Peter Fuggle

Applying attachment theory to effective practice with hard-to-reach youth: the AMBIT approach

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.

Evaluation of multisystemic therapy pilot services in the Systemic Therapy for At Risk Teens (START) trial: study protocol for a randomised controlled trial

BackgroundThere is an urgent need for clinically effective and cost-effective methods to manage antisocial and criminal behaviour in adolescents. Youth conduct disorder is increasingly prevalent in the UK and is associated with a range of negative outcomes. Quantitative systematic reviews carried out for the National Institute for Health and Clinical Excellence have identified multisystemic therapy, an intensive, multimodal, home-based, family intervention for youth with serious antisocial behaviour, as one of the most promising interventions for reducing antisocial or offending behaviour and improving individual and family functioning. Previous international trials of multisystemic therapy have yielded mixed outcomes, and it is questionable to what extent positive US findings can be generalised to a wider UK mental health and juvenile justice context. This paper describes the protocol for the Systemic Therapy for At Risk Teens (START) trial, a multicentre UK-wide randomised controlled trial of multisystemic therapy in antisocial adolescents at high risk of out-of-home placement.Methods/DesignThe trial is being conducted at 10 sites across the UK. Seven hundred participants and their families will be recruited and randomised on a 1:1 basis to multisystemic therapy or management as usual. Treatments are offered over a period of 3 to 5 months, with follow-up to 18 months post-randomisation. The primary outcome is out-of-home placement at 18 months. Secondary outcomes include offending rates, total service and criminal justice sector costs, and participant well-being and educational outcomes. Data will be gathered from police computer records, the National Pupil Database, and interview and self-report measures administered to adolescents, parents and teachers. Outcomes will be analysed on an intention-to-treat basis, using a logistic regression with random effects for the primary outcome and Cox regressions and linear mixed-effects models for secondary outcomes depending on whether the outcome is time-to-event or continuous.DiscussionThe START trial is a pragmatic national trial of sufficient size to evaluate multisystemic therapy, to inform policymakers, service commissioners, professionals, service users and their families about its potential in the UK. It will also provide data on the clinical and cost-effectiveness of usual services provided to youth with serious antisocial behaviour problems.Trial registrationISRCTN77132214

Multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour (START): a pragmatic, randomised controlled, superiority trial

BACKGROUND Adolescent antisocial behaviour is a major health and social problem. Studies in the USA have shown that multisystemic therapy reduces such behaviour and the number of criminal offences committed by this group. However, findings outside the USA are equivocal. We aimed to assess the effectiveness and cost-effectiveness of multisystemic therapy versus management as usual in the treatment of adolescent antisocial behaviour. METHODS We did an 18 month, multisite, pragmatic, randomised controlled, superiority trial in England. Eligible participants aged 11-17 years with moderate-to-severe antisocial behaviour had at least three severity criteria indicating past difficulties across several settings and one of five general inclusion criteria for antisocial behaviour. We randomly assigned families (1:1) using stochastic minimisation, stratifying for treatment centre, sex, age at enrolment to study, and age at onset of antisocial behaviour, to receive either management as usual or 3-5 months of multisystemic therapy followed by management as usual. Research assistants and investigators were masked to treatment allocation; the participants could not be masked. The primary outcome was out-of-home placement at 18 months. The primary analysis included all randomised participants for whom data were available. This trial is registered, number ISRCTN77132214. Follow-up of the trial is still ongoing. FINDINGS Between Feb 4, 2010, and Sept 1, 2012, 1076 families were referred to nine multi-agency panels, 684 of whom were assigned to management as usual (n=342) or multisystemic therapy followed by management as usual (n=342). At 18 months, the proportion of participants in out-of-home placement was not significantly different between the groups (13% [43/340] in the multisystemic therapy group vs 11% [36/335] in the management-as-usual group; odds ratio 1·25, 95% CI 0·77-2·05; p=0·37). INTERPRETATION The findings do not support that multisystemic therapy should be used over management as usual as the intervention of choice for adolescents with moderate-to-severe antisocial behaviour. FUNDING Department for Children, Schools and Families, Department of Health.

