(p. 299) “It was somebody I could trust”: A descriptive case study of one young man’s experience with an AMBIT-influenced team
Introduction: Experience and expertise
This chapter presents an account of a conversation with a young person with past experience of being cared for by a team strongly influenced by AMBIT. The team is a young people’s substance use service (referred to here as the “YPSUS”). As a descriptive case study, this chapter is less an evaluation of the effectiveness of AMBIT or this service, and more an exploration of one young man’s experiences. We privilege his own words to begin with, and then in the latter parts of the chapter we frame these with commentary, linking the experience of Thomas and his keyworker to AMBIT-influenced theory and practices. The intention was to glean insights into what difference, if any, AMBIT principles and practice might have made to Thomas’s experience of care, perhaps providing pointers for future study.
The subject of the case study, Thomas (a pseudonym to protect his confidentiality), has capacity and gave informed consent to participate in this exercise, and we are hugely grateful to him for his generosity in doing this. Thomas is no longer in treatment with the substance use team (he was four months post-discharge at the time of writing) and has had editorial control over what has been included.
A loose semi-structured interview was used to ensure that key topics of interest to readers (namely those relating to the core stance and practices of AMBIT) were explored, while giving Thomas the opportunity to tell his own story.
(p. 300) The reasons for selecting Thomas to take part in this case study were twofold. First, while the specifics of his individual and systemic circumstances are of course highly unique to Thomas, his case was in some key ways typical of the sort that AMBIT was developed to help (see Chapter 1). He had a poor history of forming effective helping relationships and he had multiple synergistic difficulties, and these resulted in the involvement of multiple workers, creating a complex professional network at risk of dis-integration. Second, and perhaps less typically, Thomas is an extraordinarily coherent narrator, and generous. He was keen to contribute to this book. He felt confident that he was sufficiently recovered from his difficulties to engage in an interview without the process upsetting his wellbeing.
Thomas’s verbatim account is offered in its entirety to start with, in order to give voice to his experience and to enable the reader to come to their own conclusions about what might be learned from it. This is followed by the worker’s commentary and reflections, quoting from the source material.
Interview (verbatim account)
Worker: Can you start by telling me what was going on when we first met?
Thomas: I was smoking a lot of cannabis. I was doing speed, cocaine, all sorts of other drugs. Never nothing hard like heroin, it was just stupid party drugs. Just going out and getting drunk all the time. Having house parties at my house. My house used to get trashed. And I didn’t care because I was always off my face. My life was miserable. Depressing. I didn’t have any money, didn’t have any nice stuff. I was always sort of just being given stuff, as a hand-me-down. It made me feel like a bit of a tramp really, and I didn’t like that.
W: Who were you seeing back then?
T: I was seeing [the housing support worker], [the adult drug service], [the youth worker], [the information advisor], and my GP. I was on the waiting list for adult mental health services.
W: What was it like seeing [YPSUS]?
T: At first, seeing you [YPSUS] was nerve-wracking because I didn’t know you and I get really wary around other people. As time went on I got to know you, and become quite good sort of friends, as such. And all in all you kind of really did help me quite a bit.
W: Was there anything different about [YPSUS] compared to other services?
T: Definitely. I think with sort of [the local adult drug service] and stuff like that, there’s a lot of people to handle. Whereas [YPSUS] sort of go one on (p. 301) one and they do help you. They muddle through your problems and help you out with other stuff as well. So it’s not just drugs and alcohol, it’s other stuff as well.
W: What sort of stuff?
T: Well, at the time I had house robberies. I’ve had people walk in my house with samurai swords and stuff like that. And you helped me out with that, because that was sort of like the PTSD.
Depression, that was another thing. And I think, at the time I was seeing you, my brother was trying to commit suicide and I had that all on my shoulders as well. I think the case of looking after my brother from the age of 16 didn’t really help. Once my brother got his new girlfriend I kind of went out and just got absolutely shit-faced because I knew that I could leave him in safe hands. So I just kind of let off a lot of steam, because at the age of 16 normal sort of 16-year-olds are going out and getting shit-faced and using drugs. And when I was 16 I was looking after my brother, so by the age of 19 I was sort of thinking I was 16 because I didn’t get to have that whole “kid getting drunk and having drugs and stuff.” And actually—not doing what I wanted to do—but experimenting with drugs and alcohol, and I think it just went wildly out of control. Really quickly.
W: Was there anything else different about [YPSUS] or me?
T: It was somebody I could trust. With somebody that’s had a lot of trust issues—it’s a case of people screwing him over and nicking stuff of his and it’s—it’s definitely an element of trust issues. And as you came in I didn’t trust you but then as time grew on I come to trust you and sort of—you looked out for me, sort of thing.
W: How did you start to think you might be able to trust me?
T: Just the way I could tell you stuff and just get it all off my chest and you wouldn’t—unless it was that I was going to harm somebody, and then you’d have to tell somebody because there’s certain protocols in place—but other than that it was confidentiality and I think that did help a lot.
W: Was there anything else?
T: The food and that. The munch. Taking me to KFC [chicken shop] and that. That was awesome. It was a case of—even when I had no food, it was like, “Come on then, let’s go and get some coffee” or “Let’s go out,” just get me out of the house, ’cos being in the house too long can sort of mess with your head a little bit, so that kind of helped in another way. You wanted to get me out of the house.
W: What did the getting you food or coffee do? Why was that important? (p. 302)
T: Because throughout my life I’ve not had a lot of people who care about me, and that showed that you cared, which I don’t think a lot of drugs and alcohol nurses would do. So … [sighs].
W: So it showed that I cared, and that helped you to trust me?
T: Yeah, definitely.
W: How else did you know that I cared?
T: Um … it was a case of when I was getting in relationships and stuff, you were sort of warning me “Be careful” because if not they’re going to hurt you and you’re going to be back the way you was, and sort of stuff like that. Just small stuff—it makes a difference.
W: Was our relationship the same as other relationships you’ve had with workers before?
T: I think I’ve had this sort of relationship before but it was kind of “Get me to a certain point then drop me from a height.” So a lot of people sort of … they’d get me over what needed to be done, and then that was it. But [my YPSUS worker] kind of did what needed to be done and sort of … slowly fizzled it out, not just dropped me as and when I’d finished doing what I needed to do. So that kind of helped a lot.
W: You said about your relationships with other people. Was there anything in the work we did that helped, or made a difference to, other relationships?
T: In the end it’s all down to what I do, but having somebody there to influence you does help a lot. Sort of—don’t get me wrong—I’ve been in and out of relationships with girls and it sort of … it always ends horribly wrong. But … I kind of accepted that, but you did help me when I was going through a messy patch with one of my ex-girlfriends. And I think that helped because it did fix it for a little while and then, sort of, there was no love there. It was just sort of, “Ah, you do my head in, piss off” sort of thing.
W: How did I help?
T: It was a case of just warning me to be careful and take it slow. But I kind of … me being me with my ADHD, sort of … I jump into things, and I don’t think about it. So I think that kind of helped.
W: Do you think you got better at … were you able to slow things down before “jumping into” things? Has that changed?
