.tiddlymanuals.com|http://www.tiddlymanuals.com]] signposting site

*An understanding of the “[[OpenSource]]” aspects of the development of AMBIT


!!!!Features not currently working 
*//An ability to use the manual to see updates on the manualizing work by other AMBIT teams in the AMBIT Community of Practice//.

*//An ability to identify whether a page in the manual exists in different versions in other local manuals, and to compare those two versions.//


!!!20. Ability to reflect on one's own, and the team's fidelity to AMBIT

*An ability to access and use the APrAT self audit form in relation to a specific case.

*An ability to use this [[AMBIT Competencies]] framework to evaluate one's own further training needs.

*An ability to audit the team's practice against the [[Core Features of AMBIT]]

*An ability to accept the inevitability of variation in outcomes in one's work with young people and families/carers.

*Demonstrate an openness to accept and learn from outcomes that have proven less successful than intended (See [[LEARNING at work]]).


!!DEVELOPING EVIDENCE ABOUT THE COMPETENCIES
!!!!Relative Importance and Use of these competencies:
We asked 41 AMBIT practitioners at the AMBIT conference 2014 to give each competency a relative rating of its ''importance'' and its ''use in current practice''. 

High scores indicate more importance/use (see [[Competency use and importance ratings]]). 

The following are useful pages in the manual - to look through as part of your initial training, but also to refer to in the future.

!!1. AMBIT Training and Implementation in general
* [[AMBIT training|Information About AMBIT Training]], especially
** [[TrainingCore]]
* [[Implementation Science]]
** The [[Implementation Team]]
** The [[Implementation Plan]]

!!2. How to help sustain AMBIT principles in the team
* [[SUSTAIN best practice]] 


!!3. Holding a manualising conversation/meeting in your team.
* [[Manualization]] is the basic page with links from it that covers everything, including how to manualize.

!!4. Technical skills for using the manual
* [[User Guide]] - the general page on USING THE MANUAL - this includes material on the best techniques for reading and searching content, as well as technical help and lots more.
* [[How to edit - Videos]]

!!5. How to increase access of the manual to team members.
* Do check out the incredibly useful [[SNAPSHOT]] button to gather specific links to useful pages that you can email to colleagues.
* Make the manual your Browser HOMEPAGE
* Organisational support for getting the manual to work in a big IT system such as an NHS Trust: [[Organisational support for the technology to run TiddlyManuals]]

!!6. How to run a team training event using the manual
* [[Planning a training event in your team]]
* [[Suggested Team Training Sessions]]
* [[Training exercises]]

!!7. How to develop and use the AMBIT Community of Practice
* See the material on [[Community of Practice]]
* See [[Other team's AMBIT manuals]]
* Consider the use of QUID PRO QUO arrangements between teams, so that external "consultants" can swap between teams to observe discussions and provide mentalizing reflections - much like the [[Fishbowl discussion]] exercises we use in training.

This page is a tag which links together all the tiddlers (pages) relevant to the AMBIT lead role. 

The AMBIT approach does not prescribe on the organisational structure for a team using AMBIT. It assumes their will be a variety of leadership arrangements within different teams.   However, AMBIT practice is unlikely to be sustained without one or preferably two people within the team taking on the role of sustaining the skills and practice of AMBIT - which we refer to as the [[AMBIT Lead]] and the [[Implementation Team]].

See also:

* [[The AMBIT Lead - role and responsibilities]] 
* [[AMBIT LEADS - useful training pages]]


----
!!Sub Pages
Below are the pages that are tagged with 'AMBIT Lead':
<<list-links "[tag[AMBIT Lead]]">>

!!Work in Progress
This is a system that is currently (June 2015) being brought in to AMBIT training - but is not yet fully operational.

!!What is this?
* A peer-to-peer support system for a pair of [[AMBIT Lead]]s in one team to connect with a pair in another team.
* This relationship is established during the AMBIT Lead training
* Allocation of AMBIT peer-to-peer partnerships:
** Peers are allocated by the AMBIT training project team before the AMBIT Basic Training Day 3 (AMBIT Leads)
** The criteria are variable but will include similarity of work, geographical proximity, etc
* We emphasise that ''this is a WORK relationship, not a social relationship''!
** There is no block on the formation of alternative or additional peer-to-peer relationships.
!!What is the intention?
* To keep AMBIT on the agenda of a local team
* To create an opportunity for [[AMBIT Lead]]s to co-train their own team alongside a visiting [[AMBIT Lead]] (or [[AMBIT Local Facilitators]]) from another team: [[Planning a training event in your team - Local]]
* To increase the confidence and competence of the [[AMBIT Lead]]s
* To create teams that are not only [[Well connected|Keyworker well-connected to wider team]] internally, but externally, too - across the the AMBIT [[Community of Practice]].
!!How might it work?
* Introduction at the AMBIT Basic Training Day 3 (AMBIT Leads)
!!Barriers for this to work
* It could be exposing for an AMBIT Lead from one team to talk to the AMBIT Lead from another team about //what is making this work hard//.

!! AMBIT as a learning organisation revisited  
This can be found in pages linked together by [[Developing learning organisations]]
''What is your team good at learning about?'' 
New games on the net? How to help each other? New drugs on the streets? New music? New fads for young people? How do they learn these things? [[Senge: Discipline 2 - Personal Mastery]]
''Learning about helping?''
Isn't this a bit wierd? Isn't it just instinctive? Like learning about having a sense of humour. Or learning about kindness? Let's take an example 'Learning how to put young people at their ease'

!!Manualizing
Manualizing is a method to support learning in groups or teams. 
For a simple introduction to the manual go to [[Using the Manual]]
A broader introduction to editing content can be found in pages linked together by [[Manualization]].
''Manualizing and mentalizing''. The need to incorporate differences in the way a team comes to know its own way of working. Differences in confidence or belief around a particular issue.  Otherwise it becomes just the voice of a dominant culture. Senge encourages people to //"listen for the whispers in a team"// - see [[Developing learning organisations]].  

The suggested plan for this webinar is to invite two of the participants to present a case that the team has worked with. The aim would be to do this by presenting the core aspects of the case and to try to consider it from the perspective of working from the fours parts of the AMBIT approach. 

The rest of the group would act as a reflecting team particularly focusing on mentalizing and there own reflections on the case. Each case would take 20 minutes so that we had 10 minutes a the end to conclude the series of webinars and consider what next. 

!!What does the manual say about ''working with your client?'' Too much! 

The manual has a wide range of material focusing on ''working with your client''. The main sections of this are shown in the opening page of this section [[Working with your CLIENT]]. Let's look at this together for a few minutes.
 
From this array of material, the aim of this webinar is to focus on two aspects; the young person's ''relationship to help'' and the worker's need to dance around this, a process which we have called ''active planning''.  The webinar will take as its starting point the following three pages from the manual. 

[[Relationship to help]]

[[Active Planning]] 

The aim of the webinar will be to look at this material together and then consider how it applies to the respective services and teams that participants come from. 

!!!''Getting started.'' 
How do local teams in your area see your team/service? What would be some of the characteristics that they may assign generally to your team? What intentions would they assign to your team? Could you imagine a malign intention that might arise in their minds!!?
!!!''Why do networks matter?'' 
The idea is that well integrated networks are likely to improve effectiveness. The direct evidence for this is uncertain despite it appearing to be a common sense idea. Formal evaluation of this hypothesis in the Fort Bragg study provided disappointing results with no improvement associated with greater integration of care. its value may be partly an extrapolation from family studies which suggest that parents who work together are likely better care for their offspring than those who are in conflict. Recent observations from the Edinburgh service has suggested that greater effectiveness may be associated with fewer professionals being involved in the case. The causal direction of this association is uncertain. 
!!!''Messing up'' 
Can you identify examples where your team inadvertently undermined the intervention of another service? PF to share a recent example from CAMHS
!!!''Using disintegration grids?'' 
How does this work in practice? Are they used? Can we share examples where this resulted in useful shifts in the functioning of the network?
!!!''What training challenges does working with networks present?'' 

!Introduction:
What are the ''boiled-down essentials'' for understanding about [[Working with your TEAM]]?

* See the sub-topics that fall under this heading: <<tag [[Working with your TEAM]]>>
** The <<tag [[AMBIT-Teamworking]]>> sub-topic contains a lot of material that has been validated through the experience of multiple teams trained (the [[Community of Practice]])
* But AMBIT is not just about dancing to someone else's tune, though;
** It is also very much about a LOCAL team adopting a systematic approach towards developing, clarifying and sharing it's own sense of identity, mission, and techniques, and situating them in relation to EXISTING EVIDENCE for what is safe and helpful
** In other words it is about developing <<tag [[OUR Team]]>>

!In a nutshell
We think that the most important elements to grasp are:
* [[Keyworker well-connected to wider team]] and the Team around the worker
** Remember that [[Mentalization]] is born //and recovered// in the context of relationships of trust.
* The disciplined use of [[Mentalization]] between worker peers in holding critical work conversations: 
** ie [[Thinking Together]]
** Consider //ways to prompt and nudge the team// towards developing this as part of their own team culture.
* The idea that local teams are AMBIT-influenced, not "AMBIT teams" and take responsibility for LEARNING and DEVELOPING their own sense of "who we are and how we work"
** [[Manualization]] and see [[Local Manualization Homework Tasks]]
** How do your [[Team Meetings]] reflect your AMBIT influences?
** The APrAT

<<list-links "[!is[system]!is[image]sort[]]">>

!!!!//Page in development//
<a class="tc-float-right">[img width= 200 [facil.PNG]]</a>

!!!This page has 2 purposes:

#To gather together resources, ideas and tips to support local facilitators in implementing and developing AMBIT within their own services.
#A guide for the AMBIT lead trainers from the Anna Freud Centre to support implementation before, during and after a local facilitator training.



!!Who are the Local Facilitators?

Local Facilitators are local team members who will facilitate training sessions in their local teams/services.

Local facilitators receive training and ongoing support in this role and will have attended the
[[Local Facilitator training|Local Facilitator Training (LFT)- training model]] (previously known as AMBIT Train The Trainer model).


!! Helping local facilitators to connect and work together 

Sometimes there are a number of workers from different services and agencies who come together to train as local facilitators. This can bring a valuable opportunity to develop relationships (i.e. integration) across networks. The local facilitators can get to know each other and each others' services throughout the training process. This brings the potential to work jointly and help train each others' services afterwards. 

''In our experience local facilitators from different service contexts working together can be a really useful approach. For example, when introducing aspects of AMBIT back to their own teams, having a 'visiting co-facilitator' from another team can bring different perspectives and knowledge and can help build relationships across services.''

<a class="tc-float-right">[img width= 200 [map.PNG]]</a>

!!Mapping out who is where 


Sometimes the network of people attending local facilitator training is quite complex and needs 'mapping out' (this may need to happen at an earlier point in the training or at the consultation day). 
Mapping helps to begin planning how people might stay connected and work together after the training as well as who might work with who through some of the group exercises in the training.

This kind of 'mapping the system' could happen in different ways depending on the needs/goals of the services. This would need to be discussed with commissioners attending to think about their ideas/hopes for developing AMBIT going forward across systems.

''Some ways to do 'mapping' are:''

* AMBIT lead trainers set up a physical sculpt with the local facilitators, whereby people can position themselves in relation to:

#Who works closer to whom (//geographically//) - This can help guide who might most easily connect up and work jointly in implementation
#Service areas/cross over of client groups - i.e. teams who do similar work in which it would be beneficial to join up to train e.g. a social care team and CAMHS team both whom see many of the same clients
#Other ways of mapping?

!!!Local facilitators staying well connected after the training


*A [[Google Map]] with pins dropped for each of the local facilitators work base. This can be put in the local manual (this idea was developed by a member of the Lancashire cohort 4)

*Local faciltators using Whattsapp groups to organise trainings together, develop plans and support each other

*Local trainer meet up days- more formal meetings bringing together the local trainers to make plans and support each other with the training

*A launch day- bringing together as many of the local facilitators as possible with commissioners and managers to plan the 'vision' going forward, review support and next steps, and to learn together from the process of implemention so far. This would be supported by some of the training team from the Anna Freud Centre with a view to manualizing these areas as a larger group

!!!Other support for local facilitators

*[[AMBIT Supervision]] from the Anna Freud Centre AMBIT training team - this would need to be planned within the network of local facilitators around how they might best use it, in what groups and format etc. //NB this might be a useful topic to plan at a local facilitator day or a 'launch day'//

 *Further support in using the wiki manual - the AMBIT team offer support/demonstrations/workshops on using the manual and manualizing

*Support in helping you measure and 'get curious about change' for your client groups - Teams can join an AMBIT project using the AIM measure to learn about outcomes in your service and explore how these can be used to develop practice

----
!Tools for Local Facilitators


!!!Below is a list of resources/links and info for local facilitators:

*[[Training Resources|Training Resources]] - a collection of the AMBIT training resources, including training slides, all videos, and training exercises. 
*''Training plans'' on key AMBIT topics - these are simple guides which can be adapted and developed to fit your local contexts:
** [[Local Session 01: What is AMBIT?]] 
**[[Local Session 02: What is AMBIT training for?]] 
**[[Local Session 03: Mentalization]] 
**[[Local Session 04: Working with your Team]] 
**[[Local Session 05: Working with your Networks]] 
**[[Local Session 06: Working with your Client pt. 1 (Mentalizing stance)]] 
**[[Local Session 07: Working with your Client pt.2 (Hard to reach)]] 
** [[Local Session 08: Review (1) and Auditing Team Practices]] 
** [[Local Session 09: Working with your Client pt.3 (Outcomes)]] 
** [[Local Session 10: Review (2) and Top-up plans]] 
** [[Local Session 11: Making a real difference - Implementation Science]] 


!!! [[AMBIT Service Evaluation Questionnaire (ASEQ)]]

 A questionnaire which asks workers about their views on how mentalizing is applied across the four AMBIT quadrants in their service/work. It can be used to plan areas that might be beneficial for future training and to measure change after training.

!!![[AMBIT Implementation Questionnaire|AMBIT implementation questionnaire.pdf]]

A tool to measure which aspects of AMBIT practice are being used by workers

Below is a template setting out a timeframe for stages of implementation over the first 6 months for local facilitators. 

<<link-doc "Implementation Template" "https://drive.google.com/open?id=1YtWLG5DLiw237xcMVkB1JZGJoezRTKnB">>



!!Other tips

* In our experience it has been useful for local facilitators to begin integrating parts of AMBIT  relevant to them in their own practice before training others

* Starting training in small manageable bits rather than attempting to 'roll out long blocks of training' at first can help to build confidence as facilitators and develop curiosity within teams.... 

*Introducing one or two ideas in your own team in small 'bite size chunks'- thinking about the aspects of AMBIT that might be most relevant or interesting to your own teams first

See [[Overcoming barriers to implementation|AMBIT Local Trainer: overcoming barriers to effective implementation]]
for information about common barriers to implementation and ideas to address these. Additionally, click the yellow tag to see a drop dow list of <<tag [[LOCAL trainers FAQs]]>>.

!Task - define a shared problem
!!1. Dealing with a ''//lack of enthusiasm//'' in team members
* Acknowledging the inertia that political situations/funding/job insecurity etc tend to bring.
* Risk of disappointment if early sessions are seen as "falling flat"
* Moving from Quick Fix to patient work towards a longer term goal
!!!Ideas
* Moving from Quick Fix to Quick Wins - clarifying clear objectives //that make sense to the team// early on
** "Doing AMBIT" is ''NOT'' an objective! Avoid connecting outcomes to "doing AMBIT" - stick with benefits for clients... and yet to avoid making outcomes focus into a BURDEN 
** MAYBE having staff feeling more enthusiastic about the work is an OUTCOME in itself?
*** Playfulness - the play of ideas
**** //"Suivrez la Juissance!"// (follow the joy/juice!)  - Lacan
*** The capacity of the team to EXPLORE together
*** To ACCEPT the stressfulness of the work we do, including thinking about new ways of working together.  
**** //"Making the best of an impossible job"// - Bion
* Think about what might help members of this team feel SAFE enough to do this work, or unsafe in ways that inhibit such exploration?
* Team's capacity to use [[Mentalization]] for itself will likely have an impact on how successful it is in working with young people.

!!2. Risk that ''//we are perceived as dangerous "agents of change"//''
** Implicit sense of a hierarchy ("you went off to London")
** Getting into fights about control/letting go
** Telling team they are "doing it wrong"
** that "you are more equal than we are" 
!!3. Concerns about the ''//dependence upon specific person (me)//''
* That it's "//up to you to DO AMBIT TO THE TEAM//"!
** Need to make ways for this to be a shared enterprise
** Creating curiosity to listen
!!4. ''//TIME and other PRACTICAL concerns//''
* Avoid this being an ADDITIONAL BURDEN, 
* Avoid a focus on "WHAT" (else) we should be doing, and rather for this to be about "HOW" we do what we already do.
!!5.''We are trying to train "old hands"''
* Our "trainees" know all the tricks about trying to implement change in behaviours! 
* Keep our practice and methods transparent ([[Broadcasting Intentions]])

!Principles/Resources
* Define our [[AMBIT]] - where can we expect to have influence?
** We have control over what we communicate about our work
** We have the capacity to (make an effort to) mentalize our work colleagues
* We have existing relationships within these teams
* ''"If isn't broken, don't fix it"'': 
** There are probably things //this team, here// does NOT need any training on
* ''Openness'':
** Supporting conditions for a team to recognise that not all we do is crowned with success all the time
** This is a policy agenda - engaging in dialogue about which of our policies address our needs, and which need improvement.

!Ideas
* Offering feedback on our experience first, rather than unfolding an "agenda for change" ([[Broadcasting Intentions]])
* Inviting hopes and concerns from the team - keep it snappy!
* What are the things this team does very well, that any training must NOT BREAK!
* Creating an initial schedule with the team
* Encourage/foster "Yes, AND!" responses, rather than Yes, BUT"

!Measures of effective change
* How would you know this had made a positive difference?
** How would the team define critical positive change?
** See material on [[Implementation Science]] 
** Consider your [[Implementation Plan]]
** Recruit your [[Implementation Team]]

{{CaptureMap.PNG}}

!!!!Click on the arrows to the left hand side to reveal the dropwdowns

!!Home
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<<toc-selective-expandable 'HomeContents'>>
</div>

!!About

<div class="tc-table-of-contents">
<<toc-selective-expandable 'AboutContents'>>
</div>

!!Training

<div class="tc-table-of-contents">
<<toc-selective-expandable 'TrainingContents'>>
</div>

!!Using the Manual
<div class="tc-table-of-contents">
<<toc-selective-expandable 'UsingTheManualContents'>>
</div>

!!!This page collects together measures that are being developed by AMBIT influenced teams or the AMBIT team at the Anna Freud Centre.

The idea is that they measure aspects of team, client, learning or network functioning


*The [[NET-AIM-Q|NET-Aim-Q]] was developed by Dr Janne Walløe Vilmar & Dr Stefan Lock Jensen in [[Regions Sjaelland,Denmark|https://manuals.annafreud.org/ambit-denmark/index.html]]. The aim of the measure is to create an ongoing focus on the quality of network meetings, encouraging mentalizied cooperative meetings

*[[The NET-STAT-Q|NET-Stat-Q]] was developed by Dr Janne Walløe Vilmar & Dr Stefan Lock Jensen in [[Regions Sjaelland, Denmark|https://manuals.annafreud.org/ambit-denmark/index.html]]. This measure is an extension of the NET-Aim-Q

*The [[ARHQ]] is hardly an outcome measure, strictly speaking, but it could conceivably be used as such. It relates to the [[Client's AMBIT Wheel]] and offers 8 questions to probe the client's relationship to help: what work are they doing in relation to their self, to working with help, to making that "help" helpful, and to learning about what works for them

*In AMBIT we are interested in [[recruiting service users to take part in the process of designing outcome measures|Involving young people in designing outcomes]] and shaping how we might use them in more helpful ways. Please see the CORC website who are currently working closely with young champions around the theme of outcome measures. CORC have been producing information and gathering feedback from young people around how we can make outcome measures more user friendly and helpful. For more on this see [[here|https://www.corc.uk.net/for-young-people/]]

!!The AMBIT Pleasure and Pain at Work Questionnaire 

List five things that you enjoy about your work with young people and their families. Rate each item on a scale of 1-10 as to how much you enjoy this aspect of the job. (10 is a lot; 1 is only a bit) 
!!! What you find enjoyable working with your clients                        Rating (1-10) 
1. 
2. 
3. 
4. 
5. 

!!! What you don't find enjoyable about working with your clients                       Rating (1-10)  
1. 
2.
3.
4.
5.

CRITERIA for accreditation as an AMBIT-accredited team:

* i. Creating at least one film about local AMBIT-influenced practice and publishing this in their local manual.
* ii. Having a one year [[Implementation Plan]] which should include:
** [[planned in-house trainings|Planning a training event in your team]] - with evidence they have been delivered.
** At least one visit from an [[AMBIT Lead]] or another [[AMBIT Local Facilitators]] from another AMBIT-influenced team.
* iii. The team is able to demonstrate adaptation of AMBIT to local practice:
** Create a series of pages in the manual. 
** Present a series of APrAT audits
** Self-assessed AMBIT competencies using the [[AMBIT Full Competency Framework]]. 
* iv. [[AMBIT Lead]]s take part in monthly half hour telephone supervision, from a nominated AMBIT trainer (nominated during the AMBIT training).

!!What is the APrAT?
This is a simple questionnaire and exercise to give teams a basic reflective measure of how closely they have followed AMBIT principles in a particular case, and to help them [[SUSTAIN best practice]].
!!How to do it?
Try to do at least one APrAT every three months with the team. 
#Set aside an hour to do this - see the [[APrAT exercise in, or across, teams]]. 
# Pick one case - preferably one that has given particular cause for concern in the recent past.
# Using the questions below, audit the 8 AMBIT stance indicators (see [[Core Features of AMBIT]]) around this case. 
# Look at the results, identify //which stance indicator is the most relevant for the team to improve its practice//, and look at the [[AMBIT Stance Exercises]] to locate a relevant exercise to practice this.
!!The Questionnaire
Full size version here: [[AMBIT Practice Audit Tool_v.2.pdf]]
[img[AMBIT Practice Audit Tool_v.2.pdf]]

!!Video introduction
Using an APrAT questionnaire to help you plan the local training sessions that your team might benefit from.
<html><iframe width="640" height="360" src="//www.youtube.com/embed/1ERcDJgTn3g" frameborder="0" allowfullscreen></iframe></html>

!!Supervisory Structures 
*Close adherence to the SupervisoryStructures are one of the [[Core Features of AMBIT]] practice.  
**Supervision in [[AMBIT]] is more than simply meeting regularly, or occasionally, to talk about work, ensure fidelity of methods, check on training needs and career progress, etc.  
**Supervision in [[AMBIT]] is much more dynamic and takes a number of forms.  
*[[AMBIT]] does not attempt to replace local [[Governance]] structures, but to reinforce them.  
***Individual staff members are expected to fulfil any local supervisory commitments.
*** //In addition// there are weekly [[Team Meetings]] that provide group supervision.  
*Another of the [[Core Features of AMBIT]] describes a [[Keyworker well-connected to wider team]]
**This refers to the use of team members for on-the-spot peer-to-peer supervisory contact.
**Such peer-to-peer consultation functions according to clearly defined [[Rituals and Disciplines]] such as [[Thinking Together]].

!!Boundaries of Competence
* There are [[AMBIT Competencies]] documented.
* The KeyWorker must always remain within the boundaries of his or her competence. 
** Practitioners in the field are respnsible for their clinical practice
** [[AMBIT training|Information About AMBIT Training]] is strongly recommended before working in an AMBIT service.
* Avoiding Omnipotence
** A risk in developing multi-skilled practitioners who can work relatively independently in an outreach setting is that a KeyWorker might develop rather 'omnipotent' ideas about what he or she is able to handle.  
** The risk in such a situation is of workers who //assume// more expertise than they have, who fail to use the SupervisoryStructures available, and get caught in a situation that escalates and places people at risk of harm.  
** Such omnipotence would represent a loss of one of the key features of a [[Mentalization]]-based approach - which is the quality of //tentativeness//, assuming the opaque nature of other people's minds (we cannot know the contents of another person's mental experience - we can only infer, guess, or ask.)  
** This aspect of practice is covered in [[Maintaining Mind-mindedness]].  
** Use of SupervisoryStructures is a key protection against the risk of breaking this important boundary.

!!The ASEQ
[img [ASEQ.jpg]]

The AMBIT Service Evaluation Questionnaire is designed as a pre- and post-training evaluation of the impact of AMBIT training, or can be used as a "temperature check" for an AMBIT-influenced team, to help highlight where ongoing training and practice would be best invested.

* ''Q's 1 - 4:'' probe the AMBIT quadrant [[Working with your CLIENT]]
* ''Q's 5 - 8:'' probe the AMBIT quadrant [[Working with your TEAM]]
* ''Q's 9 - 12:'' probe the AMBIT quadrant [[Working with your NETWORKS]]
* '' Q's 13 - 16:'' probe the AMBIT quadrant [[LEARNING at work]]

An Excel spreadsheet is downloadable [[here|https://drive.google.com/drive/folders/0B5h_CVBdhJPYMm5xNjFWNW56U2M?usp=sharing]] that allows teams to enter their data, generating a series of graphs to show the spread of answers across the team for each AMBIT quadrant, and for individual questions.

Here we are just gathering all the various [[Training exercises]] in the manual together under headings that sort them according to which area of the AMBIT stance they best support:

!On the AMBIT stance and ways of working //as a whole//:
<<tag [[Training Exercises on AMBIT in general]]>> 
!On the separate components of the Stance:
<<tag [[Training Exercises for Mentalization]]>>
<<tag [[Training Exercises for the Keyworker Relationship]]>>
<<tag [[Training Exercises for Keyworker well-connected to wider team]]>>
<<tag [[Training Exercises for Scaffolding existing relationships]]>>
<<tag [[Training Exercises for Managing Risk]]>>
<<tag [[Training Exercises for Working in multiple domains]]>>
<<tag [[Training Exercises for Taking Responsibility for integration]]>>
<<tag [[Training Exercises for Respect local practice and expertise]]>>
<<tag [[Training Exercises for Respect for Evidence]]>>

//This page is under development!//

The [[AMBIT Full Competency Framework]] describes 20 competencies for an individual worker in an AMBIT trained team. However, AMBIT is unambiguously a team approach and alongside this individual framework we are developing some ideas about what a team competency framework would look like. This page indicates some initial work on this idea. Our proposal is that an AMBIT team could be identified as having five  core competencies of its work. These are:- 

The team's ability to:-
#''Mentalize the Client''
#''Mentalize the Team'' 
#''Mentalize the Network''
#''Learn as a team''
#''Evaluate client outcomes''

We have tried to think about how a team competency can be demonstrated. For each of the five competencies, we have included a list of possible alternative ways in which this aspect of team practice could be shown. Teams are not expected to do all of these but if they are doing none of them, then perhaps a part of the AMBIT model is not being used. This may be appropriate but it would seem useful if it is explicit and choosen rather than happening by default. 

However, we are nervous about appearing to reduce a competency to a single practice. This would be unhelpful but, at the same time, if there is no explicit way by which a competency could be observed to be taking place, there is a possibility that the competency itself may be marginal to mainstream team work. As ever, the AMBIT approach is to try to balance top down definitions with appropriate local adaptations. 

!1. Mentalizing the client 
An ability for the team to support each other in drawing on knowledge that the intervention aims at increasing the young person’s capacity to mentalize.

An ability for the team to support each other in adopting the mentalizing stance in working with young people. 

An ability for the team to support each other in using the mentalizing loop in working with young people and their carers.  

!!!Team Practices that support Mentalizing the Client
*Group supervision in which a team member presents a case and the rest of the group mentalize the client and the worker either through discussion or through role play.  
*Explicitly using the mentalizing stance or the mentalizing loop in joint work with young people 
*Using mentalizing based formulations as the basis of casework interventions. 
*Using the mentalizing approach explicitly as part of individual supervision. 

!2. Mentalizing with your team 
An ability for the team to support each other in recognising that the mentalizing capacity of colleagues within a team (including oneself) is likely to fluctuate in response to anxiety, stress and other expected aspects of work with hard to reach young people. 

An ability for the team to support each other in using the ‘thinking together’ approach to consulting with a colleague in a team, as a way of ensuring that sense is made of the worker’s own feelings about a particular young person or clinical situation, and the possible impact of this upon the work.

An ability for the team to support each other in being able to challenge colleagues where evidence of a non-mentalizing approach to the work is present, and to support them to regain their own mentalized explanations for the behaviours that they are working with.

!!!Team Practices that support Mentalizing the Team 
*Using 'thinking together' method of case discussion in team meetings. 
*Using 'thinking together' in individual supervision.
*Training all new staff in the team about 'thinking together' 

!3. Mentalizing the Network
An ability for the team to support each other in making sense of the behaviour of staff from other agencies in terms of understandable  mental states and intentions of agents in that organisation.  

An ability for the team to support each other in adopting a position of respect towards staff from other agencies and to demonstrate this by positive curiosity about their work with the young person. 

An ability for the team to support each other to identify all key participants from the youth’s professional network who have an investment in the youth’s outcomes, including family members where appropriate and other formal and informal key stakeholders. 

An ability for the team to support each other in facilitating collaboration between professionals at all levels of the service system that takes into account professional beliefs about the nature of the young person’s difficulties, what may be helpful in addressing these problems, and beliefs about role responsibilities in a multi-agency system. 

!!!Team Practices that support Mentalizing the Network
*Using the method of network sculpting to reflect on difficult cases
*Using the dis-integration Grid as part of case formulation 
*Using network sculpting as part of team training events. 

!4. Learning as a Team 
An ability to reflect with team colleagues on interactions with young people and/or professionals in the network and in a systematic way agreed within the team (e.g. discussion in a team meeting) in order to enable collective learning about effective practice.  

An ability for the team to support each other to make use of the team wiki manual in order to ensure that clinical decision making is consistent with evidence based practice and the AMBIT model as applied to the specific local team.   

An ability for the team to support each other to engage in team discussion about important areas of practice with young people in order to develop a shared approach to a particular difficulty or situation that commonly arises with this client group. 

An ability to contribute into achieving a consensus approach to common clinical dilemmas based on team reflection and discussion and to manualize practice guidance from this.  

!!!Team Practices that support Learning as a Team
*Having planned manualising meeting at set times throughout the year. 
*Using the manual as part of case discussion. 
*Re-writing aspects of core AMBIT practice adapted to local service needs

!5.Evaluating Client Outcomes 
An ability for the team to support each other to recognise the importance of remaining curious as to whether a particular method of work with a young person is be experienced as helpful to them. 

An ability to support and contribute to the development of systematic methods within a team to evaluating whether young people are experiencing the service as beneficial to their problems. 

An ability to focus on continued evaluation of outcome from multiple perspectives, ensuring that both the young person and the AMBIT worker communicate their respective viewpoints and consider the viewpoint of the other. 

An ability of the team to support each other to complete an AIM assessment with a young person or  with a member of the network who knows the young person well or a family member as part of an initial assessment of the young person’s needs. 

!!!Team Practices supporting Evaluating Client Outcomes
*Having a systematic method of recording client outcomes at the point of discharge
*Discussing client outcomes as part of team awaydays.
*Reporting on client outcomes to the commissioners and including the team in such reports
*Meeting with young people to consider outcomes and how these could be improved. 

AMBIT was originally devised out of work developed by a group of practitioners at the Anna Freud National Centre for Children and Families and the Marlborough Family Centre. 

At the current time (2016), the AMBIT Project has three senior AMBIT trainers - [[DickonBevington]], [[Peter Fuggle]] and [[Liz Cracknell]] who are based at the Anna Freud National Centre for Children and Families and four AMBIT Trainers:
and a further two Lead Trainers:
Suzanne Hare
Laura Talbot

There are also [[AMBIT Assistant Trainers]] who are experienced practitioners currently working in [[AMBIT-influenced]] teams

!!''1. Expression of interest''
*Enquiries about [[AMBIT training|Information About AMBIT Training]] from teams/services go to [[The AMBIT Project Coordinator|mailto:ambit@annafreud.org]].
*We will send out published papers and a link to the AMBIT manual
*We will also make initial enquiries about the size of the team, whether it is statutory or voluntary sector and annual income of the team if voluntary sector.
*We will ask the enquirer to fill in an Expression of Interest form

!!''2. Engagement Call''
In order to assist with the process of establishing whether the AMBIT Programme can be of help to a team or service, we follow up initial enquiries by scheduling an engagement call. This is a 30 minute telephone conference call between you (it can be more than one person as relevant) and either the AMBIT Programme Lead or Deputy Lead.

<<link-pdf "Engagement Call" "https://drive.google.com/file/d/1TxIUFm5cZhDIE4z2_JzX-anpGLlkVb0q/view?usp=sharing">>

!!''3. Consultation Day ''
An AMBIT consultation is offered as standard to all teams enquiring about undertaking AMBIT training, after the initial engagement call. The broad purpose of the consultation day is to reach a shared understanding with a team (or organisation) about whether embarking on AMBIT training will be useful to them and if so, what the training objectives might be. The meetings can involve senior managers, clinicians and all staff due to attend a training. The day will be facilitated by two trainers from the AMBIT Programme, one of whom will be the AMBIT Programme Lead or Deputy Lead.

After the Consultation day the AMBIT programme will send a consultation report, summarising the key themes arising from the day, training objectives and make
recommendations about training routes and implementation support should the
team/organisation wish to proceed with booking an AMBIT training. It is important to the
AMBIT programme that training is useful for teams and as such, there is no obligation to
book training after the consultation day if it does not feel as if it would assist the team
with their development. 

<<link-pdf "Consultation Day" "https://drive.google.com/file/d/15KR2OzpDhpc6uup3A1SOdi6-VMLighjK/view?usp=sharing">>



!!''4. Application Review and Acceptance''
Following the Consultation day the application is reviewed, and a decision will be made //jointly// about whether the team wants to proceed with [[AMBIT training|Information About AMBIT Training]], and if so, by which route. Arrangements for training will be finalised with [[The AMBIT Project Coordinator|mailto:ambit@annafreud.org]]

!!!!!//Note//- //At any stage in the application process, it may be helpful for teams to hold a [[Briefing session for senior managers/commissioners]]//

!!''Intention'' 
The intention of the AMBIT project at the [[AFNCCF]] is to provide free, OpenSource resources for supporting and developing effective practice with young people whose needs are multiple, complex, and who are subject to social exclusion and who may not be seen as "help-seeking" in conventional terms.
!!''"There is no such thing as an AMBIT team"'': 
* We talk instead of [[AMBIT-influenced]] teams
* AMBIT is focused on supporting IMPROVEMENT in relation to locally-defined organisational/service goals.  
* We are, however, looking at developing an option for teams/organsations to become [[AMBIT-accredited]].
!!''Locally defined service goals''
In pursuit of these locally-defined service goals, AMBIT training is designed to:
* ''Support'' [[LEARNING at work]] so that local teams can develop, record and broadcast their own excellence and learning.
* ''Provides a robust foundation of theory and integrated practices'' 
** (see [[AMBIT: an overview]], and note the explicitly evidence-based and manualized interventions here: <<tag [[Specific interventions]]>> which are integrated within the broader framework of AMBIT.
** The content of AMBIT //has been shaped by the teams trained//, with encouraging early outcomes data published (see [[Academic references]]).
** ''Share all of our [[Training exercises]]'' that have been found to be helpful over multiple trainings.
** ''Encourage wide dissemination through supporting''  locally-delivered training sessions: 
*** <<tag [[Planning a training event in your team]]>>
!!''No rigidity''
There is no rigidly fixed method of being trained in the AMBIT approach, but note the following:
* ''We do NOT train individuals in AMBIT'' - it is a team approach
!!''Respect Local Practice and Expertise''
*We do not want to leave workers with a sense that their existing skills are wrong or devalued.
*Rather than giving didactic teaching about what we want people to do and then asking them to practice this, it is helpful to introduce new techniques by first examining present practice and existing skills.
*This includes looking at what can go wrong in present practices.
*It may include looking at video or role play examples of "unsuccessful" attempts to achieve the basic aims of the skill to practice.
*AMBIT seeks to AUGMENT these existing skills by adding mentalizing to a range of existing and perfectly legitimate skills, rather than REPLACING them.
!!''Manualizing''
*When teaching people to [[Manualize|Manualization]] material - pay attention to how new material they generate is fitted into (integrated with) //existing material// in the manual.
* Use the [[Search]] facility to check for similar or overlapping topics and themes
* Consider what related material is already there, and what [[Links]] and [[Tags]] should be added.
* If considering whether to tag a new page, first open the tag ([[Topic]]) and look at the other [[Sub-topics]] gathered under it - would this new page be "in the right company" with these other [[Sub-topics]]?
!!''Emphasis on resisting Shame''
*We constantly emphasise the ordinariness of anxiety in the work, and the fact that there should be no shame attached to feeling anxious in the work we do
*There is much that workers //should// feel anxious about.
*AMBIT seeks to help them maintain safe, sustainable and effective practice in spite of this.

For AMBIT's 4th annual conference, on 2nd June 2016, we ditched the traditional conference format adhered to in previous years in favour of a style more in keeping with the AMBIT's tradition of co-creation and the project's ambitions to foster and sustain a [[Community of Practice]] for AMBIT-influenced teams and individuals: the ''unconference''. The [[unconference | https://en.wikipedia.org/wiki/Unconference]] format provided a loosely structured space for peer-to-peer sharing of ideas, good practice and learning.

At the beginning of the day, participants were invited to make a note on small pieces of paper of particular conversations they would like to lead or take part in. These ideas were then mapped to the quadrant of the [[AMBIT Wheel]] to which they most related, and organised into five "Unconference Conversation" topics for each quadrant: [[Working with your CLIENT]], [[Working with your NETWORKS]], [[LEARNING at work]] and [[Working with your TEAM]]. We then had a participant-created schedule for the morning, with sessions relating to each quadrant to run concurrently in separate rooms. The schedule was displayed on a board so that participants could choose their own timetable for the morning:

<<image [[Unconferenceboard]]>>

Notes made by facilitators in each unconference conversation are available here, arranged by quadrant. 

|bgcolor(pink):<<tag [[Working with your CLIENT Unconference Conversations]]>>|
|bgcolor(lightgreen):<<tag [[Working with your NETWORKS Unconference Conversations]]>> |
|bgcolor(yellow):<<tag [[LEARNING at work Unconference conversations]]>> |
|bgcolor(lightblue):<<tag [[Working with your TEAM Unconference conversations]]>> |

In the afternoon we played some games designed to prompt thinking about ''Dis-integration'' (which involved silly glasses and balloons) and the use of the [[Community of Practice]] (which involved post-it notes on foreheads and long bits of elastic). We also offered three short, pre-planned talks with a view to sharing practice, sparking conversation and seeking feedback and collaboration:
*AMBIT training across a locality - James Wheeler
*Thinking about the AMBIT Wheel from a young person's perspective - Dickon Bevington
*Starting an AMBIT-influenced team from scratch: establishing a partnership between the AMBIT Project and an NHS healthcare team - Liz Cracknell

A "cafe corner" was open all day to create a space for those serendipitous encounters with fellow participants which feedback from previous conferences tells us sometimes create the most valued learning opportunities.  

See also the [[Core Features of AMBIT]] for text and video to support this diagram.
!!!Download!
You can Download the AMBIT Wheel diagram as a PDF [[here|AMBIT Wheel.pdf]] 
!!!Diagram:
Click on where you want to go (or scroll down for more content.)
[img[AMBIT wheel 2014_SMALL]]<<imageMap MapWheel_2014>>

!Explanation
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!There's more: a client's version
The AMBIT Wheel is primarily designed for the benefit of workers - helping them to map or [[mark|Marking the Task]] and [[balance|Holding the Balance]] the range and scope of their work tasks.

A new development currently under review is a "matched"  (segment-for-segment) version, the [[Client's AMBIT Wheel]].  Early feedback about this from practitioners at the 2016 AMBIT conference was positive - as a way of shaping workers' understanding of their work from the client's point of view. Whether sharing it with clients (as a form of PsychoEducation aid) adds any value is undetermined as yet. 

!!Feedback from AMBIT-influenced teams
>>"We have found that we have managed to embed use of the 'Wheel' in the team meeting (members elect to think with a view to a particular quadrant)"
>>> AMBIT-influenced team, 2014

!!''Combining the ambit wheel and the APrAT''
This page includes two visual aids created by ''Alastair Wakely'', Harmful Sexual Behaviour Services Coordinator in Wiltshire and B&NES. They were created by combining the ambit wheel and the APrAT questions. Colleagues can have these up in their offices as a quick reference for checking an AMBIT view about a case.

You can download these by clicking the pop out button on the top right hand corner, which will direct you to google docs where you can download them from. 

!!!''AMBIT Wheel with Tools''
<iframe src="https://drive.google.com/file/d/1X3lupnmO9Av6cmeta5dkj1R6b6tyrhNI/preview" width="640" height="480"></iframe>

!!!''AMBIT Wheel with APrAT Questions''
<iframe src="https://drive.google.com/file/d/1llNxnnfg2pD4NI-46tp6IjfOSWRzfrxs/preview" width="640" height="480"></iframe>

!Work in progress!

A page for documenting how AMBIT has (or intends to) interact(ed) with ''other models of practice''. To include refs to ideas of Integration, Dis-integration, Working alongside, Co-construction and Co-production.

See page on [[Signs of Safety]] for an example, and describe work with FPM (Family Partnership Model) as another.

