29th March 2018
Introduction
It is one of the Core Features of AMBIT that the KeyWorker in AMBIT takes a stance that proactively takes responsibility for integrating the multiple Specific interventions that are often being delivered to a young person or their family - sometimes from different parts of complex networks of care.There are Training Exercises for Taking Responsibility for integration in this manual to support this aspect of AMBIT.
This necessity is especially likely when the keyworker is holding another part of the AMBIT stance; ensuring that we are Working in multiple domains (rather than "just" doing some cognitive work, or "just" attending to educational re-engagement...) It is just this "wide-angled" approach to the work with a young person that means that more people and places are likely to become involved, and in turn this makes Dis-integration more likely (or inevitable).
Whereas in the early stages of Engagement the lion's share of Specific interventions may be delivered in a "barefoot" way by the KeyWorker themself, it is frequently the case that as time goes on, other workers and other and other agencies are rightly brought into relationship with the young person or family.
The different interventions that might be offered to address difficulties in different domains may well be drawn from different theories, may represent different treatment modalities (pharmacological, individual work, family work, cognitive behavioural, psychodynamic, etc etc...), and may be delivered by different workers or different agencies. Ideally they will address multiple domains, but all too often they represent Dis-integratedInterventions.
It is self evident that no service chooses to deliver Dis-integratedInterventions, but across the domain of multi-agency practice this is commonly the case.
Video
There is a video lecture on the practice of Addressing Dis-integration which covers these ideas.Thinking about Dis-integration
Examining the nature of how such dis-integration occurs helps to identify and reduce the effect of such anti-therapeutic forces, and the Keyworker uses tools such as the Dis-integration grid to address this.As the person who delivers many, even most, of the face-to-face work at least early on in the work, the Keyworker acts as a CATALYST for integration. Their work may include acting as an "interpreter" for other parts of the system, or "enacting integration" by offering different kinds of work in different domains more or less simultaneously as a single worker.
On a theoretical level, the Authors propose that there is very much more SHARED between many of the major theoretical/explanatory frameworks that we use (Attachment theory, Mentalization, Biology, Psychodynamic theory, SocialCognitiveTheory, SocialEcology and SystemsTheory) than some practitioners and theoreticians have liked to admit; in the early stages of work there may be more to gain from offering integrated interventions from a single practitioner who has a good therapeutic Attachment, than there is to have "too many experts" early on in treatment.
Developmental Considerations offer an important perspective which underpins many of the theoretical principals for integrating the various explanatory models/theoretical frameworks we use - particularly the young person's vulnerability to being overwhelmed by complex, novel settings or new kinds of relationships.
Doing integration not just thinking it
One of our primary theoretical constructs is that integration is in the doing rather than the thinking - it happens in the interstices between patient and therapist, in the conversations that take place between therapist and schoolteacher, police officer, social worker, etc, etc. This leads us to considerations about the nature and role of the KeyWorker, in particular the ways in which this mode of treatment-delivery fits within a framework of Attachment theory, engaging the individual as a physiological and psychological entity, but also in relation to the Family and the Community. It is this that gives the sense of the KeyWorker acting as a CATALYST for integration.
Attachment and Mentalizing in thinking about the system of care.
A unique feature of this approach is its consideration of each system within which the YP functions from within the perspective of Attachment theory and with a Mentalizing perspective. By this we mean that from the YP's point of view, attachment-related characteristics of the various systems (of which she or he is a part) activate relationship representations or cognitive structures which then determine their functioning in relation to that system. So, for example, within the wider SocialEcology system, the child's school may be experienced as predominantly dismissing in the way that it relates to all members of the community, so that young people feel lost and uncared about. This can aggravate a YP's feeling of being rejected or unsafe in relation also to other relationship systems.
Thus, the attachment framework helps to hold together the intervention strategy, which at all levels aims to create systems that are as far as possible felt to be secure. The hope is that these shifts in particular systems would interact and reinforce each other. This security then helps to modulate the child's emotional state. In the example of the school, the aim would be to make that environment come to feel much more of a Secure Base, similarly the Family and the wider treatment network would be worked with, with an aim to help the young person to feel safer and more able to begin to think about what has happened and about his states of mind and relationships.
An example of this, that focuses individual intervention, is the principle of creating a coherent narrative for the young person as to what was happening before the breakdown and what sense it makes. It is important that as far as possible this understanding of what has happened is shared at the different levels of system, thus the family and school and wider network, including other agencies, arrive at a single, shared perspective from which to move forward as the YP completes his brief period of intensive treatment by the AMBIT team.
A single language - or at least Translation and Interpretation
Finally, on a pragmatic level it is important to avoid a Tower of Babel experience for the young person or family, whereby multiple professionals are experienced as speaking different languages to them. The KeyWorker may well need to act as an interpreter for other parts of the Care network - which means that he or she needs to understand How to speak to a... representative of most of the key professionals working in this field.