T: The impulsivity of ADHD—it’s kind of “Ah fuck it. Jump into it and think of it later,” and it’s always going to be like that, but—I know this is sort of wrong, because this is a sort of drug and alcohol thing—but the cannabis kind of calms me down.
(p. 303) I have calmed down since you’ve known me. When you first met me I couldn’t sit still. It was probably me growing up as adult … but I do find that cannabis helps me calm down and get perspective on life.
W: What about your relationships with your family?
T: My family relationships have always been up-down, up and down. Either we love them or we hate them, but family’s always going to be family. You’re always going to love them.
W: Are there any conversations we had that were helpful with your relationships with your family?
T: Yes and no. I’m a very hot-headed person so I kind of walk into a room and if someone’s got a problem, something to say, I’m like: “What’s your problem then?” So that’s kind of what sparks it off usually, with mum and dad, and my brother and sister. But I think a lot of the time, you kind of advised me and there was me being me—just blatantly ignored it. Being a hot-headed douche.
W: You say that, but actually when I first met you, you basically weren’t talking to your parents at all, and now you’ve got to a point where …
T: It’s like you love them or you hate them, it’s like Marmite. I think as I’ve grown older, as well, getting mature as well, I think I’ve realized that life’s too short. I’ve seen a couple of my family members pass away, sort of thing, and I think that just seeing, and being there, when that happened and stuff, I think I kind of realized that you’ve only got one set of parents and you’ve got to sort of take it by the horns and grab hold of it while you’ve got it.
W: Has that realization changed how you are with them?
T: I’m still always hot-headed, but when it’s a serious situation—like recently my dad’s been in hospital, sort of thing—he had a kidney infection—I think I walked into the hospital and the first thing I done was I give my dad a cuddle—and it’s a weird thing because my dad and I never got on. We’ve always had our problems, but just in a serious sort of context like that, it’s sort of, it’s called for. And I know it’s weird because man being man—it’s sort of pride and … but I don’t care about that. I just care about my family. I love my mum and my dad and my brother and sister. Don’t get me wrong—they’re all douchebags at some points in their life but I still love them and I just want them all to get on.
W: I guess one of the things I wanted to be able to do was help your relationship with them so that …
T: I think you have repaired the relationships a little bit, because me and my mum and my dad are actually talking now, whereas before we wasn’t. And (p. 304) I think also they respected the fact that I got help for what I had—taking drugs and stuff. I think it’s because I got help with it, that they started talking to me. Because, with drugs, there is an element of trust with family members. They don’t trust you because you’re gonna rob from them for your habit. Don’t get me wrong. I’ve never ever in my life ever robbed from my family for my habit. I always supplied it myself. My friends and I buy it so you can get shit-faced. I’ve never robbed from my family. I wouldn’t do it, I don’t think it’s right. I’ve been brought up, if you’ve got morals, you’ve got somewhere to go in life.
W: You were saying [YPSUS] has been helpful—what has been helpful?
T: Well I’ve seen you and … Helen [another worker in YPSUS, covering during a period of leave] . . . I think when I saw Helen and you … you were both on the same lines, exactly, which is kind of weird because you normally have two people who are two completely different people. But you was both on the same kind of lines. You were both caring, you both sort of wanted to help. And there’s not a lot of people in life who want to do that. There’s a lot of people who are sort of “Get on with your life, deal with it, you’ve made your bed—lie in it.”
W: You’ve met a few of us … So what was it like, even though you mostly saw me, knowing that I had a whole team of people who kind of helped me, and helped me to think about you? That they were there?
T: I was quite surprised that a team like yourselves … your team … they’re caring, they want to see the best in the person, they want to make that person a better person than when they first walked through the door … First impressions count. What were your first impressions of me?
W: I was impressed by how much you knew about your situation. I know that sounds kind of silly, but you know how we were saying you sometimes can’t see the wood for the trees … but actually you told me: “You know, my glasses are broken, my teeth are sore … I’ve got ADHD. I want to go to college, but my ADHD isn’t treated.” You had this awareness … you had a lot going on …
T: I think a lot of that was my fault. Pure and simple. Fact is … when you first met me my house was a fricking dump because I used to have house parties and get shit-faced and trash things. But I think now I’ve learned self-respect. Sort of … my house at the moment—I’ve got a TV, I’ve got stuff that is … not essential … but kind of essential because I spend a lot of time in my house and you get bored if you spend a lot of time in your house.
W: Yeah, you definitely look after this place now. It looks homely.
T: … ish. (p. 305)
W: No, it does.
T: … ish!
W: My overall impression of you, and I think the whole team would say this as well, is that you are a really impressive guy. You’ve been through a lot, you’ve had a lot of challenges that aren’t your fault … you’ve had some traumatic stuff happen to you … but you put this smile on and you battle on through it. And you’re kind and friendly, and have great social skills. Maybe that’s something that’s changed actually … When we first met, you’d be swearing out on the street, even if there were kids and an old lady nearby, but now you’re super good at …”
T: Keeping a lid on it?
W: Yeah, but also being “Hi! Thank you! . . . please.” You make people smile.
T: There’s two people I can thank for that. Yourself and my best friend. ’Cos he’s 27 and he went to school with my cousins and he’s sort of been a role model and he taught me stuff. When I scratched his car, he had a go at me and went “I don’t care, just pay the money.” We’re fine again now. He’s a role model, as such. Don’t get me wrong, I have got some douchebag mates. They do some stupid stuff when they’re drunk. They shaved a mate’s eyebrows. When he was asleep.
W: You said your friend had mainly been a role model. How did I help you with that social skills stuff?
T: I think it was a case of—not a case of you having a go at me, but a case of “Oh that wasn’t called for was it” or “Well that wasn’t needed” and just it helped me sort of kick myself up the bum and say “What are you doing? Sort your life out!” So, thank you.
W: Thank you—you’ve taught me a lot. We were talking about the team and you said it was a surprise that they all cared about you as well and saw the best in you. What about the way you saw doctors in our team? Was that different to how you’ve seen doctors before?
T: Well it’s not like a GP who you sort of go to. You knew they were there if you needed them, the other end of a phone call. With doctors, my doctors especially, you ring up and not that I’ve ever done it … you’re bleeding from your arms and it takes four hours to get through to them. Whereas if I left you a message, the next day you’d get back. It was quick. If I needed to talk about something it was “OK then, we’ll sort it out” right there, as and when you knew what was happening. And the doctors on the other hand, when I had blackouts and I couldn’t remember anything, you got on the phone to [the team doctor]. Next two to three days, there was a prescription waiting. (p. 306) “There you go, sort yourself out mate.” It was a kind and friendly service sort of thing. Always polite, always nice. Don’t get me wrong, you can get some snotty doctors out there, do you know what I mean?
W: Did you like that they came here?
T: Yeah, because then if something was up I could have a chat with them or that sort of thing.
W: Thinking back to all the people you had in the beginning … what was that like having all those people involved?