See John Burnham paper - "Approach, Method, Technique"

In some ways AMBIT is at least much an approach to support Quality Improvement in a service, as it is a "therapy".  Another way of putting this is that if mentalizing is useful for our clients and their families, it's just as useful us as professionals and our teams.  See sub-topics under this heading for material relating to Service Improvement and [[Implementation Science]]

We have produced 3 sets of cards for use within supervision or case discussion contexts, which are based on ideas from several different AMBIT teams who had developed and used such cards in their team meetings. Each of these card sets is described below. 

''AMBIT stance cards''

The [[AMBIT stance playing cards|AMBIT stance playing cards]] were developed by the CASUS team, a substance use service for adolescents in Cambridgeshire. Each area of the AMBIT stance is printed on individual cards which are dealt out to team members. Each team member is responsible for holding that particular area of the stance in mind during the discussions. The purpose of this is to support a team to remain "on balance" by attending to the four different domains of AMBIT - Client, Team, Network and Learning - within the discussion taking place. 

''AMBIT Marking the Task cards''

These cards were based on cards developed by the AMASS team in Islington, an edge of care team for adolescents, for use in their weekly group supervision. The purpose of the cards is to assist team members in [[Marking the Task]], which is the first of the four steps in [[Thinking Together|Thinking Together]]. The cards contain a number of different categories of task that a worker might want help with. Sometimes selecting a clear and specific task can be a challenge for workers, particularly since the experience of having a dilemma or feeling stuck is often related to a loss of mentalizing, which can make it more challenging for a worker to think through "//What exactly do I need help with?//".  The intention of getting a worker to select the relevant card and place it on the table is therefore to help with both the identification of the task and to create a playful way of helping the worker and the team hold the boundary around being clear about task //before //moving into [[Stating the Case|Stating the Case]] i.e. ("//You can't start until you've chosen your card and helped us understand what the task is//!"). 

''AMBIT usual suspects cards''

Developed by CASUS workers, these cards are intended to be given out to team members who are wanting to assist a worker in thinking about addressing [[Dis-integration|Addressing Dis-integration]] within a network. The worker can select the relevant professionals from the pack of cards, assign each of these cards to a member of the team and ask each team member to mentalize that worker's perspective in the discussion that follows. This may help to identify areas of agreement, dis-integration and possibilities for [[connecting conversations|Connecting Conversations]] that may be helpful. 

----
Click on the 'more' button under the manual manual to see a dropdown list of all the teams who have recieved [[AMBIT training|Information About AMBIT Training]] and who have their own individual local manual.

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AMBIT conference 2014
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A rather hurried but packed conversation:

* ''Where to start?''
** How to introduce an organisation to AMBIT
** How to introduce AMBIT to the organisation

* We discussed the ''usefulness of the theory of Dis-integration'' - as the "natural resting state" of all complex multi-professional [let alone multi-agency] networks.  
** Establishing this ''reduces the likelihood ''professional shame'''' in talking about this (and reduces the possibility of workers in trouble shrinking away from help-seeking.)

* We discussed how critical it is to have ''Top-down and bottom-up conversations with staff in the organisation'' (senior managers/commissioners/CEO's AS WELL as street level workers; the latter are often easier to engage with the material and ideas.)
** Beware senior managers who engage AMBIT trainings more because "We need to spend this money before the end of the year, or it will be taken away from us" than because of an understanding of authentic need in the team.
** Discussion of the PREP day of pre-training preparation (see [[PREP day: Overview]])
** Never seems to have been as much senior management engagement as we wanted/thought we had achieved before the event!

* ''Barriers to discussion with senior management/commissioners''
** More difficult for managers to acknowledge a "learning gap" in their team, and to acknowledge their own need to understand what might be seen as "detailed clinical practice"...
** Easy to misunderstand the systemic/organisational implications of an AMBIT training
** Do the people commissioning AMBIT training understand what it is they are inviting in?!

* ''Upwards conversations "By Stealth"''
** Small influential "corridor conversations"
** Talking "their language" - especially outcomes.
*** see other discussion on [[Does AMBIT work? (Unconference conversation 2016)]]
*** Use of [[Elevator Pitch]] exercise with team: ''can you create an elevator pitch that summarises in 1 minute:''
**** The goals of the (training) project?
**** The Barriers to successful completion of the team's [[Implementation Plan]]
**** Proposed solutions to these barriers?

AMBIT is in some senses a way of working with young people or adult clients whose [[Relationship to help]] is non-conventional or troubled, and before they are ready to receive more mainstream forms of help. 

[[Active Planning]] provides:
|bgcolor(lightgrey): ''A FRAMEWORK for developing relationships'' where [[Epistemic Trust]] can be established |
And together with the other elements of [[AMBIT|AMBIT: an overview]] seeks to provide:
|bgcolor(lightgrey): ''CONTEXTS in which sustainable therapeutic change is most likely to become possible'' |

AMBIT aims to capture - from research-based [[Evidence]], workers, and [[Experts By Experience]] - some of the key dilemmas that workers experience, and to collect evidence-based practices that may assist with managing this, which are described as the [[Core Features of AMBIT]].  

We have produced 3 sets of <<tag [[AMBIT playing cards]]>> for use within supervision or case discussion contexts, which are based on ideas from several different AMBIT teams who had developed and used such cards in their team meetings. Each of these card sets is described below. 

''AMBIT stance cards''

The [[AMBIT stance cards]] were developed by the CASUS team, a substance use service for adolescents in Cambridgeshire. 

{{AMBIT stance cards}}

Each area of the AMBIT stance is printed on individual cards which are dealt out to team members. Each team member is responsible for holding that particular area of the stance in mind during the discussions. The purpose of this is to support a team to remain "on balance" by attending to the four different domains of AMBIT - Client, Team, Network and Learning - within the discussion taking place. 

''AMBIT Marking the Task cards''

The [[AMBIT Marking the Task cards]] cards are based on cards developed by the AMASS team in Islington, an edge of care team for adolescents, for use in their weekly group supervision. 

{{AMBIT Marking the Task cards}}

The purpose of the cards is to assist team members in [[Marking the Task]], which is the first of the four steps in [[Thinking Together|Thinking Together]]. The cards contain a number of different categories of task that a worker might want help with. Sometimes selecting a clear and specific task can be a challenge for workers, particularly since the experience of having a dilemma or feeling stuck is often related to a loss of mentalizing, which can make it more challenging for a worker to think through "//What exactly do I need help with?//".  The intention of getting a worker to select the relevant card and place it on the table is therefore to help with both the identification of the task and to create a playful way of helping the worker and the team hold the boundary around being clear about task //before //moving into [[Stating the Case|Stating the Case]] i.e. ("//You can't start until you've chosen your card and helped us understand what the task is//!"). 

''AMBIT usual suspects cards''

Developed by CASUS workers, the [[AMBIT usual suspects cards]] are intended to be given out to team members who are wanting to assist a worker in thinking about ''Dis-integration'' within a network. 

{{AMBIT usual suspects cards}}

The worker can select the relevant professionals from the pack of cards, assign each of these cards to a member of the team and ask each team member to mentalize that worker's perspective in the discussion that follows. This may help to identify areas of agreement, dis-integration and possibilities for [[connecting conversations|Connecting Conversations]] that may be helpful. Additionally the cards may be used within a group discussion or individual supervision to “sculpt” a network in order to make sense of the client’s system of help, visually map out dis-integration and consider the the differing perspectives. This is a quick and easy alternative to the [[Sculpting a network]] exercise and use of [[The AMBIT Pro-Gram]].

The AMBIT programme is led by [[Laura Talbot]] & [[Liz Cracknell]].  [[DickonBevington]] and [[Peter Fuggle]] are consultants to the programme, which is hosted at the [[Anna Freud National Centre for Children and Families]].

AMBIT is the work of a group of original [[Authors]], led by DickonBevington and [[Peter Fuggle]], but it has only come into its current shape through the contributions of hundreds of practitioners in the many teams that have had [[AMBIT training|Information About AMBIT Training]] and have given feedback from the field.

<div style="background-color:lightblue">
<h1>Contact us</h1>
</div>

<div style="font-size:0.7em;text-align:left;margin-top:3em;margin-bottom:3em;">
<a href="mailto:ambit@annafreud.org" class="tc-btn-big-green" style="background-color:#5E9FCA;">
{{$:/core/images/mail}} Email the AMBIT programme
</a>
<a href="https://twitter.com/AFCambit" class="tc-btn-big-green" style="background-color:#5E9FCA;" target="_blank" rel="noopener noreferrer">
{{$:/core/images/twitter}} @AFCambit on Twitter
</a></div>

<div style="background-color:lightblue">
<h1>Programme Staff</h1>
</div>

!!Dickon Bevington
{{DickonBevington}}
<div style="clear:both;"/>

!!Peter Fuggle
{{Peter Fuggle}}
<div style="clear:both;"/>

!!Laura Talbot
{{Laura Talbot}}
<div style="clear:both;"/>

!!Liz Cracknell
{{Liz Cracknell}}
<div style="clear:both;"/>

!!Gemma McKenzie
{{Gemma McKenzie}}
<div style="clear:both;"/>

!!Marianne McGowan
{{Marianne McGowan}}
<div style="clear:both;"/>

!!James Wheeler
{{James Wheeler}}
<div style="clear:both;"/>

!!Rebecca Smith
{{Rebecca Smith}}
<div style="clear:both;"/>

!!Mark Dangerfield
{{Mark Dangerfield}}
<div style="clear:both;"/>

!!Bea Herbert
{{Bea Herbert}}
<div style="clear:both;"/>

<div style="background-color:lightblue">
<h1>AMBIT Assistant Trainers</h1>
</div>

!!Verity Beehan
{{Verity Beehan}}
<div style="clear:both;"/>

!!John Lincoln
{{John Lincoln}}
<div style="clear:both;"/>

<div style="background-color:lightblue">
<h1>AMBIT Study Group Leads</h1>
</div>

!!James Fairbairn
{{James Fairbairn}}
<div style="clear:both;"/>

!!Anna Oriol- Sanchez
{{Anna Oriol-Sanchez}}
<div style="clear:both;"/>

!Key priorities for AMBIT 
1. Building access to ''data on outcomes''

2. Creating a more sustainable ''project management structure'':

*Clarifying/refining key organisational processes and roles in the training programme.
*Refining and recording updated curriculum for a consultation day
*Overseeing all AMBIT supervision (timetabling and structures)
* etc
3. New areas of research and applications:

* Manualizing as something that is now beyond just AMBIT
* [[Social Network Analysis]]

This is a means of helping a team to [[SUSTAIN best practice]] in their day to day work during [[Team Meetings]].

{{AMBIT stance cards}}

A set of playing cards with the each of main elements of the AMBIT stance (see [[Core Features of AMBIT]]) printed on one, is shuffled and the cards are dealt - one to each team member - at the beginning of a team meeting.

The holder of each card becomes a "stance monitor" for that particular aspect of practice during case discussions, trying to keep a focus for that meeting on whether there are particular aspects of practice influenced by that element of the stance that should be emphasised.

This technique works best if a certain amount of playfulness is allowed to lubricate the serious intent underlying it.  Stance bingo is an alternative that has been suggested...

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!! Background context to the study group

The AMBIT [[Community of Practice]] has grown considerably over the last 10 years with towards 300 teams and services completing AMBIT training and a continued high level of interest from other services nationally and internationally in the model. 

In general, [[feedback from teams|Feedback on AMBIT Training]] (in relation to the experience of training and impact on their service) is very positive. However, with the growth and increased reach of the model there is a clear need to formally and rigorously evaluate the effectiveness of an AMBIT influenced approach. To date, there have been some smaller scale evaluations of AMBIT influenced services and evaluations currently underway e.g. CASUS.

Given the need to evaluate we are eager to investigate questions including:

# ''Whether an AMBIT influenced approach is effective?'' i.e. Does it help those areas that we intend it to (client functioning, team function, network function and learning).
#''Does it help clients and teams in meeting their own specific goals? ''
#''Does it cause any unforeseen problems? ''
#''How does it work?'' i.e. does it work in any of the ways that we would predict based on the theories which underpin it? What are the things that mediate or moderate outcomes?

There are a number of challenges in evaluating outcomes across AMBIT influenced teams. In particular, the nature of ambit itself- as an adaptive approach aimed to be applied in different ways across different contexts and with different client groups. There are no 2 AMBIT influenced teams who work in exactly the same way (although there will be common features of ‘core practice’ across teams). 


//In February 2019 AMBIT influenced teams met together with researchers and academics to work on the theme of outcome evaluation. Some key points  came from this including://

#''Measuring client functioning'' should be a primary outcome for any evaluation of AMBIT influenced teams. This means measuring whether there is a change in overall functioning for the client from beginning to end of contact (rather than just measuring changes in specific symptoms)
#[[Logic Models]] can be an important to underpin the evaluation. These are ways of breaking down the (i) resources needed, (ii) the activities that go on and  (iii) the outcomes expected.

!!Evaluation pilot

There is currently a pilot evaluation project already underway with 5 AMBIT influenced teams who are trialling the use of the AIM as a pre and post outcome measure with their clients. These teams have been offered the use of [[Patient Outcomes Database (POD)|POD - a web based outcome measurement system]], an online secure data collection system, to record and pool their outcomes. There is also a shared spread sheet available for those teams not using POD. 

These teams have taken part in a training day around evaluation, aiming to stimulate thinking about outcomes, the potential purpose and use of outcomes in their team, as well as training in the AIM. 

!!''Plan for the AMBIT study group''


''The overall purpose of the group is'':

* To develop the AMBIT [[Community of Practice]], increase collaboration and build relationships between teams

*Support [[learning|LEARNING at work]] together in ways that are lively, creative and interesting!

*Build on the work that has started already within the AMBIT community and in the evaluation pilot teams 

*Work together on defined shared projects. These will include building a shared data set and evaluation of the AMBIT influenced approach using the AIM as a first measure

*To work with client group representatives in developing the use of [[Evaluating outcomes]] in AMBIT

*Stimulate further post graduate research around AMBIT
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!! Group membership


*The group will have representation from Europe, America and Australia
*Representatives of each team will be asked to commit to joining the larger study group twice a year, with a combination of multi-site and face to face meetings. Smaller sub-groups will join together more frequently. //Costs for attendance at meetings would need to be covered by local teams.// 

*Teams joining the group would be required to use the [[AIM]] questionnaire and AIM ‘6 key problems’ as outcome measures pre and post intervention and share these with the group as part of the evaluation project

*After the group is established we will work as a closed group for a period towards shared specific objectives, including the evaluation project 

*We intend that this would lead to publication of some of the work separately and together as a group

*We would like to stimulate shared learning around the model and it’s relation to the client groups that AMBIT teams work. We will use some of the AMBIT structures and theory to support collaboration and learning within the group meetings

The following content is curated under the heading [[AMBIT-R training programme]]:

{{AMBIT-R training programme}}

This is just the TIMETABLE for the AMBIT-R programme (AMBIT for residential settings) - see the detailed trainer instructions for each day here: <<tag [[AMBIT-R training programme]]>>

<<tag [[AMBIT-R Training Schedule]]>>

!Day 1

{{AMBIT-R Training Schedule - Day 1}}

!Day 2

{{AMBIT-R Training Schedule - Day 2}}

!Day 3
{{AMBIT-R Training Schedule - Day 3}}

!Day 4
{{AMBIT-R Training Schedule - Day 4}}

Below is the training schedule for __ [[Day 1|AMBIT-R training programme DAY 1]]__ of AMBIT-R training.

----

1. Activity: Before we start, where are you now?

2. Activity: Introductions

3. Discussion: Planning the day

4. Exercise: What are your existing strengths?

!!>BREAK for COFFEE/TEA

5.  What makes this work hard?

5(a) Activity: Describe the challenges

5(b) Activity: Create examples (Who are Our Clients?)

6. Activity: Develop Training Goals for the team

7. Discussion: What PROBLEMS is AMBIT designed to help with?

8. THE CORE IDEA: MENTALIZING

!!>BREAK for LUNCH

8. (Continued) WATCH FISH TANK CLIP

9. PRACTICE Mentalizing WITH TEAM-MATES.

9(a) ''Reminder - it's not just our clients whose mentalizing wobbles!'' 

9(b) Exercise: The [[Passed-outwards Discussion]] or 'POD'

9(c) Additional Trainer/facilitator notes on the POD:

!!>TEA BREAK 

10. Putting it together: What's the POINT of mentalizing? 

10(a) Exercise: Obstacle Course - taking advice!

10(b) Teaching on Epistemic Trust

11. Putting it together: what is AMBIT?

!!>END OF DAY

Below is the training schedule for __[[Day 2|AMBIT-R training programme DAY 2]]__ of AMBIT-R training.

----

1. Recap and feedback on DAY 1 (up to 30 minutes)

2. Preparing for today

3. EXERCISE: "a well-connected team"

3 (a) - Taking stock of our team

3(b) Help-giving for team-mates can be hard to do

!!>TEA/COFFEE BREAK

4. A disciplined approach to helping conversations: "Thinking Together"

4(a) Play the video introducing [[Thinking Together]]

4(b) Play one of the video demonstrations of "Thinking Together"

4(c) Practice this

4(d) Take feedback from groups: How was it for you?

4(e) Practitioner reflections on using Thinking Together in the field

!!>BREAK - LUNCH

5. Team around the Worker

5(a) Exercise

5(b) Think about the position of ''RESIDENTIAL CARE WORKERS''

6. Working with our NETWORKS

6(a) Dis-integration: a painful truth in complex systems

6(b) Group discussion: Wearing Different hats

6(c) Facilitated brief Group Feedback

!!>BREAK - TEA

6(d) Addressing Dis-integration

6(e) Mapping a system of help: the AMBIT Pro-Gram

7. Concluding remarks and reflections

!!>END OF DAY

Below is the training schedule for [[Day 3|AMBIT-R training programme DAY 3]] of AMBIT-R training.

----


1. Feedback

2. Plan for day

3. Why mentalizing matters in the work we do: Epistemic Trust

4. Putting mentalizing to work with clients: the Mentalizing Stance

5. Active Planning: applying the mentalizing stance to Planning help for clients

!!>COFFEE BREAK

6. Working with Networks: Sculpting

7. Working with Networks: The Dis-integration Grid

!!>LUNCH

8. Learning at work

8 (a) Line-up exercise

!!>BREAK FOR TEA

8(b) LEARNING at work conversation

8(c) Manualizing exercise, and the Wiki Manual

Feedback and end

!!>END OF DAY

Below is the training schedule for __[[Day 4|AMBIT-R training programme DAY 4]] __of AMBIT-R training.

----

!!>Trainers/Facilitators notes

!!>Feedback and orientation

!!>Plan for the day

1. General theme: fostering important conversations

2. Practice: Team Meetings

!!>Coffee/Tea Break

2. (Continued) Practice: Team Meetings

!!>LUNCH

3. Learning: Using measures/outcomes in the team

4. Implementing //what matters to the team//

4(a) Exercise: Trolley dash

4(b) ''Changing behaviours in a team is very hard''

!!>TEA BREAK

5. Catch up time

!!>END

!!Background reading for trainers

!!!__What is AMBIT-R?__

For a dropdown menu of ''trainer's instructions'' for running each day's training curriculum: <<tag [[AMBIT-R training programme]]>>

For the ''timetable for each day'' of AMBIT-R training, click here: <<tag [[AMBIT-R Training Schedule]]>>

AMBIT-R stands for ''AMBIT-RESIDENTIAL'', a specific adaptation of the AMBIT training ''designed with and for workers in the Children's Residential Care sector, in and around the Great Manchester area''.

This adaptation was made possible by funding from ''Health Education England (HEE)'' and by our partners in ''Manchester City Council'', especially those members of staff in Children's Residential Care settings across the City who took part in the original three waves of training, that led to the development of this curriculum

!!!__Structure of the AMBIT-R training__

The core theory and practices of AMBIT are the same in AMBIT-R, but the training programme has been adapted to suit the needs and preferences of the workers in this field.  There has been a particular effort to keep explanations of theory to a minimum, and to reflect preferences for //learning-by-doing// rather than through abstract (powerpoint illustrated) accounts.

!!!__BEFORE YOU START A TRAINING: Preparation__
See [[PREP day: Overview]] and these notes made in Manchester:

In planning the training with commissioners, team managers and team members always ask the question: '''WHY ARE WE BEING ASKED TO DELIVER TRAINING HERE?'''

* It is important to recognise that the teams we train ''ALREADY KNOW A GREAT DEAL ABOUT HOW TO DO THIS WORK!'' - AMBIT does not come in to wreck things that already work (one of AMBIT's key [[principles|Core Features of AMBIT]] is [[Scaffolding existing relationships]])
* This is ''not'' just a training to ''"share a few special tricks”'' that will make things work with young people - we are not selling magic!
* This is a training ''to encourage a team (or teams) to collaborate with the trainers so they can develop their OWN locally-adapted and locally-applicable approaches.'' It is about helping teams //develop their own local culture// that will help a team do this hard work in ways that are more sustainable, fun, and above all, //effective//.
* Therefore, ''in order for this to work, it requires more than that trainees simply “turn up”''
* How do we create a culture in a local team to support continuous improvement?
** ''Senior managers must reassure staff'' (genuinely!) that this is NOT about reorganisation, special measures, etc, and nor is it about “tokenism” – throwing training at workers to solve a training budget underspend, etc.
** The message from the top down must be: //“We are invested in this.”//  In order for that to happen, senior managers and commissioners must be able to grasp what AMBIT is, and is not.
** ''AMBIT-R PREP sessions:'' Consider how to ensure the attendance of the right senior managers before the training begins: they must be clear about what they are commissioning. 
** ''Attendance of senior managers at the training?''
*** There may be circumstances in which senior managers would want to attend for episodes during the training.  Could the team teach the “boss” what they need him/her to know about how they are trying to develop and work?  This would need the boss to be pre-warned about the purpose of attending such sessions…
*** It may make sense for senior managers to come for the whole training, or in other instances to make space for them to come on day 4, when the team(s) could present their understandings of what they have covered, and what support they want from their manager to implement these things.
*** In some situations, a separate managerial stream for AMBIT-R trainings would make sense.  
*** ''These decisions will rely on local expertise'', as there is no definitive evidence base that can determine the right way to engage and involve both workers and managers effectively in a particular setting.
** ''Managerial support for WHOLE TEAM ATTENDANCE:'' this is a TEAM approach that needs commitment… if only a small section of a team attends there is a risk that this creates two teams within a team.  There are smart ways to approach rotas in order to facilitate this whole team attendance, but it is important to stress this. 
** ''Pre-training reading or videos'' – some people like this.
*** See the AMBIT crash course in short videos: [[here|https://www.youtube.com/playlist?list=PLJK5O2B_tNfmo8FRObOGKZ0jr3dhaiM_D]]. 
** ''Broadcast intentions'' around the pre-training questionnaire ([[ASEQ|AMBIT Service Evaluation Questionnaire (ASEQ)]] etc)
*** These are most definitely NOT to spy on staff!
*** They are to help the trainers to get a reasonable idea of the team's //existing strengths and challenges//, and to offer the possibility of a pre- and post-training //measure// that could indicate outcomes for the team. //"Has this training made the differences we wanted it to?"//

!!!__Materials required for Trainings__
This is a non-exhaustive list of materials required for a training:

* Projector, screen, leads, and laptop
* Access to ~WiFi
* Access to the online manual at https://manuals.annafreud.org/ambit
* USB stick for videos/slides (if wifi not reliable)
* Access to the first 6 minutes of the [[Fishtank film clip]] - either on a DVD, online subscription, or you may find it on ~YouTube. 
* ROOM with space for floor exercises! - if the space for training is too cramped it will seriously affect the outcomes.
* POSTERS of the wheel (change “Key worker” to “Trusted Worker”)
* HANDOUTS – lay the materials out IN THE ORDER THEY TRAIN IN IT! E.g. Days 1, 2, 3, 4…
* Post-it notes (lots)
* Cardboard Cutout people (blanks - a commercial example is [[here|https://www.cardboardcutoutstandees.com/?gclid=CjwKCAiAksvTBRBFEiwADSBZfIEh37j2uDiIaY71mULYVQgmzH7gJJ9uj8XDlgHrgR7ToADSQlgxdxoC8EIQAvD_BwE]])
* Flipcharts and Pens
* Powerpoint slides, Projector, Screen, Internet connection and laptop
* Extension lead
* A Brain (model!)
* Cones etc and Voice-changer for Epistemic Trust game
* Toy supermarket trolleys (2) - optional but wonderful if available
* AMBIT cards - (see list for Trolley dash on Day 4)
* AIM forms

!!!__On the use of Videos__
Many of the videos were originally made for this project, as a way of "compressing" the theory elements of the curriculum.  However, the general feedback from early versions of the AMBIT-R training that trialled these videos, was that despite being shortened and simplified they were still //too long or "school-like"// or they //took away from the authority/liveliness// of the face to face training that was important to staff.

We therefore recommend that the <<tag Videos>> are better used as:

* ''Preparatory work for [[AMBIT Local Facilitators]]'', so that they are clear what the key learning points are.
* ''Resources ([[Training exercises]]) for teams to use POST-Training'', in locally-run top-up sessions
** i.e. watch ONE video together at the beginning of a team meeting
** discuss this/do one of the [[Training exercises]] to practice this/monitor your team’s use of these ideas in the week ahead
* ''E.g. watch the [[Epistemic Trust]] video as a team''
** Ask each team member to talk with a partner about how they might try to use (or have in the past used) epistemic trust, or these ideas.
** Ask them to apply this in a more purposeful way in the week ahead, and report back to the team about how this went, and whether this makes a difference.  
** Next week: feedback on this session, and on how this “tryout” went.

Repeat with next video!

----

See <<tag [[AMBIT-R training programme]]>> for a drop-down menu of each day's training curriculum.

For ''timetables for each day'' of AMBIT-R training, click here: <<tag [[AMBIT-R Training Schedule]]>>

!!Intro:
These are notes for [[AMBIT-R]] facilitators and trainers, to support them in working through a structured AMBIT training.

See the page [[AMBIT-R training programme]] for more introductory material.

See the pages tagged <<tag [[AMBIT-R Training Schedule]]>> for just the timetable (without the instructions)

The better you know these notes beforehand, the less you will need to refer to them during the training, but we think it would be helpful to have access to them during a training.

The point of these notes is to ensure that any AMBIT-R training is basically the same as the others.  If that were not the case then how would we know if one AMBIT-R training was the same as the next, and whether this work is actually making any difference?!

You can use the associated (embedded) film clips to support the exercises and team discussions in the room (assuming you have internet access where you train) OR you can use these film clips to clarify the purpose of each exercise //before// you deliver the training.

----

!DAY 1
!!!See [[AMBIT-R Training Schedule - Day 1]] for the Day 1 timetable only.

!!__1. Activity: Before we start, where are you now?__

Before any discussion, collect baseline measures (unless this has already been done at a [[PREP day|PREP day: Overview]]). Below are some suggestions:

* [[AMBIT Service Evaluation Questionnaire (ASEQ)]] questionnaire
* [[GHQ-12]] Questionnaire
* Any other measures (as agreed in the PREPARATORY sessions (see notes in [[AMBIT-R training programme]], and [[PREP day: Overview]])
** ''Why?'' - because we (us trainers, and you participants!) all need to know whether this makes any positive difference!

!!__2. Activity: Introductions__

This is to get people to warm up, to know a bit about each other, to have an experience that //''they are going to be invited to involve themselves!''//

!!!Speed dating 
See __Trainer notes__ below if you have not run this exercise before!

* Everyone get up
* All walk around the room in random patterns without bumping into anyone 
* Every minute or so, the trainers call STOP!
* At this, people partner up with the person nearest to them, and on each occasion they're told to find out from each other ONE of the following options, and take FEEDBACK in a very particular way (see below):
# Why are you here?
#What do you really want from this training? ditto
# What do you really NOT want? ditto

''Taking Feedback:''

# Invite feedback on ''what people understood of their __partner’s__ answer.'' 
# NB do NOT ask people to feedback their OWN answers!
# Invite people who heard their answers repeated to the group - what was that like if your partner represented you well?  What was it like if they phrased your words slightly differently/got the wrong end of the stick?
* Ask for general feedback on what was interesting in what they heard.
* FLIP CHART OR RECORD THE THEMES that come up on post-it notes - these will be guides for the training ahead, and can be arranged to start illustrating the AMBIT model (see guidance notes below)

!!!Trainer guidance notes on "speed dating":

* ''Set the context before starting:'' this is an ordinary introductions warm up //BUT there is a twist to it that will help us to think about this thing called 'Mentalizing'//, so __pay attention!__
* ''Record the THEMES'' arising from the group on a big blank version of the AMBIT wheel - use post-it notes or a white board marker...
** Record points in one of the four quadrants (stick them there if the points are recorded on post-it notes), depending on whether they relate to:
*** CLIENT work
*** TEAM work
*** NETWORKS
*** LEARNING at work.
* ''Record as QUOTATIONS in the CENTRE of the wheel any MARKERS of Mentalizing'' that you notice in the reporter who introduces the other person, statements like:
** //“I’m not sure but…”//
** //“What I understood from X is...” //
** Are they using eye contact and verbally checking in with the person they are introducing (//“Did I get that OK?”//)                                                                                                                                                                                                                                                                                                           
* Ask ''what it was LIKE to be the introducer of the other person?''
** Look for anxiety to get it right, do them justice, etc - //we all know how painful it is to be misrepresented!//
* Ask ''what it was like to BE INTRODUCED''
** What was it like if/when the introducer //did get something slightly wrong?// (there is something important at stake if we are mentalizing each other!)

Other (older) ways of doing intros exist: see the conventional AMBIT approach to [[Initial introductions at a Training event]].

!!__3. Discussion: Planning the day__

Here, you are [[Broadcasting Intentions]]... so allow for some comeback from trainees, but don't get too drawn into discussion!  If there are critical questions/worries, NOTE THEM on flip chart so that you can revisit these through the day, don't try to answer every worry or complaint or you may never get started.

!!!Spend 5 - 10 minutes to briefly ''outline the shape of the training ahead'':

* It lasts for 4 days
* It does obviously has //some// "curriculum" (new stuff to learn)
* The reason for having some curriculum (//learning// - which not everyone loves to do!) is:
** ''to HELP workers'' who work in very challenging places by bringing the most up to date EVIDENCE for WHAT WORKS into the field
** ''to EMPOWER workers'' - especially groups of workers who are often ''NOT RECOGNISED/VALUED'' in the wider system for the detailed //knowledge// and //understanding// and the //trusting relationships// that they are able to build with very vulnerable young people.  
** Giving workers access to some of the most cutting edge language and and approaches is just one way to help amplify their voices in the professional networks that they are part of.
* The training is designed //at least as much// to encourage ''TEAM LEARNING'' as it is for individuals to "cram" new skills.
** There are //no exams at the end!// 
** Because of this, the //conversations between and within teams// that will take place through the training //are at least as important// as anything that comes from the front of the room!
** The bad news is that //this training relies on people getting involved and thinking and communicating with each other//, rather than being spoon fed "from above".
** We want this training to help people have some useful ''shared experiences'' over the coming days, that they can think about and learn from, as well as just supplying them with some new words and ideas.
* ''Expectation management:''
** ''Day 1 is IMPORTANT but is //nearly always the toughest!//'' - it is where most of the learning/curriculum is presented.
** Finding day 1 hard is a //normal// part of the journey, so ''don't worry if it doesn't all make sense after Day 1!''
** ''Days 2, 3 and 4'' are much more about //putting this theory into your own team's practice// in ways that - we hope - help your team to develop and improve.

---
!!!More about the background of this training

* ''__Who built it?__'' This is a training designed for you by other ''people who work with Looked After Children in Manchester'', alongside members of the AMBIT programme (from the [[Anna Freud National Centre for Children and Families]])
* ''__What's the point?__'' Defining goals for the training (reminder about the Pre-training preparation – this is not about topping you up with a few extra magical individual “Ninja-skills” in how to persuade young people to be calm/happy/obedient/etc!)
** We are assuming that you are probably ''already quite/very good at this work''
** ...so this training is more about:
*** how to ''work as an effective TEAM'' - supporting each other, sharing expertise, training the next generation of workers...
*** how your team can ''work more effectively in the wider NETWORK'' of professional and informal helpers around the young people you look after.
*** how the team might ''keep CHANGING how it works (Learning)'' in ways that make sense to its members and which fits the evidence of their eyes, ears, and research.
*** More generally, the training is about helping workers to recognise that //“it is OK to not be OK”// at times in this work… this work is ALWAYS going to raise emotions in us as well as in our clients.  So in a practical way it is about “keeping our sense of direction”, especially in the middle of the storms that will always be likely to occur at times in this work.
----

!!__4. Exercise: What are your existing strengths?__

//Training is like treatment, and like treatments, there can be side effects!//

* So first, we trainers want to make sure we do no harm by accidentally undermining existing expertise (//"Don't do it like that!  Do it like this!"//)
** ''AMBIT is all about the need to [[Respect local practice and expertise]].''
* This next exercise is to help us understand ''What of your existing practice must this training scaffold and strengthen'', and not undermine or break?
** ''AMBIT is "ADAPTIVE"'' mentalization-based integrative treatment - it is NOT about sweeping away existing practice and relationships, but providing an adaptable framework for services to improve themselves, based on current theory and evidence-based practice.

!!__''EXERCISE: the [[Elevator Pitch]]''__

This is a 60 second pitch "for an interested donor/commissioner with money in their pocket"

!!!Guidance for TRAINERS setting up the Elevator Pitch exercise

* PLEASE NOTE: - the //point// of this exercise is NOT for the teams to win the money! We want them to do two things:
** ''To clarify in their own minds what are their existing strengths'' and how and why they do things the way they do...
** ''To practice communicating this in a snappy way that they can all share'' and understand why being able to do that is important.
*** What do we do here?
*** Why do we do what we do? What is the point of all our labouring?
*** What do we do particularly well?
*** Why do we do it like //that//? Under what circumstances might we do it differently (a "Plan B")?
*** How would we all know when we would be shifting to "Plan B"?

{{Elevator Pitch}}

---
!!BREAK for COFFEE/TEA
---

!!__5.  What makes this work hard?__

!!!5(a) Activity: Describe the challenges

* Invite group to develop as RICH a collection of different stresses and strains as they can (//"think as broadly as you can!"//)
* Write down each stressor on a post-it note.
* When ready, hand them in one at a time
* Trainers:
** Read them out one at a time - //''Note to trainers:'' clarify - have you really understood what they mean? - this is a helpful way of modelling the "mentalizing stance"//
** Place each note on floor in the middle of the circle (''Note to trainers:'' keep the suspense! //Without marking them out in advance//, agree as trainers where each quadrant on the AMBIT wheel is positioned on the floor, then as they are read out, place each post-it note in the relevant quadrant - ''CLIENT, TEAM, NETWORK'' and ''LEARNING'').
** ''If you are tech-savvy'' (!), take a photograph of the post-it notes, and use a photo-editing app on your phone to create a "double exposure", overlaying the picture of the post-it notes on this image of the AMBIT wheel.

<center>{{AMBIT Wheel_B+W_round.jpg}}</center>


<center> {{Wheel and probs.jpeg}} </center>

* ''LEARNING POINTS FOR THE TRAINERS:''
** Discuss with your training partner: //what is the balance or spread of the different problems and challenges this team describes?//
** If there are ''problems identified in ALL FOUR "Quadrants"'' of the AMBIT wheel, then this is generally a POSITIVE:
*** It suggests that this is a team that is intuitively thinking/mentalizing about their practice in a broad (AMBIT) way.
** If there are ''NO problems identified in a quadrant'', that is a helpful prompt for us as trainers to become curious about this: 
*** Most commonly, teams identify the least number of "problems" in the [[LEARNING at work]] quadrant - which we think is worth us worrying about a bit!)  Ask a few follow up questions to probe this:

**** Do you all feel that you are "on the same page" with the details of how you work, and why you do things in a certain way?
**** Do you ever get into confusion with "too many ideas" about what to do, or how to do it?
**** Do you ever set up formal opportunities talk about how to do this work?
*** Do you know how other people in the team do their work?
**** Would you all induct a new team member to the team in the same basic way, introducing the same basic practices and beliefs?
**** Does you team know how effective its work is (and if so, how)?
**** Does your team know which kinds of client or problems it most struggles to get positive outcomes for (and if so, how)?
** Which quadrant seems to hold the most "tension" or the strongest feelings? - Check back with the team to see if that is their experience.
*** Identifying this might influence the time allocated to exercises practicing mentalizing in that specific quadrant of the work for that specific team (//this is an example of ''adaptation'' in the AMBIT method/training!//)
* ''Most teams want some reassurance:''
** We are reassured by teams that can acknowledge the challenges in their work (teams that identify no challenges may be in a kind of [[Pretend mode]] non-mentalizing state of mind.)
** We see this work as //inherently// difficult and challenging, and would be most worried if a worker (or whole team) claimed not to recognise these kinds of dilemmas 
** We have never met a team that doesn't face these kinds of dilemmas
* ''AMBIT is an approach that has been designed by and for workers facing these kinds of dilemmas''
** it starts from an attempt to recognise and record the difficulty
** rather than offering an "easy solution"
** in the AMBIT programme's experience (training hundreds of teams across the world) ''there is a great deal in common with the kinds of problems faced'', even though the details are very specific 
* ''SHOW THE AMBIT WHEEL''
** We will cover this in more detail later, and thorughout the training, but for now, note that AMBIT has been developed for teams that identify challenges in all four quadrants:
*** [[Working with your CLIENT]]
*** [[Working with your NETWORKS]]
*** [[Working with your TEAM]]
*** [[LEARNING at work]]

!!!5(b) Activity: Create examples (Who are Our Clients?)

* Get into small groups
* Think of 1 - 3 typical (''ANONYMISED'') clients that your team works with
* Generate comments on Post-it notes that describe //their perspective//:
** how would they describe //feeling//?
** how would they explain their //beliefs// about the care system/carers/helpers?
** what would they want a helpful worker to know about their //past and present experiences?//
** how would they explain the kinds of external pressures (what the world demands/expects) they face?
* ''If you have cardboard cut-outs'' available then stick the post-it notes on these
** ''Keep them in the room'' during the training
** If AMBIT training doesn't help you to be more helpful to //them//, ''then AMBIT training is not helpful''

!!__6. Activity: Develop Training Goals for the team__

* Goals are ''aspirations, hopes, "best case scenarios"'' but can also be used to measure progress...
** Later on, today, we will create some ideas of how to measure our progress ([[Evaluating outcomes]]) 
** Just now, the exercise is about allowing the team to generate ''hopeful aims and aspirations that //make sense to them//'' in relation to the challenges that they all face.
** If these have already been drafted in a PREP day, remind the team what these were.
** Focus minds on areas of the [[AMBIT Wheel]] that were particularly challenging for their team in the earlier exercises
* ''Create a simple list, //or better still, an artistic poster// to record these''
** Later we will work on creating some more detailed measures that the team could use to know whether it was making progress.
** These goals will influence the [[Implementation Plan]] that we will develop towards the end of the training

''Trainer Notes''

* ''Here the trainers can do [[Broadcasting Intentions]]'' - //"What we are trying to do here with you..."//
** We want to help teams to do the work that they do, but in ways that they know to be //better//
** We take a position that no team on earth could ever find nothing about its work to improve upon!
* ''Stating the obvious'': 
** //"You are in a helping relationship ''with us as your trainers/facilitators''"//
** You bring your team's practice and experience, in the hope that together we can help improve things.
* Emphasise ''Parallel processes:''
** Meeting you as a team, is very like when we meet a client - not surprising as we are all human!
** ''We'' cannot start helping ''you'' until you have some trust in us - this is just as it is for a young person arriving in your care.
** You are unlikely to trust us //until you feel we have a basic understanding of how things are for you...// 
* ''Different intentions and expectations between team members:''
** Some teams (or individuals in those teams) will come a with clear idea about what they want help with to improve, others will not.
** It is important to acknowledge in a //team-based// training (not everyone has individually signed up for this!) it is likely that some people don't want to be here at all!
*** This is fine: "people are where people are"
*** We //do not// want to deny the different perspectives in the room
*** We //do ask// that attendees try to access positive intentions towards contributing to the team's practice, even if they also feel scepticism, or other frustrations
* In this training, the conversations and decisions that teams can have amongst themselves are as important as the "theory/learning" that comes from the front of the room.

