AMBIT:WorkinginanxiousplacesA team-based mentalizing approachto high risk hard to reach complex youth

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Fundación Castilla del Pino2013Dr Dickon Bevington

Thanks

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Peter Fuggle (co-lead)

Peter FonagyMary TargetEia AsenNeil DawsonRabia Malik

Suzanne HareGarry RichardsonLiz CracknellSally Zlotowitz

All the AMBIT-trained teams

AMBIT: A Community of

Practice

Derry - Omagh

MAC-UK

CASUS

AMASS - Islington

Edinburgh CAMHS

> 40 teamsusing versions of AMBIT manual

Wenger and Lave

Bexley CAMHS

Education/Training and working experienceNo. of staff

(Total n = 70)

“At times I feel anxious working with complex hard to reach

youth.”

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5

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7

“Strongly Agree”

“Strongly Disagree”

“At times I feel anxious working with complex hard to reach

youth.”( n = 67)

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2

3

4

5

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7“Strongly Disagree”

“Strongly Agree”

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A Definition of Mentalizing• The imaginative activity of making sense of behaviour

• Of self and of others• By reference to present intentional mental states

• Beliefs, Desires, Fears, Hopes…

A ‘bedrock’ neurodevelopmental capacity that is:

• Located primarily in the prefrontal cortex

• Fostered (or rekindled) in the experience of relationship with a trusted other, in which one has repeated experience of being accurately mentalized (“I find my mind in your mind”)

• Easily overwhelmed by powerful stress/arousal/attachment

Current ‘insurmountable’ life challenges

Becoming adult

Rejection

Excessive demand for excellence

CSA

Adverse parentingHistory of

physical maltreatment

Disruption of mentalization

Activation of attachment

system

Stress reaction

(fight/flight)

Genetic & early environmental

influence

INSIDE-OUT thinking(Psychic Equivalence)

ELEPHANT-IN-THE-ROOM thinking

(Pretend Mode)

QUICK FIX thinking(Teleological Mode)

Genetic & early environmental

influenceThe

Disorganised Self

Anxiety & the Failure of Mentalization

PsychicEquivalence

“INSIDE-OUTTHINKING”

Certainty about other mindsand the way the world IS…

Pretend Mode:“The Elephant in the Room”

Blah blah blah blah blah blah blah blah

blah blah….

Blah blah blah…

Gnnnnarrrgh! Gnnaaaaargh!

Naaarrrrrgh!

Pretend mode: “Too many words”…

…no fit with the feelings/realityTea’s ready!

Our tea right here is just fine! Thanks for the offer, Mum…Now, 1 sugar or 2, my dear?

Teleology – Quick Fix thinking

Teleology invites teleology

Model of the social brain - Baron-Cohen (2005)Emotion Detector

- Left inferior frontal gyrus- Mirror neurons

Intention Detector- Right medial prefrontal cortex

- inferior frontal cortex- Bilateral anterior cingulate

- Superior temporal gyrus

Eye Direction Detector

- Posterior superior temporal sulcus

Shared Attention Mechanism- Bilateral anterior cingulate- Medial prefrontal cortex- Body of caudate nucleus

Empathising System- Fusiform gyrus

- Amygdala- Orbito-frontal cortex

Theory of Mind Mechanism- Medial prefrontal cortex- Superior temporal gyrus- Temporo-parietal junction

EMOTION UNDERSTANDING BELIEF-DESIRE REASONING

Quick Fix – TeleologySeeing Mum’s Eyes follow my gaze

Inside-out - Psychic EquivSeeing my feelings

Re-presented in Mum’s eyes

MAKE-BELIEVE – Pretend (Imagining) Mum imagining

why I cried out

by 3 months

before 12 months

by 3 – 4 yrs

Mentalizing = Holding the Right Balance

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Just enough Psychic

Equivalence

so that true feeling

is communicated

Just enough Teleology

so that things

get done Just enough Pretend,

so that new ideas arise

about other minds.

MENTALIZING

STRESS - AROUSAL

MENTALIZING

STRESS - AROUSAL

Reaching hard-to-reach, high risk, multi-problem,

complex youth

AMBIT

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Outreach and working with complex youth

AMBIT: Hanging on(to mentalizing)

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Keyw

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Intervening in

 multiple dom

ains

Mentalizing

ActivePlanning

WikiManualization

Supe

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ory

stru

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ddre ssin g net work

dis-in tegra tion

Scaffolding existing

relationshipsClinical governance

Respect for evidenceRespect for local

practice and expertise

Indi

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Keyworker w

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Connected to the team© Bevington and Fuggle

AMBITSTANCE& BASIC

PRACTICE

Keyw

orke

r res

pons

ible

for i

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ratio

n

Intervening in

 multiple dom

ains

Mentalizing

ActivePlanning

WikiManualization

Supe

rvis

ory

stru

ctur

esA

ddre ssin g net work

dis-in tegra tion

Scaffolding existing

relationshipsClinical governance

Respect for evidenceRespect for local

practice and expertise

Indi

vidu

al k

eyw

orke

rre

latio

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Keyworker w

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Connected to the team© Bevington and Fuggle