T: It was alright but they kind of … I think a lot of them were sort of … they were trying to get me into a job … more than trying to sort my personal health out. So I think [my housing support worker] was trying to get me into another house or at least get me ready for moving on to the next house. [The information advisor] was trying to get me into a job. [The youth worker] was trying to … to be honest I don’t know what the frigging hell [the youth worker] was there for. [The youth worker] didn’t do anything to be honest. Me and [the information advisor] go back a long way … I knew her when I was at school so me and her have got that kind of close friendship like we can always chat, and if I went in there today she’d be “Ooh ’ello! ’Ow you doin?’ ” sort of thing. But they’re all trying to focus on all different aspects of my life, whereas you were trying to sort out my drugs and alcohol, [the information advisor] was trying to do one thing, [the housing support worker] was trying to do another, and everyone was trying to do something else and no-one was caring about how I felt inside and how I was reacting with stuff. Whereas your team, they kind of cared about what was going on in my life and how things were going and where things were going as such.
W: So different people were trying to do different bits …
T: Whereas the main important thing nobody really cared about, apart from your team.
W: How did you feel about how I spoke to [the housing support worker], your GP, and [the youth workers]?
T: You did a brilliant job ’cos like I’d go into my doctor’s—if I had to sort out my PIP [Personal Independence Payment] claim, say—you’d write a letter. We had your support—the whole team’s support—and I think that kind of influenced a lot of people into helping me, which kind of helped a lot.
W: Did you feel like … it sounds like in the beginning …
T: … It was all quite muddly.
W: Did you feel like it got a bit clearer? Do you remember we all met? (p. 307)
T: Yeah, that was with you, [the housing support worker], [the youth worker], [the information advisor], mum, dad, [the housing manager].
W: Did that help the muddle?
T: To be honest, at that point I was either tired, stoned, or drunk. I don’t know, but either way I don’t think I paid attention to that meeting. I think I was like “Ah, piss off, dickhead” and all the rest of it. I don’t think I paid much attention to that meeting. If we had that meeting now, I think it would be a very, very, very different occasion.
W: Do you think the process of getting everyone together was helpful?
T: It was helpful, but it was a pain in the ass, getting everyone in the same room on the same day.
W: Did any of the work that we did, or conversations we had, change the way you think, change the way you think about these things?
T: In which aspect?
W: In any aspect.
T: It did. I think it taught me to self-evaluate my life. So, I think we’ve already spoke about this earlier, but … when I was going through a hard time you sort of helped me, sort of “Right, just step back, evaluate your life and see what’s going on” and I think at that point I did actually do it and it kind of “Wow, not everything is what it seemed.”
W: So almost like a stepping outside and looking at yourself from the outside?
T: Yeah, and that was without drugs!
W: Did it change the way you think about or look at other people?
T: What do you mean by that?
W: Well you said you started to look at yourself from the outside, did you start to think more carefully about people?
T: No—to be quite honest. I think a lot of it was that I needed to sort myself out before I could help other people.
W: Yeah. Did anything we talked about help you to understand other people and what they do?
T: No, I never understand people in general! People in general are weirdos.
W: Did you know what I was thinking?
T: Pretty much. I think your aspect of it was “Sort your life out! Seriously,” you’re a good person, you’re a nice person.
W: How did you know what I thought? (p. 308)
T: I think a lot of the time it was sort of—not aggressive—but sort of you just wanted me to succeed. I think a lot of people don’t show that, like, they don’t show that “I want you to succeed.” I mean a lot of my friends are like “Why don’t you get a fucking job, you lazy bastard?” and it’s like … ahh … I’m trying to sort myself and I don’t want to hear it, I don’t really care for “You’re a lazy bastard.” But I think the way that they put it, and the way that you put it, it’s not the same. But I think you’ve both got the same intentions. Of trying to help me out, trying to sort me out, try to get a job, try to get a life. And yeah I think they cared as much as you cared but they say it differently.
W: Oh that’s interesting, so you do think about their intentions?
T: Yeah I do think about their intentions. I question it.
W: So how did you know what my intentions were?
T: I didn’t. But over the last three or four months, since we’ve not spoken, I’ve thought a lot about it. And I think, look! I think I thought about the way you kind of tried to help me sort my life out, have a better life in general.
W: You said you knew my intention was to help you. Does that have to do with how you knew you could trust me?
T: Yeah. I don’t know what it is and it’s weird, but as a person normally you can tell . . . from people’s body language. And I think your body language was sort of “I want you to succeed, I want you to have everything that you want. But I can’t make those decisions for you … you’ve got to make those decisions on what you do and how you play your life out.”
W: I wonder what my body language was?
T: Ah, that would be telling!
W: I’m really interested in this … do you think you would be able to tell a worker who was just like …
T: If someone walked in now you could tell from their body language whether they were angry, sad, happy. Do you know what I mean? It’s the way that they walk, their posture, their presence. You feel a vibe off them, and the vibe I got off of you was “I want to help you. I want you to sort your life out and have a good life.”
W: Do you know what the body language was?
T: It’s hard to explain. It was a mixture of … how do I put it … “I want you to succeed. I want you to enjoy life.” It’s just weird, I can tell but I can’t explain it. I think it’s your self-confidence, the way you were happy all the time, that helped me out a lot. You’re a happy person. (p. 309)
W: Do you remember that time when you’d had a bad night the night before and you’d been hitting the wall with the bar from your weights … and I came round and you started to tell me, and you picked up the metal bar thing …
T: Yeah and you started to get nervous.
W: Yeah, and I said let’s go out for a walk. Do you remember that day?
T: Yeah. I do. Shit. I remember that day quite well. And I think after that day I kinda stopped drinking as much, because I think I was quite heavily intoxicated from the day before and going for that walk I think that calmed me down a bit and stopped the whole anger and the “grrrrr” in me and I think ’cos—to be quite honest—I’ve not had a proper beat-the-crap-out-of-someone fight in years, I’ve had fights …
W: Do you remember what I said?
T: I can’t remember. We walked down the side of the river bank.
W: You remember that I told you it made me a bit …
T: I know it made you nervous, not nervous, more … I don’t know, scared? Is that the word?
W: Yeah, a little bit. What impact did that conversation have?
T: There’s one thing that you need to know, right, I would never ever hit a woman. I don’t agree with it. I think that any man that lays his hands on a woman is a fucking coward. But I think that day someone had riled me up and I was proper on one and I think I’ve not been like that for a little while because I’ve calmed myself down. I smoke weed, but I don’t drink as much. The impact had a chain reaction, as such. Sort of, that day that I noticed that I scared you, it kind of hit home that “You don’t go getting violent in front of a woman. It’s not right and you shouldn’t do it.” I think that’s what stopped me from smacking [X’s mum] in the face later, ’cos I think I had a flashback of that day with you, and I did think … I was gonna, I was SO gonna. I never had a woman square up to me like that . . . but even though she starts tearing my hair out I just pulled away and said “Get lost, just go away. I don’t fancy punching you.”
W: You had a flashback to our conversation and that stopped you?
T: Yeah. I was like “Woah!”… This might sound sexist … women aren’t as physically strong as men, they have their own strengths … but a lot of women are more vulnerable than men.