!!__7. Discussion: What PROBLEMS is AMBIT designed to help with?__

* If you want, you can watch a video about the nature of the difficulties that AMBIT has been developed to address:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/g2bk7sSKD-c" frameborder="0" allowfullscreen></iframe></html>

* If not, just use a poster or projection of the [[AMBIT Wheel]] to give a "quick walk around":
** ''(a) Emphasise the need for BALANCE''
*** AMBIT does ''not just focus all attention'' on the relationship and work with the Client 
*** AMBIT shows that to be SUSTAINABLE and EFFECTIVE, there needs to be equal emphasis on the workings of
**** ''Team''
**** ''Network''
**** and opportunities for ''Learning'' from evidence and local experience
** ''(b) Point out that in the middle is some of the science of communication''
***  [[Mentalization]] is the science of //“making sense of each other”//

* Group discussions and feedback
** Divide the large group into groups of c. 3-4
** 5 minutes of conversation
** Take feedback

!!__8. THE CORE IDEA: MENTALIZING__

* Ask the teams: //has anyone here already got some knowledge or experience of mentalizing in practice?//
** When people do have existing knowledge, try to acknowledge that the thing about mentalizing is that it is "simple but slippery" so hearing different accounts, can help to enrich our understanding.
** It's one thing to UNDERSTAND this stuff, but quite another to EXPLAIN it to someone else in ways that they can make sense of.
* The ''AMBIT training is not a THEORETICAL training, but above all a practical one'', //based on the best reading of evidence that we have at present//
** There is a huge amount of science  - some of it very complicated - BENEATH the surface of mentalizing (Brain and [[Developmental Considerations]], [[Attachment theory]], [[Psychodynamic theory]], [[SocialCognitiveTheory]], [[SystemsTheory]] and the theory of [[SocialEcology]])
** This may or may not be of interest for  practitioners in the field. 
** What we are interested in is the //putting it into practice//.
** What follows, therefore is a //'boiled down concentrate'// of the most important parts of this idea - [[Mentalization]] - this is like the "load-bearing axle" in the middle of the [[AMBIT Wheel]].
* Watch video
** For most teams (short version - 10 mins):
<html><iframe width="560" height="315" src="https://www.youtube.com/embed/sq61A5wGC8o" frameborder="0" allowfullscreen></iframe></html>

** For teams who want more academic detail (longer version - 20 mins):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/mCqrgQSe2MY" frameborder="0" allowfullscreen></iframe></html>

*''Small group discussion''
** Which bits make sense to you, which do not?  
*** How might you talk about these ideas with a colleague? 
*** With a Client?
** If people respond with confusion, reassure - we will revisit this throughout the 4 days
** ''If people respond with "This is what we do anyway!"'' - then this is:
***''(a) a relief!'' - it would be odd to think that there was some magical new thing to replace what has worked for centuries
***''(b) an opportunity for gentle challenge!'' - do you //really use these ideas in systematic, regular ways?//
* How would you know that somebody's pre-frontal cortex is busy (that they are actively Mentalizing)?
** See the [[Features of Successful Mentalizing]] for more details on this.

---
! BREAK for LUNCH
---

!!8. (Continued) WATCH FISH TANK CLIP

Watch the [[Fishtank film clip]] and discuss:

* where did you see evidence of Mentalizing?
* see notes on this exercise on the page [[Fishtank film clip]] 

{{Fishtank film clip}}

!!9. PRACTICE Mentalizing WITH TEAM-MATES.

!!!9(a) ''Reminder - it's not just our clients whose mentalizing wobbles!'' 

AMBIT suggests that it it is ''just as important'' to create strong (accurately-mentalized) relationships with your TEAM-MATES as it is to do the same with your clients.

* The analogy of the climber (the worker "out there alone with the client") and the partner holding their rope.  Do we have the right communication to know when our partner needs us to "hold on" or to pay out rope?

!!!9(b) Exercise: The [[Passed-outwards Discussion]] or 'POD'
<html><iframe width="560" height="315" src="https://www.youtube.com/embed/0hea7zaIZdw" frameborder="0" allowfullscreen></iframe></html>
* After the exercise:
<html><iframe width="560" height="315" src="https://www.youtube.com/embed/q1MNTgDLvYU" frameborder="0" allowfullscreen></iframe></html>

!!!9(c) Additional Trainer/facilitator notes on the POD:
Note: there may be some repetition from above material, and this is really more "background reading".

{{Passed-outwards Discussion}}

---
!!TEA BREAK 

(Trainers set up an obstacle course during the break.  ''Note:'' this will be moved around once the exercise gets started, so just free up the furniture you need.  Use chairs, etc.  Keep an eye on safety!)
---

!!10. Putting it together: What's the POINT of mentalizing? 

...EPISTEMIC TRUST!

!!!10(a) Exercise: Obstacle Course - taking advice!

Requires Voice-synthesizer toys!

* Divide into teams of 3 - 4 people each
* Each team picks a runner from their members
* Each runner picks their own helper from their team
* The runner and their helper leave the room and can spend a few minutes working out their strategy (the helper will direct the runner by the spoken instructions "Stop!" "Go!" "Left!" "Right!" "Back!" - no other words are allowed, but they can use tone of voice, etc, to add more information if they wish.
* As they are preparing, move the course into its final position
* The runners are blindfolded and return to the room with their helpers
* There is a five second time penalty for each time a runner collides with a part of the course, or with another runner (do emphasise safety!) and the umpire's word is final.
* Race, and reflect briefly on what this was like for the runners.
* Send the runners back out - but without their helpers.
* Change the course around again so they cannot know the way (warn them that this will be the case)
* Come back for "Round 2:
* This time the same runners are paired with an ANONYMOUS helper from their team, //who can only speak through the voice synthesizer// so that their voice is (we hope!) unidentifiable and alien.
* Repeat the race
* Ask for the runners to give feedback on what this was like, especially in comparison to the first round. 

!!!Discussion: 

How easy is it to trust the person who is trying to help you?  What helps you to trust their advice?

!!!10(b) Teaching on Epistemic Trust

Either watch the video together, or just discuss.

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/ZBeEOkwLToM" frameborder="0" allowfullscreen></iframe></html>

* ''Group discussion:'' Keep this discussion reasonably brief
** Emphasise that ''//effective work// - whether as a therapist, or a residential care worker, or a teacher, a social worker, a parent, etc, etc, //almost always requires that we create some epistemic trust.//''
** If we did NOT create Epistemic Trust, then our clients would never try anything new based on our work with them after they walk out of the door!
** //Mentalizing// that is accurate enough is what "wins" Epistemic Trust.
** //"If you can 'get' me like that, then I am interested in what __else__ you understand and know, because it just might work in my world, out there!"//
** Mentalizing probably explains WHY what we do works (when it does) and it helps us to focus our efforts on the really effective things that we can do.
** ''__NOTE!__ Epistemic Trust is NOT BASED ON SPECIAL TRAINING, OR SENIORITY OF ROLES, OR EXPERTISE'' - young people will decide who "gets" them, and who they trust... (even if sometimes those are not at all the people we would choose for them!)
** Helping systems have historically been very poor at recognising this:
*** They have //down-played// the importance of Epistemic Trust, while //emphasising// (hierarchical) specialist skills.
** ''We are NOT wanting to undermine the importance of specialist skills'', but we ARE wanting to //promote the importance of Epistemic Trust//, and the value in creating systems of help that look out for, and really value Epistemic Trust when they see it.

''If residential care workers have one skill above all others'', perhaps it is that they are often (not always!) uniquely good at establishing relationships of Epistemic Trust with young people who find it especially hard to trust anyone.

!!11. Putting it together: what is AMBIT?

* Watch video:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/HrEgDdsohNo" frameborder="0" allowfullscreen></iframe></html>

* Group discussion: 
** What do they make of this?
** How do they see this as applying to their day to day work?
*** Where do they see their work as "in balance", and where does it get "out of balance"?
*** Which quadrant do they see as the most challenging for their team?

* Feedback
* Trainers' final 'confessions':
** //The day's training you have just completed was structured to try to help you trainees experience us, the trainers, as //coming to understand you, and your own struggles and challenges in the work you do (rather than just filling you full of facts/instructions).
** If this worked at all, we hope that we have developed a little bit of [[Epistemic Trust]] in you towards us!
** We may or may not have been successful, but that was our aim - to show you by doing, as much as by telling!

----
!!END OF DAY
---

 Click <<tag [[AMBIT-R training programme]]>> for links to days 2, 3 and 4. 

!DAY 2
!!See [[AMBIT-R Training Schedule - Day 2]] for the Day 2 timetable only.

!!1. Recap and feedback on DAY 1 (up to 30 minutes)
* Discuss in small groups
** //What has stayed in your mind that seems valuable?//
** //Any key things that you are left unclear/concerned about?//
* Each small group feeds back one or two points from their discussion to the wider group
** Take notes on flipchart of any points that might need further attention

''Notes for trainers''

* ''The aim of this discussion'' is to get an understanding of the range of current states of mind that the group is in.
** You won't win their [[Epistemic Trust]] if they don't feel that you have understood //their// position.
** This training programme is perhaps slightly different from other training programmes because it is NOT just about the trainers delivering a bunch of information and instructions to trainees; it very much more about the trainers bringing their material ([[AMBIT-R]]) into a //dialogue// with workers who are assumed (because we [[mentalize|Mentalization]] them!) to bring their own experiences, expertise, hopes and fears with them.  It is also about the trainers helping to set up a context which allows trainees to explore each other's understandings and to collaborate to clarify what their //shared understandings// are about what works and what does not in the work they do in residential care.
** Remember that //a wide range of feedback is quite normal// at this stage: it may range from enthused to confused!
* ''Responding to the confused/stuck/unimpressed:''
** First, //avoid a glib answer that seeks to"quick fix" it// (this would be you falling into [[Teleological thinking]], rather than holding on to our own [[Mentalization]]).  Instead, seek to ensure //that you have really understood// (accurately mentalized) __how__ this person is confused/stuck/unimpressed - //do they feel that you have 'got them' properly?//
** Next, //offer reassurance to people that this training is a __process__// (not really a "product") - the next three days will be spent getting more into the detail of what AMBIT is (putting some mentalizing into areas of work where it often gets left out.)
** Offering //Advice and instruction// to trainees:
*** Our experience of training many teams is that things usually become clearer over the course of the different days - //"try to live with this uncertainty."// 
*** For those who do feel a bit unclear at this point some advice that is worth giving: //"You can still help by 'bringing your mind along' and contributing"//:
**** When there are opportunities for team dialogue, engage!
**** Try to play your part to ensure that your team is having the conversations that it needs to have
**** Try to help create the best conditions possible for this conversation to bear fruit - calmness, compassion, respect... all these old fashioned ideas have their place here.
* ''Trainers aim to hold a balance'' between:
** (a) //Being responsive to feedback// by making any necessary adjustments where appropriate (i.e. clarifying some content; giving more practical examples etc)
** (b) //Holding the boundaries of the training curriculum// - getting through the materials/exercises is all about creating a space for teams to embark on their own learning journeys
*** This //holding a balance// is tricky, and, because we are human, we will wobble! This is why AMBIT trainings //always use at least two trainers//.  ''Use your training partner;'' when one of you is speaking, the other should be mentalizing their partner and the trainees.  Ask each other for help in the room, so that you are //modelling// help-seeking and using each other's minds, in just the same way that a "well-connected team" uses each other to help its clients.  If this is working it makes for a much more lively, in-the-room, authentic style of training than just a mechanical "going through the material and doing the exercises".
** ''If there are trainees who take a more "combative" position:''
*** Strong characters can sometimes dominate a quieter group; it is important to avoid allowing their position to get in the way of the whole team's learning opportunities.
*** Such situations are rare; very occasionally it is helpful to set aside some time in a break to discuss with an individual your perception that their behaviour might risk shutting down other team members from feeling able to engage with the learning.
*** Our experience in the AMBIT training team has been that "sharing our dilemma" with such individuals, and //inviting them to help us// to make the training as safe as possible for all team members to explore/learn is often effective.  
*** Such individuals may be experiencing this external training as being //disrespectful// of their existing expertise and practices - which is, of course, exactly the opposite of our AMBIT stance, which includes the principle to [[Respect local practice and expertise]] - be ready to emphasise that if that is the impression they have got, we have failed to communicate this clearly enough.
** This is, of course, a good example of us trainers using [[Active Planning]] (which we cover in Day 3 under "Working with your Client": balancing ''Plans/Doing'' with ''Broadcasting'' ('why we are doing these things in this way?') and ''Sensitive Attunement'' to our audience.  Because //we are all "imperfect mentalizers"// we will always be slightly off-balance, but holding this balance is our aim! 
* ''If there are "technical" or "theoretical" questions:''
** These can be "parked" on a flipchart
** There are plenty of books and papers, and all these are listed and described in the online manual (search "[[Academic references]]" or use this direct link: https://manuals.annafreud.org/ambit/#%5B%5BAcademic%20references%5D%5D ) 
** ''If theory questions threaten to derail the task'' of getting into practice, then //gently// remind people about the [[Pretend mode]] (one of the three ways that people "fall out of" balanced mentalizing)!
** ''Remember: your role as a trainer/facilitator'' is //NOT to be the expert on the theory, but on creating and holding the context for teams to learn...//
*** ...about one another
*** ... and to experience each other (and other professionals) as separate minds //worth// making sense of (i.e. mentalizing)
* ''Trainers are not Experts on the local settings/organisational challenges for specific teams''.
** This may seem obvious, but it is common that trainees invite trainers to take up positions of commenting on/solving details of local implementation //that they cannot possibly actually know about.//  i.e. Trainers/facilitators shouldn't feel under pressure to offer quick-fixes or immediate responses to all the local dilemmas or concerns that trainees raise. ''For example:''
*** ...there might be some concerns about the applicability of the [[Team around the Worker]] ideas to a particular team's service context
*** ...there may be questions about how a team should deal with a specific Service manager, or Commissioner whom they perceive as "difficult", or some other organisational issue that is really outside the scope of what a trainer could be expected to solve (a "get out" phrase might be: //"it is just not in my AMBIT to solve this!"//)
*** ...or a belief that attempts to improve network functioning in town X will inevitably be unsuccessful.
*** ...questions about how a particular ethnic group may or may not make sense of the mentalizing model of human interaction
** Trainers may wish just to ''validate or "roll with" these perspectives/challenges, rather than seeking to argue or change them at this stage:'' invite people to revisit these perspectives throughout the training as they learn/experience more of the content.

!!2. Preparing for today

''Project the AMBIT Wheel''

<a class="tc-float-right">[img width= 500 [AMBIT Wheel_B+W_round.jpg]]</a>

For the rest of the training days, we will be "walking around the wheel" practising ways to use [[Mentalization]] in each of the four quadrants:

* ''Day 1'' tends to be the hardest (most theory, least practice)
* ''Day 2, today'' will focus on:
** ''Morning:'' [[Working with your TEAM]] help-seeking conversations and the well-connected team
** ''Afternoon:'' [[Working with your NETWORKS]] - Dis-integration in networks, and systematic efforts mentalize between different professionals and informal helpers. 
* ''Day 3'' will focus on [[Working with your CLIENT]] and on [[LEARNING at work]] - especially on helping to create and sustain a "well-connected team"
* ''Day 4'' will focus on practicing more about [[LEARNING at work]] and on //implementing change// in the year ahead.

** //"So from now on we are trying to put these things into practice!"//

!!3. EXERCISE: "a well-connected team"

!!!Scene-setting:

Watch this video by Peter Fuggle:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/Zs37DCK2-A4" frameborder="0" allowfullscreen></iframe></html>

* ''Trainers should feel able to cover the following ideas/points during this section:''
** (1) Creating and maintaining a [[well-connected team|Keyworker well-connected to wider team]] is one of the [[Core Features of AMBIT]]; one of the eight elements of our ''principled AMBIT stance'' (the outer ring of the [[AMBIT Wheel]]).
** (2) Remember that each quadrant of the [[AMBIT Wheel]] has two "principles" attached to it, which describe one of the main dilemmas in that quadrant of the work.  If you get ONE of these principles going well, it can often make you lose sight of the other one.
** (3) In [[Working with your TEAM]] the principle of "[[Keyworker well-connected to wider team]]" counterbalances the pull of trying to ensure that there are strong ''Individual [[KeyWorker]] relationships''.  It is very easy for a worker who develops a very powerful relationship with their client to then get a bit isolated from the help that their team-mates could provide (//"I'm the only one in this team who __really __ understands and cares about X"//).
* ''A helpful image/metaphor:''
** In the work that we do, it is very easy to think that it is all about how technically good at "climbing" I am, and to lose sight of //"who is holding onto my rope"//:

<a class="tc-float-left">[img width= 1000 [LoneClimber.jpg]]</a>

!!3 (a) - Taking stock of our team

!!!''Discuss in small groups (max 10 minutes):'' 
//How does this team already provide support and help to its members?//

* Think of as many different //places, times, and ways// that help-giving and help-receiving between team-mates already happens
* Think of some of the ways that, sometimes, the team is //not as helpful// to its members as it might usually intend to be?
* Note these down on flipchart paper

!!!''Large group feedback:'' (points for trainers to ensure they cover)

* ''This team is //already a helping system//'' - otherwise people wouldn't stay in their posts!
** //AMBIT does not want to change what is already working//, but to "finesse" and make small adjustments to //maximise// the helpfulness that team members provide for each other... 
** AMBIT seeks to make "helping my team-mates" (and accepting their help) into a core part of day-to-day practice, not a "luxury added extra" or an "extra mile" for workers to feel they have to walk.
*''What does a "well-connected team" actually mean?''
** A team in which ''asking for and receiving help'' from team-mates is:
*** ''Expected behaviour'', from all team members
*** ''Taken seriously'' - as a core part of our work (helping a colleague is //not// "going an extra mile" or "out of the kindness of my heart"!)
*** ''Performed effectively'' - we will cover some disciplined ways to support this next...
** A team in which all members know "who is holding their rope", and have good enough communication to tell them when to //"hold tight"// and when to //"let me have some slack"//
** A team in which those "holding the rope" for their colleagues //know how to alert them to risks that they might not yet have seen// without that being taken as criticism (we will cover this in Day 3).
* //''This work IS STRESSFUL''//
** It is ''normal and proper'' to feel anxious doing this work (sometimes, not all of the time, or so much that you can't function!)
** If you do NOT feel anxious sometimes, you are probably in the wrong job!  You are denying the real risks involved, a good example of the [[Pretend mode]] of non-mentalizing.
** Because we get stressed occasionally (however that might 'look' in our particular case - different people react to stress differently) our own capacity to Mentalize will sometimes reduce (ie. we are human)
** Because of that, we need the perspectives, knowledge, practical and emotional support of our colleagues: //when a trusted person mentalizes us accurately, we tend to recover our own abiity to mentalize//.
* So, in summary: //''Beware the "Lone-ranger" worker''//, who never seems to require the support of team members.

!! 3(b) Help-giving for team-mates can be hard to do

* Play //one// of the two videos on ''Thinking Apart'' to the group:

Either this one (Laura and Charlie):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/dhVwRaNGmtk" frameborder="0" allowfullscreen></iframe></html>

Or this one (Dickon and Peter):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/GMKWnfMN6uo" frameborder="0" allowfullscreen></iframe></html>

* ''Divide into small groups: discuss the scenario''
** What went "right" and what went "wrong"?
** ''These videos are just "caricatures"'':
*** do they reflect some of the realities of trying to help/being helped in your team?
*** have they missed out any other ways that help-giving can be hard to get right?

---
!TEA/COFFEE BREAK
---

!!4. A disciplined approach to helping conversations: "Thinking Together"

AMBIT is about helping teams to //"take back control"// of their local culture; purposefully trying to create the best possible environment for being well-connected. This section of the morning is about practicing ways to allow more mentalizing helping conversations between team members.

!!!4(a) Play the video introducing [[Thinking Together]]:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/nYFxbzL76aI" frameborder="0" allowfullscreen></iframe></html>

* Small group discussions (brief discussion for 5 minutes): what made sense in that?

!!!4(b) Play one of the video demonstrations of "Thinking Together":

Either this one (Laura and Charlie):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/iUaWgJ2ibiE" frameborder="0" allowfullscreen></iframe></html>

Or this one (Dickon and Peter):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/ZeSW-uWFfE0" frameborder="0" allowfullscreen></iframe></html>

Here the ''"4-step dance"'' is illustrated: a conversation that has four distinct stages:

# Marking the Task
# Stating the Case
# Mentalizing the Moment
# Return to Purpose

!!!4(c) Practice this

* __''Get into THREES:''__
** PERSON A: ''A help-seeker''
** PERSON B: ''A helper''
** PERSON C: ''An observer''
* __''Help-seeker'':__ Someone happy to bring a real clinical dilemma (not a piece of tough work, that they are secretly quite proud of, but a piece of work that they are genuinely a bit worried about, or feel as though they might be "going wrong" with.  
** //''NOTE TO TRAINERS:'' remind groups that (unless there were immediate safeguarding concerns!) the CONTENT of these discussions will remain confidential within these small groups of three; ''only the experiences of the PROCESS will be shared later.''//)
* __''Helper'':__ Use the 4 step Thinking Together process to help you help your colleague
** When you are first practising it is helpful to announce which "step" you are in, and when you are switching to the next one.
** When you switch to step 3, Mentalizing the Moment, //try to change your physical posture a bit, pause, and breathe (!)//; you are trying to create a sense of relaxation, of purposefully not being so focused on an end-point, but of creating space for both of you now to //use your imagination// (which is what Mentalizing is!)
** Some people describe Mentalizing the Moment as the "soft centre" - like those sweets that have a hard coating!
* __''Observer'':__ Remain silent, but watch with some specific questions in mind:
** //At any point in time, am I aware which of the four steps we are currently engaged in?//
** //Am I completely clear in my mind what TASK it is that the help-seeker is inviting the helper to join in with?//
** //How do I feel the Help-seeker and the Helper are experiencing this?//
** //How could I give feedback to each of them at the end in a way that is likely to be experienced as helpful?//

* ''__Trainers: Allow 12 minutes for the exercise__''
** Emphasise that this is a "realtime" exercise - designed for use in the rush of real working life.
** Emphasise that of course you CAN use the same format over a longer period (a supervision hour, a team case discussion, etc) but here we want people to get a sense of the STEPS and the FORM of these "disciplined" conversations 
** ''Call out time at c.5 minutes:''
*** //"Are you all really clear what Task has been marked?"//  
*** //"Have you set enough a bit of time for Mentalizing?"//
** ''Call out time at c.10 mins:''
*** //"Have you started to return to purpose yet?"//

!!!4 (d) Take feedback from groups: How was it for you?

* ''Common feedback'' 
** (and suggested responses)
* ''__(a) [[Marking the Task]] was hard to do, or "took too long"__''
** This is nearly always the case, in most teams
** We are rarely clear when we start talking to a colleague about what it is that we want from them (ie we start talking //before we have mentalized ourselves//).  In these situations how much harder must it be for our helpful colleague to be helpful, or even to know what they should be listening out for?
** Sometimes "the task" may actually be to help work out what, in a complicated story filled with feelings and concerns, should actually be the top priorities.  If that is the case, then //Mark it//! This alone will help the would-be-helper to be more helpful.
* ''__(b) //"Woodenness" in having to use such a structured format//__ for a conversation that "should be natural".''
** This is why we need to train together (we //don't do individual// AMBIT trainings - it is //only a team approach//.)
** It only really works if //both parties know// that this is a //disciplined// and highly purposeful kind of conversation... and know what to expect
** If I have shared some training with my colleague, I can "put up with this tough, boundaried beginning to our conversation" - even if it can feel wooden or blunt - because //I know that this will make it more possible for my helpful colleague to properly ''attend to __me__''// (how this affects me, what I am really concerned about, what - and why - I think I need to move forwards safely, effectively, etc) later in the conversation (when we get to to the 3rd step of [[Mentalizing the Moment|Mentalizing the Moment (in Thinking Together)]]).
** Once people get used to this, it gets much easier to "not be wooden"!
* ''__(c) //"Trying to keep to the rules" took my attention away//__ from what I wanted to be thinking and talking about.''
** This is common - especially when the steps are unfamiliar
** It is especially so in teams where there is already a clear culture of "how we talk to each other"... try to 'trust the process' and play with new ways of working.
** ''Practice'' will reduce this experience
** ''Clarity'' about //why doing it in this way makes sense// reduces this experience
* ''__(d) Helper feels //"forced into being rude"//__'' by having to create such clear boundaries (especially in [[Marking the Task]])
** Ditto the points given above, about why we only use this across teams that have //shared this training//.
** If you know the intention behind this "upside down" approach to conversation (defining what a successful end-point would be, before you actually have the conversation) it feels less "rude" or "wooden"
** You //can use this with people who are untrained//, but to do so, you need to invest additional time at the beginning (as a would-be helper) in //explaining how and why you want to conduct this conversation in this way// - if the help-seeker is very anxious, this might not be the right time for such a conversation!
* ''__(e) 'Mentalizing the Moment' can make would-be helpers feel anxious:__'' - //"have I done it properly?"// or //"I didn't know how to start mentalizing"//
** Remember the [[Passed-outwards Discussion]] exercise on Day 1: the effort of the listener is //__first to understand, not to solve__// - mentalizing the moment in the Thinking Together routine is just the same.
** Remember that the first rule of mentalizing the moment is ''First, mentalize the worker, not the client'' (the client is not present, but your colleague is!)
** One easy way to get started is to //ask the worker to help you be sure you have understood ''how this situation has made them __feel__''// (as opposed to what they believe has caused this, whose fault it is, or what they think should happen next, etc)
** Another tip is to mimic the [[Passed-outwards Discussion]] a bit; try to "tell their story back to them, as if 'from the edge of the pond'" - in ways that you hope will allow them to feel that you have heard them, and made sense of (ie mentalized) their dilemma/worry/predicament.
** Once the helper gives the help-seeker a sense that they are at least partially understood (and understandable) it is likely that the help-seeker will already have begun to feel less isolated/misunderstood/stressed and will start mentalizing themself.
** //Helping our colleagues get back into a mentalizing state of mind// is one of the main purposes of Thinking Together - in ways this is MORE important than having to "come up with an answer" - especially if the nature of the problems are that they are incredibly complex, and simple answers are likley to too simplistic. //A mentalizing worker is much more likely to be helpful to their client than a non-mentalizing one!//


!!!4(e) Practitioner reflections on using Thinking Together in the field

Watch the video:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/rrPNer2c5rs" frameborder="0" allowfullscreen></iframe></html>

!!Trainer tips: Discussion Points

* ''Thinking Together is not magic!''
** Climbers //still fall off mountains// even though they have developed and use very disciplined ways of communicating to each other about the rope that holds them together!
** Thinking Together is not a guarantee that help offered will always be helpful, but it is a serious attempt to reduce the likelihood of it being experienced as //unhelpful//.
* ''Feed back evidence that this is valued by teams''
** Many teams - across the UK, and internationally, describe significant benefits from adopting this approach:

>1. Shorter more focused meetings
>2. Adaptability of this approach - use it in one:one supervisions, "corridor chats", phone calls, and in front of clients so as to //model// what "help-seeking and help-receiving" looks like, and to allow us to work in more transparent ways (a version of [[Broadcasting Intentions]]).
>3. More of a culture of support for each other's thinking in teams
>4. More clarity in defining and very clearly marking "work conversations" leaves more room for intervals of "recreational chat"/humour, etc, which can help team morale.

* ''Further uses:'' Later in the training we will practice how to use Thinking Together in [[Team Meetings]], etc.

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!BREAK - LUNCH

----

!!5. Team around the Worker
!! Intro for trainers/facilitators

This topic is purposefully slotted in between thinking about [[Working with your TEAM]] and [[Working with your NETWORKS]], //because it applies to both//. 

'Team around the Worker' is easy to talk about, and much harder to do in practice.  It is an ideal, rather than a mechanical recipe:

* ''__How do we create systems of care that can:__''
** ''Look'' at the system //through the eyes of the client//
** ''Value the Key''- (//trusted//) -''workers'' that our client recognises at any point in time
** ''Demonstrate'' this value by //mentalizing// this KeyWorker and //creating supportive and helpful relationships// with them.

It may feel like an //extra investment//, but if we start to "get the same back" from a wider network, it will become obvious that it is also an //"invest-to-save" policy//...

!!!5(a) Exercise
* Watch this video and then discuss in small groups:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/xjYFu6VkiMs" frameborder="0" allowfullscreen></iframe></html>

* ''Discuss in small groups, then feedback'' into the large group:
** //How does our team already work as a "team around the worker"?//
*** //Within// the team?
*** //Beyond the team?// (i.e. with workers from the wider multiprofessional/multiagency network)
** //How might our team benefit// from a wider network that had a stronger "team around the Worker" culture?

!!!5(b) Think about the position of ''RESIDENTIAL CARE WORKERS''

The idea of the [[Team around the Worker]] may be PARTICULARLY relevant:

* Residential care workers are very often (obviously not //always//, but often!) the professionals that young people experience as "getting me", and who they come to trust - especially with [[Epistemic Trust]].
* Residential care workers are also often (obviously not //always//, but often!) relatively invisible/powerless in the big multiprofessional/multiagency networks that gather around the young people they look after.
** //This is unhelpful to the young people!//
* Could a [[Team around the Worker]] culture in a local area change this, by helping:
** ''Residential workers'' - whose relationship of [[Epistemic Trust]] is noticed and valued, and who get better supported/protected by others
** ''Other professionals'' - whose efforts to access and understand young people (who DON'T find it easy to trust doctors, social workers, teachers, police, etc,) could be helped by the Residential care worker who has //earned this trust//.
** ''MOST IMPORTANT OF ALL: Young People'' - whose helping network might start to become //more coherent, more understandable, more trustworthy, and more effective//.

!!6. Working with our NETWORKS

!!!6(a) Dis-integration: a painful truth in complex systems

Watch the video on Complexity and Dis-integration:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/lRoOYlPwzWo" frameborder="0" allowfullscreen></iframe></html>

!!!6(b) Group discussion: Wearing Different hats

!!!''Wearing Different hats: Part 1''

''What do OTHERS say about US?''

[img[Wearing different hats.jpg]]

!!!''Wearing Different hats: Part 2''

''What do WE say about OTHERS?''

[img[Wearing different hats2.jpg]]

!!!6(c) Facilitated brief Group Feedback

* ''TRAINER TIPS:''
** Quite often it is the case that trainees are very enthusiastic in talking about all the myths and unhelpful misunderstandings that //other agencies, or outside professionals hold about us//, but are rather taken aback when they are invited to think about how WE must hold similar myths and misunderstandings about THEM!
** ''Use their examples'' to help them think about how it was quite easy to become a bit "certain" about the wrong-headed ideas others have about us
** ''Remember that //certainty// is often a clue'' that there is non-mentalizing ([[Psychic equivalence]]) happening!
** ''It makes sense that we become a bit non-mentalizing about other professionals'' because it is //frustrating/upsetting/worrying to be misunderstood//.... and when we are frustrated/upset/worried it is harder for us to mentalize!
**Emphasise the importance of recognising that ''mentalizing each other across professional networks is ALWAYS GOING TO BE HARD''.  Failing to do so (we call this [[Dis-integration]]) is not necessarily a mark of professional shame/failure; it is pretty much inevitable.
** ''The professional response to this'' is to //predict it//, and be ready to //correct it// when it happens.
** ''This is not rocket science!''  In fact it is much harder than rocket science (which is just sums that either add up or not)!  
** Multiagency and multiprofessional working should be seen as a much higher level skill than rocket science!

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!BREAK - TEA

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!!!6(d) Addressing Dis-integration

''Watch video:''  This is a very short introduction to three techniques (explained in later videos) that help workers in the task of ''Addressing Dis-integration''

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/QxCNC08TJo8" frameborder="0" allowfullscreen></iframe></html>

!!!6(e) Mapping a system of help: the AMBIT Pro-Gram

* Watch the Video: emphasise that the [[The AMBIT Pro-Gram]] is a "back of an envelope" tool -one that only really needs a piece of paper (although a big white board, or flipchart paper is better!)

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/yU3jiKYUJEE" frameborder="0" allowfullscreen></iframe></html>

''Example of a Pro-gram:''

[img[Pro-gram picture]]

''NOW PRACTICE this technique based on a real client known to you:''

* In pairs. 
* Ideally work with a team-mate who also knows the same case
* One person plays the client, one plays the worker.
** As in all AMBIT role-plays, ''if you are playing the client, //be generous!//''
** This is NOT an exercise to test ability to manage confrontation/challenging behaviour, but to practice [[The AMBIT Pro-Gram]] technique
* Try to reach the point where you can discuss possible ways to enrich/improve relationships across the network:
**(a) //"Who would it be helpful to arrange a conversation between?"//
**(b) //"If we know who we would LIKE to get talking, then HOW might we go about helping that to happen?"// (''NOTE:'' very often in networks it is //not within our __ambit__// [ie not within our sphere of influence/direct authority] to order such conversations... so a degree of subtlety and "soft power"/influence might be required to encourage/facilitate this.

* Discuss feedback in large group
* Then watch Liz Cracknell and Laura Roberston discussing and reflecting on the use of [[The AMBIT Pro-Gram]] in face-to-face work with clients:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/rAqx0uB82ns" frameborder="0" allowfullscreen></iframe></html>

!!7. Concluding remarks and reflections

* We have now covered some ''theory'' (mainly Day 1)
* We have covered some ''practice'' (applying this theory) in:
** ''Working with your Team'' 
** and in ''Working with your Networks''
* ''On [[Day 3|AMBIT-R training programme DAY 3]]'' we will look at
** Applying this with our ''Clients'' in face-to-face work
** Learning at work - ways in which teams might work towards mentalizing (making sense of) their own shared practices ("our own local culture of working") and starting to make purposeful changes, so as to develop themselves as a ''Learning Organisation'' (see [[Developing learning organisations]] for more detail on this).


----

 Click <<tag [[AMBIT-R training programme]]>> for links to days 1, 3 and 4. 

!DAY 3
!!See [[AMBIT-R Training Schedule - Day 3]] for the Day 3 timetable only.
!!1. Feedback
(a) ''Divide into small groups'' (3-4 people)

(b) ''Discuss where you have got'' to in small groups (for 10 minutes max)

* What was of interest and made sense to you from Day 2?
* How could you see any of these ideas or practices influencing your own team's practice?

(c) ''Send an envoy'' (each small group picks and sends an 'envoy' to the neighbouring group)

* ''Group'' describes to the envoy the key themes from their discussion
* ''Envoy'' reflects on what they have heard, and describes the key points of his/her own group's discussion

(d) ''Large group reflections on where the group is today''

!!2. Plan for day:
!!Morning:

# [[Working with your CLIENT]] - Epistemic trust, Mz stance, Egg and Triangle
# [[Working with your NETWORKS]] - sculpt and Dis-integration grids

!!Afternoon

# [[LEARNING at work]]:
## Teams, differences, and change.
## Manualizing areas of practice (Starting with Thinking Together in [[Team Meetings]])

!!3. Why mentalizing matters in the work we do: Epistemic Trust

Watch the video:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/ZBeEOkwLToM" frameborder="0" allowfullscreen></iframe></html>

!!!Discussion in small groups:

* What makes sense about this idea, and what doesn't?
* Think of some real world examples where you or a colleague were able to create epistemic trust in a client, by first creating conditions for them to say "you've really understood me!" - which then allowed them to "listen" to advice/understanding and then (perhaps!) to follow this and try something different later on...
* Feedback

!!4. Putting mentalizing to work with clients: the Mentalizing Stance

Watch the video:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/QF93rO36NaQ" frameborder="0" allowfullscreen></iframe></html>

Brief group discussion

* Feedback
* Ask the group to recall ''"What are the four legs of the Mentalizing Stance?"'' - in the stress of face to face work, it can be hard to keep more than four things in mind!
* We will practice the mentalizing stance shortly


!!5. Active Planning: applying the mentalizing stance to Planning help for clients

* Watch this video 
** ''from 5:00 mins'' to hear about ''Active Planning'' (the video will automatically start here, rather than at the beginning where the [[The Therapist's Mentalizing Stance]] is described.) 
** Alternatively, ''if you just want a description of the Egg and Triangle, start at 20:20 mins'' 

<iframe width="560" height="315" src="https://www.youtube.com/embed/GQZ6EIt_aP0?start=300" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

!!!Practice (ROLE PLAY):
Use the [[Egg and Triangle|Active Planning Map]] - pictured below - to practice the Mentalizing stance:

[img[Ment_Table_Stance_pic]]

[img[Egg and Triangle]]

[img[Egg and triangle (marked)]]

* ''Divide into groups of three (or four)''
* ''One worker presents a case'' (known to him/her) to the others
* ''The listeners, then collaborate'' to fill in the Egg and Triangle, while the presenter just listens/observes
** Those recording their understandings try to use statements in the "egg" that the young person (if he or she were present) would experience as accurately "getting me".
** They consider their intentions and plans for this client, and record these in the triangle
** Remember to think hard about the //top section// of the triangle (the //"Why?"// question that tries to connect the workers best intentions to something that would have value for the client.)
* ''The original presenter now ROLE PLAYS'' as the young person
** ''The others take it in turns to role play a worker'' //broadcasting their understanding and intentions// to the young person - using the Mentalizing Stance, and the Egg and Triangle that they have just filled in to "shape" the conversation
** Can they offer these ideas //tentatively// without trying to "mind-read", but offering them as a "best first-effort to make sense", one that they are sure the client can help them improve upon?
* ''__Advice on ROLE PLAYING:__''
** Note the word "Playing"!  Play is the primary way in which children learn
** If you are role-playing a client, ''BE KIND!''  This is for your colleagues to practice, not for proving that some clients you know can be very challenging!
** Use "Time Out" when the worker "runs out of mentalizing" - all role players can talk about what is happening, why the the worker might have "got lost", and how they might restart the role play
** THEN RESTART! It is important not to get lost  in talking //about// the role play (the [[Pretend mode]] of non-mentalizing!), rather than practising it!
** Notice how, once the role-play is paused, //it is much easier for everyone (especially the worker) to mentalize again//; this is probably because the anxiety for the worker reduces when they are not 'on show'!
** Try to bring the (mentalizing) conversation that happens in these //pauses// back into the role play itself: the mentalizing stance has been described as "thinking thoughtfully and kindly, but //aloud//, hoping that feedback will improve the quality of these first thoughts" - it is a "non-expert" stance, but takes practice (perhaps expertise!) to hold onto it, especially if the situation is stressful.
 
----

!COFFEE BREAK

''Advice for trainers/facilitators:'' during the break try to identify a trainee who can help to create a sculpt around a client.  Choose a client whose professional network is reasonably extensive (and ideally, one which is not seen as working as effectively as it might in an ideal situation!) 

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!!6. Working with Networks: Sculpting

See [[Sculpting a network]]. 

* The point of this technique is to encourage workers to "take different perspectives" across a complex network of different professionals, agencies, and informal 'helpers' around their client.
* Especially, the exercise seeks create "thinking space" to help workers //make sense of the different positions that other workers find themselves placed in// (with their explanations, interventions and responsibilities all defined by their training, organisational priorities, personality, etc)

{{Sculpting a network}}

!!7. Working with Networks: The Dis-integration Grid

* It may be possible to complete the [[Dis-integration grid]] simultaneously with the sculpting exercise
* Complete the grid for the same case example
* This makes it very clear the fact that //both exercises// are just "thinking tools" to help workers mentalize the different minds of the people who make the wider network
** ''LEARNING POINT 1: Systems, Organisations, and Networks are in themselves //mindless//'', but they are composed of many minds.
*** AMBIT seeks to enrich understanding (mentalizing) of the different minds that are at work in networks
*** Networks that have improved relationships and understanding are much more likely to be able to adapt to become more effective
** ''LEARNING POINT 2: Use the Dis-integration grid to help identify 1 or 2 "Connecting conversations"'' 
*** [[Connecting Conversations]] are ones that - if you can help facilitate them - might reduce the largest, most unhelpful 'holes' (dis-integrations) in the existing network.

[img[Dis-integrationGridPicture]]

* ''More practice:''
** Divide into twos or threes - ideally pair with a colleague who knows the same client
** Discuss the network
** Fill in the Dis-integration Grid
*** Keep asking yourselves //"what would this worker think if they saw the points we have recorded about their position?  Would they feel we have accurately 'got' their perspective?"//
*** Identify 1 - 2 [[Connecting Conversations]] that would make the most positive impact on the functioning of the network
*** Discuss //how you would strategically go about setting up, and facilitating these conversations// 
*** ''Note: it may not be within your ambit to 'order' different people to talk to each other!''... how might you extend your ambit, to influence things in a positive way?
*** Remember the material on [[Epistemic Trust]] - if you want to encourage someone (another professional, for instance) to try something different, then first they have to feel that you have shown interest and understanding in them, and their dilemma, here and now!

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!LUNCH

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!!8. Learning at work

Note that LEARNING is in the lowest quadrant of the wheel - which is //"where the rubber hits the road"//

* It is LEARNING by local teams that will create the traction to move things forwards (not the clever words of the trainers!)
* Having the right conversations between team members is at least as important as the "curriculum" that comes from the trainers/facilitators

[img[AMBIT Wheel_B+W_round.jpg]]

''8 (a) Line-up exercise''

* Make sure you have enough space for the team to do the line-up exercise
* Watch the film AT THE SAME TIME AS YOU CONDUCT EXERCISE - the video instructs you to PAUSE it on occasions as you go...

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/tTJ6E6F3H7c" frameborder="0" allowfullscreen></iframe></html> 

* Allow some group discussion

Watch the reflections on the Line-up exercise video:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/gsoWvi41a6E" frameborder="0" allowfullscreen></iframe></html>

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!BREAK FOR TEA

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''8 (b) LEARNING at work conversation:''

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/DrNxEfCuM-4" frameborder="0" allowfullscreen></iframe></html>

Discuss briefly, then watch the next video which introduces a manualizing exercise:

''8 (c) Manualizing exercise, and the Wiki Manual''

* This video requires PAUSING at points to allow teams to practice as directed in the video
* trainers might prefer to watch the video beforehand, and then run the exercise themselves, or use the video to help them in the group:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/J-dzA7n8ZTo" frameborder="0" allowfullscreen></iframe></html>

* We suggest that teams start by manualizing something that they are QUITE PLEASED ABOUT
** //...something that they would want to be able quickly to induct a new team member into 'following their lead'//
* ''Alternative suggestion'': If teams wish to practice and then manualize how they could use [[Thinking Together]] in their [[Team Meetings]] then they could watch the two videos below to give some context:

Team meeting: "Thinking //Apart//":

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/CPuTn9ExNuw" frameborder="0" allowfullscreen></iframe></html>

Team Meeting using Thinking Together:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/lKI3zeHrQX8" frameborder="0" allowfullscreen></iframe></html>


!Feedback and end

[[AMBIT-R training programme DAY 4]] will concentrate on helpng the team bring these ideas together and make plans about which parts they want to try to ''implement'' in the weeks ahead.

