Dickon Bevington, ‘Working as therapists and allied professions with hard to reach youth’ - Vienna 2019 keynote speaker

“Teams as the critical agents of change in systems”

Dr Dickon Bevington "AMBIT was a flexible beast"‘Hard to reach’ youth (high risk, complex, entrenched and not conventionally help-seeking) can’t be treated and supported by an individual therapist alone, it requires a team of therapists and allied professions to build trust and understanding with these troubled youth. The Adaptive Mentalization-Based Integrative Treatment (AMBIT) program holds ‘team’ as the pivotal part of the change process required to “make help helpful”. “The approach moved from a hypothetical and imaginary one - of training an individual with special skills - to a more pragmatic and user-led team-based approach” states Dr Dickon Bevington, Medical Director at the Anna Freud National Centre for Children and Families, and co-lead with Dr Peter Fuggle for the AMBIT programme. Here, Dr Bevington talks to ESCAP about the AMBIT project and will reveal more in his upcoming keynote talk in Vienna.

Dr Bevington’s work is centred on the AMBIT approach. Developed since the turn of the century through continuous iterative trainings and adaptations, the AMBIT structure may seem a bit baffling at first glance but as you delve into the functions and reasoning behind each step, and with Dr Bevington’s prowess for teaching, it opens up with the evolutionary aspect of mentalizing at its heart and the rest slots into place like a puzzle piece.

The ‘hard to reach’ youth

Dr Bevington and his colleagues focus on ‘hard to reach’ youth, who usually are defined by serious, multiple and complex needs, presenting professionals with difficulties in delivering effective help to them, and poor long-term outcomes. “They are described as ‘hard to reach’ for a reason; their avoidance of help is frequent, active and intentional, rooted as it may be in profound disorganisations within their attachment systems”. Such young people, who are seen as both risky and complex, will almost always require the expertise of multiple professionals from different agencies. These young people are the core constituency for AMBIT.

How did AMBIT develop?

AMBIT is a really nice example of deployment focus innovation, first beautifully described by John Weisz (Weisz and Simpson Gray), and developed in response to the demand from the very teams we were training. In the early years our target group was quite narrowly defined (outreach services for high-risk adolescents), but later we ended up developing an approach that at its heart must be adaptable.  Despite our original focus, rather quickly we found ourselves being asked by big charity donors to support youth work, or street level interventions that were more focused on gangs, or violence, or programs addressing social deprivation across an area, in which of course, mental health was a component but only a small part”. Dr Bevington describes the development as a “flexible beast”. “Slowly, as the model began to mature, it was clearer that the people we were working with were starting to find value in what we were teaching. Their needs and experience of the work were extraordinarily valuable to us, too. Over time, in response to their feedback, the model started to describe the everyday dilemmas of street level or face to face workers and to offer an array of work around a useable framework for understanding the techniques used in real-life experience. The AMBIT model started, as it were, to articulate the inside out experience of the worker; their anxieties, fatigued situations, moments of despair. It would be nice to say that it happened by design, but to some extent, the way we developed AMBIT was a kind of happy accident. We designed AMBIT as we went, it was almost like a field trial”.

So, AMBIT is constantly being adapted?

“It is now adaptive by design, and if we don’t keep improving and modifying it, then it will become dead. The difficulty is how you evaluate something like this that is changing all the time. Different parts of the design are applied in different ways across many different settings”. Dr Bevington goes on to explain that to address the design change and outcomes they are generating a generic, large-scale outcomes framework, which he hopes to discuss further in Vienna.

How did mentalizing become the central focus?