W: So although you said you’re as impulsive as ever, you did think before acting then? (p. 310)
T: Yeah, there’s a first time for everything. If I’d have hit her, I wouldn’t be here today. I don’t know if he would, I don’t know if he wouldn’t, but her sister’s husband is a massive-time traveler, and his sons would set fire to you … He’s lumped me one, because he’s her sister’s husband.
W: On that day, for you to be able to stop and think … that really made a difference.
T: Yeah. Part of it was as I was getting tensed up I was like … just breeeathe. And calm down a little bit. And she was getting in my face and I was like … arghhh … my hands were tensing and [X] and [Y] saw it … The thing is [my brother] was on her side … I had a go at him about that the other day … “What sort of family are you—not to back your own up, but you’ll back her up instead? I’ve been there through everything with you and you’ve just gone ‘fuck off’ pretty much. That’s the way it felt.” And he said: “That’s not what it meant” and I said “That’s what it felt like.”
W: It’s good you were able to tell him how it felt.
T: Yeah, if you don’t tell him, how’s he supposed to know? It’s the same with everyone. No-one’s a mind reader. If you’ve got a problem with someone, bring it up. Talk about it.
W: So in that moment were you able to do that—“look at it from the outside” thing?
T: No. If I’d have done that I’d have walked away a long time before in that argument!
W: Yeah, it’s hard. Is there anything else you want to say?
T: Thank you?
W: Ah, you don’t have to say that.
T: No I do, because you’ve made a massive impact on my life. It helped me a lot and do you know, honestly to god I wouldn’t be here today if it wasn’t for [the YPSUS team]. Suicide. There was a few times I thought about my ex-girlfriend and all the rest of it and I’d try and slit my wrists and … bad times … But now everything’s good.
W: Are there any other particular conversations or sessions we had that stand out?
T: Ooh. There’s been millions of conversations. The one when I was in KFC. We sat in the car at KFC. We had a massive conversation about my mum and dad and the way that … sort of … the drugs doesn’t help and stuff. That helped.
W: Do you remember what it was about? (p. 311)
T: I think a lot of it was about how … not you saying this, but me … I was sort of saying “I only get one set of parents” and you said “Well that is very true” sort of thing, and you were very supportive when I was going through a bad time and I think that helped quite a bit.
W: OK, and that stands out?
T: It stands out because there’s not many out there who are willing to help someone like myself and other people who are in my predicament.
It’s your presence. Just you being there. When you’ve got someone like yourself who is willing to take your time up to sort of sit in a car, buy me some food, have a chat … it’s brilliant. It’s absolutely brilliant. I could go from being depressed, hate myself, being miserable and then I’ll talk to you and that will give me a buzz for a few days like “la la la” and then something will happen again and then I’ll see you and it’ll be like “la la la la la” again and that’s how it would go. I like talking to people—my own company scared me. If I sit here, I’ll think. And if I sit here and think, shit just comes back and it just hits me like a ton of bricks and I’ll be like miserable for days. Until somebody talks to me and then I’ll be like “ho ho hum” … sort of doodling along as I go through life.
W: Was there anything I did … and it’s OK to say this … that made you cross? Or didn’t feel helpful?
W: What about like …
T: No no no, with me I’ve always been brought up … be upfront about it … if you don’t like something, tell people how you feel. Don’t hold it back.
There was one day … I don’t think that it was the case that you were angry … there was a day I told you I’d used cocaine and it was anger, it was disappointment. Always disappointment with you. It was a case of “Oh really? You didn’t really need to do it” … It’s not your fault … it was a case of you’re disappointed because you want to see me succeed.
W: How did you know it was that?
T: Body language. You were sort of “Ah really …?”
W: It sounds like you’re getting better at working out what’s going on for people?
W: I’m interested in this. How you know my intentions were good? Do you think you’ve got better at that?
T: Reading people? Definitely.
W: Do you do that more with your parents now? (p. 312)
T: No. With my family it’s like bleeehhghh!
W: What about your friends?
T: Yeah … and I’m better at knowing what I do that annoys people … I’m better at reading people and it means I’m better at not annoying people … but also if I really want to piss people off, I’m better at that too!
W: So, understanding what you do that pisses people off helps you to not do it …
T: And it also means I can do it really well! [laughs]
W: Thank you for talking about all this.
T: No, thank you.
W: Is there anything else that stood out about [YPSUS]?
T: No … I think we’ve talked about everything to be honest.
Commentary by worker
Thomas referred himself to the substance use team having met one of the team’s support workers at an outreach event. At the time he was 18 years old and under the care of an adult substance use service, but wasn’t turning up to his appointments there. The age criteria for the local adult service and the young people’s substance use team are deliberately designed to overlap, with both services accepting 18- to 21-year-olds. Services were commissioned in this way with the intention of enabling vulnerable young people to access care from the service most appropriate for their individual needs, in recognition of the difficulties many young people experience in accessing services primarily designed for older adults. After a period of discussion and liaison, it was agreed that Thomas’s needs were not being best met in the adult service, and his care was transferred to the young person’s substance use service (here referred to as YPSUS). At that time, Thomas was using multiple substances:
“I was smoking a lot of cannabis. I was doing speed, cocaine, all sorts of other drugs. Never nothing hard like heroin, it was just stupid party drugs. Just going out and getting drunk all the time. Having house parties at my house. My house used to get trashed and I didn’t care because I was always off my face. My life was miserable, depressing.”
In addition to the substance use, Thomas had numerous difficulties across multiple domains of his life: he was living independently after his relationship with his parents had broken down, and was struggling with independent living skills; he was a carer to his older brother; he had mental health problems (post-traumatic symptoms, anxiety, and depression); and he was seen by professionals (p. 313) as vulnerable to exploitation. The parties at Thomas’s house became a problem. His house became a place for local youths to drink and use drugs, and police were called out on several occasions to respond to the antisocial behaviour of his peers. Consequently, he was at risk of eviction. His house got “trashed,” as he describes above, and—worse—his acquaintances stole from him:
“I had house robberies. I’ve had people walk in my house with samurai swords and stuff like that . . . that was the PTSD.”
Thomas’s post-traumatic stress disorder related to events in his earlier childhood. He had also been low in mood for several years, and had been diagnosed with ADHD at a young age. He had been treated with pharmacological and psychosocial interventions by Child and Adolescent Mental Health Services (CAMHS) but was lost to follow-up after turning 17 years of age. In Thomas’s case the most significant gap in services resulted from the lack of any local service for adults with ADHD to be transitioned to from CAMHS. Thomas transitioned instead on to a general adult mental health service waiting list, but moved address—becoming unreachable—before reaching the top of the list. He had fallen out of the education system too. He had had a chequered academic career, having been excluded from multiple educational placements, and at the time of referral he was “NEET” (not in education, employment, or training).