Training that results in no change of behaviour is probably a waste of everyone's time!


----

 Click <<tag [[AMBIT-R training programme]]>> for links to days 1, 2 and 4. 

!DAY 4
!!See [[AMBIT-R Training Schedule - Day 4]] for the Day 4 timetable only.
!!Trainers/Facilitators notes
The final day has a slightly less packed curriculum, specifically in order to allow flexibility for catching up (if material was missed out, or under-covered from previous days) and to allow for local teams to spend time on locally-relevant conversations/planning, etc.  The aim for today is that the facilitators should perhaps say rather less, and the team members should say more to each other!

!!Feedback and orientation
Where are we, now and where do we need to get to?

* Small groups - discuss and then each group feeds back to the large group
* Are there any key areas that need to be covered (missed from earlier days, or new material brought up by teams?)

!!Plan for the day

Here, we trainers are doing some [[Broadcasting Intentions]]! (Remember this from our practice with [[Active Planning]] yesterday?  It is often helpful to ''do something'' with the group, and ''then explain what it was you did, and why, using AMBIT terms'', so as to bring these things to life.)

!!1. General theme: fostering important conversations
* Conversations that need to take place between team members
* Today is definitely not just about information flowing from facilitators/trainers to the trainees, but if trainers discover that important conversations are required then we hope (expect?!) them to agree to hold them ''in an AMBIT framework:''
** ''Use [[Thinking Together]]'', trying to support everyone in the team to bring their mentalizing to the table (recognising that this is fragile, especially if there is emotion connected to what is being discussed.  Hint: //and there nearly always is in this work!//)
* Having said this, as trainers, you may have to ''Limit conversations to what is relevant to this training'' (what might this team as a whole choose to do differently, drawing on what we have been covering?)
** ''Conversations that do NOT fit into this, might include...'' significant inter-personal conflicts within the team, or between the team and management (this training is not the same as team facilitation/conflict resolution, even though it offers tools that might be helpful in doing this work) or very complex casework (many of the cases AMBIT teams work with are extremely hard to "solve" and,  again, this training is not designed to do this here and now, but to help workers learn tools that might be helpful in this process.) 
* ''If conversations arise that are not appropriate'' to be worked right through from start to finish, but which are important anyway, then "mark" or "park" them on a piece of flipchart:
** agree quickly what is the proper work-based forum for them to happen in
** agree quickly who would need to be there
** facilitate the right people to agree how/when they will fix a time to arrange this, or book it in to diaries straight away

!! 2. Practice: Team Meetings

Nearly every team has some kind of meeting that allows time for them to discuss the work.

* ''Discuss existing team meetings:''
** Divide into small groups of three or four
** In groups, discuss:
***//What works well and is valued about our team meetings?//
***//What makes them challenging, or less helpful than they might be?//
**Large group feedback

* ''Using [[Thinking Together]] //as a whole team//:''
** Watch videos (or parts of videos):

(a) ''Thinking APART'' in team meeting (well-meaning but ultimately unhelpful practice):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/CPuTn9ExNuw" frameborder="0" gesture="media" allow="encrypted-media" allowfullscreen></iframe></html>

(b) ''[[Thinking Together]] in a team meeting'' (fictionalised case: Jamil):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/lKI3zeHrQX8" frameborder="0" gesture="media" allow="encrypted-media" allowfullscreen></iframe></html>

(c) ''Another example of Thinking Together'' in a team Meeting (fictionalised case: Paul):

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/jyOQdu9QwAc" frameborder="0" gesture="media" allow="encrypted-media" allowfullscreen></iframe></html>

(d) ''When a team member is resistant'' to using Thinking Together:

* We suggest that the team (or Chair) responds by:
** //Mirroring his/her upset// (not by apologising and being embarrassed, or by trying to look sympathetic!)
** Reflecting //with our own sense of urgency// that "we __get__ that there is some urgency/frustration/etc here; and //we want to help// (rather than just nodding and look //as if// we are being thoughtful...)"
** In order to maximise the chance of us being genuinely helpful, however, we need a clearer understanding in our own minds of the task for us (the team) to "chew on".
** Note how this boundary-setting is intended to help to kick-start the help-seeker's own mentalizing - //"Why am I bringing this case to the team?"//:

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/G9myCdw6WrM" frameborder="0" gesture="media" allow="encrypted-media" allowfullscreen></iframe></html>

(e) ''Prompts for AMBIT-influenced practice:'' There are some simple ways of prompting/reminding workers about their shared intention to develop a mentalizing focus (balance-holding) into whole team practice/culture, as well as between individuals:

* ''AMBIT's Principled Stance cards'' Below is a video example of a team meeting, using cards (see below, too) to appoint members as "monitors" for each of the 8 different elements of the AMBIT stance (it is hard for an individual to hold the whole stance in mind, but a whole team can do so collectively, and this is good way to rehearse and remind each other what the principles are.):

See [[AMBIT stance cards]] 

[img[AMBIT stance cards]]

<html><iframe width="560" height="315" src="https://www.youtube.com/embed/gFOlVBLCmwY" frameborder="0" gesture="media" allow="encrypted-media" allowfullscreen></iframe></html>

(f) ''ROLE PLAY A TEAM MEETING''

* One member of the team brings a real case with a concern attached to it to the team.  ''Allocate a Chair'' for the meeting, whose role is to:
** (i) Hold to the "4 steps" of [[Thinking Together]]:
*** Mark the Task
*** State the Case
*** Mentalize the Moment
*** Return to Purpose
** (ii) Ensure that the thinking of all team members has the opportunity to be heard
** (iii) ''MOST CRUCIALLY:'' Ensure //the help-seeker's mind is kept in mind// by the team, rather than letting the discussion become a "battle of ideas"!

!!!Trainers tip:
Do keep in mind the fact that ''this is TRAINING'', so you are mainly focused on ''practising the new TECHNIQUES'', rather than getting too deeply involved in trying to solve the details of day to day work.  This is much harder than it sounds! Work is what everyone here knows how to do, and it is tempting to let go of the difficult task of //trying to do something differently// in favour of the (difficult, but well known) task of fixing family X, or young person Y, or network Z.  As a trainer, you may have to keep pulling people out from very detailed case discussion, and back into the technique.

A useful reminder to groups getting too far into the "nitty gritty of work" might sound like this:

>//"We are just __borrowing__ this actual case to help us practice.  IF we find we suddenly solve the real problem out there, that is great!  BUT the point of this exercise today is to __practice the technique__, not necessarily to solve the problem!  Remember, too, that many of our cases are extremely difficult, and there is no magic that will change that!  Often when teams practice a new technique, it is tempting for them to throw the most insoluble problem at it to 'see if it is any good' - but insoluble problems are generally insoluble! Try to concentrate on learning and making sense of the steps, and thinking about whether a STRUCTURE like this would be helpful if we practised it.  It __has helped__ a lot of other teams (similar to yours) to have better meetings, but hasn't solved all the problems they discuss!"//

----

!Coffee/Tea Break

----

(g) ''TEAM DISCUSSION on TEAM MEETINGS:'' 

* Might this [[Thinking Together]] approach to case discussion be relevant in trying to make OUR FUTURE team meetings more helpful to individual team members?
** Try some [[Manualization]] - manualize the outcomes of this discussion (use the online wiki if you have one, or posters if not.)
*** Record points that receive general agreement
*** Record where there are two (or more) different ideas about what to do ("Path A" and "Path B", etc)
*** Teams are allowed to have a menu of options!
*** Manualizing is about keeping a scrapbook of our current thinking, not producing a perfect finished product.
** Use the online manual, or flipchart paper, to record these ideas (take photos of any written record)...
** Make sure there is a CHAIR (as before) and a SCRIBE, whose job is to record the key points of the groups thinking - ideally in front of them, so that corrections and clarifications can be called out, and the notes become "shared real-time minutes" that summarise things in a way that the team feels its collective thinking has been reasonably represented

(g) ''ON TEAM LEARNING and REMEMBERING:''

* TEAM DISCUSSION: 

However you recorded the discussion above, have another team discussion now to try to reach agreement about ''what happens going forwards after this training?'':

*  ''(i) How could we make time for reflecting on elements of our team's practice?''
** Think of //existing meetings/training slots// that could be "tweaked"?
** Try to avoid creating new meetings if possible?
* ''(ii) If we did create this opportunity for the team, then what elements of our practice would we want to work on?''
** The task is to CREATE A TOPIC LIST
** You don't try to have all of these conversations now!
** If you make a good enough list full of stimulating topics that the team is KEEN to discuss, this will encourage the team to get into [[LEARNING at work]] after the training has finished.
** That is //real change//, not just doing things on a training course, and then going back to business as usual!
*** ''START'' by picking elements of practice that the team is generally PLEASED with (//what elements of our team practice would we want to introduce a NEW TEAM MEMBER to quickly?//)
*** ''THEN'' identify a few challenging elements of day-to-day working life for the team (//"Where are there areas in which we agree 'WE COULD DO BETTER'?"//)
* ''(iii) Discuss practical ways to store the team's collective thinking and agreements'' that might flow from these opportunities:
** A big book or file? (easily gets lost, only one copy, in one place, but simple!)
** Use the AMBIT wiki manual? (https://manuals.annafreud.org) - accessible anywhere, can't get lost, teams get their own local version that you can use to add new pages, or improve on existing pages, takes about 30 minutes to learn how to use it.)
** NOTE: there are instructions (and instructional videos) on [[Manualization]] in the AMBIT manual

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!LUNCH

----

!! 3. Learning: Using measures/outcomes in the team

How else can we do [[LEARNING at work]] if we don't actually have any real-life measures to see if what we do changes anything?

* ''DISCUSS "MEASURING":''
**In small groups
*** (i) What measures do we already use?
*** (ii) Measuring what matters: Do we? Could we? What would we measure that matters, if we could measure it?
*** (iii) What are we //interested// to measure, to see if we could change it?

* ''Other measures, that may be of interest'' (try these out in role plays if there is time):

(a) ''The AMBIT Practice Audit Tool'' [[APrAT]] – an occasional individual practice audit.  Try it out in pairs //with a case that (one or both of) you know://

[img[AMBIT Practice Audit Tool_v.2.pdf]]

(b) ''The AMBIT Relationship to Help Questionnaire'' - [[ARHQ]] -  A reflective questionnaire that helps a client to describe their relationship to helping services, and to set goals on how (or what) to improve.

See [[ARHQ_20.06.17.pdf]]

[img[ARHQ_20.06.17.pdf]]

A worked example of the ARHQ:

See [[ARHQ_WorkedExample.pdf]]

[img[ARHQ_WorkedExample.pdf]]

(c) [[AMBIT Service Evaluation Questionnaire (ASEQ)]] – an occasional whole team check in: what’s it like to work here? - we will look at this at the end of the afternoon

(d) [[AIM]] and [[AIM Cards]] - a 40 item questionnaire which has a worker-rated version, and more recently a client-rated version usually presented as a set of playing cards (see [[AIM Cards]])

See [[AIM form]]

[img[AIM form]]

!!4. Implementing //what matters to the team//

!!4(a) Exercise: Trolley dash

''__Purpose of the exercise:__''

* Inject energy with some noise and fun
* Remind trainees of the range of things they have covered, and the resources that are available to them afterwards to remind, prompt and guide practice
* Help start the process of team reflection on //"What do we want to take away and USE from this training?"// rather than leaving the training as a remote external process, as if it was just something that was //"done to us"//. 

''__Materials:__''

* A pre-prepared collection of pieces of paper, each with //one// of the following AMBIT-influenced practices or tools described on it:
** [[Thinking Together]] in Team Meetings (Mark the Task, State the Case, Mentalize the Moment, Return to Purpose.)
** Thinking together in informal 1:1 staff interactions
** [[Dis-integration grid]]s to identify why networks might not be working as well as they might.
** 'Egg and Triangles' (see [[Active Planning Map]]) for collaborative care planning
** [[The AMBIT Pro-Gram]] for mapping existing helping networks
** Using [[The Therapist's Mentalizing Stance]] in day to day interactions with young people
** Using CUSS or PACE '[[Graded Assertiveness|Graded assertiveness in challenging a team member]]' disciplines to alert colleagues to risks that they might not have seen( //without that alert being taken as criticism!//)
** [[Sculpting a network]] to help workers mentalize the people in complicated (and often dis-integrated) helping networks
** Regular '[[Manualization]] sessions' when the team meets to discuss and records their shared understanding of "how we do it" in relation to particular specific elements of the work we do.
** Using [[Active Planning]] (balancing ''Planning'', ''Broadcasting Intentions'' and ''Staying sensitively attuned'' in adapting what we do with young people)
** [[AIM Cards]] for helping young people to tell their story and prioritise what they want help with ("Key problems").
** [[AIM form]] questionnaire: a way of assessing a young person that covers a wide range of functions, contexts and experiences, which also allows you to measure their progress (//"Are we improving the key problems?"//)
** [[AMBIT stance cards]] for Team Meetings, to ensure that collectively the team holds all eight elements of [[AMBIT's principled stance|Core Features of AMBIT]] in mind as a case is discussed
** [[AMBIT usual suspects cards]] to offer a table-based way of [[Sculpting a network]]
** [[AMBIT Marking the Task cards]] to help team members to Mark their task clearly when they bring a case for team discussion (//which in turn helps the team to offer them the help that is asked for, rather than the help they feel like giving!//)
* If there are two toy shopping trolleys these would be excellent extra props!

''__Preparation:__''

* Arrange the room like a supermarket with chairs scattered around the room, creating aisles.
* Aim to maximise the distance between each item, so that there is further for the "trolley-dasher" to have to travel. 
* Lay out the pieces of paper on the chairs in the "supermarket aisles" - randomly, and spread around the room.

''__The Trolley dash challenge:__''

* ''STEP 1:'' divide into two teams
* ''STEP 2:'' All players spend 10 minutes, walking around as a team browsing the supermarket, and discussing //which items they would choose if they were only allowed 5 items to take back into their work.//
* ''STEP 3:'' Both teams record these 5 items on their own ''"shopping list"''
* ''STEP 4:'' Each team elects one member who will be their team's seeker/trolley dasher...
* ''STEP 5:'' The trainers/umpires now turn all the pieces of paper over (face down!) while leaving them in place in the supermarket (//N.B. ''do not warn players'' that this will be happening!//)
* ''STEP 6:'' explain the SCORING SYSTEM:
** ''2 points'' for every item they collect //that is on their shopping list//
** ''1 point'' for any item that is //not on their shopping list// but which //all members of the team can (independently, without conferring!) explain in a few sentences// roughly what it is and why it matters!
** ''Minus 1 point'' - any substituted item (i.e. //not on the shopping list//) that //cannot be roughly explained by all members of the team// as above
** ''Minus 2 points'' - any Missing item (i.e. less than 5 items selected)
* ''STEP 7:'' At the given signal, seekers enter the supermarket and  have //2 minutes to find the five items on their shopping list.//
** //''Strategy hint:'' if they think there is a high likelihood that the other team will go for the same item, they had better go there first!// - once it has gone, it has gone!
** Team members can call out to direct their dasher if they remember the location of an item on their list
** Otherwise, the dasher will have to search by turning pieces of paper over - turn them back straight afterwards, if they are not what is sought
** If an item has already been taken, or cannot be found, the dasher and team-mates can call out to each other to decide //what substitute item to choose.// (//''Strategy hint:'' choose something that everyone in the team will have a rough idea what it is, rather than picking up any old item!//)
** ''STEP 8:'' After sixty seconds the whistle is blown, and the trolley dasher must stop where they are. SILENCE!
** ''STEP 9:'' If a team has any substitute items, these must be declared and all team members have 60 seconds (''with NO CONFERRING!'') to describe on paper roughly what it is and why it matters.
* ''STEP 10:'' Group discussion and collective scoring of a team's descriptions of any substitute items.

* Prizes are optional

!! 4(b) ''Changing behaviours in a team is very hard''

There is a whole science of "implementation" of evidence-based practices.  Research shows that //just because things "work" or make things better it doesn't mean that teams immediately start doing/using them!//

__''(i) You need an implementation PLAN...''__

* ''You need people''... an "implementation team" who can help encourage, support, prod, cajole (and who will take some responsibility for, and be supported by the team, in doing this.)  The best of intentions do not just happen!
* ''Team discussion:'' create your ''Implementation PLAN''
** Choose the right person to CHAIR you discussion
** Choose a SCRIBE to minute what you agree on
*** Make your plan //realistic, not idealistic//
*** Make it specific: provide timetables, names, etc, if possible


__''(ii) You need Implementation SUPPORT''__

Create and build up resources that could help to prompt, remind, and support the team to make changes:

* ''People are resources''
**Choose team members happy to be ''"AMBIT nudgers"'' who (by invitation) can encourage team members to try things, and keep doing things
*** Consider who could act as external supporters/reviewers who could check in some weeks ahead to see how you are doing.  Ideally, invite colleagues from neighbouring teams (your [[Community of Practice]]) to VISIT or PHONE at an appointed date, and give them a copy of your Implementation Plan - do the same for them?
* ''The power of visitors'' to help teams change behaviours
** Think of having your in-laws round to tea!  Everyone behaves!
** //Regularly having visitors to team meetings// encourages team members to //explain why we do things like this// and keeps them in a "showing off" frame of mind, which are both powerful ways of learning (//teaching//, and //role-playing//) 
*** ''Discuss:'' who could your team invite to team meetings? Students? Other professionals from the wider network? Workers from other residential settings?

__''(iii) You need material Resources:''__

You can use MORE than the tools you selected in the trolley dash earlier.

What does the team want to use/have available from next week?

* ''Posters in strategic places:''
** The [[AMBIT Wheel]]
** The  4 steps of [[Thinking Together]]
** The four-legged table: [[The Therapist's Mentalizing Stance]]
** The [[Dis-integration grid]]
** The [[Egg and Triangle.pdf]]
* ''Playing Cards:''
** [[AMBIT stance playing cards]] (see video above) for use in Team meetings
** The [[AMBIT usual suspects cards]] for sculpting a network on a table (in your [[Team Meetings]]):
** The [[AMBIT Marking the Task cards]]

!! Final practice of [[Manualization]]:

Rather than writing - create a beautiful, funny, inspiring, etc, creative poster for the office wall.

Divide into two or more small groups and pick a subject (or make up a better one) - ''the main point of this exercise'' is not to produce a work of art (although you may) but //to practice sharing ideas and understandings and getting better at arriving at a written/illustrated account of ''"where we all stand together on this question today."''//

* Describe/ illustrate the team's ''Implementation plans''?
* Describe/illustrate '''Why'' we want to do these things?'
* Describe/illusrate 'What ''Resources'' we are gathering/using?'
* Describe/illustrate '''Top tips and reminders'' from the days we spent thinking about our work

----

!TEA BREAK

----

!! 5. Catch up time

* Use this time for catching up if there has been slippage against the timetable
* Take feedback on the experience of the training
* What would the trainees have had you do differently if you were starting over?  How could you do (even) better in the next training that you deliver?

----

!END

----


 Click <<tag [[AMBIT-R training programme]]>> for links to days 1, 2 and 3. 

AMBIT is as much about strengthening team practices as it is about anything.  See [[Working with your TEAM]] for a breakdown of the core content in this area.

!!Video on AMBIT and Team Working
By [[Liz Cracknell]], one of the senior [[AMBIT Trainers]] - addressing a Training for [[AMBIT Local Facilitators]]

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This page gathers all the material that relates to team working together. Use the dropdown arrow (top right hand corner) and click info to access the 'tagging' tab, where you can see the [[Sub-topic]]s offering guidance from an AMBIT perspective on team working.

!Work in Progress

This is not yet in action, but is in active development.  This is seen as a "next step" beyond the notion of an AMBIT-influenced team.

!What it is:
Teams become AMBIT-accredited via a voluntary assessment of a team's competence in AMBIT knowledge and skills, conducted at least a year after training.  If completed it leads to accreditation as an [[AMBIT-accredited]] team.  We see this as the equivalent as a "quality kitemark" for teams working under the influence of AMBIT, with the possibility of moving towards a "membership" model that would carry certain advantages in terms of access to new training opportunities for that team, the opportunity to become satellite AMBIT training centres, and to influence the development of new content in AMBIT.

Criteria for acceptance, etc are still being worked out (Dec 2015) - and we actively invite feedback from collaborators in the AMBIT [[Community of Practice]] about these ideas, and expressions of interest in becoming an AMBIT-accredited team.

!Accreditation Criteria
AMBIT Accreditation covers:
!!!1.	Moving from AMBIT-influenced practice to become an AMBIT-accredited Team
!!!2.	Moving from AMBIT-accredited Team status to become an AMBIT-accredited Training Centre
 
!!1.	AMBIT-accredited Team status:

* At least one year post an accredited AMBIT training
* Evidence of AMBIT-influenced practice:
** AMBIT Leads attendance at requisite number of phone/web/face to face supervisions.
** Documented changes in practice pre- and post-training
** Broad adherence to a pre-arranged Implementation Plan
** Evidence of use of practice audit (eg APrAT, or PREP questionnaires)
** Evidence of some form of local manualizing of learning (web based or other)
** Contributions to the wider AMBIT community of practice (eg attendance +/- presentation at AMBIT annual conference, sharing best practice via AMBIT manual, buddying training relationship with another AMBIT-influenced team, etc)
* Submit application to the AMBIT project, at the Anna Freud Centre.

!!2.	AMBIT-accredited Training Centre status

The accreditation programme for AMBIT Training exists to accredit organisations - and individuals within that organisation - to deliver training in AMBIT.
 
In order to become an Accredited AMBIT Training Centre, organisations must have previously:

* Received an accredited AMBIT training
* Have been implementing AMBIT principles in their work for at least 12 months. 
* Have achieved AMBIT-accredited Team status.

The organisation must:

* Identify two or more individuals to apply to become “Accredited AMBIT trainers”. 
* Agree to the following limitations:

** Accreditation enables those individuals to deliver AMBIT training whilst in the employment of their accredited organisation.
** Only individuals employed by an Accredited AMBIT Training Centre may apply for accreditation. 
** This accreditation does not cover any training that any individual may deliver outside of the Accredited AMBIT Training Centre. This is to ensure that all Accredited AMBIT Trainers are actively working in, and developing their training within, an AMBIT-influenced service.
 
Accreditation process
 
There are three stages to the accreditation process:
 
!!!Stage 1:
Applying organisations should meet these basic criteria:
* Have received an accredited AMBIT training
* Have been applying AMBIT principles and practices for at least 12 months
* Can identify at least two members of staff who have:
** Ongoing employment in the organisation
** Completed AMBIT training
** Stated a wish to become Accredited AMBIT Trainers
 
The organisation and prospective trainers submit an application form detailing evidence of prior AMBIT training and practice as well as a 10 minute video clip of the prospective trainers presenting or discussing an aspect of the AMBIT approach.
 
Successful applicants will be invited to progress to stage 2 of the accreditation process.
 
!!!Stage 2:
Applicants will be asked to identify a local organisation/ team who desire AMBIT training. This training will be co-delivered by the Anna Freud Centre and the prospective Accredited Trainers. In this way, prospective Accredited Trainers are simultaneously trained and assessed. The team/s being trained will reap the benefit of a training delivered both by fully trained AMBIT Trainers and the prospective Accredited Trainers, with their local knowledge and expertise.
 
Fees for this training will be paid to the Anna Freud Centre. Prospective Accredited Trainers effectively receive Train the Trainer training free of charge. Prospective Accredited Trainers’ expenses may be charged to the local organisation being trained.
 
Upon satisfactory completion of this training, trainers and their organisation will be accredited and are then welcome to offer and deliver their own trainings.
 
!!Re-accreditation
 
Accredited AMBIT Training Centres and Trainers must renew their accreditation bi-annually. Re-accreditation involves:

* Submission of a reflective account of any trainings offered by the centre over the past year.
* Standardised post-training feedback data from teams they have trained over the year.
* A 10 minute video clip of the Accredited Trainers discussing one aspect of the AMBIT approach
** note: we are looking for their reflections and understandings of the chosen material, not a simple re-presentation of it.  
** E.g. their experience of its application, usability and effectiveness in practice, and their experience of training workers on this aspect.  
** We are looking for reflections that include both positives and negatives.
 
!!Fees

Accredited Training Centres pay a yearly fee for accreditation of their trainers. This is to cover:

* Administration costs
* Quarterly telephone supervision sessions
* An annual webinar for trainers provided by the AMBIT Project

Accredited Training Sites pay a percentage of fees charged for all training events to the AMBIT project at the AFC. This money contributes to:

* On-going development of the AMBIT approach
* The AMBIT manual service costs
* Development of new Training materials

As part of the agreement; 

1.	Partners must notify the AFC Short Courses and Conference Co-ordinator of any AMBIT trainings that they plan to host for staff from other agencies. 
2.	All AMBIT trainings delivered by Partners will be administrated by the Partner.
3.	All course bookings will be processed by the Partner.   
4.	All trainings delivered by Partners will be advertised on the AMBIT Global Network section of the Anna Freud Centre training website and will be marketed as a separate training course to the AMBIT trainings held at the AFC. 
5.	It will be the responsibility of the Partner to identify a suitable training venue. 
6.	Should Partners wish to recruit AFC AMBIT staff to tutor one or more of the training days, this will be deemed as a course expense and will be charged at a rate of £800 per day. 
7.	Partners are authorised to set the training fee that participants pay, but are encouraged to be advised by existing fees advertised by AFC. 
8.	The Partner and AFC both have to agree the overall financial plan before going ahead with a training.  

!!!Outcomes measurement 

Accredited AMBIT Training Centres must collect training feedback from their trainees and submit this on the web-based POD outcomes system to enable evaluation of training by the AMBIT Project. Accredited AMBIT Training Centres will ask the teams they train to chose outcome measures for their training from a menu of measures provided on the POD (or other measures of their choosing) and collect pre- and post-training outcomes. 
 
!!!Benefits of Accreditation:
* Accredited Trainers will have access to quarterly supervision sessions and an annual webinar provided by the AMBIT Project to support them in their training efforts and keep them abreast of developments within the project and wider Community of Practice.      
* Developing and maintaining the expertise required within your organisation to deliver AMBIT training can support and sustain your own organisation’s on-going implementation of the model.        
* Your organisation will become a key influence within the growing AMBIT Community of Practice, supporting the wider dissemination of AMBIT ideas.
* Your organisation can publicise itself as an Accredited Training Centre, bearing the AMBIT Accreditation logo on your literature. You will be listed as an Accredited Training Centre on the AMBIT web pages.
* Accreditation gives you the right to benefit commercially from training you deliver.
 
Differentiating Accredited AMBIT Trainers from other AMBIT Trainers
 
* AMBIT Trainers – fully trained AMBIT Trainers employed by the AMBIT Project at the Anna Freud Centre
* Associate AMBIT Trainers – AMBIT Trainers employed by the AMBIT Project at the Anna Freud Centre and enrolled on a training programme to become a fully trained AMBIT Trainers.
* Accredited AMBIT Trainers – employed by an Accredited AMBIT Training site and licensed to offer (and charge for) their own AMBIT trainings to other organisations.
* Local AMBIT Trainers – Trainers who have attended an AMBIT Train the Trainer programme to enable them to train workers within their own organisation. Local AMBIT Trainers are not able to provide accredited training to other organisation.

!!Licensing arrangements:
Note that under the existing [[creative commons licence|Licensed]] under which all AMBIT materials are published on the web, anyone can offer training to others on AMBIT as long as they:

* Credit the Anna Freud Centre as the original authors
* Do not charge for that training or otherwise gain commercially from it.

On achieving AMBIT-accredited Training Centre Status, and in accordance with the conditions described above, a new and adapted license to use the AMBIT materials would be issued to allow the above.

Increasingly we prefer not to talk about "AMBIT teams" but rather refer to "AMBIT-influenced" teams, emphasising the fact that AMBIT is not a monolithic culture, or a "unimodal" intervention: an essential principle in AMBIT is the need to [[Respect local practice and expertise]], balancing this with [[Respect for Evidence]].  

The [[AMBIT programme]], based around the [[Anna Freud National Centre for Children and Families]] seeks to provide a platform upon which multiple adaptations and improvements can be built, and shared - creating a [[Community of Practice]] which blends evidence based techniques and components of practice with //practice-based evidence// from specific real-world  teams.  open access to the different manuals managed by Community members is via the [[signposting site|Other team's AMBIT manuals]].



Although ''anyone can access the core material, and can even freely create their own version of the AMBIT manual'' (see [[here|https://manuals.annafreud.org]] only teams with a formal [[AMBIT training|Information About AMBIT Training]] become members of the AMBIT [[Community of Practice]] by being included in the list [[here |Other team's AMBIT manuals]]. Members of the Community of Practice are able to use the comparing and sharing functions in the manual to keep abreast of (and benefit from) the learning other teams are documenting in their work. 

{{nathan-anderson-kTaIjvHsyJg-unsplash.jpg}}

!!''What is AMBIT? ''

* A Mentalization-based approach, designed for teams and services who work with clients presenting with multiple and complex problems
*AMBIT has been developed with a focus on those for whom help-seeking, or using conventional forms of help, can be particularly challenging

* AMBIT works to support services in developing systems of care adapted to their local context and client group
*AMBIT is guided by a central theory- [[Mentalization]]- which is applied in a conscious and deliberate way to 4 areas of practice:

**''[[In direct face to face work|Overview: Working with your CLIENT]]'' - Applying a [[Mentalizing Stance|The Therapist's Mentalizing Stance]] to therapeutic work.
**''[[Between members of the team|Overview: Working with your TEAM]]'' - The ways in which colleagues support each other in their work to foster a [[well-connected team|Keyworker well-connected to wider team]].
**''[[To the wider professional network|Overview: Working with your NETWORKS]]'' - The way in which the service relates to and supports the complex network of professionals that often develop around this client group.
**''[[To the way in which teams learn about their work|Overview: LEARNING at work]]'' - Through encouraging a culture of continuous learning and adaptation.

The range of problems that AMBIT-influenced services address are varied, there may be many different treatment aims- addressing clients' fundamental [[Relationship to help]] is often one of the core treatment aims shared by the many services that use or adapt this approach.

!!!(<4 mins) A very brief introduction
By [[Liz Cracknell]] and [[John Lincoln]], both [[AMBIT Trainers]]

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!!!(10 mins) The AMBIT model

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!!In summary…

''AMBIT is NOT:''

* A ''"one-size-fits-all"'' rigidly-determined "tick-box" approach to therapy
* A new form of individual therapy
* A template for team structure and organisational arrangements
* An approach for specific psychiatric disorders
* An approach that can only be delivered by statutory services

''AMBIT is:''

* A ''mentalization based approach''
* A[[ team approach|Working with your TEAM]]
* An approach for clients with severe and complex problems including mental health problems 
* An approach for clients who may have a very poor or negative [[Relationship to help]] (See also [[Who is AMBIT designed to help? |Who is AMBIT designed to help?]]for more detail) 
* An outreach approach, but one which can be adapted for other types of service delivery
* An approach that emphasises [[relationship building |Scaffolding existing relationships]]and uses ideas from [[Attachment theory]]




* A manualized framework with a strong emphasis on supporting local adaptations and further development of the model within a local context (see[[ Manualization|Manualization]])


AMBIT's name changed recently from Adolescent Mentalization Based Integrative Treatment to ''ADAPTIVE Mentalization Based Integrative Treatment'', because many of the clients that teams using this approach are working with now fall outside the category of adolescence.


''The Core Features of AMBIT''

For the worker the [[Core Features of AMBIT]] are intended to be practical "grab-rails" - which describe a STANCE - and important features of PRACTICE, that are designed to help the worker stay 'on track' - especially at those times of high stress or anxiety that are common in this work. The [[AMBIT Wheel]] is an attempt to present them in a simple and memorable way.


!!!(<10 minutes) Walking through the Wheel
See the [[AMBIT Wheel]] and [[Core Features of AMBIT]] for more

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''For those who would like to read and watch more, below you will find more text and links explaining in further detail (and in slightly different ways) what AMBIT is, as well as directing you to other useful pages////.''

*[[Other key aspects of AMBIT in a little more detail]]
*[[AMBIT FAQs]] This includes questions frequently asked at training events awell as questions about ''doing'' AMBIT training  
*In 2017, a 'book of the AMBIT wiki' was published by Oxford University Press - and there are a number of publications too, find these at [[Academic references]]

!!''Feedback from AMBIT-influenced teams''
Here are some comments received in a 2014 survey of teams who have undertaken AMBIT training.

>>"//AMBIT has been helpful in bringing together a shared sense of purpose for a team while under re-organisation//"

>>"//Team was newly set up when AMBIT training was attended so it has been key to the team's development and ethos from the beginning.//"

>>"//We continue to use AMBIT as a focus to ensure that we work in a different way. AMBIT is becoming the language by which we do this//"

>>"//Has offered a set of principles for working with complex systems organised around mentalizing which we can compare ourselves against and relate to as we develop how we work//".

>>"//We are growing a pilot multidisciplinary young person's service (including support for providers of youth services) ... and find that AMBIT helps us better support young people as well as build non-adversarial and positive working relationships with colleagues from other services//"


----

!!Relevant links
# [[Core Features of AMBIT]] - This should be your next step in understanding AMBIT - it provides the main "grab rails" for a practitioner to remember that determine his or her STANCE in the work, and the key features of PRACTICE that flow from this. 
# [[Mentalization]] - This is the key supporting theory, that shapes specific work with the young person and family, and the work of the team. 
# [[AMBIT Stance Exercises]] offer a range of [[Training exercises]] to practice different elements of the stance.

Another acronym... for [[AMBIT Practice Audit Tool (APrAT)]]

!!The aim of this exercise is:
* to work with practitioners, or teams who are training together 
** to reflect on the degree that each practitioner uses AMBIT methods already in their work
**to consider the use of other practitioners/teams/agencies in the helping process (the [[Community of Practice]]).
** to practice seeking advice from a colleague (even, or especially) from another team about a case/your practice. 

!! Instructions for exercise
1.  ''In pairs with another person from your own team'', //select a case that you both know// which is proving hard.

2.  Using the [[AMBIT Practice Audit Tool (APrAT)]] form, complete this in your pairs. 

3.  Reflecting on your answers, try to make an intervention plan for next week.

4.  These pairs //separate now// - one will continue to work with this case (they become the ''consultee''), the other will become a temporary ''consulting colleague'' to someone from a DIFFERENT pair/team: //try to work with somebody that you do NOT know well, or don't work with regularly.//

5.  Consult with this new partner about the case, or offer consultation to them. 

6.  The Consultant may want to bear in mind ways of [[Thinking Together]], and may invite the Consultee to complete  [[The AMBIT Pro-Gram]] for the case and/or to discuss who //outside of the caseholding team// might help in any way with the planned intervention.  They may want to help the consultee fill in a [[Dis-integration grid]].

7. Reverse  the consultation process to give feedback on the process - so that Consultant briefly becomes the consultee - //"how did I do as a consultant to your team?"//

8. Feedback on exercise in the large group

9. Identify any LEARNING NEEDS that arise, and look for [[Training exercises]] that might support this.

!!Time allocation
45 minutes

! The AMBIT Relationship to Help Questionnaire
This is a measure that is still under development.  Feedback from field applications is invited.

[img[ARHQ.jpg]]

This measure is designed less as a formal outcomes measure, and more as a //clinical aid// - to:

* help build alliance
* encourage collaborative care planning
* help "unstick" a therapeutic relationship when it has got stuck.

An overarching treatment goal for most AMBIT-influenced teams, however, is ''to improve the [[Relationship to help]]'' and some measure of whether there has been movement in this measure in keeping with the goals identified at its first use might contribute to the measurement of this complex change.

The Questionnaire builds on work to develop a "clients'-eye view" of the AMBIT Wheel (the [[Client's AMBIT Wheel]]). 

! The Questionnaire:

|||>|>|>|>| !HOW OFTEN IS THIS STATEMENT TRUE? |
|||!ALWAYS|!MOSTLY|!REGULARLY|!OCCASIONALLY|!NEVER|
| 1. |I’m making/rebuilding relationships that really matter to me ||||||
| 2. |I’m looking after my basic safety (avoiding trouble, illness, or danger) ||||||
| 3. |The people offering help seem to understand me, so I can trust them ||||||
| 4. |I can understand the people offering me help and how they try to do this ||||||
| 5. |All the things I want to improve in my life are covered in a plan ||||||
| 6. |All the different kinds of help I’m getting are working well together ||||||
| 7. |I’m learning from experiences in my own life, so that I can make changes ||||||
| 8. |I’m learning from other people, so that I can make changes ||||||

After completing the questionnaire the client AND worker should have a conversation:

* For things to start looking better, how would your existing scores need to change? (''Use arrows to show where the X should move'')
* What might you do help them change in the right direction? (''Make notes, or ask your worker to'')
* What might workers do? (''Make a plan together'')

!Discussion
There is a worked example at the bottom of this page.

There is no "right" or "wrong" answer for these questions, as different situations will call for different responses, but in general answers that are only "occasionally" or "never" should raise a question as to whether in an ideal world, that statement would be true somewhat more often than that.  Some questions are designed to be ambiguous - for instance Q's 1 and 2 - is it desirable to be //constantly// making and repairing relationships?... to be //constantly// looking after my basic safety?  If these are marked as "Always" does this suggest anxiety or distress that, in an improved situation, would allow these activities to take place, perhaps, "regularly" or just "occasionally"?

The key point of discussion is to open up thinking about these areas of the helping process (that AMBIT seeks to strengthen), identifying areas in whcih there is a clear interest in a direction of travel (//mark arrows from each X on the questionnaire to the position that would be more desirable// - an example of [[Goals-based outcome measures]]) , and collaboratively developing plans to make such changes.

A subsequent (post-treatment) ARHQ might then indicate if there has been movement towards such goals.

[img[ARHQ_workedEg.jpg]]

----
The tag [[Who does what?]] gathers together material that relates to the wider context in which the young person and family are functioning.  

In particular it offers material relating to the attention that the KeyWorker will being paying to two of the [[Core Features of AMBIT]], namely the stance of trying to make sure that different methods of help by different agencies are explained and discussed with the young person [[Taking Responsibility for integration]] and the related task of working to ensure that agencies have a shared approach to the problem [[Addressing Dis-integration]].
*[[Boundaries]] define the tasks, roles and responsibilities of the KeyWorker in the midst of a complex set of relationships.
*[[Dis-integratedInterventions]] describes the ways in which the care network may unwittingly work against itself.
*[[KeepingYourBearings]] offers advice to the KeyWorker on managing oneself amidst complex, competing priorities.
*[[ProfessionalNetworkMembers]] provides information on the key parts of a young person's 'care ecology'.
*[[SupervisoryStructures]] are one of the [[Core Features of AMBIT]] and assist the KeyWorker in maintaining their own [[Mentalization]] and fidelity to the interventions.
*[[Working with other professionals]] offers information on how to reduce the effects of [[Dis-integratedInterventions]].

[img width=100% [adam-solomon-WHUDOzd5IYU-unsplash.jpg]]

This page provides you with an overview of the AMBIT manuals. Each team who trains in AMBIT receives their own individual AMBIT manual. The manuals are online and can be accessed by the AFNCCF Manuals signposting site https://manuals.annafreud.org/. 

Each team's manual contains all of the core AMBIT content, which is updated and added to by the [[AMBIT programme]], and additional space for a team to manualize their own practice, for example how they have adapted the AMBIT approach to suit their service.

Through providing each team with their own individual manual which can be added to and edited and using an [[open source |OpenSource]]approach, which allows teams to access (but not edit) [[each others manuals|Other team's AMBIT manuals]] via the manuals sign posting site (see above), we are encouraging what we call a [[Community of Practice]] where teams can share with each other ideas around best practice. 

!!Things to know
The links below provide you with information on how the information in the manual can be reused, who writes the AMBIT content, how to use the manual and how to give feedback on the manual! 

* [[Licensed]] content
** Information about the way this manual is released under the Creative Commons to maximise sharing and wide dissemination.
* Information on [[Using the Manual|User Guide]]
** How to navigate around it easily
** How find content you seek
** How to compare what is in this version, and those of other teams
* [[Authors]]
* [[Sponsors]]
* [[Feedback please!]]
* [[Error messages]]

See:
* [[When to suspect maltreatment - NICE guideline]] 
* The UK Government's advice page [[What to do if you're worried |https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419604/What_to_do_if_you_re_worried_a_child_is_being_abused.pdf]] is a helpful starting point.
* See also:
** [[Child Protection]]
** [[Child Protection Referral]]

----
This is a necessarily abbreviated list of references and influences - mainly including systemic rather than cognitive behavioural or psychodynamic references, although these are certainly also highly influential on the model. 

The developers of Mentalization-based practices are at pains to repeat that in many important ways there is nothing //new// in theories of mentalizing, and its application in therapeutic work. Indeed, Prof Fonagy has written that 
>//"mentalization-based therapy is the least novel approach imaginable..."//
There is a reasonable argument to be made that //most// therapeutic approaches, insofar as they are successful, are probably acting by stimulating, or repairing mentalizing function.  The only difference in the MB approaches is the extent to which this function is explicitly focused on as the target for treatment, and to some extent the 'stance' and core features that support this.

