29th March 2018
One of the Core Features of AMBIT is that therapeutic change is achieved through Engagement of the young person in an individual therapeutic Attachment Relationship, where the young person feels understood (Mentalized) and is able to access Epistemic Trust (we might just as well refer to this simply as "Trust" - but the point of the jargon Epistemic ["pertaining to new learning"] is to emphasise what new research tells us about how we establish this kind of trust [by mentalizing accurately], and why it is a crucial key to "opening the doors to learning" from another human being. It is a specific trust in the value and generalisability of the knowledge in the helper's mind.) In other words, therapeutic change, if it is to occur, is most likely to spring from the territory of a trusting individual relationship. Much of AMBIT is subsequently devoted to how a Team around the Worker can support a Key worker to create and sustain the conditions for that relationship to develop. Thus workers' energy must be balanced between developing that crucial keyworker relationship, and, conversely, ensuring that there is a Keyworker well-connected to wider team - AMBIT is not individual therapeutic work, but using a team to support individual helping relationships.
| The KeyWorker, as we use the term, is much less about defining an organisational role, and much more about focusing on "Who, in the mind of the young person, is currently key to finding help that is genuinely helpful?" |
In this manual there are Training Exercises for the Keyworker Relationship to help workers practice some the ideas we use in AMBIT-influenced practice.
What's integrative work?
In order to support this aim, the great majority of work with the young person and his or her family and wider network is provided by a single specially trained member of staff - and developing the relationship between this worker and young person is crucial to the success of the intervention (see Manage CLIENT RELATIONSHIP).
The keyworker is familiar with the principles and techniques of a number of theoretical frameworks.
But AMBIT's a team-based approach!
If AMBIT is described as a team-based approach, isn't this stress on the the KeyWorker relationship a contradiction?
Paradoxically, although great effort goes in to reducing the number of different individuals who actually interface with the young person and family, individual Keyworkers are very actively supported by a team of colleagues, who can provide ongoing supervision and consultation (see SupervisoryStructures). We use the idea of a Team around the Worker as much as the the more conventional idea of the "Team around a child". So from the perspective of the young person and others involved in the crisis, the work is carried out by one main person, but they will also be aware that their keyworker is supported in their work by a team that is experienced as being active and present in the background.
This models to the young person the way that we can all use our relationships to support the work that we do - AMBIT works very hard to avoid the dangerous illusion that any one person, unsupported, has the resources to sustain this work successfully. This relates to the second of the Core Features of AMBIT, which is (Keyworker well-connected to wider team). See also discussion of this in If I am the KeyWorker, do I hold sole responsibility for everything?
Why work like this?
The thinking behind this is rooted in Attachment theory; what contributes to the wish to hospitalise the child (whether expressed by the YP or by the family, school, etc) is the breakdown of the perception of a Secure Base. The introduction of a key individual, (supported by a second co-worker who will be Keyworker to other patients), who is equipped and skilled at a basic ("Barefoot") level to deal with all aspects of the family's problems within the home context, is intended to lay the ground as quickly as possible for the re-establishment of a Secure Base for the future. The Keyworker is not a 'Jack-of-all-trades' but a "specialist generalist".
A contributory factor to the crisis may have been a collapse of confidence in the Family's ability to cope with the young person's behaviour and problems. Thus, there is a loss of 'self-efficacy' at the Systems level, added to by a number of external systems of care coming to the aid of the family simultaneously, each trying to help the family by taking on some of the responsibility which the family are assumed no longer to be able cope with, or by taking a young person away from a family which has become unbearable to him.
In either case it is very important that through FamilyWork a service should offer strong support for the family's own care of the YP, Restoring family capacity by Scaffolding existing relationships, if you like, rather than seeking to replace these.
In AMBIT this is provided via an integrated system delivered primarily through a single Keyworker (and his or her co-worker - keyworkers will support and cover each other for leave, study days, etc). This is a fundamental difference from the conventional Multi-Disciplinary Team or MultiAgency context whereby a variety of different services offer different types of support to different people within the crisis situation. Freqently such multi-agency input unwittingly fragments the support on offer (something we refer to as the Tower of Babel experience.) Hence one of the Core Features of AMBIT is specifically directed at ensuring that the Keyworker is Taking Responsibility for integration through, amongst other things, the development of a therapeutic relationship that allows activation within the young person of some version of a Secure Internal Working Model of an Attachment Relationship.
Having a keyworker system allows the family and its social network to be held in mind continuously, offers contact as frequently as is needed in the early stages in order to help the network to regain its effectiveness, and delivers whole range of basic interventions (that are more or less EvidenceBased) flexibly, light footedly, via a single person who is known and trusted, and contingently - according to the demands of the moment. (It is well known that adolescents are often poor at deferring the gratification of their wishes, and families in crisis will often also have a very limited capacity to wait for another unknown professional to arrange and deliver a specific intervention - by the time the intervention is on offer they will often feel "the moment has passed".
The Keyworker also engages with the Community