Thomas now—demonstrating his capacity to mentalize—has some ideas about how and why things might have become particularly difficult toward the end of his adolescence. He describes caring for his older brother, who was permanently disabled by an accident:
“My brother was trying to commit suicide and I had that all on my shoulders as well. I think the case of looking after my brother from the age of 16 didn’t really help. Once my brother got his new girlfriend I kind of went out and just got absolutely shit-faced because I knew that I could leave him in safe hands. So I just kind of let off a lot of steam, because at the age of 16 … normal sort of 16-year-olds are going out and getting shit-faced and using drugs. And when I was 16 I was looking after my brother, so by the age of 19 I was sort of thinking I was 16 because I didn’t get to have that whole ‘kid getting drunk and having drugs and stuff’. And … experimenting with drugs and alcohol, and I think it just went wildly out of control. Really quickly.”
Working with your client
Building a relationship
Thomas describes his trepidation about meeting a new professional after his self-referral to the substance use team:
“At first seeing [the team] was nerve-wracking because I didn’t know the person and I get really wary around other people.”
(p. 314) It is not a surprise that Thomas felt this way. To minimize this anxiety associated with building new relationships, and based on the AMBIT principle of the primacy of the keyworker relationship, the YPSUS developed a policy that wherever possible the same worker offering the initial assessment goes on to become the allocated keyworker within the service. The establishment of this relationship is an essential task in the initial phase of AMBIT work (see Chapter 3). Previously, there had been more separation between the processes of assessment and treatment, and these were often carried out by different people. This is just a small example of the kind of “local adaptations” that AMBIT encourages teams to make, incrementally trying to improve their offer of help through a judicious balancing of evidence-based practice (where it exists) with respect for local practice and expertise (or practice-based evidence.) This policy seeks to minimize the risk of frustration or being overwhelmed by requirements to relate to multiple new professionals—not least the risk that in the moment of crisis when assessment often occurs, a young person begins to build a degree of (epistemic) trust with the assessing worker, only to have to start from scratch with another worker if accepted into treatment. Importantly, the intention behind this policy is communicated to young people from the outset. This approach is certainly not unique, but is in contrast to some other service models, which prioritize flow and effectiveness by ensuring timely assessment by one worker, followed by allocation to another worker for intervention. Of course, there are benefits to the latter model, but we suggest that these are mainly for young people who are able to tolerate multiple workers.
Thomas noticed the difference in service design between the substance use service and other services in terms of the immediate allocation of a single worker:
“I think with [other services] and stuff like that, there’s a lot of people to handle. Whereas [the substance use team] sort of go one on one and they do help you.”
Thomas talks about the relationship with his keyworker developing over time, despite his initial fears:
“As time went on I got to know you and become quite good sort of friends, as such. And all in all you kind of really did help me quite a bit.”
Asked what had made it possible for this to happen, and what was different between this relationship and other relationships he had had with professionals, Thomas referred to the development of trust in the relationship:
“It was somebody I could trust. With somebody that’s had a lot of trust issues—it’s a case of people screwing him over and nicking stuff of his and it’s—it’s definitely an element of trust (p. 315) issues. And as [my keyworker] came in I didn’t trust [her] but then as time grew on I come to trust [her] and sort of—[she] looked out for me, sort of thing.”
He has some ideas about what made it possible for him to trust his keyworker over time:
“I could tell [her] stuff and just get it all off my chest and [she] wouldn’t—unless it was I was going to harm somebody, and then [she’d] have to tell somebody because there’s certain protocols in place—but other than that it was confidentiality and I think that did help a lot.”
“The food and that. The munch. Taking me to KFC and that. That was awesome. It was a case of—even when I had no food it was like ‘Come on then, let’s go and get some coffee’ or ‘Let’s go out,’ just get me out of the house, ’cos being in the house too long can sort of mess with your head a little bit, so that kind of helped in another way. [She] wanted to get me out of the house.”
Here, Thomas describes his own perspective on what, in the keyworker’s mind, was an explicit effort to offer contingent care based on sensitive attunement to his current perception of his needs and his mental state. The worker’s efforts to achieve and sustain this attunement were directed by the goal of generating the experience for Thomas that his worker was someone offering help with a good “fit” with his perception of reality (see Chapter 4). This in turn supports the development of epistemic trust—trust in communication from another—which we understand as the cornerstone of helping relationships (see Chapter 2). Of course, there is potentially a circularity here: do we become helpful (i.e. effect meaningful change) when our clients have learned to trust us, or do our clients begin to trust people who have first been helpful to them (i.e. those who have actually effected meaningful change)? There is evidence suggesting that this relationship between alliance and outcomes works in both directions, but here we are stressing the former, as we see this as the first barrier to effective work. In support of this, Falkenstrom et al. (2013) found that positive measures of therapeutic alliance in one session predicted positive clinical outcomes in the next session.
In the scenarios described by Thomas, the keyworker was operating on a pre-existing plan for the sessions—perhaps trauma-focused work, or psychoeducation around substances—but, upon finding that Thomas had not eaten properly for several days, or was agitated after being alone in the house, needed to adjust these plans. Balancing adherence to pre-existing plans for care (interventions designed to tackle “upstream” difficulties nearer the “source”) with sensitive attunement to issues in the here and now may have multiple benefits (this is described in Chapter 3—“Active Planning”).
In the example of the keyworker taking Thomas to get some food when he had not eaten, there are long-term benefits from offering the experience of (p. 316) sensitive attunement and so supporting the development of epistemic trust. For Thomas, this attention to his needs was important, and facilitated the development of trust because:
“throughout my life I’ve not had a lot of people who care about me and that showed that [she] cared, which I don’t think a lot of [workers] would do.”
Asked if that helped him to trust his keyworker, Thomas replied:
In addition, however, and in the more immediate term, getting some food for Thomas may have supported the effectiveness of the pre-existing intervention plan. Still hungry, Thomas’s capacity to mentalize and to engage helpfully in the planned intervention would most likely be very low. Once fed, however, he and his keyworker were more able to return to the planned interventions. Creating a small budget to facilitate such flexibility is another example of adaptation, and was justified to commissioners on the grounds that this is a very small investment compared with the cost of a wasted session.
In addition to (or perhaps supportive of) being able to trust his keyworker, other aspects of the relationship with his keyworker and the wider team were important to Thomas:
“It’s [the keyworker’s] presence, just [them] being there. When you’ve got someone like that who is willing to take [their] time up to sort of sit in a car, buy me some food, have a chat … it’s brilliant. It’s absolutely brilliant.”
He spoke particularly of the importance of being able to get hold of someone when he needed to:
“It’s not like a GP who you sort of go to. You knew [YPSUS] were there if you needed them, the other end of a phone call. With doctors, my doctors especially, you ring up and not that I’ve ever done it … you’re bleeding from your arms and it takes four hours to get through to them. Whereas if I left [my keyworker] a message, the next day [she’d] get back. It was quick. If I needed to talk about something it was “OK then, we’ll sort it out” right there, as and when [the keyworker] knew what was happening. And the doctors on the other hand, when I had blackouts and I couldn’t remember anything, [my keyworker] got on the phone to [the YPSUS doctor]. Next two to three days, there was a prescription waiting. “There you go, sort yourself out mate.” It was a kind and friendly service sort of thing. Always polite, always nice. Don’t get me wrong, you can get some snotty doctors out there, do you know what I mean?”