!!''AMBIT - specific references''

<center>[img[AMBIT_BookCover.jpg]]</center>

*[[Bevington, Fuggle, Cracknell and Fonagy (2017) Adaptive Mentalization Based Integrative Treatment: a guide for teams to develop systems of care. (Book, pub. OUP)]] - as at 2017, and except for this online manual, this is the most complete description of AMBIT.  Note the name-change from "Adoelescent.." to "Adaptive..." - there are many teams working with other age groups using AMBIT nowadays.
*[[Bevington, Fuggle, Fonagy (2015) Applying attachment theory to effective practice with hard-to-reach youth: the AMBIT approach]]
*[[Bevington D, Fuggle P (2012) Supporting and enhancing mentalization in community outreach teams...]]
*[[Bevington et al (2012) Adolescent Mentalization-Based Integrative Therapy (AMBIT)]]
*[[Asen, Bevington (2007) Barefoot practitioners]]
*[[Fuggle et al (2014) The AMBIT approach to outcome evaluation and manualization: adopting a learning organization approach]]
*[[Griffiths et al (2016)]] Innovations in Practice: evaluating clinical outcome and service utilization in an AMBIT-trained Tier 4 CAMHS service.

!!''References to AMBIT in other (independent) reviews, etc''

* [[Account of AMBIT presentation - ACAMH magazine (Autumn 2013)]]
* [[Krueger and Glass (2013) Integrative Psychotherapy for Children and Adolescents: A practice-oriented literature review]]
* [[Gilvarry et al (2012) Practice standards for young people with substance misuse problems]]
* [[CSJ (2012) Rules of Engagement: Changing the heart of youth justice]]
* [[Khan et al (2010) You just get on and do it: healthcare provision in Youth Offending Teams]]
* [[Siri (2012) Mentalization-based therapy for adolescents]]
* [[Straussner and Fewell (2011) Children of Substance-Abusing Parents: Dynamics and Treatment]]

!!''Selected other interventions with/studies on hard to reach/under-served families''
*[[Bachler (2014) Differential effects of the working alliance in family therapeutic home-based treatment of multi-problem families]]
*[[Ungar et al (2013) Service use, risk factors and resilience in adolescents using multiple services]]

!!''Deployment-Focused treatment development:''
*[[Bearman et al (2010) Adapting CBT to fit diverse youths and contexts: applying the deployment-focused model...]]
*[[Chorpita, Daleiden and Weisz (2005)]]
*[[Weisz, Simpson-Gray (2008) Evidence-Based Psychotherapy for Children and Adolescents]]
*[[Weisz, Jensen-Doss, Hawley (2006) Evidence-based youth psychotherapies versus Usual Care]]

!!''MBT-Adolescents (~MBT-A) References''
See also MBT-A and MentalizationBasedWork

*[[Rossouw, Fonagy (2012) Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial]]

!!''MBT-F Specific References''
See also MBT-F and FamilyWork

*Fearon, P., Target, M., Sargent, J., Williams, L. L., McGregor, J., Bleiberg, E., et al. (2006). Short-Term Mentalization and Relational Therapy (SMART): An Integrative Family Therapy for Children and Adolescents. In J. G. Allen & P. Fonagy (Eds.), Handbook of Mentalization Based Treatment. Chichester: John Wiley and Sons Ltd.
*Asen, E., & Fonagy, P. (In press) Mentalization-based Therapeutic Interventions for families. Journal of Family Therapy, x, 1-24.

*Keaveny, E., Midgley, N., Asen, E., Bevington, D., Fearon, P., Fonagy, P., Jennings-Hobbs, J. & Wood, S. (2012) Minding the Family Mind: The development and evaluation of Mentalization Based Treatment for Families at the Anna Freud Centre in London. In N. Midgley & I. Vrouva (Eds.), Minding the Child: Mentalization-based Interventions with Children, Young People and their Families. London: Routledge.

!!''Mentalization References''
*Allen, J.G., and Fonagy P., (Eds.) Handbook of ~Mentalization-Based Treatment, 2006, Chichester, UK: John Wiley & Sons
*Bateman, A., & Fonagy, P. (2004). Mentalization based treatment of borderline personality disorder. Journal of Personality Disorder, 18, 36-51.
*[[Choi-Kain, Gunderson (2008) Mentalization: ontogeny, assessment, and application]] - good on the overlapping concepts of mindfulness, empathy, etc.
*Fonagy, P., Bateman, A., & Bateman, A. (2011) Commentary: The widening scope of mentalizing: A discussion. Psychology and Psychotherapy: Theory, Research and Practice, 84, 98-110.
*Fonagy, P., Gergely, G., Jurist,E., and Target, M. Affect Regulation, Mentalization, and the Development of the Self, pub. 2002 by Other Press
*Fonagy, P., Steele, H., Moran, G., Steele, M., & Higgitt, A. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 13, 200-217.
*Fonagy, P., & Target, M. (1996). Playing with reality I: Theory of mind and the normal development of psychic reality. International Journal of Psychoanalysis, 77, 217-233.
*[[Gergely, G (2004) The social construction of the subjective self]] 
*Luyten, P., Mayes, L., Fonagy, P., & Van Houdenhove, B. (2009) The interpersonal regulation of stress. Unpublished manuscript.

!!''Learning Organisations, Communities of Practice, Wikis as learning aids''
*[[Cole, M (2009) Using Wiki technology to support student engagement: Lessons from the trenches]]
*[[Lave and Wenger (1991). Situated Learning: Legitimate Peripheral Participation]]
*[[Seddon, J. (2008) Systems Thinking in the Public Sector]]
*[[Senge (2006, 2nd edition) The Fifth Discipline: the Art and Practice of the Learning Organisation. Random House Business Books]]
*[[Kyratsis Y, Ahmad R, Holmes A (2012) Technology adoption and implementation in organisations - BMJ]]
*[[Jason Shaw (2013) Developing a Hypertext Educational Environment using TiddlySpace]]
*[[Wilson, G. T. (1998). Manual-based treatment and clinical practice]]

!!''Systemic References''
*Byng-Hall, J. (1995). Rewriting Family Scripts. New York, London: Guilford Press. New York, London: Guilford Press.
*[[Cecchin, G. (1987). Hypothesising, circularity and neutrality revisited: an invitation to curiosity]]. Family Process, 26, 405-413.
*de Shazer, S. (1982). Patterns of Brief Therapy: An Ecosystemic Approach. New York: Guilford Press.
*Diamond, G. S., & Josephson, A. (2005). Family based treatment research: a 10 year update. Journal of American Academy of Child and Adolescent Psychiatry, 44(9), 872-887.
*Donovan, M. (2009). Reflecting processes and reflective functioning: shared concerns and challenges in systemic and psychoanalytic therapeutic practice. In C. Flaskas & D. Pocock (Eds.), Systems and Psychoanalysis. Contemporary Integrations in Family Therapy. London: Karnac.
*Larner, G. (2000). Towards a common ground in psychoanalysis and family therapy: on knowing not to know. Journal of Family Therapy, 22, 61-82.
*[[Mason, B (1993) Towards positions of Safe Uncertainty]]
*Minuchin, S. (1974). Families and Family Therapy. Cambridge, Mass: Harvard University Press.
*Pocock, D. (2009). Working with emotional systems: four new maps. In C. Flaskas & D. Pocock (Eds.), Systems and Psychoanalysis. Contemporary Integrations in Family Therapy. London: Karnac.
*Rober, P. (1999). The therapist's inner conversation in family therapy practice: some ideas about the self of the therapist, therapeutic impasse and the process of reflection. Family Process, 38, 209-228.
*Selvini Palazzoli, M., Boscolo, L., Cecchin, G., & Prata, G. (1980). Hypothesizing-circularity-neutrality; three guidelines for the conductor of the session. Family Process, 19, 3-12.

!!''General Evidence-based practice references''
There are too many to reference here, but we refer readers (with apologies for blatant partiality) to the forthcoming title:

*[[Fonagy, Cottrell, Phillips, Bevington, Glaser and Allison (2014) What Works for Whom]]

!!''Evaluation References''
*Attride-Stirling, J. (2002). Development of methods to capture users' views of child and adolescent mental health services in clinical governance reviews: Commission for Health Improvement.
*[[Goals-based outcome measures]] - Report, ed. Duncan Law, chair of the CO-OP group in Child IAPT (UK): A Practical Guide to Using Service User Feedback & Outcome Tools to Inform Clinical Practice in Child & Adolescent Mental Health (2012).
*Goodyer, I. M., Tsancheva, S., Byford, S., Dubicka, B., Hill, J., Kelvin, R., ... & Wilkinson, P. (2011). Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomised controlled trial. Trials, 12(1), 175.
*Gowers, S. G., Harrington, R. C., Whitton, A., Lelliott, P., Beevor, A., Wing, J., et al. (1999). Brief Scale for measuring the outcomes of emotional and behavioural disorders in children: Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). British Journal of Psychiatry, 174(5), 413-416.
*[[Larsinou, E. (2017).|The Development and Properties of the AIM]] The psychometric properties of the AIM;a multidimensional assessment for adolescents. Unpublished MSc 
*Shaffer, D., Gould, M. S., Brasic, J., Ambrosini, P., Fisher, P., Bird, H. R., et al. (1983). A Children’s Global Assessment Scale (CGAS). Archives of General Psychiatry, 40, 1228-1231.
*Target, M. Fonagy, P. (1994). Efficacy of Psychoanalysis for Children with Disruptive Disorders:  Journal of the American Academy of Child and Adolescent Psychiatry 33. 44-45.
*Target, M. Fonagy, P. (1994a). Efficacy of Psychoanalysis for Children with Enotional Disorders: Journal of the American Academy of Child and Adolescent Psychiatry 33 (3): 361-371.
*Target, M. Fonagy, P. (1994b). Efficacy of Psychoanalysis for Children: Prediction of Outcome in a Developmental Context. Journal of the American Academy of Child and Adolescent Psychiatry 33 (8): 1134-1144.
*Target M, Fonagy P. Raters’ Manual for the Hampstead Child Adaptation Measure (HCAM). 1992.
*Eilis Kennedy and Nick Midgley (Eds.) "Process and Outcome Research in Child, Adolescent and Parent-Infant Psychotherapy: A Thematic Review" Pub. North Central London Strategic Health Authority March 2007 - includes a review of HCAM (adapted into the AIM for AMBIT) - //"A comprehensive coding scheme, with a highly detailed rating manual, has been developed and preliminary investigations of the HCAM’s psychometric properties have been good. The HCAM rating scale was used as part of the Anna Freud Centre's Retrospective Study (Target and Fonagy, 1994; Fonagy and Target, 1994) and was shown to be a clinically-significant measure of overall functioning."//
*Schneider, T. (2000). Measuring adaptation in middle childhood: the development of the Hampstead Child Adaptation Measure. Unpublished ~PhD thesis, University College London

[[Link|https://docs.google.com/file/d/0B5h_CVBdhJPYbHR0aGR4b2FJM2M/edit?usp=sharing]]

<html><div align="center"><iframe src="https://docs.google.com/file/d/0B5h_CVBdhJPYbHR0aGR4b2FJM2M/edit" frameborder="0" width="100%" height="600"></iframe></div></html>

The phrase Acting Out comes from [[Psychodynamic theory]], which states that unbearable feelings may be "enacted" rather than articulated in mind (being thought about).

It is an example of a [[Teleological thinking]] process - solving an unbearable state of mind by DOING - which is one of the [[Pre-mentalistic stances]], which are "primitive" forms of mental functioning that occur when [[Mentalization]] fails.

!What to do:
#Consider how you are [[Managing Risk]], as Acting Out can imply significant risks to self or others.
#What is the young person's understanding of the problem?  If this relates to their motivational state as regards thinking about //changing// this response to anxiety, then consider [[Motivational Work]].
#Apply [[Crisis Contingency Planning]] to generate alternative courses of action for the young person at times most likely to end in Acting Out, as well as planned responses from the Family/carers to maximise safety.
#[[Cognitive Behavioural]] approaches that develop Relaxation skills (see [[Progressive Muscle Relaxation]]) may offer a first line in.
#Deploy [[MentalizationBasedWork]], as acting out is a failure of this (a [[Teleological thinking]] response.)

!Other relevant areas:

There are particular NeuroDevelopmental vulnerabilities during adolescence that make this response more likely.

As the description suggests, this is the point at which the client is putting plans into action.  A good set of plans, including [[Crisis Contingency Planning]] will help to support the changes.

Consider the establishment of establishing some positive [[Reinforcement]] for the new behaviours, by altering [[Contingencies]] - sometimes in simple ways such as putting aside all the money that would have been spent of drugs, and spending this on something positive each week, etc...

----
   !!''What is Active Planning ? ''
<center>{{ap..PNG}}</center> 

* Active Planning is a practice that underpins how we make plans together with clients


* It is a way of helping maintain an appropriate balance between having a purpose, being open about our intentions, and attuning to what's happening in the here and now

*It involves applying [[Mentalizing|Mentalization]] to the process of making and working to plans

This is a 10 minute teaching session on Active Planning by DickonBevington at a training for AMBIT Local Trainers:

<html><iframe width="640" height="360" src="//www.youtube.com/embed/v8BeQeABRvM" frameborder="0" allowfullscreen></iframe></html>

!!Why focus on planning?
Evidence-based approaches tell us that having clear and jointly constructed goals and plans are essential to creating change. 

However, there are a number of factors that can make planned work difficult in the contexts within which AMBIT influenced teams work. 

''These can be related to both:''

''1.Worker barriers'',

for example:

*Challenging work in isolation or without strong connections to team members  ([[Keyworker well-connected to wider team]]) to help think about where the work is headed and what might need to happen next
*Working within a team where members do not feel confident or supported adequately to raise and address difficult issues with their clients
*A stressed or overwhelmed worker (and/or team) meaning there is less capacity to ''mentalize'' the client and attune to what might be important or helpful for them in the 'here and now'. 

''2. Client barriers'', 

for example:

*For people who have complex and multiple problems and a fragile [[Relationship to help]], trusting that a plan is well intentioned or that it may be useful, can be a significant challenge
*Motivation can fluctuate and there may be important reasons for keeping things as they are 
*States of mind may shift rapidly and  the ability to focus on a plan changes
*Intentions or priorities shift
*Previously unknown problems or crises can arise which need attending to.


''In practice these barriers can look a bit like.....''

* Meetings overun and things that were agreed don't get thought about
*The focus seems to change constantly between or within meetings

*Lots of talking but not much action

*A worker imposing their own ideas about what would be helpful, or allowing the client to lead without any particular purpose or input in our mind.

!!How do you do it?

''Active planning is about holding a balance between 3 key points:''

1. In any therapeutic interaction the worker having a ''purpose'' (i.e. a plan) in mind about 'what we're trying to do here and why', is essential

2. Our purpose or intention should be made open and explicit. We call this [[Broadcasting our intentions|Broadcasting Intentions]]

3. At the same time, we aim to attune to the clients situation and state of mind 'in the moment'. We call this ''sensitive attunement''.

We can apply these principles to any planned work with a client, from making a brief phone call, to setting overarching care plans (which some teams use to guide their work towards goals).

Below is an example of how we might structure the start of a session or a meeting with a client, holding in mind the active planning triangle:


>// Last week you were talking about how cutting down the self-harm is the most important thing that you want to change in your life right now....I was thinking that it would be really helpful for us to understand more about the self-harm and why it happens ''(purpose/ plan)''.  If we can understand better some of the things that lead to self-harm, we can start to think more about what might need to change ''(Broadcasting intentions)''.  How do you think that would be for you to think about today?...are there other things we might need to talk about too? ''(sensitive attunement)''//


We suggest using the [[AIM cards|AIM Cards]] as a way of applying active planning in practice to develop collaborative plans with clients. The AIM cards give a structure to support clients think through and prioritise the most important areas for them, whilst the  worker listens and attunes to the clients' perspective  (sensitive attunement). The cards then allow workers to contribute their own ideas (Broadcasting intentions) in designing a joint plan about the way forward.


!!Holding the balance

The 3 points of active planning do not follow any particular order. Rather, by the worker mentalizing themselves and their client, we attempt to hold an appropriate balance between them. 

 
If we can maintain sensitive attunement to the clients' state of mind and situation it is more likely they will experience our offers of help as 'fitting' with where they are at (whether our offer of help is ''contingent''). 

For example, rigidly sticking to a plan from last week, with a client who arrives overwhelmed by an argument at home, may well undermine the client-worker relationship. This would be an example of a worker in [[Teleological thinking|Teleological thinking]] or ''Quick fix'' one of the [[Features of UNsuccessful Mentalizing]].

At the same time, if we were only focusing on sensitive attunement, this would risk losing the worker (and teams') perspectives on other factors, such as risks, or situations that can't be ignored. This might take on a kind of [[Pretend mode|Pretend mode]] thinking where we are not addressing some important realities. 

The above points are held in balance with , [[Broadcasting Intentions|Broadcasting Intentions]]. Here the worker is explicit and open about their purpose, in order to make their behaviour understandable. We assume that our intentions and behaviour are not clear to our client, (or, that they may expect that we have negative intentions). In this sense, we try to increase the chances that a client can clearly understand our intentions (i.e. mentalize us, the worker), and opt in or out of a plan, rather than it being experienced as something done //to them//. Again, the worker attempts to balance this appropriately, as over-reliance on broadcasting intentions would be another example of [[Pretend mode]] (or ''waffle'') and not connected with the experience of the client in the 'here and now'.


''Please see here for a tool to support active planning with clients:''

 The [[Active Planning Map]] also called the [[Egg and Triangle|Egg and Triangle.pdf]]. We would usually use this after early contact with a client as a way of explicitly sharing our 'best efforts at understanding so far' (broadcasting our intentions and sensitve attunement). This allows the opportunity to 'correct' and further adapt this understanding together (sensitive attunement), based on the clients' perspective. This helps us begin shaping a collaborative plan about the work ahead. 


<<image [[ {{ActivePlanningTriad}} ]] width:560 height:480>>



!!''Video example: Active Planning in action''

Balancing sensitive attunement with the need for work towards a planned focus is a constant dilemma for the worker, and one which may need help from SupervisoryStructures in the team.

Here, a worker's initial plan is clearly out of sync with the dilemma that the young person is wrestling with, and adjustment is required:

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----

''The Active Planning Triangle is not only applied to face to face client work. We can equally hold this stance in any situation where we are working towards plans in relationship with others.''

For example;
  

*A meeting with professionals in the network around a client,

If these three points become un-balanced there is a risk that network meetings fall into lots of discussion or broadcasting of intentions, without any clear plans or actions taking place (''pretend mode''). On the other hand, losing balance could mean too much rigid setting of plans without sensitive attunement to the clients' immediate situation (or to the workers' current state of mind). We suggest that this can be a helpful stance when chairing or running meetings in this context.



*If you would like to do extended reading on Active Planning, and how this is applied further within the team culture, please see <<tag [[Extended learning]]>>

*Please see [[CLIENT exercises from AMBIT training]] for training exercises on Active Planning 






 

!!''Purpose''
This is to help clarify and practice the process of [[Active Planning]] and [[The Therapist's Mentalizing Stance]], especially to consider how the worker manages the situation when there are significant differences between //their// intentions (goals) and those of the young person.  



!!''Exercise''
!!!Choose either (a)
Watch videos of young people discussing their aims/goals from the work - and pause these at the time-point indicated, to allow for team discussion

* //What is going on?//
* //What does the therapist need to do to improve things?// 

Then restart the video to finish it and discuss the BALANCING ACTS required:

* What worked?
* What didn't work?
* What might improve the outcome?

<html><object width="560" height="315"><param name="movie" value="//www.youtube.com/v/tdXhCvXHcY0?version=3&amp;hl=en_GB&amp;rel=0"></param><param name="allowFullScreen" value="true"></param><param name="allowscriptaccess" value="always"></param><embed src="//www.youtube.com/v/tdXhCvXHcY0?version=3&amp;hl=en_GB&amp;rel=0" type="application/x-shockwave-flash" width="560" height="315" allowscriptaccess="always" allowfullscreen="true"></embed></object></html>

PAUSE VIDEO FOR DISCUSSION AT: 1 minute 39 secs

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PAUSE VIDEO FOR DISCUSSION AT: 1 minute 33 secs

!!!Afterthoughts:
In these scenarios there are clear differences between the worker's stated goals and those of the young person.  The creation of a Care Plan is not convincingly collaborative, and it is unclear whether the intentions of the worker are understood by the young person... as new information is revealed, the worker begins to be able to re-fashion plans... could they have got there sooner?  Are they going too far off their own plans?

!!!or (b)
Role-play an early therapeutic encounter that involves the beginning of developing a care-plan.  Similar to the video clip - there is some (not //catastrophic!//) divergence between young person and worker's goals.

* This is //not the first meeting// so assume that you have gathered the basic history and you have a basic idea of what the problems are.
* Note the [[Advice about Role Playing]]
* Make use of what you have learned about:
** [[The Therapist's Mentalizing Stance]]
** [[Broadcasting Intentions]]
** [[Comparing Destinations]]
** [[Agreeing Waymarks]]

!!''What is this?''
The Active Planning Map has also been referred to as the [[Egg and Triangle|Egg and Triangle.pdf]].

It is a simple "back-of-an-envelope tool" to support the stages of <<tag [[Active Planning through phases of AMBIT work]]>>

Important practice points in using this tool, which simplifies and adapts Maslow's [[HierarchyOfNeed]], are as follows:

* A worker may develop and present their "//first efforts//" either in real time, during a session or between sessions, but crucially the point is to present these to the client:
** //"what I have heard and understood from you, about what you need and want..."// but also 
** //"...what you should know about what the wider system expects of me."//
*** i.e. The system expects proper [[Governance]] and [[Managing Risk]] by all workers
*** Which is particularly focused on ensuring basic safety.
* For the worker to get quickly to the point where they are able to ''share this "first effort"'' with their client
** When sharing a first effort to articulate one's clients story and one's aims and goals, use 
*** ''Tentativeness''
*** ''Hesitancy''
*** ''Self-deprecating humour'' 
*** ''Invitations'' to "//Help me get this much more accurate than I can on my own, please!//"
* Understand that this exercise is all about [[Broadcasting Intentions]]!
** If these do not agree with those of your client, see below.
!!''The Active Planning Map''
Go to [[this link|https://docs.google.com/file/d/0B5h_CVBdhJPYNkJNamFPVXhsYXM/edit?usp=sharing]] to download this in PDF format, or just use the back of an envelope!
[img[Egg and Triangle]]

[img[Egg and triangle (marked)]]

!!''Video of introducing this to trainees''
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!!''Managing Differences of Opinion ''

[img[Managing Differences (Egg and Triangle)]]

There are frequently [[Individual Differences and Disagreements]] that separate the ''worker's'' intentions and plans and those of the ''client''.  Workers come with some pre-ordained priorities, and they are inevitably (and quite properly) part of a system that is larger than them, and to which they are answerable.  

!!''1. Foundations''
The ''foundation'' of any work from the professional's point of view is ''safety'' - without which any further, more elaborate building work would be liable to crumble.  In [[Broadcasting Intentions]] about our work and our ideas about [[Aims and Goals]] for the work ahead, it is helpful for our clients to hear this stated in simple terms:

>//"Above all, it's worth saying that everything I do is __first of all about helping things to be safer__... that is my job, and its worth understanding that this is absolutely at the centre of how I //must// work.  I guess the reason is that if we can get things safe enough then you and/or the people around you don't need to spend so much time worrying, and can start to spend more time being imaginative, and planning, and experimenting with new ways to work things out..."//

From the client's point of view Safety //may// be a shared foundation priority, but they may have //other// ''"Needs"'' aside from this that they would feel need to be the starting point (that if their worker did not show them they had //recognised// would leave them feeling misunderstood, or ignored.

>//"It's also important for you to know that I DON'T KNOW exactly what YOU see as the things that you really need right away - but I really want to get these things straight in my own head, as I am pretty sure that if you think I haven't got a clue about what YOU feel you really need right now, then I'm not going to seem very helpful to you!"//

!!''2. Directed activity''
Thereafter (once basic safety is assured with the implementation of a reasonable/defensible safety plan) the worker may be focused on developing shared ideas about what ''"Recovery"'' would look like for the client(s), and devising the means by which to get there.   Likewise, the client may have particular ''"Wants"'' that may or may not overlap with the intentions of the worker.

!!''3. Rationale''
Finally (at the top of the triangles in the "hierarchy") the''"Why?"'' marks //"the __point__ of all this effort"//.  Now, this kind of ''discovery-focused'' work (as opposed to ''recovery-focused'' work) may be seen as the "icing on the cake" for a worker, but in developing and working towards [[Agreeing Waymarks]] with a young person, it may be much easier to find common ground in the more distant ''wondering'' about longer term [[Aims|Aims and Goals]] than it is to agree on more specific Goals, or detailed plans.

!!What is this?
A culture of planning means that all members of the team share an understanding that //time is an extremely valuable resource// and should be spent as wisely as possible, and that //having a plan is usually better than having no plan!//  

Given the risky nature of the environment and the predicaments that many clients in treatment with AMBIT-influenced teams are facing, Active Planning refers to the maintenance of a culture that, while sensitively attuned to the clients or family's needs, we hold on to proper [[Governance]] (doing things 'properly' - safely and effectively).

Team members support each other with the constant process of identifying [[Aims and Goals]] ( some services may refer to this as developing [[Formulation and Treatment Aims]]). These would then shape the plans that are made - balanced by the need to be sensitively attuned to the experiences of the clients.

So, a [[Keyworker well-connected to wider team]] is consistently helped by colleagues to:

* Make plans
* Broadcast the plans ( make them explicit in the team and with the client)
* Put them into action (attuning them with the client)
* Review the progress of plans

This can relate to the SHORT term, the MEDIUM term, or the LONG term:

!!SHORT term
Across minutes, as in [[Marking the Task]] during [[Thinking Together]], or planning your next session with a client…

!!MEDIUM term
Across days, as in planning goals and activities for the next week - for instance this is something that the [[Team Meetings]] can ensure they focus on (//so what is your plan for next week?//)

!!LONG term
Across weeks or months, developing, using, and adapting Plans.

These might be applied from the length of time it takes to conduct a phone-call, to the weeks or months of a whole therapeutic journey.

This is particularly something that the [[AMBIT Lead]] and the [[Implementation Team]] may want to consider - 

''//How do we support the development of this in our team?//''

Click on <<tag [[Active Planning]]>> for subtopics of this area.


Here you can find The [[Active Planning Map]] also known as the [[Egg and Triangle|Egg and Triangle.pdf]], a tool for supporting active planning.

!! Final note....
''PLANNING, not PLANS ''
!!!!(Map-reading, not Maps...)
Active Planning seeks to emphasise the //activity of planning//, rather than the holding of plans-as-things.  This is not to say that it isn't important to have the appropriate documentation, ''just that the documentation is only worth anything if it is a record of the //work of thinking//...''

[img[https://lh4.googleusercontent.com/-RMPKuN9Ce3U/URIYD_fGNJI/AAAAAAAAGqw/AmxUhoGys7s/s912/ActivePlanning-CoProduction.jpg]]

Active planning is not something we only do at the start of our work with clients. Rather, it is a process that we apply throughout the entire journey together. It is a continuous way of checking where we are, reviewing where we're headed and what we need to do to get there.

Below is a description of how we apply active planning across the [[Phases of AMBIT work]]. It describes steps in how we go about making plans collaboratively, and how we work to and review these plans continuously.

These steps are unlikely to be much different in practice from effective planning in many teams and treatment models.  What we intend is that these steps fit with the rest of the AMBIT model, and are //explicit// rather than being carried out //implicitly//.

[img[https://lh4.googleusercontent.com/-D9UT2mFATUk/UOh2qxjA2AI/AAAAAAAAGdY/ZFTT1FmanwQ/s720/ActivePlanning.jpg]]


It is important to emphasise that:

*1.The steps don't always follow in sequence
*2. The specific details of the plans will be different depending on the [[Phases of AMBIT work]] you are currently in



!!!Active Planning steps across the phases of work:




|OUR NAMES||CONVENTIONAL DESCRIPTIONS|
|[[Taking Aim]] | = |Collaboratively //noting// the way things are (Assessment) and learning [[What's the problem?]]|
|[[Broadcasting Intentions]] | = |Using [[Mentalizing]] skills to build engagement and collaboration |
|[[Comparing Destinations]] | = |Collaboratively defining therapeutic direction ([[Aims and Goals]]); developing a [[Formulation and Treatment Aims]]|
|[[Agreeing Waymarks]] | = |Collaboratively developing a [[Care Plan]] that sets out the route ahead|
|Setting out together | = |Getting started on this specific planned work is part of the KeyWorker relationship|
|[[Taking Aim]] again| = |Reviewing, and sensitively/strategically //adapting// these plans|

Finally, see also [[In my beginning is my end]] as one of the [[Engagement techniques]] that begins this process.

Please see also [[How to draw up a Care Plan]] which describes the steps in forming and working to a careplan, applying active planning to this.

!!''3. Tools to help'' 
* Teams may use tools as a part of regular practice to create structure for this process in face to face working.  

*''1. Active Planning Map''

** The [[Active Planning Map]] is a simple back-of-the-envelope tool (a simple adaptation of Maslow's [[HierarchyOfNeed]]) to help structure the interactions between worker and client.
** Some teams may primarily use this tool just as a training exercise to emphasise the principle of //collaborative care planning//, //attunement//, and //adjustments// to create [[Contingencies]] in what is offered. 

*''2. Formulations and Communications''

** Creating and communicating a clear ([[mentalized|Mentalization]]) narrative for how the difficulties arose, what maintains them, and what the aims in our work may be is a crucial step in collaborative working.
 See [[Formulation and Treatment Aims]] for advice on how to present and communicate this (an example of [[Broadcasting Intentions]]).

----

Much of AMBIT is concerned with the way we try to present our offer of help in ways that "speak to the condition" that the person we are trying to help finds themselves in.

!In relation to Motivational Stage of Change:
A key part of the [[Motivational Work]], including the [[assessment for substance use disorder treatment|Assessment for SUD-Rx]] consists of identifying which of the [[Stages of Change]] best describes your client's state of mind or motivation.

A young person in [[Pre-contemplation]] will not be interested in [[Making plans for change]], or developing [[Relapse prevention]] strategies.  There is a high risk of a loss of [[Engagement]] in such circumstances.

!In relation to the here-and-now Mentalizing state:
If a client is mentalizing well (able to reflect on their own and other people's behaviours in terms of wishes, fears, feelings and the context that has influenced these) then conversation can be more challenging than if there is evidence of [[Pre-mentalistic stances]] (failed mentalizing).

!In relation to Help and attaining outcomes:
See the [[Relationship to help]] for more on this, and [[Active Planning]] for the subtle balancing required between holding to  ''Plans'' and ''sensitive responsivity'' that keeps [[Engagement]].

<a class="tc-float-right">[img width= 500 [Dis-integration pic.jpg]]</a>












Addressing Dis-integration brings together the practices and tools that AMBIT influenced teams may use when working with their networks, trying to work in integrated ways and reduce Dis-integration. 



 


!!Firstly.....

''To address Dis-integration effectively we propose that we need to re-shape our expectations...''

!!//Anticipating// misunderstanding and conflict

A fundamental assumption is that network differences and conflicts should be ''//anticipated as inevitable//'' and not be seen as an indication that people in the network around the client are somehow //''getting it wrong''//.

 AMBIT adopts a position that ''actively anticipates the likelihood of conflict and contradiction between agencies or professionals'', and promotes the explicit view that this is //understandable//, as an aspect of ''our best intentions and best efforts'' to provide services for the client.  




!!What to do?  

With shared understanding of the problem, agreed intervention and collaborative relationships, effectiveness will improve

!!The Dis-integration Grid


The [[Dis-integration grid]] is a practical tool aimed at supporting Mentalizing of the network. It helps us to think about which parts of the system may be helping or hindering integration and where we may be able to bring a helpful influence towards integration.


!!Sculpting a network

Please see the [[Sculpting a network]] exercise which is a way of physically mapping and making sense of network dis-integration. This is an exercise that can be carried out with your team.

!!AMBIT Pro-Gram
[[The AMBIT Program|The AMBIT Pro-Gram]] is a tool for workers to use with clients to help them map out and make sense of their network. It is a way of thinking with clients about which relationships are most helpful for them, who members of the network are and what they do. It is also used for the worker to understand how the client see's these areas and to guide the worker in how they might support or scaffold the existing relationships.

!!Training Exercises

There are other [[Training exercises|NETWORK exercises from AMBIT training]] on working with your network here that explicitly encourage workers to practice mentalizing the network or each other in your team. These include [[wearing different hats|Wearing different hats]] exercise and the [[what's it like to be|The 'What's it like to be...' exercise]] exercise.

 
!!Why do we do this? 

The purpose of paying close attention to the wider network is partly to improve the effectiveness of interventions, but it also consistent with the overall mentalizing stance of AMBIT.  One of the core aims for the keyworker is to help the client //make sense of the professionals' behaviours// - by encouraging the client and family to mentalize. 

In our view, [[Mentalization]] provides a crucial technique in trying to help professionals to make sense of each others' behaviour, and hence reduce mis-understandings in the same way. We believe this opens up opportunities for authentic collaboration between members of the network.

!!Addressing Disintegration Video

Liz Cracknell 
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This in early draft [[(a) Work in Progress - Major change]]

Needs conversation and manualizing
* AMBIT as a whole-systems change approach
* Holding onto the "guerilla-change" elements of local individual changing stances AS WELL as engaging with largescale organisational/managerial change

Adolescents are often diffident, avoidant, and socially awkward, especially in conversation with adults, and even moreso in relation to subjects that are perceived as embarrassing, or in any way "odd" (as much of a mental state examination frankly is, when judged according to common sense standards.)

Research on Adolescent [[NeuroDevelopmental]] characteristics, demonstrates that (primarily on account of a mismatch between their relatively under-developed frontal brain regions compared to other components of the limbic system which log socially relevant communications and generate affective responses to these) they are easily overwhelmed by the //emotional impact// of social situations. This triggers "fight or flight" responses or attachment behaviours, both of which inhibit [[Mentalization]] and limit the capacity for engagement.

Many people hate role playing.

We accept this, but would want to explain:

!!(a) WHY we think that role playing is very important and helpful.
* Role playing is in ways nothing like real therapeutic work... But... It is the closest we can get to practicing how to develop and use the [[KeyWorker]] relationships that are so central to the effectiveness of any AMBIT-influenced practice.
* The point of most role playing is to practice the [[The Therapist's Mentalizing Stance]] 
* And role play does have one thing in common with real therapeutic work - it is (or can be) stressful.
* So while the stress is different, it will have a similar effect on your capacity to work effectively (to mentalize) as it does when it occurs "in the field"; learning to work in stressful settings is part of what AMBIT is about.
* Having said this, we do NOT want any role play to have any shaming effect on any workers - as this is not a good context for learning. 

!!(b) HOW to make role playing less painful
* It is tempting always to pick the WORST client we can imagine for a role play - particularly if we are learning a new way of working ("I'll test this out to destruction!") - DON'T!  Pick a young person or family who have got some motivation to change - the point is to give each other scenarios to practice and play.
* Remember the clue is in the name - it is role PLAY, so keep it playful, and allow oneself and others the chance to make a time out sign and break out of role to discuss what is going on, how //"I have lost it!"//... but then be sure to talk about why, and what to do next, and then get back in and play some more.
* Do try to stay on task - it is easy to get drawn into very meaningful conversations about the work in the middle of a role play, which may be very effective defences against exposing oneself to the anxiety of role playing
* Do practice being a mentalizing presence for your colleagues in the role play - //"I wonder what does X maybe need to help her feel that she can get back into that role play and try again?"//

!!(c) WHAT to avoid doing in role plays
* Do not use role plays to humiliate or shame others!
* Accept it if a colleague opts out of active role playing - they can still play an active role as a "mentalizing presence" watching from a "meta-position".
* Don't assume that you "can't do it" - consider the possibility that you may be mistaken on that count!

!!Advice
Developing, improving and changing practice does not happen quickly. Training events on their own are unlikely to make much impact on routine practice unless such training is complemented by a range of on-going activities that encourage learning and development. Most teams have existing systems around this, e.g. supervision, mandatory training, appraisal and individual training plans. If AMBIT practice is to develop and grow, it is essential that it is connected to these systems. 

This requires a plan!! The plan should include the following:

!!!Specific objectives 
This refers to the [[Post-training outcome goals]] that we encourage teams to start to set at the very beginning (or before) any formal [[AMBIT training|Information About AMBIT Training]].

*Following AMBIT principles, these are best if they are [[SMART goals]] (objectives) which are //realistic// to the teams work and practice. Some examples are shown below.
**During the first six months, to establish thinking together as part of case discussion in teams. 
**To use the AIM on a 10 cases and review its usefulness. 
**To practice manualizing once a month as part of a team meeting.

!!! Agreed on-going training activities 
*Most teams have some meeting structures and support time. It is useful to be clear whether any of this time can be used for on-going development of AMBIT practice. Again, modest plans likely to work best. 

!!! Relationship of AMBIT to supervision
*It is helpful to consider how supervision links to AMBIT. If the team members are receiving supervision from supervisors unfamiliar with AMBIT this is likely to make progress more slow. One suggestion would be to have a meeting with all supervisors to consider their ideas about how to use AMBIT in supervision. 

!!!Relationship of AMBIT to wider training activities
* There will be a range of existing on-going training activity including, for example, child protection training. It is useful to consider how  AMBIT sits alongside this. It is not intended that AMBIT should replace all of this but there may be some creativity as to how different training tasks can become more linked up. 

!!! Team Induction 
* AMBIT needs to be part of the induction programme for new team members. 

!!! Methods of reviewing progress 
The Implementation Plan should be reviewed by the Implementation Team periodically. This should be explicit in the plan itself. 

We provide a template for an [[Implementation Plan]] that should be edited by the team.  It contains a range of headings that the [[Implementation Team]] may wish to consider.

!Introductory comments:
[[Aims and Goals]] should flow directly from the [[Formulation|Formulation and Treatment Aims]] that you develop collaboratively with a young person; this is because formulating a young person's story is really about [[Mentalizing]] them accurately, and mentalizing is directly related to making sense of their [[Intentional stance]].

Compared to the immediacy of the concrete steps suggested by a plan, treatment [[Aims and Goals]] are more distant pointers/directions - that act like the compass and map for the therapeutic journey, describing the [[Intentional stance]] and intermediate [[waymarks|Agreeing Waymarks]] against which progress can be measured.

The [[Aims and Goals]] will shape those changes that various parts of the system ([[Family|FamilyInformalNetworkMembers]], ProfessionalNetworkMembers) consider to be ''the minimum change necessary'' to make a real, and positive difference. 

!Taking Aim

[[Taking Aim]] is a specific aspect of the AMBIT approach to [[Active Planning]], that takes into account the fact that a young person's, the family's and also the worker's //ideas about the goals of work// may change over time, but that [[Goals-based outcome measures]] are also immensely helpful.  Aims and Goals cannot be set until there is first clarity about what resiliencies and problems are present within, and around the young person/their family/carers.  We recommend the [[AIM]] assessment as one way to approach determining [[What's the problem?]] that you as a worker are being invited to help with.

!Consulting widely

The ''Treatment aims'' are drawn up ''in consultation with the young person'' and ideally with their FamilyInformalNetworkMembers, too; they represent the best attempt to reach a prioritised and achievable set of outcomes.

In order to understand ([[Mentalize]]) these desired changes accurately you will need to understand the young person's views, as well as those of other parts of the young person's system; the FamilyInformalNetworkMembers, and the ProfessionalNetworkMembers.  Use the [[Dis-integration grid]] to help with this task.  The use of SupervisoryStructures in your team is crucial in this stage of [[Active Planning]]

!Drawing up Aims

AMBIT does not have  predefined treatment aims - although developing the young person's or their family's [[Relationship to help]] is likely to be one aim.

Consider //all// the major functional domains:

!@@color(red):Patient priorities@@

What does the young person most need to see changing in order for him or her to think "since seeing you, things have started to get better."  (In the event of //disagreement// about the extent, or worrisomeness, of mental health symptoms, you can also make reference to professional observations/aims on mental state under "Health priorities" below.)  Consider also the [[StrengthsResiliencies]] that might usefully be built upon.

!@@color(red):Family/carer priorities@@

Ditto for the family/carers.  Include professional observations on family-functioning, and be clear //whose aims are whose// if there are differnt perspectives on what the problem(s) is (are).

!@@color(red):Health priorities@@

Are there significant health priorities, such as mental or physical health-related risks?  Include the risk of deterioration, and bear in mind the developmental trajectory of the young person (in childhood and adolescent developmental terms, 'standing still is going backwards'.)

!@@color(red):Education + Vocation priorities@@

Are there requirements for new opportunities or support in order to maintain or recover trajectories into adulthood?

!@@color(red):Social-ecology and Cultural priorities@@

Is there a need to support culturally relevant integration into normative activities and contact with existing local community resources?  Think of sports groups, youth resources, faith networks, groups serving specific cultural or ethnic populations...

!@@color(red):Professional network priorites@@

Are there examples of [[Dis-integrativeProcesses]] or [[Dis-integratedInterventions]]that require correction?  In relation to the <<tag [[Care Plan]]>> consider what conversations may be required to achieve the desired integration/coordination...  Use a [[Dis-integration grid]] to help clarify what you know and do not know about the different aims within the system, and to determine how best to reduce dis-integration between these.

!Conflicting Aims:

Sometimes there are CONFLICTING treatment aims:

>//the family wants more control over their son who they see as behaving recklessly... the son wants more freedom for himself, from a family that he sees as overlooking his nearly-adult status, and treating like a younger child..//

In this case the task of the KeyWorker is to find a position to which all parties can sign up as the MINIMUM change that they could agree upon.  (In the example given, they might not agree on practical details, but they might agree that they want to see the number of arguments at home reduce from twice daily to once weekly, and for them not to escalate to violence. 