The Adolescent Mentalization-based Integrative Treatment (AMBIT) approach to outcome evaluation and manualization: adopting a learning organization approach

AMBIT (Adolescent Mentalization-Based Integrative Treatment) is a developing team approach to working with hard-to-reach adolescents. The approach applies the principle of mentalization to relationships with clients, team relationships and working across agencies. It places a high priority on the need for locally developed evidence-based practice, and proposes that outcome evaluation needs to be explicitly linked with processes of team learning using a learning organization framework. A number of innovative methods of team learning are incorporated into the AMBIT approach, particularly a system of web-based wiki-formatted AMBIT manuals individualized for each participating team. The paper describes early development work of the model and illustrates ways of establishing explicit links between outcome evaluation, team learning and manualization by describing these methods as applied to two AMBIT-trained teams; one team working with young people on the edge of care (AMASS — the Adolescent Multi-Agency Support Service) and another working with substance use (CASUS – Child and Adolescent Substance Use Service in Cambridgeshire). Measurement of the primary outcomes for each team (which were generally very positive) facilitated team learning and adaptations of methods of practice that were consolidated through manualization.

Are clinician ratings useful in evaluating outcomes in Child and Adolescent Mental Health Services (CAMHS)? A study of a continuous series of 1446 cases from an inner city CAMHS.

RATIONALE, AIMS AND OBJECTIVES Routine outcome evaluation in Child and Adolescent Mental Health Services is an essential part of effective service delivery but it has been hard for services to obtain client-rated outcomes on more than 50% of cases. Clinician-rated outcomes are examined whether this would provide a valid and reliable way of contributing to addressing this difficulty. METHOD This paper will evaluate the pragmatic utility, reliability and validity of a method of measuring clinical outcomes using clinician ratings using an adapted form of the Clinical Global Impressions scale with additional items based on the Every Child Matters framework on a continuous case series of 1446 cases. RESULTS A rating of clinical outcome was obtained on 93% of cases. Approximately 55% of cases were rated as improved and about 30% as showing no change with about 5% reported as being worse. Test-retest reliability was acceptable (Pearson r = 0.94; P < 0.001) and criterion validity, comparing clinician and parent ratings, showed a significant correlation of 0.42 on severity of problem (Kendalls tau; t = 2.321, P = 0.02) and 0.36 on the degree of improvement (t = 2.637, P = 0.008). Rates of clinical improvement in studies of usual care suggested similar rates to those reported in this study. CONCLUSIONS Clinician ratings were obtained for a high proportion of cases and the burden on clinicians was extremely low with negative outcomes similar to known rates of usual care. This high coverage may add value to the evaluation of service outcomes.

The AMBIT approach: working with hard to reach youth

Purpose – MBIT is a manualised mentalization-based approach to working with hard to reach young people at risk of a wide range of life adversities including severe mental illness, substance misuse, family breakdown, school exclusion, offending and homelessness. The on-line manual (www.tiddlymanuals.com) describes how Adolescent Mentalization-Based Integrative Therapy (AMBIT) is a systemic intervention requiring attention to four different domains of intervention simultaneously; much emphasis is placed on the support systems for workers to maintain this balance in what are often chaotic working conditions. The purpose of this paper is to illustrate how these four main components of the AMBIT approach link together in actual clinical practice. Design/methodology/approach – The authors illustrate the core techniques of the AMBIT approach, namely, “working with your client”, “working with your team”, “ working with your network” and “learning as a team” with a series of case vignettes, demonstrating the inter-relationship of these components rather than seeing them as separate strands. Findings – A range of mentalization-based techniques such as “thinking together”, mentalized formulation, “disintegration grids” and web-based manualising are described and illustrated in relation to a series of case vignettes in order to address barriers to effective practice. The vignettes emphasise how these components must be linked together and held in balance, and how easily they become disconnected in working with young people’s ambivalent or even hostile relationships to help. Practical implications – First, developing a shared, mentalized formulation of a young person’s difficulties is an important aspect of working with highly troubled young people. Second, mentalizing is a relational process and is easily disrupted, for both workers and young people, by raised anxiety and affect, a common feature of working with this client group. AMBIT provides specific methods, for example, “thinking together” for supporting the mentalizing of individual workers in their team in an explicit way. Third, workers from different agencies may often find it difficult to make sense of each other’s behaviour and decision making. AMBIT proposes the use of a mentalizing approach to this difficulty using a technique called a disintegration grid. Finally, AMBIT proposes a new practitioner focused approach to manualising as a method by which a team can become more explicit about its methods of working in order to support systematic practice and evaluate outcomes. Originality/value – The innovative AMBIT approach proposes that clinicians need to attend to team and network relationships at least as much as their relationship with the client, in addition to adopting a stance of learning as a team from their casework. A high level of clinical skill is needed to support a team to achieve this balanced approach to casework. This work is of interest to all multi-disciplinary teams working with hard to reach young people.