Thomas talks about how the work he did with his keyworker resulted in some changes in the way he thinks:
“I think it taught me to self-evaluate my life … When I was going through a hard time [my keyworker] sort of helped me, sort of ‘Right, just step back, evaluate your life and see what’s going on’ and I think at that point I did actually do it and it kind of ‘Wow, not everything is what it seemed.’ ”
This encouragement to “step back” and “self-evaluate” is Thomas’s account of his keyworker’s efforts to promote mentalizing. Thomas also refers to improvements in his ability to try to make sense of others. Talking about the intentions of different people who have tried to help him, he demonstrates his capacity to think about the intentions that underlie the behaviours of others:
“I think a lot of the time it was sort of—not aggressive—but sort of [my keyworker] just wanted me to succeed. I think a lot of people don’t show that, like, they don’t show that ‘I want you to succeed’. I mean a lot of my friends are like ‘Why don’t you get a fucking job, you lazy bastard?’ and it’s like … ahh … I’m trying to sort myself and I don’t want to hear it, I don’t really care for ‘You’re a lazy bastard.’ But I think the way that they put it, and the way that [my keyworker] put it, it’s not the same. But I think [they’ve] both got the same intentions. Of trying to help me out, trying to sort me out, try to get a job, try to get a life. And yeah I think they cared as much as [my keyworker] cared, but they say it differently … Yeah I do think about their intentions. I question it.”
Thomas talked about how one does this:
“If someone walked in now you could tell from their body language whether they were angry, sad, happy. Do you know what I mean? It’s the way that they walk, their posture, their presence. You feel a vibe off them. It’s hard to explain.”
Thomas recognizes that making sense of others is more difficult in some situations:
“With my family it’s like bleeehhghh!”
However, he talks about his efforts to help his brother to mentalize him following an argument in which Thomas felt his brother was on the other party’s side:
“I had a go at him about that the other day … ‘What sort of family are you—not to back your own up, but you’ll back her up? I’ve been there through everything with you and you’ve just gone “fuck off” pretty much. That’s the way it felt’. And he said ‘That’s not what it meant’ and I said ‘That’s what it felt like’… If you don’t tell him, how’s he supposed to know? It’s the same with everyone. No-one’s a mind reader. If you’ve got a problem with someone, bring it up. Talk about it.”
Interestingly, Thomas recognizes that the ability to mentalize people more accurately can be used toward both good and bad ends:
“I’m better at knowing what I do that annoys people … I’m better at reading people and it means I’m better at not annoying people … but also if I really want to piss people off, I’m better at that too! [Understanding what pisses people off] also means I can do it really well!”
(p. 318) Broadcasting intentions
Thomas recalls a particular session in which his keyworker shared her thinking and feelings out loud (see “Broadcasting Intentions” in Chapters 3 and 4). His keyworker had arrived at Thomas’s house for a scheduled session that day to find holes all over one of the walls of his sitting room. Thomas explained that he had become very upset the night before and had picked up a metal pole and repeatedly hit the wall, creating large holes in the plaster. As he recounted his distress from the night before and the incident that had caused it, he became increasingly agitated and he demonstrated his story by picking up the pole and swinging it around in front of the keyworker. Wishing to ensure her own safety, and to punctuate Thomas’s non-mentalizing state of mind, she suggested that she and Thomas go for a walk, having observed in the past that this was an effective way for Thomas to reduce his emotional arousal and restore his mentalizing. According to Thomas:
“We walked down the side of the river bank … Going for that walk I think that calmed me down a bit and stopped the whole anger and the ‘grrrrr’ in me.”
Once Thomas was calmer, his keyworker asked Thomas to mentalize her by asking how he thought she might have felt when he was shouting and swinging the metal bar around in front of her. He wondered whether it had scared her, and she shared with him that it had, a little:
“I know it made [her] nervous, not nervous, more … I don’t know, scared? Is that the word?”
Thomas talks about the impact of that realization:
“I remember that day quite well. And I think after that day I kinda stopped drinking as much, because I think I was quite heavily intoxicated from the day before … I think that day someone had riled me up and I was proper on one and I think I’ve not been like that for a little while now because I’ve calmed myself down … The impact had a chain reaction, as such. Sort of, that day that I noticed that I scared [my keyworker], it kind of hit home that ‘You don’t go getting violent in front of a woman. It’s not right and you shouldn’t do it.’ ”
Most interestingly, Thomas talks about generalizing this learning, from a session with his keyworker over a year ago, to a recent incident in which he was in a confrontational interaction with another older woman:
“I think that’s what stopped me from smacking [her] in the face, ’cos I think I had a flashback of that day with [my keyworker] and I did think … I was gonna, I was SO gonna. I never had a woman square up to me like that . . . but even though she starts tearing my hair out I just … ‘Get lost, just go away. I don’t fancy punching you’… I was like ‘Woah!’… This might sound sexist … women aren’t as physically strong as men, they have their own strengths … but a lot of women are more vulnerable than men.”
(p. 319) Thomas reflects on how the situation impacted upon his own mental state, and how he noticed this and recognized the need to manage it before being able to think in a different way:
“Part of it was as I was getting tensed up. I was like … just breaaathe. And calm down a little bit. She was getting in my face and I was like … ‘arghhh’… my hands were tensing.”
We do not think we are reading too much into what Thomas describes here to say that this describes the beginnings of a change now generalizing beyond the specific relationship with his keyworker where this new understanding was first articulated. Thomas describes the signs of an emerging capacity for conscious inhibition of violent impulses, and this seems to have been mediated by the earlier experience of explicitly mentalizing fear in another (trusted) person, his keyworker, which was neither repudiated by her nor resulted in reciprocal threats or recriminations. Perhaps, during that “mentalizing walk,” Thomas also recognized that his keyworker had, on her part, also been able to mentalize his own distress at having caused her fear (unintentionally, it would seem), and she had been able to use this understanding in a way that he experienced as benign, contingent, and understanding. It is this recognition of self, as it is represented accurately in the mind of the other, that is the key to epistemic trust.
A key task for an AMBIT-influenced team, which supports the Ending Phase (see Chapter 3), is the practice of scaffolding existing relationships. As described in Chapter 4, this element of the principled AMBIT stance describes explicit efforts by the keyworker to help strengthen or build around the client a reasonably reliable and sustainable network of relationships that is able to provide ongoing support and help. For Thomas, this work commenced quite early in the intervention journey, through family work, with the aim of bolstering Thomas’s resources and resilience, and reducing the likelihood that family conflict would destabilize things. The aim was to create the capacity for him to maintain improvements in his wellbeing beyond the ending of his relationship with his keyworker.
Of his relationships with his family members, Thomas says:
“I think [my keyworker has] repaired the relationships a little bit, because me and my mum and my dad are actually talking now, whereas before we wasn’t. And I think also [mum and dad] respected the fact that I got help for what I had—taking drugs and stuff. I think it’s because I got help with it, that they started talking to me. Because, with drugs, there is an element of trust with family members.