!Changing Aims 

Sometimes aims need to be altered during the course of treatment  (new information, changing circumstances, etc)

...then record these in a NEW Formulation 
!Once aims are agreed:

You should record these as the conclusion of your [[Formulation and Treatment Aims]] of the case. 

!Aims and the Plan

Treatment Aims should shape the [[Care Plan]] - they are overarching targets, where the Care Plan is more specific and practically-oriented.  See [[Active Planning]] for advice on how to do this.

Affect refers to the emotional state //right in the here-and-now//. The ups and downs of a person's //affect//, as they average out over a longer period of time (say weeks or months) are what we call their //Mood//.

A helpful analogy is that ''WEATHER is to CLIMATE as AFFECT is to MOOD.''

[[Affect storms]] are common and unhelpful for therapy, as they effectively stop, or invalidate, mentalizing.
[[Affect Regulation]] is a capacity that therapy is designed to increase.

[[Affect]] is much harder for adolescents to regulate than it is for adults, owing to the particular NeuroDevelopmental changes that are in train during adolescence.  Adoelscents are much more easily overwhelmed by the emotional context of their social activities, and once overwhelmed, take longer to settle back to their 'baseline'.  See [[Affect storms]].

Regulation of emotional responses occurs via structures in the frontal areas of the brain (see NeuroDevelopmental for details), but when these are inadequate for the task, other methods may be recruited.

Included amongst these is [[Self Injurious Behaviour]], but less dramatic techniques are also used, such as tending to communicate through the mitigated medium of text messaging, or email, rather than face-to-face contact, the use of drugs and alcohol, or more 'healthy alternatives' such as vigorous exercise, etc.

One of the cardinal features of many, if not all of the personality disorders is a pervasive failure to regulate affect in adaptive, effective ways.  [[Mentalization]], when working effectively, is a powerful tool in helping to regulate affect, but, equally, it is severely constrained when affect is uncontrolled; you  cannot have effective [[Mentalizing]] when there is uncontrolled affect.

Aside from the NeuroDevelopmental aspects, Affect Regulation is developed within the context of a secure [[Attachment Relationship]] (see [[Secure Base]]).

!What is an Affect Storm?
When feelings ("[[Affect]]") run high in a particular situation, a person’s ability to mentalize is at risk of being impaired. If family members are present, this can be ‘infectious’, leading to ‘emotional knee jerk’ reflexes all round. 

In family sessions one can then observe heated interactions, with the participants blaming each other:

''//“you never….”'' or ''“you always”//''

Here the therapist’s task is to reduce the heat, so as to help family members to recover some degree of successful mentalization.

!What to do in an affect storm
See [[Simmering Down]], [[Taking a break]] and [[Therapist's use of Self]].

These could be seen as another version of what [[SystemsTheory]] practitioners refer to as a reframing - picking out the positive aspects of an account that may have origianlly been framed in more negative terms.

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!What is this?

This is the final stage of [[Active Planning through the phases of AMBIT work]] referring to collaborative care-planning that is at the heart of [[Active Planning]].

Having mapped out the different intentions and goals (or destinations - see also [[Aims and Goals]]) that worker and young person may have in their minds, and explored the reasons for any differences, the worker now seeks to find ''compromise, or destinations that might act as waymarks on a longer journey'' whose ultimate destination is undecided as yet.

There is an implicit acceptance that goals or ultimate destinations are ''"just plans"'', and may change with circumstances, with the growth of knowledge and understanding, etc (see some of the [[Features of Successful Mentalizing]]. This includes the ability to take a developmental perspective, the belief in changeability, and the stance safe uncertainty).

! A Useful Tool for agreeing waymarks:

A useful tool for this is the [[Active Planning Map]].

!Keeping it real: the obligation to manage risk 
There are obligations upon the KeyWorker to demonstrate they are [[Managing Risk]] safely and appropriately.  

This may lead to significant ''differences becoming apparent'' (for instance the worker is very worried about safety, and the client is not). 
In these situations we aim to ''make the differences in our persepctives explicit and acknowledged''. We would aim to work towards a ''mentalized explanation of why we both see these differently, taking into account the intentions and mental states of worker and young person.''  Please see [[Individual Differences and Disagreements]] for more in this.

If there are major risks identified, then the KeyWorker must be open (see [[Broadcasting Intentions]]) about the constraints that these place upon her.  This will be easier if discussion about [[Confidentiality]] and its limits has occurred early in the therapeutic relationship.

At the very least there may have to be [[Crisis Contingency Planning]] to cover the key areas of concern.

There are many ways to translate Aims, Goals and Plans... and other words that could be used in their place.  We define them below, in terms of the proximity/distance to the opportunities in the present.  See the [[Formulation and Treatment Aims]] for consideration of how to develop these ''collaboratively'' and in ways that speak to the young person's own experience of life.

!Note, there is an //assumption of intention//:

* Even if the young person's //current// behaviour (their immediate 'plan') is difficult to make sense of, their goals and more distant aims may be rather more understandable, even though they may take a little more "teasing out". (See the examples below.)
* Aims (and perhaps Goals) may often be the place where the keyworker and young person can have a "meeting of minds."  Plans are often where the workers intentions and the young person's intentions most obviously diverge.
* One of the shared treatment aims that most [[AMBIT-influenced]] teams would agree on, is to have a positive impact upon the young person's [[Relationship to help]].

!What to do

|There is [[Advice on setting Treatment Aims and Goals]].|

!Definitions
Note that it may be much easier to find common ground about relatively distant, or more general ''Aims'' than it is about close-up ''Plans''!

!!The "AIM"
|''...is the direction of travel towards the horizon.''|

Examples:
@@color(red):(a)  - Be happy, create happiness@@
@@color(green):(b)  - Be respected@@
@@color(blue):(c)  - Being truly and publicly myself@@

!!The "GOAL"
|''...is to get to “Town A” by nightfall.''|

Examples:
@@color(red):(a) - Hook up with good friends, enjoy ourselves@@
@@color(green):(b) - Feel good about myself with a cool phone@@
@@color(blue):(c) - Develop a gorgeously shocking body@@

!!The "PLAN"
|''...is to start out on //this// road, here.''|

Examples:
@@color(red):(a) - Score some good weed, and persuade X to come dancing…@@
@@color(green):(b) - Hit the man with the iPhone@@
@@color(blue):(c) - Get my tongue/nipple/penis pierced@@

!Differences of opinion
There is a greater likelihood that a worker and client will find common ground in the more general/distant Aims, than there are in the more immediate Plans.  See the [[Active Planning Map]] for the "Egg and Triangle" tool that can be used help draw these out and encourage collaboration.

!What are the Aims of Family Work?

The main aim of family work is [[Restoring family capacity]] - which relates to the [[Core Features of AMBIT]] as it is an example of [[Scaffolding existing relationships]].  

The worker attempts to do this by working to //contextualize// the presenting symptom(s); that is, to develop an understanding of how these difficulties might fit in the context of the young person's current and past relationships with family members and/or significant others, as well as of social and cultural factors and discourses. 

Systemic interventions aim to:
*help the young person and the various family members to get //new perspectives// or new understandings on the presenting problem(s)
*to attach different meanings to these
*to experiment with new ways of relating to one another
*to jointly find new and practical solutions to pressing problems and dilemmas. Interventions aim to 
*block dysfunctional family interactions and communications 
*activate new, more functional transactions. 

This is the third stage in the [[Social-Ecological Work]] that AMBIT recommends

!Allocating tasks

Once the mapping of needs and resources is complete (although remember this is a dynamic process so that new items may be added and subtracted at any time) allocate who should be taking responsibility for arranging what, and decide on a rough timetable for these activities, which can be noted down. 

This can be checked upon weekly, and the timetable adapted to suit the changing circumstances of the family. It will act as a route map and a measure of progress of the young person's return towards more normative patterns of social functioning. Moreover, if co-constructed with the young person and the family, it is to be hoped that it is one that acknowledges differences within the system, but is owned collectively by that system.

This process is closely linked to [[Addressing Dis-integration]], which is one of the [[Core Features of AMBIT]] practice - as it is anticipated that the network around the young person may well have implicit or explicit conflicts and difficulties. The basic AMBIT stance is to address this aspect of agency working proactively (see [[Active Planning]]) and to take a high level of responsibility in trying to address network problems. 

!Identifying gaps

Gaps between perceived needs and known resources need to be managed collaboratively - [[Active Planning]] is required to develop strategies for managing these.  

''The KeyWorker is not responsible for the absence of available community resources'', and needs to avoid being drawn into the position of apologist for the wider system with all its inequalities. 

''Acknowledgement of the reality of gaps'' may help to emphasise the collaborative relationship between KeyWorker and family, so that the professional is seen as much as someone who stands with the family in their struggle, as a representative of external power structures.

''Ask the question: "Is a perceived gap a real gap?"'' (i.e. a need for which there is no resource available to provide for it), or whether it is because the appropriate resource has simply not yet been identified.  

''Are there different search strategies that can be employed'' by the family or the KeyWorker to locate the resource that is missing?  

''Is there an acceptable 'second best' available?''

In the event of an unbridgeable gap (hopefully rare) are there authorities (Social Services managers, local councillors, MP's) that the family could contact?

Considering the [[Relationship to help]] that a young person engaged with a service demonstrates may be helped by thinking about the feelings stirred in the worker.

A sense that I am "pushing too hard" may be an indication that we are in the [[INTERVENTION PHASE]] and that this is a common perception that the young person has about "help" - (that it doesn't often feel like help, but more like a kind of persecution)... or it may indicate that the work is moving towards the [[ENDING PHASE]], and what I am wrestling with is my OWN attachment to my client, with the risk that I may inadvertently demonstrate a lack of confidence in the capacities of the young person (that may mirror the kinds of attitudes that he or she has faced for many years.)

Please do not edit this tiddler. It was created during setup.

Literally "both sides": the notion of holding conflicting ideas or feelings about something //simultaneously//.

It is a part of the human condition, and not a pthaological state in itself.

[[Motivational Work]] stresses the normal nature of this state of being.

//"I want to stop drinking, and I don't want to stop drinking."//

This content was developed by Helen Fletcher and Susannah Gilmour from Hertfordshire Partnership University NHS Foundation Trust, who work in an adult learning disability team. 

!!Aim
To help us in our work with complex or stuck situations to think from different perspectives. The aim is to prevent us from get stuck thinking from just one perspective.
The aim is not to get everyone to agree but to highlight different viewpoints to help us move forward together in our work. 

!!What it is?
It is a tool to help people think from different perspectives, imaging what it is like to be in someone else’s shoes. 
It involves thinking from each person’s point of view (as best as we can) about:
1) What the problem is
2) What should be done about the problem
3) Whose job it is to do what

!!What it isn’t
The information contained in the grid is not factual, it is based on people’s thoughts about what other people might be thinking. This would then need to be checked out with them to see if we have got anything right or wrong!   For example …… “if I was in your situation I think I might feel …….. what do you think about that?” 

!!How we use this
The tool can be used in therapy sessions, supervision, meetings with service users and / or professionals and reflective practice sessions. However,'' it is best to ensure you are only sharing the grid with those who were involved in creating the grid so that the content is not misinterpreted.''

See [[AMBIT Disintegration Grid template with instructions.pdf]] to download the adapted disintegration grid.

tracker: UA-25463221-1

There is not much evidence for the effectiveness of traditional anger management techniques even though anger management is commonly cited as something that should be offered to young people. 

Mentalization based approaches would not tend to see anger as requiring a fundamentally different approach to managing other mental states. 

#The basic stance of [[MentalizationBasedWork]] is aimed at increasing awareness and sensitivity to one's own and others mental states and to develop capacities to recognise such feelings, preferably at an early stage.  
#Similar to [[Cognitive Behavioural]] approaches, Mentalization based approaches would take a neutral non-judgemental approach to angry FEELINGS but would sharply separate angry feelings from angry BEHAVIOUR.  For many highly troubled young people, anger may be a highly appropriate almost adaptive state of mind in relation to their life experiences and the key worker would wish to adoptive a respectful curious stance towards such //feeling states//. This respectful stance is not adopted towards angry and violent //behaviour//.
#Being able to [[Notice and Name]] early warning signs that point towards an anger outburst is a key feature of most anger-management programmes.
##This fits the process of the [[Mentalizing Loop]].
##It is also an element of a cognitive behavioural approach
!!!When anger erupts
There is material on dealing with [[Affect storms]] and [[Manage Violence]] gives information on de-escalation, and Body Language, etc.
!!!Anger and Mentalizing
Anger rapidly reduces mentalising and also capacity to problem solve. Because of this, reasoning with people in angry states (these might be best described as [[Psychic equivalence]]) is often unproductive and the focus should be on de-escalation and reducing the effect of [[Affect storms]].

The Anna Freud National Centre for Children and Families is a charity dedicated to ''Innovation'' in the the treatment of mental health difficulties in Children and Young people, ''Evaluation'' of new treatments, and the ''Dissemination'' of effective techniques to the widest possible audience.  Further information can be found at the Centre's  [[website|http://www.annafreudcentre.org/]].

The AMBIT project is hosted and [[supported|Sponsors]] by the [[Centre|http://www.annafreud.org]].
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!!''Consider supporting us''
AMBIT relies entirely on charitable donations and the fees it raises through training, it works to keep its training prices as low as possible to enable maximum dissemination, and all of its training and theoretical materials are presented freely (OpenSource) on the web.  ''Giving'' can be arranged via the [[Centre|http://www.annafreud.org]] website.

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!!!AMBIT Trainer
Anna is an AMBIT Trainer based in Barcelona as well as an AMBIT Study Group Lead. Project Officer for the [[AMBIT programme]]. 


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!!!AMBIT Trainer
Anthony, better known as Scotty, is an AMBIT Trainer based in London. 

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!!Purpose
To give an overview of Anxiety as a common problem affecting young people and adults, with pointers towards how to treat this.

!!Information
Below is a leaflet produced by the Royal College of Psychiatrists, or you can open it in a separate browser window [[Here|http://www.rcpsych.ac.uk/mentalhealthinfo/problems/anxietyphobias/anxiety,panic,phobias.aspx]]

Underneath this, you will find links to material in this manual to direct treatment.

*http://www.rcpsych.ac.uk/mentalhealthinfo/problems/anxietyphobias/anxiety,panic,phobias.aspx
!!Panic
There is a separate page on [[Panic Attacks]]

!!What to do

* The most powerfully-evidenced treatment for Anxiety is [[Cognitive Behavioural]] work.
*Some [[FamilyWork]] is advisable, especially in order to:
** Recruit the family to support treatment
** Provide some PsychoEducation so that family members share the same understanding of the child's problems.
** Reduce any criticism, or blaming, and reduce expressed emotion in the family.
* With permission from the young person/family it is helpful to liaise with the school or other agencies to ensure that there is a shared understanding of the problem and the solutions we are working towards (see [[Working in multiple domains]]).

No.  

* [[AMBIT]] refers to ones "sphere of influence" - and as a method of practice encourages that the limits of this are brought into explicit awareness/acknowledgement, rather than this being //implicit//.
* There is a wide a range of material in the AMBIT manual, from general material that would be relevant to all practitioners, to more specific manualised [[Interventions|Specific interventions]] that may be of interest to many - by way of "making sense of" ([[Mentalizing]]!) the actions of workers more specifically focused on that aspect of work, but of //specific use// to a smaller range of workers.
* If there is doubt or anxiety for a worker about //"what should I do?"// in a specific case then this would seem to be a useful prompt for using the SupervisoryStructures in the team to help [[mentalize this|Mentalization]].

Asen, E. & Bevington, D. (2007): Barefoot practitioners: a proposal for a manualized, home-based Adolescent in Crisis Intervention Project. In: Baruch, G., Fonagy, P. & Robins, D. (eds): [[Reaching the Hard to Reach|http://www.amazon.co.uk/Reaching-Hard-Reach-Evidence-Based-Intervention/dp/0470019417]]. John Wiley, Chichester

//An early description of the model, with less emphasis on the __organisational elements__.//

!Inexact Science:
Remember that the stage of change is not a static thing, and like [[Mentalization]] it is in a constant state of flux - you are looking for a broad estimate of where the young person is //at this point in time...//

!!Ask the following questions:
To help clarify which of the [[Stages of Change]] your client is in...

!1. How important?

How important does it feel for you to change now?  
* Scale 0 - 100
* Where 0 is completely unimportant and 100 is the Most Important thing.

!2. How confident? 

How confident are you about making those changes?  
* Scale 0 - 100
* Where 0 is no confidence and 100 is complete confidence.
 
!3. How far?
 
How far have you got in the journey towards making those changes?  
* Scale 0 - 100
* Where 0 is "haven't started any planning yet" and  100 is "job done".

!Record your findings:

This should be recorded in your notes.  
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!What's here?
* A video from Harvard business school about what is a [[Learning Organisation]], and how to help develop one.
* A questionnaire from Harvard Business School to assess where your team is in relation to this ideal
!What are you looking for?
This video from the Harvard Business School provides an introduction to a method of assessing how closely your own team complies with some of the core features of a learning organisation.  ''@@color(blue):there is a particularly key part of the discussion from 4min 48sec, where they cover WHAT DO YOU HAVE TO DO to start to create a Learning Organisation...:@@''
<html><iframe width="640" height="360" src="https://www.youtube.com/embed/lUP4WcfNyAA?rel=0" frameborder="0" allowfullscreen></iframe></html>

!!Online survey to assess your team's proximity to a "Learning organisation"
The survey referred to in the video above is freely available online [[here|http://los.hbs.edu]] (note -  the survey does not save your results, so cut and paste your scores onto a word document to save them) - or if you are online it will be displayed below:

<html><div align="center"><iframe src="http://los.hbs.edu" frameborder="0" width="100%" height="600"></iframe></div></html>

!!'Learning Organisations' and AMBIT
AMBIT is designed to be an open system where the need for on-going learning, skill development and new knowledge is placed at the centre of the approach. This is partly because, at best, the desired outcomes of this area of work remain modest and the motivation is to find increasingly effective ways of offering help to troubled young people. 

The intention is that AMBIT is designed so that it can be adapted and used in organisations with very different structures and organisational cultures. This includes both statutory and third sector organisations. However, we would advocate that, independently of formal structure, the organisation needs to attend to processes of learning. 

See [[What's the problem?]] for a broad framework, and [[Taking Aim]] for more detail on what you can try to do when making your assessment.

The point of an assessment is to start the process of developing your [[Formulation and Treatment Aims]].

!Why?
''Some principles of Assessment for Drugs and Alcohol:'' Making a good assessment of a young person's drug and alcohol use is key because:
*The assessment is an important INTERVENTION in and of itself - especially if it is properly handled.
*A good assessment helps to set the scene for the most appropriate [[Care Plan]]
*Young people using drugs and alcohl are at greater RISK than those who are not
!What to do?

The UK's National Treatment Agency (NTA) has produced a good document that covers the essentials of assessing a young person's substance use in great detail.  See [[NTA - Assessing Young People for Substance Use]].

For guidance contained within this manual, see below.

''__1. DRUG/ALCOHOL HISTORY__''
Taking a good [[Substance Use History]] is important.  

''__2. ADDITIONAL KEY INFORMATION:__''
There are three key additional areas that should be enquired about in an assessment IN ADDITION to the drug and alcohol history:

(a) ''Risks:'' You can use the [[RiskAssessment]] at [[Make or View Client Notes]].

(b) ''Mental Health, other Comorbidities, and Resiliences:'' You can use the [[AIM]] and consultation with the team/Psychiatrist via SupervisoryStructures.  Remember there are [[Multiple interacting aetiologies]] for adolescent Substance Use Disorder, and within resiliencies you will be looking at Family and other pro-social relationships within the young person's social ecology.

(c) ''Stage of Change:'' You can refer to [[Assess Stage of Change]], and record this under the [[Formulation and Treatment Aims]] via [[Make or View Client Notes]].  This is key to fulfilling one of the key [[SUD-Rx principles]], which is that, as practitioners you should [[Adapt your Discourse]] to fit //where the young person is// re. the [[Stages of Change]].

It is helpful to clarify what STAGE the young person is at:  the following grid adapted from [[Mirza and Mirza (2008) Adolescent Substance Use]] offers helpful markers along the route to harmful and dependent use in youth, that are more relevant to the [[Developmental Considerations]] that "set the scene" in which this drama unfolds.  

(There is a direct external link to this table [[here|https://lh4.googleusercontent.com/-utBsBfmyG7o/UHMdJBNY02I/AAAAAAAAFRU/p9T0iJwr2SI/s864/SUDClassification.jpg]]) and SEE BELOW FOR THE ~ALL-IMPORTANT ''//FEEDING BACK//'' of your findings to the young person:

[img[https://lh4.googleusercontent.com/-utBsBfmyG7o/UHMdJBNY02I/AAAAAAAAFRU/p9T0iJwr2SI/s864/SUDClassification.jpg]]

''__3. ASSESSMENT = INTERVENTION! - Giving FEEDBACK__''
You must GIVE ''FEEDBACK''.  Giving clear, personalised feedback about the assessment is a key part of the assessment; where an Assessment actually becomes an Intervention.  See [[Assessment for SUD-Rx - Giving Feedback]].

!Importance of feedback:
An important component of successful Brief Interventions is the delivery of //personalised// feedback on the young person's assessment, so as to //contextualise// his/her substance use in respect of his/her peer group.
!!It is important to:
#''Be honest'' - do not exaggerate the extremity of a young person's substance use.
#Conversely, ''avoid unwittingly "normalising"'' (and potentially reinforcing) the young person's reported drug use.
#Consider the fact that the young person's immediate peer group/social ecology may be either (or both): 
##A ''resilience factor'' (non-drug-using, pro-social, supportive and challenging YP's substance use) or... 
##A ''vulnerability factor'' (drug-using, normalising substance use, antisocial, collusive.)

!How to deliver feedback:

!!1. @@color(red):Invite curiosity@@:
>//''"I've been asking all these questions... I find myself wondering if YOU might be wondering what kind of things I have begun to understand from this assessment?"''//
!!2. @@color(red):Use understandable and memorable images@@:
>//"Imagine all the young people of your age within twenty miles of here were lined up in long line...  Now imagine they are lined up in order of how heavily involved with substance use they are... the ''very heaviest involved'' are on that end, moving down to the ''lowest involved'' at this end.//

>//''where would you ''want'' to be on that scale?''//
 
>//''where do you think you ''actually'' are?''//
When they answer that question, do remember that it may be that they are moving in a group that use more, or less than ''most'' young people. Use web-based statistics to compare their use to that of the general population of their age-group.

!!3. @@color(red):Cover core details@@:
Assuming the young person can be engaged to show interest, try to cover your assessment of their habit in terms of:
#AMOUNT
#SEVERITY
#RISKS
!!4. @@color(red):Conclude with choices and treatment options@@:
>//''"Now that you have this knowledge, I am guessing that you may want to leave it at that, but you may also like to think about the kinds of choices you have about what to do next?"''//

This is one of many [[Tags]] which links you to all aspects of Attachment in the manual.  

These are triggered when an individual is stressed in any way.  

At that point, the [[Attachment]] system is activated, and the person is driven by this to //modulate// how near or far he or she is from whatever is seen as the [[Attachment Object]].  

The way that the individual goes about organising themself (and others around them) so that the distance between them and their [[Attachment Object]] starts to feel //"right"// is largely dictated by the style of their [[Attachment Relationship]]  (Secure, ~Ambivalent-Enmeshed, ~Detached-Dismissive, Disorganised).  Examples of Attachment Behaviours might therefore be:
*Crying, distress (draws my [[Attachment Object]] in to closer proximity to me...)
*Ignoring, walking off (increases the distance, but keeps me in their mind...)
*Angry verbal (or even physical) attacks (Keeps them close to me, but punishes them for making me feel so needy...)
!!Attachment Behaviours and Mentalizing
Crucially, when [[Attachment Behaviours]] are //activated// the neurological structures that allow [[Mentalization]] are //de-activated//.  This //"see-saw"// between Attachment Behaviours and Mentalizing is a crucial understanding for practitioners to apply in their work.

Links to definitions of [[Attachment]] styles, behaviours and other concepts to go here:
!!Basic Attachment concepts:
[[Attachment Behaviours]]
[[Attachment Object]]
[[Secure Base]]
[[Internal Working Model]]
!!Attachment styles
See [[Attachment Relationship]]:
* Secure
* ~Anxious-Ambivalent-Enmeshed
* ~Detached-Dismissive
* Disorganised

This refers to whoever (or even whatever) a person in distress, whose [[Attachment Behaviours]] have been activated, sees as ''the strong authority figure'' that is available to them.

*For most children, their most important Attachment object is their ''mother''.
*Most children will have more than one Attachment objects available (''father'', ''grandparent'', ''teacher'', etc), and may have different [[Attachment Relationship]]s or styles, towards each of these.
Depending on their [[Attachment style|Attachment Definitions]] (which in turn is dictated by their [[Internal Working Model]] of how an [[Attachment Relationship]] can be predicted to work) they may react in different ways towards this person (Secure, Ambivalent-Enmeshed, Detached-Dismissive, Disorganised).

''The tag <<tag [[Attachment]]>> gathers together other material relating to this topic. '' This is a particular and important aspect of human relationships described by Bowlby, and subsequently developed by a large body of researchers and theorists.

!!Definitions
When we speak of there being an Attachment Relationship between two people (for instance between a KeyWorker and young person) ''this does not mean that they are 'attached' in a //sentimental// way''! 

An attachment relationship refers to the fact that a ''specific person'' responds to ''another specific person'' in somewhat predictable ways, particularly at a time of stress.  Note that one person might have quite //different// styles of attachment relationship towards the different key figures in their life - and it seems that during adolescence one of the things that happens is that multiple parallel (perhaps quite different) attachments start to merge (to "average out", if we were to put it crudely) - in this way humans start to form increasingly lasting "expectancies" about helping/caring/authority relationships that we call [[Internal Working Model]]s - maps of how certain kinds of relationships tend to work.  This is absolutely crucial when we think about how AMBIT seeks to influence a young person's [[Relationship to help]]; what we are suggesting is that we want to introduce some differences and change in a young person's [[Internal Working Model]]s of helping relationships.  

Driven by the different kinds of expectancies held within a young person's [[Internal Working Model]], a range of different (increasingly ingrained and automatic) responses to distress and towards caregiving/authority figures emerge in attachment relationships; these are what are described by the different styles of attachment...

!Attachment styles
''Do they seek proximity?''
*The //reassurance// of being close (using someone as your [[Secure Base]]), that allows them "space to think" ([[Mentalization]]) - this is typical of ''SECURE attachments''

''Do they push away/drift off?''
*As if avoiding the //stress// of intimacy/feeling the sense of need that denies them the "space to think" - this is typical of ''DETACHED/DISMISSING attachments''

''Do they anxiously cling and yet angrily reject at the same time?'' 
*As if torn between their neediness, and fury at being so needy, and mistrustful of what might be on offer - this is typical of ''ANXIOUS/AMBIVALENT/ ENMESHED attachments''

''Do they switch back and forth between these styles, in ways that seem disconnected, bizarre, unpredictable?'' 
*This is typical of ''DISORGANIZED attachments'' - this is the most worrisome presentation, the one most strongly associated with maltreatment or trauma, and most predictive of future psychopathologies. 

//''IMPORTANT:'' //Please note that ''an attachment style is NOT a diagnosis, or a pathology in itself'' - it is just a //description of the style of relating to people and reacting to stress// - in some settings one or other attachment style may be more adaptive than others, and there are plenty of very successful people who exhibit ambivalent or detached attachment styles.  While there are a range of advantages for people classified as Securely attached, and disorganised attachment is very often a marker for other significant adaptive difficulties, it is important not to make too a concrete link between attachment style and "pathologies". 

!Development of Mentalizing within an attachment relationship.
[[Mentalization]] develops in children within their [[Attachment Relationship]]s.

If a mother is able to respond "contingently" (i.e. with enough sensitive attunement to the demands of the baby's condition; see [[Contingencies]] for how this is carried into [[Cognitive Behavioural]] approaches) and to apply [[Marked mirroring]] of her baby's mental state, then repeated experiences of this:
>//"Another mind that seems to understand and find ways to describe and respond to my experiences!"//
...helps to build a sense of ''//self//'', and of ''//self-agency//'':
>//"There is an "I"// ''[I can see this represented in her face]''//, and this "I" finds itself in different states// ''[happy, sad, frightened, hungry, hurting, surprised - which I can see her mimicking to me in ways that fit how I feel]''//, and this "I" can operate upon the world it somewhat predictable ways// ''[I find I can change things about the world, and me, by calling out, moving, and thinking differently]''...")
...and "thinking differently" here might refer to "thinking about thinking", or starting to "take a meta-perspective upon thoughts and feeling" - which is really the birth of [[Mentalization]].

Creating a more accurate narrative (see [[Explicit mentalization]]) is not the ultimate goal of MentalizationBasedWork. 

In order to manage and regulate feelings we first need to be able to 'feel' and experience them. For this to happen, we need a relationship in which it is safe to explore our mind and feelings (in the mind of another). The development of mentalizing in the context of a secure attachment relationship is therefore closely connected to the development of [[Affect Regulation]]. 

The concept of ''affective mentalization'' is about the relationship between mentalizing and affect regulation. It is seen as the highest order of the [[Mentalizing Levels]].

It means ''simultaneously feeling a feeling //and// thinking-about the feeling''. For example, feeling angry or upset, and at the same time being able to explore why this might be happening, in the moment (i.e. mentalizing this experience). 

An example of this in a therapy context might be a patient experiencing a strong feeling in the session, but rather then avoid or dismiss it, stays with the feeling whilst trying to make some sense of it, with the support of the therapist.

Affective mentalization is a key part of affect regulation, both on an individual level and at the level of the family system.

If we can 'be with' a feeling and make some sense of it at the same time, it is much more likely that we can regulate or manage this experience, rather than it being overwhelming. In the same way, if feelings that are happening within a family-relational context can be mentalized by members in this way, as they are happening, it is more likely that people find ways to get on.

The creation of a safe environment within the family for all its members is critical for this process to happen.

Feeling recognized as an individual helps to promote the experience of a secure base (see [[Attachment Relationship]]). This allows the activation of mental models, (internal representations of secure relationships, mostly held below the level of our awareness).When activated, these mental models relate to confidence in experiencing distress, knowing that it is manageable and will not be permanently overwhelming.

[[Mentalizing the Moment (in the Mentalizing Loop)]] is a key process that the KeyWorker uses in MentalizationBasedWork, and fostering this capacity in the young person and family members is an aim in therapeutic work.  In [[AMBIT]] this is additionally something that workers take responsibility for fostering in each other, using [[Rituals and Disciplines]] such as [[Thinking Together]].

For definitions of attachment styles, behaviours and other concepts click on [[Attachment Definitions]]

Following Bowlby, we assume that attachment is an essential facet of human development and that a key function of the family is to provide a framework for the development of increasingly autonomous personality functioning, underpinned by a secure attachment system. 

Families in which serious psychiatric crises arise in adolescence tend to have distortions of the attachment system. This may be a result of chronic disturbance in a specific individual, or the parental relationship; additionally it may reflect the behaviour of a caregiver in the past, the intense pressures placed on the caregiver by the child earlier in development, or most commonly both of these. 

In some key respect, the family has ceased to be a [[Secure Base]], in that either the YP does not feel reassured by the presence of other family members, or those family members have ceased to be able to offer support and acceptance, thus the attachment system does not function to contain the YP's disturbed emotional states or behaviour. 

Within our framework, the capacity of the family to have a sufficiently coherent picture of each others' states of mind is a key facet of attachment (see [[Mentalization]]). One sign of the disturbance in the attachment system is that there are massive distortions of perceptions of other people's attitudes and intentions, and that an aim of the intervention is to reinforce attachment processes through enhanced understanding.
 
The moment of crisis may be understood as a breakdown of the attachment system, in which the parents and/or the YP are willing to give up the bond that would normally make the troubled YP seek security and safety in the family. This may be a reaction to a long history of dismissing attachment style, or preoccupied entanglement, or the dramatic exaggeration of a developmentally appropriate move away from the family. Whatever the roots may be, the aim of the crisis intervention is to make the family a more secure base for the YP. What may be most important in that context is that the keyworker (KW), through his intensive and reassuring presence, begins this experience for the family members of a more secure base. The calm, sensitive, appropriate behaviour of the KW is intended to activate more secure [[Internal Working Model]]s of attachment relationships for all members of the family.

!!''Content''
This manual is an attempt to synthesise the work of a group of clinicians and academics based in London and Cambridge, UK:

!!!Original Authors:
*Dr DickonBevington
*Dr [[Peter Fuggle]]
*Dr EiaAsen
*Prof PeterFonagy
*Dr MaryTarget
*NeilDawson
*RabiaMalik

!!!AMBIT Editorial Group
Ongoing changes, adaptations and additions to content are made by the [[AMBIT Editorial Group]] - see relevant content management material here:

<<tag [[AMBIT Editorial Group]]>>

!!!Licensing
Note that all the content of the AMBIT manual is released under a [[Creative Commons Licence|Licensed]] - please check the terms of this if you or your team are using this material.

!!''Tiddly Manuals''
Tiddly Manuals are an approach to the use of wikis as adaptable opensource treatment manuals is the copyright of Dr Dickon Bevington ([[link|http://www.tiddlymanuals.com]]) and is also released under Creative Commons License - see the tiddlymanuals website for details of this.

!!''Software and Programming''
The Software that this manual is written in is called [[TiddlyWiki|www.tiddlywiki.com]], and was originally invented by [[Jeremy Ruston|http://osmosoft.com/]].  It is licensed separately, and is an OpenSource product.  With a bit of work a beginner can quickly learn to do a lot with it.  

We acknowledge with gratitude the support of Jeremy, and his colleagues at [[Osmosoft|http://osmosoft.com/]], and in particular Jonathan Lister and Joshua Bradley at [[withjandj|http://www.withjandj.com/]] who have supported the design and programming of the new AMBIT [[theme|http://ambit-theme.tiddlyspace.com]], with the generous backing of our [[Sponsors]].

Literally "~Self-Teaching" it means [[Self-directed learning]] - we envisage the resources being developed and shared openly in AMBIT's OpenSource approach to therapy innovation and development as being increasingly open for use by teams and individuals who are self-directed learners.  Please do note our [[Disclaimer]] - clinicians remain responsible for their own practice.

Literally "Self-rule".

The open-source programming arm of British Telecom has helped to develop the free resource ([[TiddlyWiki]]), and its online hosting ([[TiddlySpace]]) that powers the AMBIT treatment manual.  We acknowledge the vital support and expertise of [[BT-Osmosoft|http://osmosoft.com/]] in our non-commercial collaboration to develop the treatment manual. 

!Reference:
Egon Bachler, Alexander Frühmann, Herbert Bachler, Benjamin Aas, Guido Strunke and Marius Nickel (2014) //"Differential effects of the working alliance in family therapeutic home-based treatment of multi-problem families"// Journal of Family Therapy (2014) doi: 10.1111/1467-6427.12063

!Abstract:
Families with a low socioeconomic status play an increasingly significant role in health services, research and social policy. The present outcome research study is a pre/post naturalistic study of home-based therapeutic work with multi-problem families (MPF), as conducted by Therapeutisch Ambulante Familenbetreung, an integrative family therapy with a structure-related, mentalization-based, psychoanalytic orientation. With a mean treatment duration of 75.7 weeks, 379 families showed significant psychological improvement on 10 scales concerning patient–therapist collaboration, treatment expectancy and psycho-social outcome measures with a medium to large effect size for all parameters (range: .35–1.49).
About two-thirds of the sample improved by two SD on individually set treatment goals, further supporting the clinical significance of the therapeutic effect of home-based family treatment. Improvements in goal-directed collaboration and treatment expectancy are shown to be related to clinical improvement. Structural family therapy interventions for families
with multiple problems thus benefit from individually setting goals and improving their self-efficacy and problem-solving by means of improved treatment expectancy.

!Practitioners' responsibility

It is the Worker who takes responsibility for maintaining a ''BALANCE''...

Between ''"Inside"'' change work, and ''"Outside"'' change work.  

In keeping with the [[Multiple interacting aetiologies]] in adolescent Substance Use Disorder, interventions that focus on //either// internal (cognitive or motivational) factors, //or// external (family or social-ecological) factors are immediately at a disadvantage.

Recognising that individual practitioners will have "favourite practices" and blind spots (losses of [[Mentalization]]) they sustain this balance via regular use of the SupervisoryStructures within the team.

!'"Inside" change work

[[Motivational Work]]
[[CognitiveBehavioural for SUD-Rx]]

!"Outside" change work

[[FamilyWork for SUD-Rx]]
[[Social-Ecological Work]]

The phrase originally comes from China - Chairman Mao in his 'Great Leap Forward' advocated the training of 'barefoot doctors'; practitioners trained in basic techniques of hygiene and simple treatments who provided the only possible way of beginning to address the needs of a hard-to-reach population.

In Mental Health the situation is very different, but in some ways analogous; there are undeniably large amounts of unmet need and shortages of highly specialised staff. It is perhaps not unreasonable to surmise that if service development pursues a path that insists upon only increasing super-specialisation of workers then this risks (albeit unwittingly) serving an agenda of //social exclusion//; it is difficult to envisage a time when there might really be enough highly trained specialists to fill vacant posts.  However, more significant by far, the barefoot KeyWorker (or '[[IMP]]') can deploy therapeutic modalities in settings where there would otherwise be none, and the ''integrated'' and ''multimodal'' nature of these interventions, that are delivered ''flexibly'', largely ''contingent upon the needs of the here-and-now'', offers hope for effectiveness in these hard-to-reach settings that has currently not been realised.

So, while KeyWorker described in this manual shares some of the features of the barefoot doctors of revolutionary China, the comparison is more descriptive analogy than fact.

!Barriers to help seeking in teams

In this Unconference workshop, we explored the barriers to seeking help in teams. Participants felt that establishing a culture of honesty and openness in teams, whereby team members felt able to share thoughts or feelings about their work without having to “dress them up” was a fundamental part of being able to practice effectively, but could be difficult to achieve.

We brainstormed some barriers to asking for help in teams, as follows:
*A worry about appearing incompetent 
*Low trust in colleagues – may be the case in newly formed teams, where building trust might be part of the developmental journey of the team, but equally could occur in well-established teams if there are difficulties between team members
*Worrying about one’s work and professional identity being negatively judged
*Not knowing who to ask for help
*Not knowing how to ask for help
*Not knowing what it might be ok to ask for help with
*Being physically separated from colleagues, by location (e.g. hot-desking or different localities)
*No time with colleagues, due to everyone being busy
*Worrying that the kind of help offered won’t be what was needed (e.g. “They’ll just give me even more to do!”)
*Competitiveness between team members 
*Not trusting/valuing the opinions and ideas of colleagues
*Previous negative experiences of seeking help from colleagues (either in current or previous roles)
*Experiences of seeing other help-seeking colleagues being helped in “unhelpful” ways
*Team members beliefs about their competence and help-seeking (e.g. “I should be able to do this work on my own”; “I should know what I’m doing by now”; “I can manage this on my own”; “I don’t need help from anyone”; “Asking for help from others is weak”)

!How to develop a culture of help-seeking within a team

We talked about the importance of a team having a culture that explicitly supports and encourages help-seeking between team members. Members of the team should have a sense that “This is how we do things round here; we ask for and offer each other help with our work”. 

In terms of how this might be established, we spoke of the importance of team members having conversations with each other about how they will establish help-seeking as part of their culture, in terms of how this might look within their team.

Part of the rationale for having an explicit culture of help seeking and help giving came from us reflecting that although teams usually have formal structures via which team members could seek/receive help with their work (e.g. team meetings, case discussion meetings, supervision, reflective practice groups), these tend to occur at set frequencies, rather than being available to team members when they might need them. In this sense, the help that these meetings provide (setting aside whether or not these meetings are experienced as helpful by team members) is not necessarily contingent on when a team member might be in need of help.  We reflected that the kinds of dilemmas and challenges that workers face when working with hard-to-reach young people and their families are usually ones that require a fairly quick response (whether that be helping a worker to talk through difficult feelings after a stressful visit; a family calling up because they are experiencing a crisis etc), where waiting for the next scheduled meeting would not be effective or practical. 
 
!Beliefs that support help seeking within teams

We brainstormed some of the helpful messages/beliefs that might support team members to feel ok about help-seeking and help-giving 

*It's ok to talk about being stuck
*It's ok to say that you don't know something or aren't sure what to do
*It's ok to ask for help
*It's ok to accept help
*It's ok to offer help
*It's ok to say if you're not managing
*It's ok to talk about your feelings about your work
*It's ok to ask someone about their feelings about their work
*It's ok to say if you feel you've made a mistake

!Working out ways to get help

*Teams may wish to make an agreement about how and when to use the [[Thinking Together]] framework to get help with their work
*Teams may wish to come up with a system so that someone is always available to offer help if needed (e.g. a rota or on-call system)
*Teams may wish to come up with informal systems for checking in with each other (e.g. team members enquiring how visits/meetings have been when team members return to the office)
*Teams may think about how they might use phone calls to get help from other team members (e.g. calling another team member from a session if stuck; having a conversation with a colleague on speaker phone so that the family can be part of the conversation too; calling a colleague after a stressful visit to debrief or discuss dilemmas)
*Having a designated area of the office/team base where team members can sit with a colleague if they want to discuss a dilemma (to prevent stress spreading through the team)

!Maintaining a help-seeking culture

We reflected on the importance of new team members having a “cultural induction” as part of their introduction to the team, so that they had a good understanding of the values that underpinned how the team behaved towards each other and examples of the behaviours that arose from these values (e.g. “We value help-seeking here, so you’ll notice us asking each other for help with our work, people offering to help others with their work and team members being open to accepting help from others with their work”), enabling new team members to become part of the help-seeking culture and support its continuation. 