“In the early stages of AMBIT, integration happened (or was intended to happen) in the body of a worker, who we would train deliberately in the most pragmatic, useable elements of the main models of practice; basic systemic practice, basic psychodynamic practice, basic cognitive behavioural, social learning, basic social-ecological, street-level project work. One of these training modalities was mentalising. We originally overoptimistically thought that by training a single person with useable elements of all of these that we would create a rather light-footed, flexible, adaptable worker. This may have been a nice idea, but it didn’t work. The individual trainees loved it, but on returning to their teams, nothing substantive changed in their practice, mainly because no one else in their teams could make sense of what they were doing, or could really support them to try. From then on we only did whole-team or multi-team training: creating a relationship between workers in a team, or between teams is a powerful help for change that is always an uphill task in large systems. So AMBIT is now only offered as a team-based approach. Another adaptation was that, as we went forward, the one part of the model that always captured peoples’ interest was mentalizing, and it became the load-bearing axle of the “AMBIT wheel”. It binds things together by its nature as a theory; it’s a very integrative framework, and this was largely by design; Peter Fonagy and other experts asking ‘how do we create a field of inquiry that respectfully builds on psychoanalytic, neurodevelopmental attachment, cognitive, social and learning frameworks, and systemics? How do we find some territory in which all of those are used in some respectful way?”

The act of mentalizing

“One of the great strengths of mentalizing is that it is an extraordinarily trainable concept or framework; it is not a new idea, but it systemically offers a re-framing of existing concepts. Once people get it, it is a rather simple idea, even if the implications for practice and the therapist’s stance are significant. Peter Fonagy has talked about mentalizing as folk psychology, simply put, people behave the way they do because of stuff that goes on it their minds, what they believe, what they fear, desire, intend; this is self-evident to most people. The act of mentalizing is then the “puzzling it out”. Either doing it about oneself or someone else. It’s questioning, and a curious state of asking about our own and each other’s actions. How do I modulate my interactions with clients and colleagues in the light of this? It creates a slightly different ambience in relational terms; it is a very humane and (if we get it right) rather a humble theory. We’re not very good at mentalizing, and that’s allowed. Mentalizing by design is fragile. We’re going to make errors, do things slightly strangely at times (because when we are anxious or upset our mentalizing collapses) but if we have the ability to be ready to correct, then it’s fine. Failure of a therapists mentalizing in therapy is in ways a prerequisite for success in therapy, because the therapist has to show the patient the fragility of their own mentalizing and that correcting failures of understanding to show learning is a universal human given.”

How does team work and mentalizing go together?

“The approach moved from a hypothetical and imaginary one of training an individual to a team-based approach. Teams as the critical agents of change in systems.A team means acollective, shared understanding, and really focusing on a central idea. AMBIT was really an attempt to identify some of the key dilemmas that workers in the field brought to us, and then perhaps rather arbitrarily what started to resonate with us was that there was a tendency in our field to work with 95% of our attention going to work on the dyadic relationship; me and the client (or family), with a kind of a corresponding absence of attention going into the relationships between me and my teammates. It appeared to us that mentalizing is as much as a social capacity as a neurodevelopmental or psychological one. I can only mentalise on the basis that I know I have a network of connections and people whom I trust and whom I know can and do mentalise me. AMBIT, therefore, stresses balancing attention between the relationships with our clients, and those between team members, or between the team and elements of the wider system. AMBIT is trying to create an environment where paying attention to the minds of your working colleagues is as important as the paying it to the minds of your patients, because without such a context, our own mentalizing of our patients is inevitably threatened by the risk, the frustrations, or the despair that are always part of a real engagement.”

Within the AMBIT structure, is the element of dis-integration the most challenging part?

Many can agree that working within a team can also have its disadvantages. An aspect of the AMBIT framework describes “dis-integration” when the teams or professionals fail to work together. “Many workers will have said at some point, how they love working with their clients, but it’s their teammates or other professionals in the network that can be frustrating at times. Working in a multi-agency, multi-professional environment can be difficult and can result in a disconnect between one team and their goals and another team with their goals. Patterns of disintegration are the natural resting state of complex systems and networks. The aim is to try to create a team that purposefully holds a more mentalizing approach that expects these kinds of disintegration, and that has strategies in place, broadly mentalizing-base, to prevent this disconnect and not fall into the uncertainty and grumpiness that can be extraordinarily detrimental to the children we’re trying to treat”.