AMBITSTANCE& BASIC

PRACTICE

AMBIT:A shift of emphasis

Mentalization as my integrative therapeutic stance, AND a shared responsibility: sustaining my colleagues’ Mentalizing

Team around the child

Team around the worker

Mentalizingininvalidatingenvironments

MENTALIZING

“Speak unto my condition”

Mentalization & Supervision

Thinking TogetherConsultationReflectionCo-workingKeyWorker

Chaos& enacting

What makes a good pass?1.MARKING the TASK2.STATING the CASE3.MENTALIZING the MOMENT4.RETURN to PURPOSE

Purposeful return

Keyw

orke

r res

pons

ible

for i

nteg

ratio

n

Intervening in

 multiple dom

ains

Mentalizing

ActivePlanning

WikiManualization

Supe

rvis

ory

stru

ctur

esA

ddre ssin g net work

dis-in tegra tion

Scaffolding existing

relationshipsClinical governance

Respect for evidenceRespect for local

practice and expertise

Indi

vidu

al k

eyw

orke

rre

latio

nshi

p

Keyworker w

ell-

Connected to the team© Bevington and Fuggle

AMBITSTANCE& BASIC

PRACTICE

© Dickon BevingtonCreative commons License BY-NC-ND

Adolescent substance use, offending, school refusal, violence, educational

failure......are often just flagssignalling multiple

synergisticvulnerabilities

Psychiatric comorbidities are more commonly present than absent in substance using youth (Kessler and Walters, 1998 ).

Tower of Babel

Multidisciplinary, Multi-agency input:each worker offers,implicitly or explicitly,his or her explicatoryframework…

Different tongues

“I, as a fragmented adolescent, and my fragmented family,

have to integrate what you lothave failed to integrate for 100 years...”

Young Person

grandmothergirlfriend

Youth worker

FatherPsychiatrist

AMBIT worker

School SENCO

Brother

Gang

Social Worker

Police

Dis-integrationDis-integration can be explained as the failure of different constituent

parts of a network accurately to mentalize each other

It is COMMON, and requires not SHAME, but thought and contingency planning

3 levels of Dis-integration

1. Explanation What’s the problem? Why? 2. Intervention What to do? What could help?4. Responsibility Who does what?

Domains of Dis-integration(individual, person, or agency)

EXAMPLES 1. Family2. Grandmother 3. Youth worker 4. School 5. CAMHS team 6. Best friend

Processes of Dis-integration(examples)

1. Conflict and disagreement 2. Fear/rivalry 3. Lack of communication 4. False beliefs/lack of confidence5. Policy contradictions6. Financial constraints

 

LEVELS OF INTEGRATION Grandmother Youth worker School SENCO Young person

Explanation What’s the problem?

Intervention What to do?

Responsibility Who can help?

DOMAINS

Peer relationships – links to gangs

Use of drugs Lack of family authority to support school attendance

No money

Send him to a boarding school

Engage him with drugs team

Alter friendship group

Needs to go into foster

care

Have money to stop offending

Education authority

Drug and alcohol team

Youth club team

Social care My Dad

“Conn

ecting c

onvers

ations”

LEVELS OF DISINTEGRATION Young Person Parent/carer Other agency

(actual person) Other agency

(actual person)

Explanation ‘What’s the problem?(Why is it happening?)

       

Intervention ‘What to do?’

(…that might help…)       

Responsibility ‘Who does what?’(who’s responsible

for doing this?)

       

© Dickon Bevington and Peter Fuggle (AMBIT) – copy and share freely under Creative Commons Licence SA-BY-NC

Dis-integration Grid – map the key Connecting Conversations

Keyw

orke

r res

pons

ible

for i

nteg

ratio

n

Intervening in

 multiple dom

ains

Mentalizing

ActivePlanning

WikiManualization

Supe

rvis

ory

stru

ctur

esA

ddre ssin g net work

dis-in tegra tion

Scaffolding existing

relationshipsClinical governance

Respect for evidenceRespect for local

practice and expertise

Indi

vidu

al k

eyw

orke

rre

latio

nshi

p

Keyworker w

ell-

Connected to the team© Bevington and Fuggle

AMBITSTANCE& BASIC

PRACTICE

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Etc.Etc.

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All content specific to AMBIT working

Gives the site its“look” and behaviour

Makes specificfunctions work

Explains technicalaspects of manual

Explains how AMBIT uses manuals

TiddlyManuals:LOTS OF SPACE(s)

local “manualizing”

“inclusion”(of one space

in another)

“Cloning”

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References

CAMH JournalBevington, Fuggle,

Fonagy, Target, and Asen

2012

Attachment and Human Development

Special editionDue 2013

Eds. Midgley and Vrouva,

Routledge2012

www.tiddlymanuals.com

Follow links to AMBIT