Teams may also wish to review how they are doing with regards to maintaining a culture of help-seeking by discussing this at team meetings. Teams may wish to reflect upon times they are doing help-seeking well, as well as missed opportunities for help-seeking within the team and ways in which they might improve this. 

Consider the [[Stages of Change]] here, as well as the [[Maintaining factors for problems]].  

The [[AIM]] questionnaire also contains information about the young person's response to care.

<a class="tc-float-right">[img width="150" [bea manual.jpg]]</a>

!!!Young Person's Lead
Bea is a social entrepreneur and is lead for a youth-led project at the [[Anna Freud National Centre for Children and Families]], working with young people on a Hackney estate to understand what is important to them in terms of mental health and to co-create a system of peer support for local young people. 

You can read more about the project here: [[Pembury Project wiki manual|https://manuals.annafreud.org/ambit-pemburyproject]]

<div style="clear:both;line-height:0px;"></div>

Bearman, S.K., Ugueto, A., Alleyne, A., & Weisz, J.R. (2010). Adapting CBT for depression to fit diverse youths and contexts: Applying the deployment-focused model of treatment development and testing. In J.R. Weisz & A.E. Kazdin, (Eds.), Evidence-based psychotherapies for children and adolescents, 2nd edition, (pp. 466-481). New York: Guilford.

The Becks Depression Inventory can be found [[here|https://www.ismanet.org/doctoryourspirit/pdfs/Beck-Depression-Inventory-BDI.pdf]].

Reference:

//Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression
Inventory-II. San Antonio, TX: Psychological Corporation.//

!!!![[Source|https://www.pearsonclinical.co.uk/Psychology/ChildMentalHealth/ChildMentalHealth/BeckYouthInventories-SecondEditionForChildrenandAdolescents(BYI-II)/BeckYouthInventories-SecondEditionForChildrenandAdolescents(BYI-II).aspx]]



The Beck Youth Inventories for Children and Adolescents are designed for children and adolescents aged 7 to 18 years.

The are 5 self-report inventories can be used separately or in combination to assess symptoms of depression, anxiety, anger, disruptive behaviour and self-concept.

Each inventory contains 20 statements about thoughts, feelings and behaviours associated with emotional and social impairment in youth. Children and adolescents describe how frequently the statement has been true for them. The instruments measure emotional and social impairment in five specific areas:

''Beck Depression Inventory for Youth:''
In line with the depression criteria of the Diagnostic and Statistical Manual of Mental Health Disorders— Fourth Edition (DSM– IV), this inventory allows for early identification of symptoms of depression. It includes items related to a child's or adolescent's negative thoughts about self, life and the future, feelings of sadness and guilt and sleep disturbance.

''Beck Anxiety Inventory for Youth:''
Reflects children's and adolescents' specific worries about school performance, the future, negative reactions of others, fears including loss of control, and physiological symptoms associated with anxiety.

''Beck Anger Inventory for Youth: ''
Evaluates a child's or adolescent's thoughts of being treated unfairly by others, feelings of anger and hatred.

''Beck Disruptive Behavior Inventory for Youth:''
Identifies thoughts and behaviours associated with conduct disorder and oppositional-defiant behaviour.

''Beck Self-Concept Inventory for Youth: ''
Taps cognitions of competence, potency, and positive self-worth.

This is what an observer can //see// - things that are ''done'', rather than the thoughts, intentions, wishes, or feelings that we might use to explain //why// these particular behaviours have taken place (working out this //"why"// question is at the heart of [[Mentalization]].) For many clinicians, behavioural therapy is unattractive because it can appear to remove personal agency from the description of a person's behaviour. AMBIT prefers to describe behaviour more in terms of actions than behaviours. Action is really behaviour with the assumption of intentionality, and the assumption of intentionality is the basis of mentalisation. The trick is to maintain the discipline of functional analysis while including aspects of intentionality to develop understanding. 
!


In this way, one of the basic behavioural techniques is doing [[ABC Diary-keeping]]. This simply takes a specific situation and examines the antecedents, behaviours and consequences of a particular interaction. The value of this method is that it invites clients to go beyond general, global attributions of others (//"You are always like this..."//) to describe what they //actually// did, when. It fits extremely easily to add descriptions of internal mental states either experienced in oneself or imagined in others. 

The behavioural approach has developed methods of getting accurate descriptions of what actions have taken place in specific circumstances. The effort to get accurate and specific descriptions of who did what, who said what to whom and then what happened are paradoxically capable of being very stimulating of processes of mentalisation. What might appear to come from a very different theoretical model can be integrated into this model of practice without abandoning the useful methods which behavioural work has developed over many years.

Behavioural activation is something that every parent knows about and basically means gently encouraging a young person to increase physical and general activity. This technique is [[Cognitive Behavioural]] and is consistent with the idea that mood and feeling is influenced by both thinking and behaviours. In general, low activity levels are likely to maintain low mood states and the so increasing activity is generally beneficial for mood.
There is nothing complicated about this approach. It all depends on the usual things of timing and sensitivity.

''First step'' is to try to get ''a general idea about the young person's daily routine''. Its important to be completely non-judgemental about this and just convey interest in the young person's daily life. But it may require some gentle persistence to really get an idea about a young person's general routine such as when he/she goes to bed, gets up goes out, eats etc.

Having mapped things out, it may then be helpful to try to ''link weekly routines with mood''.. i.e. at what times in the week does the young person feel more depressed or low etc. The aim would be to try to link low activity with low mood.
 
Make a number of suggestions about ''very small changes in routine'' and see which of those would be more acceptable to the young person. Never go for big changes however enthusiastic the young person becomes and its best not to aim for 100% of days. For example, if the young person decides to try to get up before midday during the week, only encourage him/her to do this five days out of seven. Its always important to leave a space for old habits otherwise the old habits will fight back too hard. 

Having agreed a plan for the following week, ''stay interested'' when you next meet even if nothing has changed. Rarely do things move straight away. The important thing is to try to keep a balance between not being too casual about the plan and not being at all critical at things not progressing quickly. This response is a key part of the approach. Assume that persistence is part of the approach. 

Changing daily patterns is hard for young people to do on their own. ''Looking for others to help '' with such changes is also important. Parents or other carers can easily fall back into 'nagging' interactions that may not be helpful so this needs to be monitored. The important thing is for others to celebrate positive changes and not focus on negative behaviours. Others who may be helpful are youth and "Connexions" workers who are often very skilled in encouraging positive daytime activity. See [[Social-Ecological Work]]

The impact of three days training on a whole service system; has there been any and what have we learnt. 

Some options on how we could explore these questions. 

!!AMBIT Impact survey 
Monkey survey the AMBIT leads in 20 teams with a brief initial screening interview about implementation of AMBIT ideas. 

!!A Follow-up Two Day Event
Objectives: to be agreed with them but to include: 
*providing consultation on the continuing development of the model to those who would like it. 
*obtain feedback from services by carrying out a series of interviews 
*inclusion of doctoral study in this evaluation?

 

Bevington D, Fuggle P (2012) Supporting and enhancing mentalization in community outreach teams working with socially excluded youth: the AMBIT approach. In “[[Minding the Child|http://www.amazon.co.uk/Minding-Child-Mentalization-Based-Interventions-Children/dp/0415605253/ref=sr_1_1?s=books&ie=UTF8&qid=1336178888&sr=1-1]]: mentalization-based interventions with children, young people and their families.” Ed. Midgley N and Vrouva I, Routledge, 2012.

Bevington D, Fuggle P, Fonagy P, Asen E and Target M (2012) “Adolescent ~Mentalization-Based Integrative Therapy (AMBIT): A new integrated approach to working with the most hard to reach adolescents with severe complex mental health needs.” 

*[[CAMH Journal|http://onlinelibrary.wiley.com/doi/10.1111/j.1475-3588.2012.00666.x/abstract]] (May 4th 2012 | DOI: 10.1111/j.1475-3588.2012.00666.x)

This is the "book of the wiki" so to speak.

Published by Oxford University Press, it is the most complete statement of AMBIT in a linear (as opposed to non-linear wiki) format.

The work of turning a non-linear developmental account (as this wiki is) into a coherent narrative was interesting and - we hope - fruitful.  Some of the material in this will now be updated in keeping with learning from this process.

[img[AMBIT_BookCover.jpg]]

A link to the OUP website is here: https://global.oup.com/academic/product/adaptive-mentalization-based-integrative-treatment-9780198718673?cc=be&lang=en&

!Reference:
Bevington, Fuggle, Fonagy (2015) //"Applying attachment theory to effective practice with hard-to-reach youth: the AMBIT approach."// Attachment & Human Development DOI: 10.1080/14616734.2015.1006385 (link to it [[here|http://www.tandfonline.com/doi/abs/10.1080/14616734.2015.1006385#preview]])
!Abstract:
Adolescent Mentalization-Based Integrative Treatment (AMBIT) is a developing approach to working with “hard-to-reach” youth burdened with multiple co-occurring morbidities. This article reviews the core features of AMBIT, exploring applications of attachment theory to understand what makes young people “hard to reach,” and provide routes toward increased security in their attachment to a worker. Using the theory of the pedagogical stance and epistemic (“pertaining to knowledge”) trust, we show how it is the therapeutic worker’s accurate mentalizing of the adolescent that creates conditions for new learning, including the establishment of alternative (more secure) internal working models of helping relationships. This justifies an individual keyworker model focused on maintaining a mentalizing stance toward the adolescent, but simultaneously emphasizing the critical need for such keyworkers to remain well connected to their wider team, avoiding activation of their own attachment behaviors. We consider the role of AMBIT in developing a shared team culture (shared experiences, shared language, shared meanings), toward creating systemic contexts supportive of such relationships. We describe how team training may enhance the team’s ability to serve as a secure base for keyworkers, and describe an innovative approach to treatment manualization, using a wiki format as one way of supporting this process.

In this approach we do not distinguish between "biological" and "functional" disorders. As the brain is the organ of the mind, it is axiomatic that any mental disorder will be associated with biological dysfunction.  There is a NeuroDevelopmental context for work with children and adolescents, and a KeyWorker cannot ignore [[Physical Health matters]]

Medication ([[Pharmacological]] interventions) may be extremely helpful in containing a crisis, whatever factors have precipitated the problem or may be exacerbating it. 

This is an intervention in the [[domain|Working in multiple domains]] of biology, but it almost inevitably carries [[Systemic|SystemsTheory]] implications.

Accepted (NICE) treatment guidelines require that there should be rapid access to appropriate medication, and the general principles of the intervention are to make it as likely as possible that the recommendation of medication is taken seriously, while not excluding other modes of intervention which may be required to address the YP's problems. 

Medication can also have secondary psychological effects of reducing anxiety and thus making the family environment more secure. In particular, medication is not used to move the focus of the intervention from the family system to the YP, or to encourage the idea that the YP has something wrong with his brain which explains all the problems, an idea which makes it less likely that the family will retain a feeling of responsibility for being part of the treatment.

See the [[NICE Bipolar guidelines]]

Any young person who is sexually active or who is using substances, and ESPECIALLY any person who is using intravenous injection as a means of taking substances, should be offered the opportunity to be screened for certain blood borne viruses that are known to be transmitted via these routes.  In particular the viruses tested for are:
*HIV
*Hepatitis B (inoculations are available for this, and should be offered)
*Hepatitis C
!Local Protocols
Screening and Inoculations will be available from specific sources in a neighbourhood - some G-U (Genitourinary) Clinics offer this; in other areas there may be arrangements with local GP practices or other specifics.  It is important for local teams to make a note of this information and contact details in their own team manual.

*[[Patient-Worker Boundaries]] - Managing appropriate, professional, ethical, safe relationships with our patients.

*CheckLists - A list of tasks/paperwork etc that an [[AMBIT]] practitioner must have.

*[[AMBIT Practice Boundaries]] - Things like minimum supervisory contact, forms of supervision, etc

*[[Interprofessional Boundaries]] - Includes links to transitional and interagency protocols, and to a [[How to speak to a...]] (doctor/nurse/teacher/policeman) section.

* [[Manualization Boundaries]] - The rules governing the team's interaction with the Manual and how FEEDBACK is incorporated into shared practice - this includes DataSecurity.

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This is a commonly used technique.

In order to shape a behavioural change it is important to minimise the likelihood of a young person experiencing failure.

Thus a target is broken down into small ''achievable'' steps... let the young person guide you about what they believe is or is not achievable.  Use [[Rating Scales]] to help structure these conversations, aim to develop a ''graded hierarchy'' of difficulty.  The key here is to find enough steps and to get into detailed discussion about which variant of a task is likley to be more or less anxiety provoking.  Moving up this ladder of steps is the process known as [[Graded Exposure]].  This sort of work follows very well from the use of [[ABC Diary-keeping]], and goes alongside relaxation work such as [[Progressive Muscle Relaxation]].
!!In substance use:
Moving from smoking 12 joints a day to abstinence may be better achieved by concentrating on smaller steps:
>//"So you smoke with your mates usually, and we have agreed that amongst your mates you have the reputation as the greediest cannabis smoker around!  What if you were to start by trying to take just one, max two, drags on the joint each time it comes around, rather than the four or five you say you take at present.  That way your mates won't be upset by you, adn you'll get to cut back a bit... how would that be?"//

>//"What if you were to cut back from 12 joints a day to 10 joints?  How difficult would you find that on a scale of 0 - 100 (0 = easy, no problem, and 100 = impossible).  Do you want to try that for the next two or three days and then let's talk about whether it was harder than you thought or easier - or about how you guessed it would be."//

!!When should this occur?
Ideally before an AMBIT training is booked

!!Who should give the briefing?
Senior members of the team requesting the training - or AMBIT trainers

!!The Necessity for Senior Managerial Support
* There is ample evidence from [[Implementation Science]] that achieving organisational change of any form is challenging
* The adoption of evidence-based or evidence-oriented practices such as AMBIT is no different.  
* This is backed up by the experience of the AMBIT project at the [[Anna Freud National Centre for Children and Families]], which has now trained over 150 separate teams in AMBIT.  
* Those teams which have lacked significant senior management support to empower them to create new ways of working have struggled to implement much objectively new staff behaviour, regardless of how positively (individually or collectively) they have rated their impression of the [[AMBIT training|Information About AMBIT Training]].

!!Examples of low senior managerial support:
* Lack of engagement by senior managers in understanding the core features of AMBIT.
** Consider senior managers attending for part or all of the training
** See [[AMBIT: an overview]]
** Consider the ways in which AMBIT may or may not "fit" with existing service priorities and structures.
* Purchase of AMBIT training as a means of "avoiding underspend on the training budget" rather than for its perceived intrinsic value.
** Consider alternative ways to spend money
** AMBIT is not a one-size-fits-all approach but...
** It is also about empowering teams to develop clearer, more explicit ways of working, that are sensitive to the existing service eco-system, but which may also invite greater flexibility in working roles (following the //service user's needs//, rather than primarily the //institution's//.)

!!Clarity about the intentions for the training
* Senior managers should be part of the discussion that helps to define a set of [[Post-training outcome goals]]
* They should sign these off, as being in keeping with the goals of the wider organisation.

<center>{{broadcasting Pic.jpg}}</center>

Broadcasting Intentions is a key part of the active planning stance. This is when the KeyWorker makes an effort to be EXPLICIT and clear about their intentions or ideas to their client. In other words, the worker is open about 'what my intention or purpose is, and why'.

The point of this is that we cannot assume that our clients will have the kind of [[Relationship to help]] in which they would experience our approaches as well-intentioned.  It may be that our behaviour does not make sense, or represents something more threatening or troubling, in relation to their past experiences of others.

//In the anxiety of the therapeutic encounter it is often hard for young people to [[Mentalize|Mentalization]] their therapist accurately.//

So, we Broadcast our Intentions in order to;

*Prevent an intention from being misunderstood.
*Help an intention be understood
* Resolve a misunderstanding
*Build trust 

This is also a key element in the process of Engagement:

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!!How to broadcast our intentions

The AMBIT KeyWorker is encouraged to verbalise his/her intentions.  

This might be in terms of their general aims of the intervention such as "being helpful" to the young person, or the specifics, such as //"to register for a college course"//..

My invitation to consider registering for a college course might be well-intended, but might be read my client as a move to separate her from her boyfriend, or to humiliate her mother, etc...  If those were my true intentions, then it would make sense for my client to resist them, and I am unlikely to have any influence in that sphere!


Intention can be expressed in moment to moment interactions, for instance:

>//"My intention here is just to try to understand more accurately what you are feeling, and why."//
or

>//"What I am trying to do here is to be helpful, or at least to think of some new ideas about this familiar problem, and definitely to to avoid being unhelpful!"//
Being clear about moment to moment interactions would be adopting an explicitly intentional stance. 

>//"I may not have got things quite right yet, but these are the things that at the moment seem to me the most important ones for me to try to help you deal with... ...I would like to hear from you which bits you think I have got about right, and which bits I still need to work on so that you can recognise them more clearly..."//

!! A tool to help this: 
The [[Active Planning Map]] (also known as the Egg and Triangle) is about helping the worker to share their "first effort" in 
'"what I have understood from you", then inviting the young person to help improve it.  When you are sharing your first effort, ''that'' is Broadcasting Intentions!.  

Go to [[this link|https://docs.google.com/file/d/0B5h_CVBdhJPYNkJNamFPVXhsYXM/edit?usp=sharing]] to download this in PDF format, or just use the back of an envelope!

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.

Video on the [[Community of Practice]] that AMBIT emphasises as part of [[LEARNING at work]].

Part 1
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Part 2
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This is all in keeping with one of the [[Core Features of AMBIT]], which is [[Scaffolding existing relationships]], though as a young person moves towards moving on, there may be a requirement to build new relationships as well.

!Scaffolding the Informal network
A [[MAINTENANCE PHASE]] allows for increasing focus on [[Social-Ecological Work]] - this is focused on establishing ''meaningful activity'' and ''social bonds'' that add to the "[[Social Capital]]" that an individual can access.

In addition, continued work towards [[Scaffolding existing relationships]] (one of the [[Core Features of AMBIT]]), invites the young person to continue the work of building their own equivalent of the [["team around the worker"|KeyWorker]] - perhaps inviting them to consider this as a form of [[Self-efficacy]], as they increasingly take on the role of a KeyWorker in relation to their own responsibilities for their self.  In doing so, they may be encouraged to recognise the need to develop and mainain an active 'back-up' team that can offer accessible support for times when their own capacity for [[Mentalization]] is diminished.  Although there may be a continuing role for professionals to play a part in that team, [[FamilyWork]] and [[Social-Ecological Work]] may help to widen the membership of such a network.

By this stage we would expect that their AMBIT KeyWorker will have already demonstrated quite explicitly the kind of appropriate help-seeking behaviour that is promoted, modelling the principle of a [[Keyworker well connected to wider team]] in the way that they have used [[Thinking Together]] with other team members, etc.

Equally, by engaging a client in voluntary services, or local clubs and groups, this may help that same individual to add to the Social Capital of their neighbourhood - itself a "virtuous circle" in terms of the positive impact such giving has on the self esteem of the giver.

!Scaffolding the Professional network
Particularly as the young person heads towards the [[ENDING PHASE]] and discharge, it is critical to: 
* Define who will be in the young person's network going forwards.
* Check for, and if necessary [[address Dis-integration|Addressing Dis-integration]] between parts of the network, using a [[Dis-integration grid]] if required.
* Use the appropriate paperwork (for instance CAF [Common Assessment Framework], Child in Need or Safeguarding, or CPA [Care Programme Approach] forms) to ensure that a agencies are aware of each other and who does what.
* Arrange a [[Multi-agency meeting]] to bring key players together.

Cambridgeshire Child and Adolescent Substance Use Service

CASUS is an AMBIT service commissioned to provide Substance Use services for youth in Cambridgeshire, with a website [[here|http://www.casus.cpft.NHS.uk]]

Cognitive Behavioural therapy (CBT) provides an explanatory model, based on SocialCognitiveTheory and [[Developmental Considerations]], and this model underpins a series of quite simple ''therapeutic techniques'' that are aimed at improving psychological functioning.  

The model evolved from Behaviour Therapy and emphasises the triangular way in which an individual's [[Behaviour]] is influenced by patterns of [[Thinking]] (including your [[Implicit Core Beliefs]] about your self ([[Self-efficacy]]), the world, the future) and [[Feeling]].  
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There are many different techniques under the tab ''CBT techniques'' ([[CBT techniques]]) in the manual; note that many of these have been derived from work with adults and some therefore require adaptation for use with young people.  See [[Cognitive Behavioural work - CheckLists]] for a checklist to help structure your intervention.

This stands for [[Cognitive Behavioural]] Therapy, and is one of the most well-researched and well-evidenced approaches to helping people change.

There is a lot of information about CBT at [[Cognitive Behavioural]], which is one of the many [[Specific interventions]] included in this treatment manual.

!!CBT involves the use of a wide range or techniques
The key ones are listed below, in an approximate "running order", although this is something that must remain flexible and adaptive to the needs of the client:
*[[PsychoEducation]] - key early stage of CBT, orienting the client to the reasons behind the work they will be doing.
*[[Rating Scales]] - useful to include early on - changes in ratings are evidence for the client and therapist as "Co-experimenters"...
*[[Progressive Muscle Relaxation]] - a useful early engagement tool, allowing experimentation with [[Rating Scales]] and preparation for more challenging aspects of therapy.
*[[Re-breathing]] - a more physiologically-directed relaxation techniques for panics with hyperventilation.
*[[ABC Diary-keeping]] - useful in the assessment phase, helping to guide the keyworker in...
*[[Breaking down tasks into steps]] - useful at the planning stage in developing
*[[Graded Exposure]] programmes and other forms of...
*[[Behavioural activation]] - treatment by changing behaviours, that in themselves change mood and thinking...
* [[Thought Blocking]] addresses ways of taking more control of what thoughts to "run" and what thoughts to discard - useful if there are [[Obsessions|Obsessional compulsive disorder]] that are distressing or destabilising for the young person.
*[[Contingencies]] - refers to developing programmes that change the way in which a young person's surroundings may or may not offer [[Reinforcement]] to 'positive' (desired) behaviours and help to extinguish 'negative' ones.
*[[Problem solving]] - a structured and collaborative approach to solving problems.
*[[Weighing Pros and Cons]] - also known as a decisional balance - part of [[Problem solving]].
*[[Life practice]] - is the transporting of these techniques into real life situations
*[[Training Challenge]] - or "homework"...

!Special applications of CBT:

!!!1. Substance Use Disorders

[[CognitiveBehavioural for SUD-Rx]] - this is one of four key techniques of intervention deployed with substance use disorders (SUD).  See [[Substance use disorder - treatment]] and [[SUD-Rx Techniques]]

!!!2. Trauma

[[Trauma-focussed CBT]] is the most evidence-based approach and is recommended in the [[NICE Guidelines for PTSD]].

!!!3. Coping with Stress

[[The Coping With Stress Course - Gregory Clarke]] is an evidence-based [[CBT]]-based course, for which all the treatment manuals are freely available online.

!Clinical Global Assessment Scale
Use intermediary levels (e.g., 35, 58, 62).  Rate actual functioning regardless of treatment or prognosis.  The examples of behaviour provided are only illustrative and are not required for a particular rating.
!Record scores at...
[[Outcome measures (T1, initial)]] after inital assessment
[[Outcome measures (T2, 3 months)]]
[[Outcome measures (T3, treatment close)]] after end of treatment.
!100 - 91	
Superior functioning in all areas (at home, at school, and with peers); involved in a wide range of activities and has many interests (e.g., hobbies or participates in extra-curricular activities or belongs to an organised group, such as scouts, etc.); likeable, confident; "everyday" worries never get out of hand; doing well in school; no symptoms.
!90 - 81	
Good functioning in all areas, secure in family, school and with peers; there may be transient difficulties and everyday worries that occasionally get out of hand (e.g. mild anxiety associated with an important exam, occasional "blow-ups" with siblings, parents or peers).
!80 - 71
No more than slight impairment in functioning at home, at school, or with peers; some disturbance of behaviour or emotional distress may be present in response to life stresses (e.g. parental separations, deaths, birth of a sibling) but these are brief and interference with functioning is transient; such children are only minimally disturbing to others and are not considered deviant by those who know them.
!70 - 61
Some difficulty in single area but generally functioning pretty well (e.g. sporadic or isolated antisocial acts, such as occasionally playing hooky or petty theft: consistent minor difficulties with school work; mood changes of brief duration; fears and anxieties which do not lead to gross avoidance behaviour, self-doubts); has some meaningful interpersonal relationships; most people who do not know the child well would not consider him/her deviant but those who do not him/her well might express concern.
!60 - 51
Variable functioning with sporadic difficulties or symptoms in several but not all social areas; disturbance would be apparent to those who encounter the child in a dysfunctional setting or time but not to those who see the child in other settings.
!50 - 41
Moderate degree of interference in functioning in most social areas or severe impairment or functioning in one area, such as might result from, for example, suicidal preoccupations and ruminations, school refusal and other forms of anxiety, obsessive rituals, major conversion symptoms, frequent anxiety attacks, poor or inappropriate social skills, frequent episodes of aggressive or other anti-social behaviour with some preservation of meaningful social relations.
!40 - 31
Major impairment in functioning in several areas and unable to function in one of these areas, is, disturbed at home, at school, with peers, or in society at large, e.g. persistent aggression without clear instigation; markedly withdrawn and isolated behaviour due to either mood or thought disturbance, suicidal attempts with clear lethal intent; such children are likely to require special schooling and/or hospitalisation or withdrawal from school (but this is not a sufficient criterion for inclusion in this category).
!30 - 21
Unable to function in almost all areas e.g. stays at home, in ward, or in bed all day without taking part in social activities or severe impairment in reality testing or serious impairment in communication (e.g. sometimes incoherent or inappropriate).
!20 - 11
Needs considerable supervision to prevent hurting others and self (e.g. frequently violent, repeated suicide attempts) or to maintain personal hygiene or gross impairment in all forms of communication, e.g. severe abnormalities in verbal and gestural communication, marked social aloofness, stupor, etc.
!10 - 1
Needs constant supervision (24 hour care) due to severely aggressive or self-destructive behaviour or gross impairment in reality testing, communication, cognition, affect or personal hygiene.
!Record scores at...
[[Outcome measures (T1, initial)]] after inital assessment
[[Outcome measures (T2, 3 months)]]
[[Outcome measures (T3, treatment close)]].

*The  IMPROVEMENT scale for the [[Clinical Global Impression (CGI)]]
*To be done at treatment close (part of the [[Outcome measures (T3, treatment close)]])
!~CGI-I
The ~CGI-I is a seven point scale of the amount of improvement during or at the end of treatment. 
''@@color(red):1=Very much improved
2=Much improved
3=Mildly improved 
4=No improvement
5=Mildly worse
6=Moderately worse
7=Very much worse@@''

*The SEVERITY scale for the [[Clinical Global Impression (CGI)]]:
*To be done at:
** ''TREATMENT START'' ([[Outcome measures (T1, initial)]])
** ''3 MONTHS'' ([[Outcome measures (T2, 3 months)]])
**''TREATMENT CLOSE'' ([[Outcome measures (T3, treatment close)]]
!~CGI-S
The ~CGI-S is a seven point scale of the severity of the clinical problem;
''@@color(red):1=Normal 
2=Close to normal
3=Mild
4=Moderate
5=Quite severe
6=Severe
7=Very severe@@''

!!Recapping AMBIT training
This page gathers key exercises/learning you will have done in your [[AMBIT training|Information About AMBIT Training]] that relate to the quadrant of the [[AMBIT Wheel]] described as:

!!><<tag [[Working with your CLIENT]]>>

Note, there is plenty more to AMBIT than what is covered in your training, so feel free to browse further!

!!><<tag [[CLIENT exercises from AMBIT training]]>>

Centre for Social Justice, Youth Justice Working Group (2012) //Rules of Engagement: Changing the heart of youth justice// see page 101. (web-based pdf [[here|http://www.centreforsocialjustice.org.uk/UserStorage/pdf/Pdf%20reports/CSJ_Youth_Justice_Full_Report.pdf]])

See the CLARHC's website [[here|http://www.clahrc-cp.nihr.ac.uk/]], or embedded below:

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----
!!''Answer... Yes!''
There is a debate to be had about whether there is any such thing as "//doing AMBIT//".  

AMBIT is designed to be: 

''__A systematic way for local teams to develop their own "Treatment as Usual":__'' //Treating "Usual Care" with care//, as it were, that is integrated through a core theory, [[Mentalization]], (that has evidence in its support in a range of specialist settings), and which includes a range of already-evidence-based components of practice...The current applications of AMBIT are many, and varied, with local teams drawing on different elements of AMBIT and adapting them to suit their local needs.

Hence the AMBIT project authors prefer to speak of [[AMBIT-influenced]] teams, rather than "AMBIT teams".  We suspect that, barring a few exceptions where very robust measures are in place to ensure very high fidelity to a very closely defined model of practice, most teams delivering care to hard to reach young people deliver a practice that is //influenced// by a wide range of practices, some of which is more or less evidenced.  AMBIT seeks to move such practices from ''implicit'' to ''explicit'', and to stimulate [[Mentalization]] in teams to support thinking about and learning from questions such as 

//"Why do we work in ''that'' way with ''those'' kinds of problems? Under what circumstances might we work in ''this'' way?"// 

In other words, AMBIT places particular emphasis on supporting local teams to adopt the practices of a [[Learning organization|Developing learning organisations]] - in keeping with the AMBIT principle of [[Respect local practice and expertise]].

!!''Yes, but...''
#Evidence does exist to suggest that ''manualized'' practices get better results for their clients than ''eclectic'' approaches, that leave method and practices to chance.
# It is hard for teams to learn from their day to day experiences, and to hold on to, or develop, a strong sense of team identity if there is staff turnover and a high workload.  Recording our learning as a team in a systematic way is worth doing.
# There is sense in terms of the theory of [[Mentalization]] in taking a stance of being boldly "open source" in one's approach to [[Broadcasting Intentions]].
# The AMBIT project is currently gathering evidence about whether teams that do actively engage in [[Manualization]] demonstrate better outcomes than those that don't (because not all the teams that we train do actively engage with their wiki manuals).  
* We do not yet have robust evidence to answer this question.  
* However, our //hypothesis// is that manualizing has a positive impact on team functioning and outcomes.  
* Of course it may be that already well-functioning effective teams are the ones that have greater scope and motivation to manualize their work...  
* In that case, though, it might benefit other teams to examine what practices it is that they are manualizing!

See the ~MAC-UK website at http://www.cannabiseffects.org/ and their AMBIT manual at @ambit-mac

>//"Check out this animated video of lyrics and music written by three members of music and change about their personal experience of cannabis."//

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!In the UK Cannabis is a Class B drug
The government reclassified cannabis from Class C to Class B in January 2009. The decision was part of the drug strategy: //"Drugs: protecting families and communities"//  This information is adapted from government information availabel onthe web.
!!Why Class B?
Classing cannabis in Class B reflects the fact that skunk, a much stronger version of the drug, now dominates in the UK. Skunk has swept many less potent forms of cannabis off the market, and now accounts for more than 80% of cannabis available on our streets, compared to just 30% in 2002.
!!The classification of cannabis means:
* the government will robustly enforce laws on cannabis supply and possession
* police and other agencies will work to shut down cannabis farms and arrest the organised criminals who run them
* the consideration of additional aggravating sentencing factors for those caught supplying cannabis near schools 
!!Current penalties related to cannabis
!!!Penalties for supply, dealing, production and trafficking
The maximum penalty is 14 years imprisonment.
!!!Penalties for possession
The maximum penalty is five years imprisonment.
!!!Young people in possession of cannabis
A young person found to be in possession of cannabis will be arrested and taken to a police station where they can receive a reprimand, final warning or charge depending on the seriousness of the offence.

Following one reprimand, any further offence will lead to a final warning or charge. Any further offence following a warning will normally result in criminal charges. After a final warning, the young offender must be referred to a Youth Offending Team to arrange a rehabilitation programme.

!!!Adults in possession of cannabis
Anyone caught in possession of cannabis could be arrested.

Alternatively, police may:
* issue a warning (primarily for first-time offenders)
* issue a penalty notice for disorder, with an on-the-spot fine of £80

For the most appropriate of the [[Specific interventions]] in this manual, see the collection of material under: [[Substance use disorder - treatment]]

!Legal issues:

See [[Cannabis Legal issues]]
!PsychoEducation about Cannabis
See the great [[Cannabis Effects video by MAC-UK]] - a short video from the MAC-UK organisation (their AMBIT manual is at @ambit-mac) made by and for young people.

!Health concerns:

The most serious health concerns are:
*Increased risk of [[Psychosis]], especially in young people who have pre-existing vulnerability, i.e:
**A past history of a psychotic episode
**"Prodromal" symptoms
***Suspiciousness
***Paranoia, misinterpretations, occasional hallucinations
***Withdrawal, other 'odd' behaviours or experiences.
**A family history of psychosis
*[[Anxiety]], [[Panic Attacks]], and [[Depression]]
*Irritability, relating to paranoia, or poor Affect Regulation (when Cannabis is used as a means of avoiding the processing of emotions.)
*Dependency - for instance:
**Needing more cannabis to get the same effects
**Craving it when it is not available
**It becomes increasingly central in the young person's concerns/interests - other interests are dropped in its favour.
*Developmental and Educational failure
**Spending large proportions of ones youth intoxicated means there is less time or capacity to practice developing:
***Basic SocialSkills, 
***[[Affect Regulation]]
***Scholastic skills and academic qualifications (which is itself linked to poorer long term health outcomes)
*Long term risks of Cancer
**From the Tobacco it is usually smoked with
**Direct from the oily cannabis resin
*Helath risks from ADDITIVES
**Cannabis is not uncommonly "cut" with other substances that add weight to it, or give it the appearance of being more resinous than it really is - one substance used for this is GROUND GLASS - which adds weight to the cannabis leaves, and gives them a faintly glittery appearance that can look like cannabis resin.  When smoked the ground glass can be inhaled and lodge in the lung, with potential to cause inflammatory diseases rather similar to the ones that miners can develop (silicosis) or to be a focus for infection (pneumonia, etc).
*Addiction to OTHER drugs
**There is some evidence to suggest that Cannabis can act as a "gateway drug" - introducing the user to dealers and users who will in turn introduce them to harder drugs.  
**Alcohol and Nicotine are at least as potent as "gateway drugs" in this respect, BUT there is a risk that cannabis may be "cut" with other drugs (ampthetamines, crack cocaine, mephedrone, etc) as "loss-leaders" - so that the user comes back for more and learns about the magic "ingredient X".
!What to do?
See [[Substance use disorder - treatment]]

This is the curious interrogative stance adopted by the KeyWorker - part of [[The Therapist's Mentalizing Stance]], which refers to [[The Inquisitive Stance]], a state of not-knowing that stimulates questions. 

One way of keeping hold of this state-of-being-with is to think of one's questions as being modulated by ([[Holding the Balance]] between) two conscious wishes: 

* The wish to avoid causing harm or undue distress ('''Care''')
* The wish to facilitate positive change ('''Concern''').

[[Client Case Review - Date and Agenda]]
[[Client CASE REVIEW - CheckLists]]

!!Introduction

The techniques described below have been developed to improve the quality of Case Discussion in AMBIT.  In many respects there is (in common with most of Mentalization-based practice) little that is startlingly //new// about this; rather, the theory of [[Mentalization]] offers a framework for understanding how or why such practices might be effective.

The common thread that attaches these is the fact that [[Mentalization]] is reduced/prevented in situations where there is very significant //affect// present - particularly if this emotional context triggers the [[Attachment]] system into action.  This happens when a worker is "alone" with a case, or in a team meeting (the opposite of the [[Keyworker well-connected to wider team]].)

Both techniques given below are designed to create a well-demarcated "safe zone" around an stressful situation, to allow the kind of imaginative activity (which includes Mentalizing) required for thinking out a therapeutic course of action, whilst maintaining the structure to ensure that basic safety requirements are maintained.

!!Techniques/Skills in case Discussion

[[Thinking Together]] - points at how to set up a discussion that allows the right information to be shared and then thought about... This can structure a 1:1 conversation, but also a whole team cae discussion.

[[Passed-outwards Discussion]] or [[POD|Passed-outwards Discussion]] - the Keyworker arranges for information that s/he has passed down to a colleague to be 'passed down' again in his/her presence.

!Reference:
Cecchin, G. (1987). Hypothesising, circularity and neutrality revisited: an invitation to curiosity. Family Process, 26, 405-413.
!Abstract
This essay examines the systemic guiding principles of neutrality, hypothesizing, and circularity, historically developed by the Milan Team of Selvini-Palazzoli, Boscolo, Cecchin, and Prata (12, 13). With the reorganization of these team members (see 11 for a summary of the distinctions between the work of the Selvini-Palazzoli and Prata research team and the Cecchin and Boscolo training team), different reconstructions of the original systemic principles have evolved. New understanding of the concepts of circularity, hypothesizing, and neutrality are now possible, given the systemic epistemology on which the early Milan model was based. It should be emphasized, however, that the ideas presented in this essay are most associated with the systemic work of the Cecchin and Boscolo team

When working in therapeutic relationships with our clients, in particular, when managing risky clients', workers can at times feel out of balance. 

There can be a tension between working to develop and strengthen relationships (attuning to the client and their network), with the need to challenge our clients, and at times adopt clear risk management procedures. This can be a complicated balance to negotiate in face to face work. 

Closely related to this balance, is the notion that many teachers and therapists describe the difficulty of knowing when to challege and when to offer support in bringing about therapeutic changes with clients (Sanford, 1966). 

In thinking about this balance, we suggest that it is helpful to see the process as finding a pathway balancing between:


* ''CONTAINMENT'' (nurturance, safety, responsivity, sensitive attunement)

and 

* ''CHALLENGE'' (promotion of concrete changes, termination of non-mentalized [[Pretend mode]] patterns of behaviour, etc).

The important point is to avoid an overly rigid position, but to maintain a thoughtful ([[Mentalizing]]) journey towards change.

Please see below for a brief explanation of this balance adapted from Sanford (1996).

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Too much focus on containment and attunement to the client without any introduction of new perspectives, differences or challenge may be seen as falling within the 'fan club position'. Whilst overly adopting a position of challenge and introducing differences to the client might be experienced as being a 'persecutor'. 

Rather than avoiding either of these (an 'abdicator role') we would want to find a balance between these two points. In the journey towards creating an effective therapeutic relationship there are likely to be times when the workers' estimations about the right level of challenge  turn out to be wrong. At these times the client may experience being pushed too hard or being misunderstood. The worker acknowledging this and taking responsibility for these episodes, showing genuine motivation to understand better for next time is critical in the process of continuing towards change. 

The above theory is adapted from N. Sanford, Self and Society: Social change and individual development, 1996.


For further material on this, see the dynamic balances involved in [[Active Planning]], and [[The Therapist's Mentalizing Stance]].

!Intro
A legitimate (but we argue wrong) question is [[Isn't mentalizing just being supportive?]] This page is about offering //Challenge// alongside the //Support// that good mentalizing delivers - all while [[Holding the Balance]] between them.
!Background
Over time, individuals, couples and families all develop their own way of seeing things, or of constructing their own "scripts".  

In a sense, these are examples of a [[Pretend mode]] style of thinking - where the obvious ("Elephant in the room") is (perhaps temporarily, perhaps over years) overlooked... to allow a "make-believe" situation to continue.  Now, whereas in childhood this often makes good sense (much good learning about social roles, etc, is achieved through playful exploration), in other situations (if unbalanced) the pretend mode can prevent any meaningful change from happening.

In therapeutic encounters, there are more than likely issues that, whilst it is understandable that they are avoided, really //need to be looked at, thought about, and acted upon// in order to change things for the better. Ultimately, the worker in these situations needs to find a way for material to be introduced //in a way that allows the possibility of change to arise.//  

This gets to the heart of what we refer to as [[Holding the Balance]] in the [[The Therapist's Mentalizing Stance]] - here ''the balance is between CHALLENGE on the one hand, and SUPPORT on the other'':

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!How to challenge:
Fixed belief systems and/or behaviours can (indeed must, ultimately) be challenged by the keyworker, so as to facilitate the emergence of new viewpoints or interactions. Generally the keyworker will proceed in the following way (this is really a restatement of what we call the "[[Mentalizing Loop]]":

!!!Noticing
The KW punctuates a particular sequence of the family or individual's interaction/process in the session 
>"I notice that X happens..."
This is a version of the [[Therapist's use of Self]] - deliberately referring MY experience, without assuming that my perspective is the "right" viewpoint, but nonetheless, highlighting it as something that is new and un-contestable (if this is //my// experience, then this is what it is! - whether or not it is 'accurate', or 'equivalent' to the experiences of others.)