Recently my dad’s been in hospital, sort of thing—he had a kidney infection—I think I walked into the hospital and the first thing I done was I give my dad a cuddle—and it’s a weird thing because my dad and I never got on. We’ve always had our problems, but just (p. 320) in a serious sort of context like that, it’s sort of, it’s called for. And I know it’s weird because man being man—it’s sort of pride, and … but I don’t care about that. I just care about my family. I love my mum and my dad and my brother and sister. Don’t get me wrong, they’re all douchebags at some points in their life but I still love them and I just want them all to get on.”
“Slowly fizzling out”
Reflecting on what was different about his engagement with his YPSUS keyworker compared with other relationships with professionals in the past, Thomas referred to differences in the amount of time dedicated to the Ending Phase of the relationship:
“I think I’ve had this sort of relationship before but it was kind of ‘get me to a certain point then drop me from a height’. So a lot of people sort of … they’d get me over what needed to be done, and then that was it. But [my YPSUS keyworker] kind of did what needed to be done and sort of … slowly fizzled it out, not just dropped me as and when I’d finished doing what I needed to do. So that kind of helped a lot.”
Chapter 3 details the critical importance of the Ending Phase of AMBIT work, and how preparation for that ending starts at the beginning of the relationship. Thomas refers to previous helping relationships that he thinks ended rather too suddenly, dropping him “from a height” upon completion of care plan goals. Mentalizing Thomas for a moment, we wonder whether such an experience of ending being perceived as too sudden may have been particularly bruising for him after the painful breakdown in his relationship with his parents, resulting in him being asked to leave home. Thomas refers to having “this sort” of relationship with other workers prior to his contact with the YPSUS keyworker, so we can suppose that significant attachments were formed in those relationships. If that is so, then it is not surprising that he experienced the abrupt end of those relationships as having been “dropped.”
Thomas’s perception that his work with his keyworker “slowly fizzled out” may have a basis in two intentional practices undertaken by the keyworker. First, the prospect of the inevitable ending of the work was discussed explicitly from very early on in the relationship, making it clear that a good attachment was desirable, but in pursuit of particular goals for Thomas, and thus time-limited. Second, the intensity of intervention was tapered off slowly toward the end of Thomas’s engagement with the service. Once care plan goals were more or less achieved, the focus of the work shifted toward maintenance, and weekly appointments became fortnightly, then three-weekly, and so on, over a period of several months.
Working with your team
Much of Thomas’s testimony about his experience of the AMBIT-influenced substance use team revolves around his relationship with his keyworker, rather (p. 321) than his experience of specific interventions or of the functioning of the team as a whole. Given AMBIT’s emphasis on the centrality of a secure relationship with a keyworker, this is perhaps unsurprising, or at least reassuring.
However, as we have learned in Chapter 5, successfully establishing a powerful keyworking relationship is not without risk. Describing his relationship with his keyworker, Thomas said that, after initial distrust on his part, they became “sort of friends,” indicating perhaps a degree of rapport that was different from, but reminded him of, friendship. We hypothesize that this was a key ingredient in Thomas’s progress, for the reasons outlined above. However, this degree of “closeness” to Thomas’s own difficulties and distress also impacted upon his keyworker’s own state of mind, putting at risk her capacity to mentalize both herself and Thomas, and thus, ultimately, her capacity to be as helpful as possible to Thomas. AMBIT stresses the importance of the keyworker being “well connected to the team” to counter such risks. This phrase describes not just a culture of “team support” but of quite explicit efforts by team members to support one another’s mentalizing capacity in this anxiety-provoking work. Home visits, conversations in cars and in fast-food establishments, and walks by the river characterize the kind of outreach work Thomas’s keyworker engaged in with him. This may have been key in supporting and maintaining his engagement in treatment, but also required the keyworker to work autonomously, often quite isolated from her team.
The YPSUS team uses a number of the team-based techniques outlined in Chapter 5. Team members encourage a strong culture of explicit help-seeking between colleagues. The Thinking Together process is used both informally and more formally in weekly group supervision. Much of this work goes on “behind the scenes” from the client’s perspective, but YPSUS also makes efforts to share something of its team approach quite explicitly with clients.
Thinking Together between the worker and another team member is sometimes conducted in front of the client in the same room (not dissimilar to systemic therapists’ use of a “reflecting team”). Alternatively, it may take place via a mobile phone switched to loudspeaker mode, so that the client can listen in and contribute as they see fit. In such circumstances, the keyworker does make it clear to the client that this is a conversation primarily designed around themself as a worker getting help (ensuring a plan is sound, developing new ideas, balancing risk with care, etc.); the invitation to listen is so that the client has access to this thinking in a transparent way, and, although they are welcome to join the conversation, they should not feel obliged to contribute. Thoughts or “take-home messages” from team conversations about a client’s predicament are shared with the client by the keyworker, mentioning team members who have helped move thinking forward by name, where possible. This models a (p. 322) positive relationship to help—that workers, like anyone, can be helped to better understand things or to gain fresh perspectives by thinking things through with trusted others. It also marks the keyworker–client relationship as a helping relationship, and not an “exclusive” friendship or any other category of relationship.
Asked about his experience of knowing that his keyworker had access to a team of people who helped her to help him, Thomas explained that:
“I was quite surprised that a team like [YPSUS]—they’re caring; they want to see the best in the person, they want to make that person a better person than when they first walked through the door.”
It is interesting to note that here Thomas describes, and attributes shared intentions to, a team of people he either has not met, or has met on only a handful of occasions. Separately, Thomas referred to his experience of meeting another member of the team who was observing the practice of his keyworker (for training purposes):
“I think when I saw [the other team member and the keyworker they] were both on the same lines, exactly, which is kind of weird because you normally have two people who are two completely different people. But you was both on the same kind of lines. You were both caring, you both sort of wanted to help.”
In this brief anecdote Thomas finds these two workers to be “on the same lines,” and the hope is that his observations and description reflect the effect of a team with a developed culture around shared understandings of mentalizing, and explicit efforts in practice to adopt a mentalizing stance.
Working with your networks
“Not just drugs and alcohol”
When Thomas referred himself to the substance use team he had problems in multiple domains of his functioning: he was using drugs and alcohol in risky ways; was getting into fights and had close calls with the police; was struggling to live independently after being thrown out of home; was being exploited by others who used his flat as a place to use drugs; had a difficult relationship with his parents, with infrequent contact characterized by conflict; was low in mood; had untreated ADHD; was not in employment, education, or training (NEET); was caring for his brother; and had unmet physical health needs (his eczema was flaring up, he needed new glasses, and he experienced significant dental pain). It would have been hard to claim that any single difficulty was the “primary problem.” Rather, these difficulties were interacting synergistically. For example, Thomas managed his distress arising from relationship difficulties and caring responsibilities by using drugs and alcohol—and his drug and alcohol use led to further conflict with his parents. Impulsivity resulting from (p. 323) ADHD made it harder for Thomas to manage his money, and he was often without food and in debt to his landlord. This in turn became a further stressor, maintaining his low mood and substance use, and so on. When Thomas first referred himself to the substance use team it felt, he said, like he had a “mountain” to climb to get back on track.