Knowledge management by ‘wiki’ platform

AMBIT has generated a wiki-based approach that emphasises the benefits of the activity of manualizing treatments rather than the manual as a “finished product” as if it were a pharmaceutical agent.  The AMBIT wiki manual is a multi-layered collaboration with academics, clinicians and programmers, and some teams are able to involve input from their own service users, too. “It is built to allow us to create a layer cake effect. We build the first layer in the Anna Freud National Centre with our best knowledge and trying to summarise the available evidence. Every time we train a team, they get their own upper layers which inherit our core material, but which they can add to and create improved, or locally customised content.  This local material skips around so that different teams can see how others are working in a particular field and new effective practice can be shared quickly and easily. It is a knowledge management system where we adopt the information that is robust enough but may be of a type that doesn’t easily lend itself to randomised trials. Much of the developing practice in AMBIT is information provided as a starting block, which would need to be implemented in different ways according to local culture, service ecologies, etc”.

Where to next?

As well as developing a generic, large-scale outcomes framework, Dr Bevington and colleagues are working with specialists in sociology, anthropology and mathematics to look at social network analysis. They aim to move from a hypothecated idea of what might be going on in a network, to the possibility of a data-driven map of the helping network around a young person. “Social network analysis shows how interventions and their effectiveness are often based on multiple players in a network collaborating well, without a formal managerial pathway ever being possible to define. Some of the findings from social network analysis currently have a really uncanny fit with what we think we have stumbled into with AMBIT. For instance, there are two contrasting kind of ties that an effective team needs to balance to be maximally effective in its role; one being the creation of close or strong relationships between the immediate team members, providing stability, security, and a strong culture (this is referred to as “closure” – at its worse it creates an unchanging gang, but at its best it creates orthodoxies and disciplined structured behaviours.) The other is a contrast, and is known as “brokerage”. Basically, individual people in the team need ‘non-redundant weak ties’ that go out into the wider network; brokerage is how new thinking or opportunities are introduced for entrenched problems. If two workers both connect to the same little corners of the wider external network then these ties are a redundancy because they’re both connecting to the same source. Teams need to be connected outwards to weak ties but towards lots of new places, bringing in new ideas that can bridge relationships beyond the team. The research is clear that the teams that have a mix of this closure and brokerage slightly paradoxically are most correlated to effectiveness.  These findings from social network analysis directly support the balancing that AMBIT promotes between close ties within a team and constructive outreaching ties from within that team into the wider interprofessional and multiagency networks”.

The success of AMBIT doesn’t just expand to the corners of the UK. Dr Bevington and his team have collaborated with numerous European teams to help them to establish such a system. They have delivered ‘train the trainer’ sessions in Germany, Denmark, Norway, and Spain, Switzerland and in the USA and Australia. An important principle for them is not for the existing team to wipe away all existing expertise and practice to create a clean slate for AMBIT. Dr Bevington says “it’s important not to invalidate an existing process in a team or system but to work hard to complement the established system. Before undergoing any training, we ask teams: Why do you need training at all? What do you currently do really well? The aim is not to harm a functional system; the key is to integrate the existing systems of what is working and take what you need from the new training and complement the whole process”. “This is much the same as we try to work with families – increasing existing resiliencies, rather than breaking things up.  Much of AMBIT is based on the understanding that training, like any therapeutic intervention, has possible side effects as well as benefits, and avoiding these is of critical importance. I’m always particularly impressed at the way those international teams that approach us adopt the AMBIT structure and implement it effectively in their practices”.

Further reading:

Head to the AMBIT YouTube channel to learn about all aspects of the AMBIT project.

Bevington et al. Innovations in Practice: 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. 2013. Child and Adolescent Mental Health. Vol 18;1;46-51.

Bevington et al. Applying attachment theory to effective practice with hard-to-reach youth: the AMBIT approach. 2015. Attachment & Human Development. Vol 17;2;157-174.