!!!Checking
The keyworker then questions his perception 
>//"I am not sure that you would see it the same way...perhaps I am wrong to see it that way?..."//

!!!Correcting
The keyworker takes the young person's or family's feedback into account and might then asks (each/that) person how //they// see that particular interaction
>//"What do you make of this...how do you see it?"//

!!!Naming
Once different family members have themselves identified a particular interactional sequence and given their own "frame" to it, the KW will use a variety of different challenging techniques:

!(a) Unbalancing
A technique used to deliberately disequilibrate the family organization, by temporarily joining and supporting one individual at the (apparent) "expense" of another, by enhancing her view, commiserating with her predicament etc. 
//"I notice that every time you talk your husband stops you or says things that I think may put you down. Perhaps I'm wrong. Is that the way you see it? Is that the way you want it? So, if you don't - how is it that you allow your husband to put you down all the time? What would happen if you stopped him next time that happened?" //

//"How did you get your mother to answer that question?! Do you want your mother to answer for you? Your mother seems to know you inside out- is that a good thing? Who else does she know so well? How did you get your father to do this? If your father got it wrong - how would I know? Who trained/coached your father to be so careful/diplomatic/respectful? Is he always upset about upsetting the balance? What would be the dreadful thing that could happen if s/he was less careful?"//

!(b) Intensification
This is a technique, to be used carefully, and generally only after discussion with your SupervisoryStructures, which involves "turning the heat on" - //increasing the affective component of a transaction//, by increasing the time in which two or more people are involved in such a transaction (see enactment), or frequent repetition of the same message, or by physically or emotionally altering the distance between different family members. 
//"I can see that you want to give up now...what would happen if you didn't, if you kept going, even if things become uncomfortable?"

"Do you think it might be useful to keep going -so if you think that, why don't you keep it going?"//

!(c) Testing boundaries 
This is a way of challenging each individual's and the family's perceived lack or abundance of private space, their way of allowing differentness to emerge, their ability to be close, their mutual emotional responsiveness, their way of making decisions and use of hierarchies. 

//"How is it that you allow his mother to dictate how you conduct your marriage? Is he married to his mother or to you?"//

!(d) Disrupting: 
If a family member "specializes" in monologues or prolonged episodes of depressive venting, then the KeyWorker may challenge this, initially by inviting the partner to join in: 

//"How do you respond to this?" ”What is your view on this?"//

!...(e) and Apologising
See the video above.  These challenging techniques are important, but the worker who holds [[The Therapist's Mentalizing Stance]] will be ready to acknowledge his or her //not-knowing// about quite what the correct balance between support and challenge is for this client, here, now... and to be transparent in acknowledging if they have got this wrong.
>//"It wasn't my intention to challenge you too hard, and I'm sorry I've upset you by doing this.  What can we - __what should I?__ - learn from understanding how I came to believe that pushing you in that way was likely to be helpful?"// 

<a class="tc-float-right">[img width="150" [cs.PNG]]</a>

!!!AMBIT Trainer
Charlie is an AMBIT Trainer based in Wandsworth, London. 

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This tag gathers together a collection of checklists for the KeyWorker to use to ensure that specific pieces of work are organised and important things are not missed.

See the Related Information for sub-topics that have checklists...

Checking is a key component of the [[Mentalizing Loop]] and one of a range of helpful [[Engagement techniques]]).

It is important to ''check'' whether the KW has understood what people are saying (e.g. "let me just check with you that I've got this right...") Thus repetition, in slightly changed language, offers confirmation of being understood, emphasises what has been said by repetition, and offers the opportunity to begin to frame the family's presentation somewhat differently (e.g. "he always deliberately tries to hurt me..." to "when it feels to you as if he is trying to hurt you deliberately ..."). Very often the change would be to add a mentalizing stance, i.e. to recognise that the behaviour of self and others is mediated by mental states.

!//Checking// is a powerful enactment 

Checking is an enactment of the [[The Therapist's Mentalizing Stance]], modelling respectful curiosity, expressed tentatively, about mental states.  It models the 'not-knowing' that comes with a belief that our mental states are interesting, useful to understand accurately, but also //opaque to// each other.

It is also a helpful example of one of many [[Engagement techniques]] described in this manual.

!//Checking// the Links

Accurate mentalizing increases the narrative coherence of an event, and reinforces the assumption that our understanding of behaviours is improved when they are perceived as being embedded within (and to some extent contingent upon) a wider context, including repetitive historical patterns.  Linking an observed interaction, such as a momentary loss of mentalizing in a family, with previous accounts or reports of problems is an important beginning of the task to [[Generalize (and Consider Change)]].

!//Checking// as confirming the limits of our 'mind-reading'.

Checking understandings also powerfully affirms the mentalizing notion that //we do not have privileged access to the contents of each other's minds// (mentalizing is never the same as mind-reading).  It is an enactment of the [[The Therapist's Mentalizing Stance]] which offers a //tentative// stance, that is inquisitive about other people's mental states.

!//Checking// as affirming of the value of mentalizing.

Implicit in our checking understandings and feelings is that //we affirm the importance of understanding other peoples' mental states.//  This is an enactment of the [[The Therapist's Mentalizing Stance]] which constantly affirms the value and signficance of mentalizing.

!//Checking// at the end of the loop

By the end of a session it is important to conclude a therapeutic sequence by getting each family members to view what happened from a meta-perspective. This is, in effect [[Mentalizing the Affect]].

This helps to evaluate what may have been a new and emotionally charged experience, giving them the opportunity to reflect together about what happened and the possible consequences:

>//“What did you make of what happened? Can you talk together about what this was like for each and all of you? Are there any conclusions you can draw from this?”//

''__Child Protection or more general SAFEGUARDING concerns "trump" all others__''.  First, decide if you need to to take action (see "What to do if you are concerned" just below.)  Then, underneath that you will see more guidance and information to help you think through and plan your responses in more detail.

!If you are concerned right now:

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If there are Child Protection Concerns then you must consider making a [[Child Protection Referral]], and you will want immediate contact with your SupervisoryStructures to discuss this.

!Background

See this external link to [[Working Together to Safeguard Children|https://www.education.gov.uk/publications/eOrderingDownload/00305-2010DOM-EN-v3.pdf]] - the UK government's guidance on this whole area, which particularly emphasises the need for good inter-agency practice (see [[Addressing Dis-integration]] which is one of the [[Core Features of AMBIT]]).



Child Protection relates to the notion of "[[Significant harm]]": if there is a risk of significant harm to any child (note, not just your own client/patient) then as a professional you are OBLIGATED to take action.

Clearly this is an area that  dominates one of the [[core AMBIT stance|Core Features of AMBIT]] elements, which is [[Managing Risk]] - often seen as the more active/interventionist/paternalistic "partner" of the other principle that [[Working with your CLIENT]] is guided by, [[Scaffolding existing relationships]].  Sometimes, in our enthusiasm to //engage// with the world and relationships that our clients live in - and to scaffold these in ways that are as ''strengths-focused'' as possible, we can find ourselves drawn unintentionally into ignoring, or decreasing the priority that should be given to the very real risks that exist.  This, we argue, is at the heart of the many dilemmas that field working practitioners negotiate constantly in their work.

!For Local Adaptation:
See [[Child Protection]] for more info on this area (which will need adaptation by local teams to reflect local practices).

This [[page|Tiddler]] is for local teams to add details of local CP/Safeguarding services, including contact details.

!Supporting Other Models of Practice
If existing Safeguarding practices are already in place it is absolutely crucial that AMBIT is not seen, or used, as a "rival model" - this would be a serious mis-use of AMBIT, and seriously non-mentalizing.  It would also directly contradict one of the [[Core Features of AMBIT]] which is the stance principle that workers must [[Respect local practice and expertise]].
!!!An example: Signs of Safety
For instance, an allied area of practice that is quite widely used in this area, and which we think AMBIT has a particularly good "fit" with, is the [[Signs of Safety]] program, which originated in Australia but has traveled internationally.  Where this program is already implemented in an area it would be entirely in keeping with AMBIT that it should seek to [[scaffold the existing relationships|Scaffolding existing relationships]] that this prior training will have established ''AND NOT TO UNDERMINE THEM!'' In this case, the material under [[Managing Risk]] would be dominated by existing [[Signs of Safety]] practice and procedures and AMBIT would seek to enrich and augment the culture that this program helps to define.

* Children or young people who are looked after away from their family of origin are known to be at significantly higher risk of substance use disorders.  
* The statutory medical assessments that the Local Authorities with responsibility for such children are obliged to arrange offer a valuable opportunity for screening.
* Without the consistency and permanency that placement in a family setting offers, efforts to develop a sensitive, well-informed, watchful and protective “eco-system” around a young person are considerably more challenging.  
** Early identification of key caring figures acknowledged in the young person’s mind is of value (ideally these may be the allocated social worker or keyworker, but they may be workers with less explicit responsibilities towards the young person, or less formal training, such as another care worker in a shared home, or a local youth worker).   
** Liaison between these figures and other experts (for instance members of the young person’s substance use service) may offer an additional ‘portal’ through whom education and therapy can be delivered; crucially, this liaison may ensure that such figures remain “on message” with more specialised work as it gets under way.

* The risk of substance use in children is greatly increased if there is a history of parental substance use.  
* Engaging the parents in their own treatment is an effective intervention for children, both in terms of prevention and treatment of the child’s own substance use.  
** Some local adult services will have facilities for family therapy, others will not.  
** Young person’s substance use services should all provide family-based interventions, and the worker may have an important role to play in ensuring or insisting that these services integrate their work around the needs of the child.  

* Safeguarding issues ([[Child Protection]]) will be central in planning care, in respect of potential parental neglect, or the emotional abuse implicit in exposing children to their own intoxication.  Early liaison with the Local Authority in this respect is advised.

* Children with complex mental health needs, who may have suffered abuse, neglect or trauma, and who may have conduct disorders, or other emerging personality disorders (particularly with difficulties in the arena of affect-regulation) are also at higher risk than the general population.  

* Risks may be associated with:
** ''Extrinsic factors'' such as the tendency to mix with other substance-using peers so as to have substances easily available to them, or:
** ''Intrinsic factors'' such as the use of substances to “treat” distressing states of mind (such as depression or anxiety), or a “sensation-seeking” temperament.  
* Identification of these risk factors in an individual, being able to reflect sensitively upon this in understandable language with that young person, and to formulate simple plans with them to address their own specific vulnerabilities, has been shown to be an effective early intervention (Conrod et al.)
* Conduct disorders have an especially high risk of co-occurrence with substance use disorders, and this should be borne in mind during assessment.  
* The treatment of affective or psychotic disorders should not be delayed if there is co-occurring substance use disorder, not least because these conditions are often reciprocally synergistic in their effects upon each other.  
* Psychological approaches should be the mainstay of most treatment plans.  
** Prescribing in such conditions is more difficult (and should normally be assessed and initiated by specialists), but is certainly not an absolute contraindication.  
** Prescribing may, in addition to any intrinsic effectiveness, offer routes to engagement in treatment for a young person whose attitude to the mental world is highly materialistic (“a pill [or other substance] for every ill”.)  
** Measures to ensure that prescribed medication is carefully tended, and is not available to be misused by the young person, usually require the presence of a responsible adult.  
** Avoiding prescribing large amounts of any medication at one time is a sensible precaution.

!ADHD 

* Children with ADHD tend to score more highly on measures of sensation-seeking, and are at higher risk of later conduct disorder and substance use disorders.  
** Large treatment studies have shown that the risk of later substance use disorders is significantly reduced by effective treatment of ADHD, and that this outweighs the putative risks associated with introducing vulnerable youth to stimulant drugs.  
** However, it should be borne in mind that the stimulant medication (mostly methylphenidate in the UK) used most commonly is still a controlled drug, and has its own “street value” so that active parental support and involvement is essential.  
** Long acting (modified release) preparations of stimulants tend to reduce the risk of misuse, and non-stimulant treatments (such as Atomoxetine) are also available. 

!Online
http://www.ncbi.nlm.nih.gov/pubmed/18676591 - abstract
http://mentalizacion.com.ar/images/notas/Mentalization%20Ontogeny,%20Assessment,%20and%20Application%20.pdf
!Reference
Am J Psychiatry. 2008 Sep;165(9):1127-35. doi: 10.1176/appi.ajp.2008.07081360. Epub 2008 Aug 1.
Mentalization: ontogeny, assessment, and application in the treatment of borderline personality disorder.
Choi-Kain LW, Gunderson JG.

!Abstract
This article aims to review the development of the concept of mentalization, its applications in the understanding and treatment of borderline personality disorder, and the issue of its assessment. While conceptually derivative of theory of mind, Fonagy's concept of mentalization concerns more affectively and interpersonally complex understandings of oneself and others, reflecting abilities that enable an individual not only to navigate the social world effectively but also to develop an enriched, stable sense of self. The components of mentalization can be organized around self-/other-oriented, implicit/explicit, and cognitive/affective dimensions. Concepts of mindfulness, psychological mindedness, empathy, and affect consciousness are shown to partially overlap with mentalization within these three dimensions. Mentalization is assessed by the measure of reflective function, a scale to be used adjunctively on semistructured narrative interviews such as the Adult Attachment Interview. Its validity has not been fully tested, and its usage has been hampered by the time and expense it requires. Although the concept of mentalization is a useful heuristic that enables clinicians to adopt a coherent treatment approach, it may be too broad and multifaceted to be operationalized as a marker for specific forms of psychopathology such as borderline personality disorder. Research elucidating the relationship between reflective function, overlapping concepts, and features of borderline psychopathology is needed

{{what to measure pic (2).jpg}}

!!How do we figure out which aspects of our work to measure?

When we are finding out about the impact of our work, it can be tricky to decide on exactly what to measure...

What individual workers and services choose to measure will depend on a number of factors, including: their client group, the overall goals of the service, the time frames they work within, the approach or model that the service uses.

!!!Below are three different areas of our work that we can measure to help us learn about the impact of what we do. 

!!1. The experience that people have of using the service 

What was it like to use the service? What worked well ? What could be different or improved...?

The purpose is that [[Service User Feedback]] has a direct impact on the way the service works. Client feedback allows continual adjustments to be made over time, making the service more acceptable and helpful to those who use it.

The Experience of Service Questionnaire (CHI-ESQ) is one frequently used measure to evaluate feedback on using a service. There are different versions available for different age-groups and parents.  Access this via the [[CORC website|http://www.corc.uk.net/]] or directly [[here|http://www.corc.uk.net/resources/measures/]]


!!!Session Rating Scales 
These allow workers to take direct feedback on how a session or meeting has gone. They are usually used after a session, breaking it down into areas such as  'how much did we talk about the important things?', 'How well did I listen to you?' The aim is to promote work on the therapeutic relationship and create opportunities to adapt  the work based on 'in the moment' feedback.

You can find further explanation and information on the CORC website [[here|https://www.corc.uk.net/outcome-experience-measures/session-rating-scale/]]

!!2. Measuring progress or change in our clients

These measures are ways of tracking whether things are improving in the lives of the clients that we see.....

''But what does 'improving' actually mean ???''

Of course, what this means depends a great deal on the person, how they experience things, and on the context...

Recent research and client feedback tells us that clients' own perspectives on what is important to change should take a central place when we are evaluating the impact of our work (for more on this please see the [[AIM cards|AIM Cards]] and [[Goal Based Outcomes below|Goals-based outcome measures]]). 

The following outcome measures are used for tracking whether things are changing for our clients. 

Some measures do this by looking at ''overall functioning'' across multiple areas of life , whilst others focus on more ''specific symptoms'' or problems. 

Some measures have versions which gather perspectives of different people (e.g. client, family, teachers version).


!!!Measures of overall functioning across a clients' life

*The [[AIM]]- The AMBIT Integrative Measure

This is a questionnaire completed by workers. It gives a detailed picture of a clients' overall functioning  (a multi- domain assessment) measuring a 'holistic' picture of their life. The worker gives a rating from 0-4 on a number of areas, including a clients' mental health, social relationships, family relationships, education and work. It allows strengths to be identified as well as a focus on specific key problems.
The 'key problems' allows workers and clients to identify specific goals together that can form the basis of interventions.

There is a protocol for using the AIM currently under development. Find this here at[[ AMBIT Client Impact Project|AMBIT Client Impact Project (ACIP)]], which is a collaboration of teams working to establish a framework for outcome measurement across AMBIT influenced services.

*The [[AIM Cards|AIM Cards]] - These are an AMBIT tool used directly with clients to help build a relationship and develop a shared understanding of the clients' strengths and difficulties across their life. They link directly to the [[AIM]]. They can be used as a measure of change with clients and can form joint goals to guide the intervention work

* [[CGAS]] - the Clinical Global Assessment Scale (a worker rated scale where a single score is used to describe the overall level of client function)
*[[Global Assessment of Function (GAF)|Global Assessment of Function (GAF)]] (a worker rated scale measuring the degree to which mental health symptoms effect a clients' life)
*[[HoNOSCA]] - Health of the Nation Outcome Scales for Children and Adolescents (a worker and parent questionnaire to measure aspects of client functioning across their life)


!!!Measures of Specific Symptoms

*[[Beck Youth Inventories (BYI) |Beck Youth Inventories (BYI)]](a questionnaire for young people measuring a range of mental health symptoms)
*[[Beck Depression Inventory (BDI)|Beck Depression Inventory (BDI)]](questionnaire for adults measuring symptoms of depression)
* [[SDQ|Strengths and Difficulties Questionnaire (SDQ)]] - the Strengths and Difficulties Questionnaire (Young person, teacher and parent versions measuring mental health symptoms)
* [[Clinical Global Impression (CGI)]] (a worker rated scale for adults and children measuring severity of symptoms and change in these)
* [[TOP - Drug and Alcohol Outcomes]] - The Treatment Outcome Profile (a brief interview and rating scale for workers to use with their clients)


!!!Measures of attachment

*[[IPPA-R (The Inventory of Parent and Peer Attachment—Revised)|IPPA-R (The Inventory of Parent and Peer Attachment—Revised)]] (a questionnaire for clients measuring the quality of relationships with parents/carers)

!!!Measures of Family Function

*[[SCORE 15 Family Functioning|Score 15 - Family functioning]] (a questionnaire for family members to complete measuring aspects of family relationships)

''For further information the
CORC (Child Outcomes Research Consortium - website ''[[here|http://www.corc.uk.net/]] has a very good overview of different measures that can be used to track aspects of client function/problems and family function. It also includes explanation around how to use the measures  and their [[psychometric properties|Psychometrics and Psychometric Tests]].



[[Goal-Based Outcomes|Goals-based outcome measures]] These cover the way in which we set specific goals together with clients based on our clients' perspective of what is  most significant to them e.g. 'what is most important for you to work on in life right now?' We use a scale to measure these together. The goals then guide what we do, and we refer back to them to track how we are doing in our journey towards them. The key is that they are simple, practical and meaningful for our client. The CORC website has a great explanation of what they are and how to use them [[CORC Goal Based Outcomes|https://www.corc.uk.net/outcome-experience-measures/goal-based-outcomes/#:~:targetText=Goal%20Based%20Outcomes,the%20beginning%20of%20an%20intervention.]]


!!3. Overall Service Goals

*These will be the specific priorities of the service. They will usually include the reason or rationale for the service being developed and commissioned in the first place. 
For example:

//A team commissioned to support young people who are placed in foster care may be particularly interested in the number of foster placements which break down or are maintained over a given period as one way of evaluating their impact. Measuring this would allow them to evaluate the impact of their service on this area, by exploring changes over time //

*Measuring these kinds of service goals is often crucial for evaluating the impact of the service and highlighting the value of a service in relation to an identified need

*It means finding simple ways to record the specific information related to the service goal  over time


''This video shows Dr Sarah Harman from Bexley CAMHS talking at an AMBIT conference about the use of outcome measures to evaluate the impact of her service in relation to reducing in-patient admissions''

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*Please see here to learn about [[Measuring the Impact of AMBIT Training]] on your service





*If you would like to explore other outcome measures which are under development by AMBIT influenced teams please see  [[AMBIT Measures under development|AMBIT Measures Under Development]]

*Also, see here for examples of the [[measures used by some AMBIT influenced teams|Measures used by AMBIT Teams]] who attended an AMBIT outcomes day in 2018 

!Identifying and Selecting the Common Elements of Evidence Based Interventions: A Distillation and Matching Model

Bruce F. Chorpita, Eric L. Daleiden, and John R.Weisz

Mental Health Services Research, Vol. 7, No. 1, March 2005 ( C 2005) DOI: 10.1007/s11020-005-1962-6

A model is proposed whereby the intervention literature can be empirically factored or distilled
to derive profiles from evidence-based approaches. The profiles can then be matched
to individual clients based on consideration of their target problems, as well as demographic
and contextual factors. Application of the model is illustrated by an analysis of the youth
treatment literature. Benefits of the model include its potential to facilitate improved understanding
of similarities and differences among treatments, to guide treatment selection and
matching to clients, to address gaps in the literature, and to point to possibilities for new
interventions based on the current research base.

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The theory on which this technique is based is one of circular causality: there is an assumption that human behaviour can best be understood from a point of view that regards actions as both responses to other actions and the triggers for further actions. 

While it is possible to describe behaviour so as to show a ''linear connection'' between cause and effect:
>//"She is ‘mad’ because this is the only way she can show her anger towards her parents"//
...a ''circular construction'' is less likely to lead to ideas of blame, and more likely to enable families to alter their interactions and belief systems:
>//"Regardless of who ‘first’ had the problem, even if it were possible to establish that, the whole family can be seen as caught in a circular loop whereby symptomatic behaviours lead to carers’ responses, such as high levels of criticism, that in turn reinforce those same symptoms, which in turn lead to more critical responses on the carers’ part, and so on..."//
!!How to do circular interviewing:
The practice of interviewing follows a circular (or spiralling) pattern, where the feedback to the KW's question will influence and shape the KW's next question, and so on. 

This is a purposive and responsive interviewing style: ''Purposive''... because the KW is central as the primary asker of questions. Yet ''responsive'' to feedback and openings offered by the various family members. 

In this way both KW and family together can construct a new understanding of the situation. Circular interviewing involves a ''particular interest in questions of difference'', since it is through the perception of difference that we construct new information, and different perceptions of self and others become possible. 

There are a variety of questioning techniques which make it possible for KW and family to explore issues of difference and the definition of relationships, such as:

!!Comparison questions
//"Were you closer before or after he became psychotic?"//
!!Ranking questions
//Who would be most surprised if she stopped being low and withdrawn?" "...Who the second-most?" etc//
!!Triadic questions
One person is asked to comment on the relationship between the two others, e.g. //"When her father got ill, did your mother become closer to her father or more distant?"// The answer to questions such as these will stimulate further exploration, e.g. by asking another family members to comment on the answer of the first one, and then exploring differences or similarities in their perceptions of relationships and events etc. 

By participating in such an interview the family members perceive themselves through the eyes of the other; not only may they hear other people's views differently, but also their own views, expressed in this context, may look different to them. The links between this style of questioning and [[Mentalization]] are obvious.  

Thus for the KW and the family, their interest and curiosity about one another remains stimulated, and changed perceptions of actions or relationships may lead to new and different behaviours and relationships, as well as a re-examination of belief systems which had to date been held with firm conviction.
!!Hypothetical questions
A special sub-category of this style of questioning is known as hypothetical questions. These are particularly useful when individuals or couples are locked in a rigid stance of blaming about who is "at fault" or "ill" and who is not. In the face of such a stuck interactional pattern the KW can proceed via an "as-if" stance, which makes it possible to consider change in fantasy, even if it does not - yet - seem possible in reality. 
These are a particular form of hypothetical questions, where couples are invited to project current relationship patterns and problems into the future, and consider the effects of such lack of change on their future lives:

//"So if you continue to argue in this way about James coming home late for the next week, do you see anything changing? ...What about for the next couple of months?  for the next 2 years?..."//

!Aim of circular questioning
The effect of circular questioning is to invite the family's curiosity about the history, context and pattern of their unsatisfactory interactions, which includes any psychiatric disorder and associated symptoms. Just as the KW gains an understanding of how these interactions fit together to result in a relationship pattern which is stressful to the family, so the aim is to help the family members themselves see their situation differently, make new connections, and see new opportunities for change and flexibility. 

Another effect of circular interviewing is to disrupt and perturb set patterns of thinking and action, functioning as an intensive but contained challenge to the family's previously held views. Thus while overtly it may seem less challenging than some more directive techniques (see under Challenging techniques), it tends to have similar effects, namely of altering set balances in relationships by interrupting habitual patterns.

We gratefully acknowledge funding from the [[City Bridge Trust|http://www.citybridgetrust.org.uk/CBT/]], that has funded AMBIT training and evaluation in [[Kids Company|http://www.kidsco.org.uk/]], and some of the early development of this TiddlyManual.

The Case Review is an important way of keeping track of progress in working with a client. 

!Preparing for the Case Review
[_] Check the [[Client Case Review - Date and Agenda]]
>[_] Liaise with the young person and family - are there any comments/feedback/questions that need adding?
>//"Are there any questions that you need answered, or other things we should cover in that meeting - so that if we DIDN'T cover them, you might think this meeting had been a waste of your time?"//
[_] Check invitations have been sent to family members, the young person, and any relevant ProfessionalNetworkMembers.
[_] Check that a room has been booked for the meeting.
!Conducting the meeting
[_] Introductions/Welcomes
[_] Review the [[Formulation and Treatment Aims]] 
[_] Review the RiskAssessment 
[_] Review the [[Care Plan]]
[_] Review the [[AIM]]
[_] Any other business?
[_] Set a new date to meet, and record this in the next [[Client Case Review - Date and Agenda]] along with any new items to add to the agenda.
!After the meeting
[_] Circulate a record of the meeting to the:
>[_] Young person/carer
>[_] Relevant ProfessionalNetworkMembers (GP? local CAMHS? Youth Offending? Probation? etc)

!Keep a diary date booked for each young person's next review.
!Who are they for, and when should they happen?
We recommend that any young person who is seen regularly for more than one month should have a review, between one and three months after starting treatment.
!Who attends?
*The young person and family should be invited, but they may choose not to be there.
*The Keyworker must be there
*Ideally an AMBIT colleague will accompany the keyworker, specifically to help model [[Thinking Together]] in the meeting.
*Other key parts of the care network as appropriate
!Why do Reviews?
*Take a 'long distance' view of the progression of a piece of work - what is working, what is not? 
*Remind the network, especially the informal/family/social network, that the work of the team is time-limited.
*Check that what we are doing is consistent with the AMBIT approach
*Consider how a successful intervention might look:
>//"How would we know when the work we are doing together had achieved enough?"//
There may be a requirement to reduce unrealistic expectations.  Mindfulness of the //effect// that such conversation may have on a young person is absolutely key in these settings, to avoid stirring up anxiety or other reactions:
>//"They are going to abandon me..."//
>//"They want rid of me, like everyone else..."//
>//"What, you think I'll stay THAT long with you?  Think again!"//
!!Tasks and Agenda
#Introductions - does everybdoy know each other?
#Use [[Thinking Together]] to frame the meeting (start with [[Marking the Task]])
With the Young person, and any available network (family, professionals, etc), check the RiskAssessment, the [[Formulation and Treatment Aims]], and the [[Care Plan]] are still up to date and relevant:
#Record who is present and record apologies for those prevented.
#Summarise situation and progress
##Use the [[AMBIT Practice Audit Tool (APrAT)]] to assess whether we are on track in offering AMBIT.
#Current key problems (review the [[AIM]])
#Review the [[Care Plan]] - and if required make a new one via [[Make or View Client Notes]]
#Set a new date for the next review and record it above.
#Any other business.
!!Recording
Use [[Make or View Client Notes]] to record this clinical contact.

!!Work in progress
This is a new development, and has not yet been field-tested.  Feedback is very welcome to the AMBIT project at the [[Anna Freud National Centre for Children and Families]].

!!The Client’s Wheel: parallel processes

!!!A matched (segment-for-segment) version of the AMBIT Wheel
The client's version of the wheel is designed as a "mirror image" - to be stuck on the back of the worker's standard version of the [[AMBIT Wheel]] in order to create a double-sided wheel, in which each segment relates to a parallel process on the other side.
<<image [[ClientWheelDoubleSided]] width:480 height:600>>
<<image [[ClientWheelsingle]] width:600 height:480>>
The client’s version of the wheel simply emphasises the parallel processes that worker and client must be engaged in if help is to become helpful and sustainable.  The two wheels can be printed in ‘mirror image’ on opposite sides of a single card, so that the paired and equivalent sections form ‘two sides of the same coin’.

!!Working with Help
* Before anything useful can occur, the client first needs to engage in a helping relationship (the __''Working with Help''__ quadrant parallels [[Working with your TEAM]] for the worker) 
* Where the //worker’s// stance is directed at the formation of an [[individual keyworker relationship|KeyWorker]]... 
* ...in reciprocation, the //client’s// first "task" is __''Trusting Help''__.  This goes to the heart of the theory of [[Epistemic Trust]], which if established in that worker, allows [[Engagement]].
* While the //worker// counteracts the risks associated with forming such intense keyworking relationships by placing equal emphasis on the requirement for a [[Keyworker well-connected to wider team]] (who help them to keep their balance in this work)...
*...so in turn, the //client// may hope to increase the extent to which they are __''Understanding Help''__.  Being able to witness the [[helping relationships|Relationship to help]] (with colleagues) that are modelled by their keyworker offers opportunities to understand the nature of the help that is on offer: for instance, understanding that their worker is not an omnipotent lone ranger, that there are responsible layers of supervision, that receiving help - as their worker obviously and explicitly does from their team-mates - is less a sign of weakness or failure, and more one of professionalism, adulthood or mastery.

!!Making help work
* The client's __''Making help work''__ quadrant parallels [[Working with your NETWORKS]] for the worker 
* The //worker’s// efforts to ensure that efforts towards helping are directed at [[Working in multiple domains]] (individual, family, education/employment, peers, etc) are echoed by an invitation... 
*...for the //client// to collaborate to ensure that the work is __''Covering all my needs''__: there is an emphasis on the expertise of the client here, in the sense that appropriate [[Assessment]] requires their help so that any help offered is actually helping with the things that matter. 
* As a rich multi-domain and multi-modal package of interventions is developed, almost inevitably involving other workers and other agencies, the client witnesses the efforts of their //worker// in [[Taking Responsibility for integration]] wherever they have influence in these workstreams. 
* In turn, the //client// witnesses and is ultimately invited to shares or take responsibility for the work of __''Balancing and organising help''__; managing the various forms of help that they are receiving, which will include making sense of ([[Mentalizing]]) the actions of the different players, and if necessary - helped by their worker - helping the different players to make sense of and accommodate each other’s roles. 

!!Working with myself
*With the foundations for ‘help that is likely to be helpful’ in place, the client may now be better placed to take more responsibility for __''Working with my Self''__ (and the key relationships that sustain or undermine this), which parallels the worker's quadrant [[Working with your CLIENT]]. 

*Here, the effort of the //worker// to identify and work on [[Scaffolding existing relationships]] to allow for repair (starting with the client’s relationship to their own self, extending to family or carers, key friends and other workers) invites... 
*...the //client// to consider in parallel what are the __''Relationships that matter''__ for them, and the kinds of work that repair and strengthening these might require. 
*As they engage in that work, the //worker’s// counterbalancing focus on [[Managing Risk]] - sometimes involving more active interventions, aside from simply averting disasters, evokes a similar focus in... 
*...the //client// who is invited to reflect on what is required to assure __''Basic Safety''__ in their life, recognising perhaps that once basic safety is assured, more creative thinking an energy can be directed towards questions of improving quality.

!!Learning what works
*There is a more future-facing focus in the bottom quadrant for the client, whose __''Learning what Works''__ parallels [[LEARNING at work]] for the worker and their team.  Here, the task is to begin to distil not just the lessons of what has helped and why, but also the //‘how’// of learning itself - that fine balance between learning from one's own experience and learning from other evidence. 

*Where the //worker// must [[Respect local practice and expertise]]... 
*...the //client// is invited to [[reflect on|Mentalization]] what it means to be __''Learning from my experience''__ (many clients may swing between over-reliance on their instincts and under-confidence in their ability to really learn at all.) 
*Where the //worker// must counterbalance respect for local practice and expertise with [[Respect for Evidence]]... 

*...so the //client// is invited to reflect on how they might be experiencing the benefits of __''Learning from Others''__. If worker and client have been successful in building sufficient [[trust|Epistemic Trust]] in their [[helping relationship|Relationship to help]] then the worker might become (helpfully) positioned as part of the “other evidence” that a client comes to incorporate in their thinking and decision-making and there may be grounds for hope that a more lasting shift in the client’s [[Relationship to help]] might begin to take effect. 


Whether a version of this ‘client’s wheel’ on the back of the standard AMBIT wheel will provide a helpful PsychoEducation field tool for workers struggling to help their clients make sense of the work remains to be seen.  //If any workers are using a double-sided version of the wheel in the field to help provide a means of explaining the overarching model or framework for what they are trying to achieve//, the [[AMBIT programme]] at the [[Anna Freud National Centre for Children and Families]] would be keen to hear feedback! 

!What is the CGI?
The Clinical Global Impression (CGI) measure was initially devised  in 1976  (Guy, 1976)  and has been extensively used to assess the outcomes for both adults and children.  It has been particularly well used in pharmacological studies. 

The major advantage of this measure is its face[[ validity|Psychometrics and Psychometric Tests]] and extreme simplicity. The measure consists of two scales which are rated by the worker.
!CGI-S - Severity: at //Treatment Start//, at //3 months//, and at //Treatment End//
The ~CGI-S is a seven point scale of the severity of the clinical problem;
''@@color(red):1=Normal 
2=Close to normal
3=Mild
4=Moderate
5=Quite severe
6=Severe
7=Very severe@@''
!CGI-I - Improvement: at //Treatment Close//
The ~CGI-I is a seven point scale of the amount of improvement during or at the end of treatment. 
''@@color(red):1=Very much improved
2=Much improved
3=Mildly improved 
4=No improvement
5=Mildly worse
6=Moderately worse
7=Very much worse@@''
![[Psychometric properties|Psychometrics and Psychometric Tests]] of the CGI
The CGI is used in a huge number of studies, mainly drug trials. However, it is also used in treatment evaluation in adult and child psychiatry. The validity of the CGI was recently evaluated by on an adult series of 786 psychiatric in-patient admissions (patients aged from 16-91 years) for which the CGI was compared with HONOS, the MHQ and ~DASS-21 (Berk et al., 2008). The MHQ and the DASS are patient rated measures. The CGI-I correlated 0.71 with measures of change from these other standardised instruments.  However, the limitations of such a simple scale have also been recognised (Beneke & Rasmus, 1992).

The CGI has been used in recent child mental health outcome studies on OCD (Coskun & Zoroglu, 2009), Depression (March, Entusah, Rynn, Albano, & Tourian, 2007), Anxiety (March et al., 2007)and ADHD (Schachar et al., 2008). These studies range from pre-school children through to adolescents. 
!Use of CGI in AMBIT
For AMBIT, it is suggested that the ~CGI-S could be rated by clinicians at the beginning of treatment, at three months and then at discharge. The ~CGI-I could be rated at discharge.  
!References:
Beneke, M. & Rasmus, W. (1992). //"Clinical Global Impressions" (ECDEU): Some critical comments.// Pharmacopsychiatry, 171-176.

Berk, M., Ng, F., Dodd, S., Callaly, T., Campbell, S., Bernardo, M. et al. (2008). //The validity of the CGI severity and improvement scales as measures of clinical effectiveness suitable for routine clinical use.// Journal of Evaluation in Clinical Practice, 979-983.

Coskun, M. & Zoroglu, S. (2009). //Efficacy and safety of fluoxetine in preschool children with obsessive-compulsive disorder.// Journal of Child and Adolescent Psychopharmacology, 297-300.

Guy, W. (1976). //ECDEU Assessment Manual for Psychopharmocology - Revised.// U.S. Department of Health, Education and Welfare, Public Health Service, Alcohol, Drug Abuse and Mental Health Administration, NIMH.

March, J. S., Entusah, A. R., Rynn, M., Albano, A. M., & Tourian, K. A. (2007). //A randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder.// Biological Psychiatry, 1149-1154.

Schachar, R., Ickowicz, A., Crosbie, J., Donnelly, G. A. E., Reiz, J. L., Miceli, P. C. et al. (2008). //Cognitive and behavioral effects of multilayer-release methylphenidate in the treatment of children with attention-deficit/hyperactivity disorder.// Journal of Child and Adolescent Psychopharmacology, 11-24.

These are your basic record of contact and activity with a young person or their network - effectively an 'audit trail' of your thinking and actions with a client.

!Definition of a Clinical Theme:
A Clinical Theme is anything that occurs to either the young person, a family member, or the KeyWorker ''__that appears to represent a meaningful pattern or 'thread' running through the system centred around the young person__''.  

It may be a vulnerability factor, a specific problem that is active in more than one place in the network, or a particular strength or opportunity for an intervention.

For instance, a family may have a rich involvement in preparing and enjoying //food//, shared betwen several generations; this could be both a strength (a shared language, and shared interest), a vulnerability (the context for a son with an eating disorder, for instance) or the opportunity for an intervention (helping to prepare food for the family group) but above all it would be an important piece of information to complete an understanding of the functioning of any individual within that system... 
>//Something you would need to know about the X family is that they nearly all ..."//

!Application:
This might relate to a situation where the child was not thought about properly, but could not elicit a response from the parents that would have focused them to see the child’s feelings and thoughts as these were at the time.
!Activity:
The therapist suggests some ways of responding that the child may not have thought of during the moment. For example, the therapist might say:
"When your mom was talking about your room being messy, I saw you start to get upset. I wonder what might have happened if instead you…"
!Purpose: 
The purpose is not to correct the experience but to encourage flexibility in the child’s behaviour repertoire in relation to this type of experience. This activity can also be used with parents in the absence of the child.

This refers to thoughts or beliefs (as opposed to feelings, or "[[Affect]]", or Behaviours.

<<tabs "[[CB-Principles]] [[Cognitive Behavioural work - CheckLists]] [[CBT techniques]] [[CBT-Special Circumstances]]" "SampleTabOne" "$:/state/tab1">>

[[Cognitive Behavioural]] work is one of the specific interventions that are included within the integrated AMBIT model. 

!Flexibility and Clinical Judgement
The detailed structure and contents of sessions is offered here as a guide; recommendations contained here should never be allowed to replace clinical acumen.  The basic tasks for specific sessions should be covered as directed, but the therapist must feel able to move flexibly between different techniques and interventions //according to clinical need// - so that the detailed suggestions and examples set an overall ethos and 'style'  rather than offering a mechanical and step by step manualization, sacrificing the flexibility required to maintain [[Engagement]].

#[_] Before starting: read through [[Getting started with CBT]]
#[_] Session 1 
##[_] Assessment - this may supplement the [[Multi-Domain Assessment]] and focusses on the triadic relationship between [[Thinking]], [[Feeling]] and [[Behaviour]] (see [[CB-Principles]]).
##[_] Setting specific goals for the CBT focussed sessions.
##[_] [[PsychoEducation]] around the specific need to be addressed
#[_] Session 2: Collaborative formulation (linking thoughts, feelings and behaviour) and Planning of the therapy
#[_] Session 3: [[Problem solving]]
#[_] Session 4 - Final (total number of sessions varies): [[Life practice]]
#[_] Session Final: [[Reviewing change]]

The main theoretical basis of these approaches is in SocialCognitiveTheory.

Strongly held beliefs about Cannabis (//"It is harmless"// or //"Without it I am much more aggressive"//, etc) may take the form of [[Implicit Core Beliefs]] and threaten a young person's motivation or the application of planned change behaviours.

The [[Cognitive Behavioural]] approach is similar to [[Motivational Work]] in that direct confrontation is avoided ([[Roll with Resistance]]), but there is slightly more room for gentle challenge.

In keeping with the Cognitive therapist stance (see [[CognitiveBehavioural for SUD-Rx]]) the approach towards a particular cognition is:
!!Identify the cognitions:
Via a joint exploration of the young person's [[Thinking]] the client and therapist seek to uncover the [[Implicit Core Beliefs]] that underpin a young person's thinking and influence [[Feeling]] and [[Behaviour]].
!!Externalise the problem:
Consider a specific cognition (for instance //"Without drugs I am totally unlovable."//) as ''separate from the thinker''.  Note this is dirently related to the ideas about [[Psychic equivalence]] from [[Mentalization]]-based approaches:  
*//"What would an observer from a distance see as the effect on you when this particular thought comes into your mind?"//  
*//"Would it seem to make it more or less likely that you would use cannabis in the hours after it had been in your mind?"//
!!Design experiments to test these (dysfunctional) ideas:
*//"How could we design a test to see if this thought is true all of the time, only some of the time, or none of the time?"//
*//"'TOTALLY' is a strong word - I mean if just one person still found you lovable then that wouldn't be TOTALLY, would it?"// 
*//"Who might we ask, or what do we think the people closest to you would say, if we did ask them whether you are 'totally unlovable'?"//
!![[Weighing Pros and Cons]] 
This is another version of a Cognitive approach to the notion that //"I don't want to change my cannabis habit."//

This tag collects particular cognitive behavioural techniques that are specifically useful in working with SubstanceUseDisorder such as Cannabis.  You might also want to read about [[Cognitive Behavioural therapy|Cognitive Behavioural]] in general.

!The Cognitive Behavioural Therapist's Stance: a SHARED exploration

Cognitive Behavioural therapists attempt to work alongside clients, fostering a sense that they and the client are ''co-workers'' approaching the problem, rather like scientists inquiring into an area of research together; each brings areas of special expertise.

!Keeping engagement

The Practitioner has expertise in techniques, and from her previous experience in work with other clients.  The young person has expertise about him or herself  - it is helpful to stress this (//"You are the world expert on being you - more than I could ever hope to be!"//) as one of a range of other [[Engagement techniques]]. (See also [[Experts By Experience]].)  

This is an ''externalisation of the problem/challenge'' - whic