He appreciated that the substance use team were interested in the whole picture, despite their relatively narrow “formal” area of speciality and responsibility:
“[YPSUS] muddle through your problems and help you out with other stuff as well. So it’s not just drugs and alcohol, it’s other stuff as well.”
As is commonly the case for young people who have multiple difficulties, Thomas had multiple named workers, across multiple agencies:
“I was seeing [the housing support worker], [the adult drug service], [the youth worker], [the information advisor], and my GP. I was on the waiting list for adult mental health services.”
Navigating this network of support was not plain sailing:
“It was alright but they kind of … I think a lot of them were sort of … they were trying to get me into a job … more than trying to sort my personal health out. So I think [my housing support worker] was trying to get me into another house or at least get me ready for moving on to the next house. [The information advisor] was trying to get me into a job. [The youth worker] was trying to … to be honest I don’t know what the frigging hell [the youth worker] was there for. [The youth worker] didn’t do anything to be honest … But they’re all trying to focus on all different aspects of my life, whereas you were trying to sort out my drugs and alcohol, [the information advisor] was trying to do one thing, [the housing support worker] was trying to do another and everyone was trying to do something else and no-one was caring about how I felt inside and how I was reacting with stuff.”
AMBIT holds as a core assumption that, when young people have multiple problems and thus multiple workers are involved, the kind of dis-integration described by Thomas above is the norm. Thomas describes a number of workers, each—we can assume—with good intentions but with different priorities, although it appears that Thomas was not clear on what exactly the priority was for the youth worker. Again, we suggest that it is not unusual for a client and/or their family to be unclear about the priorities or the role of one or more workers in a crowded network. As Thomas says:
“It was all quite muddly.”
Thomas had clear substance use needs, and it would have been reasonable to agree a transfer of responsibility for Thomas’s substance use care from the adult (p. 324) substance use service (with whom he was struggling to engage) and for YPSUS to offer straightforward substance use interventions in its place. However, it was not obvious that adding an additional worker, or new interventions, to the muddle was going to be helpful to Thomas’s overall wellbeing where other well-intentioned and very capable workers were struggling to be effective.
It appeared that workers were each pulling in different directions—directions that were all ostensibly reasonable and helpful when considered individually, but in combination were ill-sequenced and even contradictory. This was not due to lack of communication between the parties. On the contrary, the network was reasonably well functioning in that, on the whole, workers were aware of one another’s involvement, roles, and planned interventions. There was plenty of communication in terms of keeping one another up to date about their involvement and Thomas’s progress. What was lacking, from an AMBIT viewpoint, was explicit sharing by workers with one another of (a) how they understood the nature of Thomas’s difficulties, and (b) how they thought their combined interventions would fit together or be experienced by Thomas.
So, rather than adding to the dis-integration by immediately offering another worker and further interventions, risking at best not being very helpful, or at worst, causing damage to the existing network and Thomas’s wellbeing, Thomas’s keyworker decided first to intervene (with Thomas’s permission) at the wider network level. This work started with mapping out a Dis-Integration Grid (see Chapter 6) with Thomas, then writing a letter to all involved parties to share Thomas’s and the keyworker’s understanding of the current situation and suggesting that it might be helpful for a new meeting to be arranged by the lead professional for all to share ideas about how best to deliver and sequence interventions. This was offered as a view from “the edge of the pond,” with great care taken to maintain the stance of “Respect for local practice and expertise.” The underlying assumption in this communication was that Thomas, his family, and existing professionals in the network were best placed to make such decisions, rather than the “Johnny-come-lately” substance use team keyworker.
This meeting took place and the professionals involved agreed that it would be helpful to sequence interventions intelligently, based on priority (e.g. first addressing problems that were a risk to Thomas’s immediate safety) and a shared understanding of the primary direction of influence between Thomas’s different problems (e.g. helping Thomas to manage his agitation and ADHD better before offering him a further educational placement might help to avoid setting him up for yet another failure). For some workers in the network, this meant offering less help, not more, initially. At this meeting it was also decided that Thomas’s substance use needs would be better met by YPSUS than the existing adult team, as the young person’s team had the expertise and (perhaps (p. 325) at least as important) the capacity to offer the outreach approach that Thomas was likely to benefit from. A transfer of care was therefore agreed.
Thomas does not recall getting much from this meeting himself:
“To be honest, at that point I was either tired, stoned, or drunk. I don’t know, but either way I don’t think I paid attention to that meeting. I think I was like ‘Ah, piss off, dickhead’ and all the rest of it. I don’t think I paid much attention to that meeting. If we had that meeting now I think it would be a very very very different occasion … It was helpful, but it was a pain in the ass, getting everyone in the same room on the same day.”
However, he did appreciate the different approach taken by YPSUS:
“… the main important thing nobody really cared about, apart from [YPSUS].”
“[YPSUS], they kind of cared about what was going on in my life and how things were going and where things were going as such.”
Learning at work
During the course of working with Thomas, one old and two new issues arose that stimulated discussion and reflection in the wider team in team manualization sessions (see Chapter 7). These areas of interest were by no means unique to Thomas’s case, but brought into sharper focus areas of practice that, although they may lack a powerful evidence base in literature, nonetheless shape local practice in important ways.
First, existing practice around how the YPSUS team used its small budget to provide coffee/sandwiches or other food for its clients was raised in a team meeting. Specifically, there were questions about the extent to which a worker could claim expenses for such an outlay, and how the team was justifying this outlay to its commissioners. Discussion in a team manualizing session took place, and notes on “Staff Expenses” were updated in the YPSUS team’s online manual, which included clarification about what a staff member can and cannot claim for from petty cash, and the principles behind this approach. The team clarified its understanding that the offer of food or drinks to a client is not simply a routine offer, nor even a standard “carrot” to help engagement, but instead should be specifically indicated on the grounds of (a) basic physical needs, which, if not met, would hinder mentalizing in the session (see Maslow’s hierarchy of needs; Maslow, 1943), or (b) that doing so allows the worker to demonstrate sensitive attunement specific to the situation and in keeping with the process of Active Planning (see Chapter 3).
Second, the use of text messaging between the worker and Thomas contributed to a wider discussion in the team about this, which ended with the drafting of learning points in the local online manual about how to ensure that text (p. 326) messages are properly documented, and how to clarify to clients that this is not an appropriate channel for emergencies, as they are not accessed out of hours.
Finally, this case contributed to team discussion and manualization about how a worker might judiciously share their emotions with a client in certain circumstances, and more generally describing the team’s approach to therapeutic relationships so that Thomas could describe his worker as being “like a friend,” but nonetheless remain within a firmly boundaried relationship. As a result of these discussions, a new page on “How do you answer questions inviting personal disclosure?” was created in the team’s online manual, documenting the team’s most up-to-date collective thinking about this.
Besides the general limitations of the single-case study methodology used, we must note some more specific limitations and potential for bias in this exploration of Thomas’s case. Thomas could be described now as a “happy customer” of the AMBIT-influenced team in question and, as such, although it meant that he was willing to agree to help us in writing this chapter, it also meant that he was unlikely to make negative comments about his experience (when asked by the interviewer, he said he “would not change anything” about his experience). Moreover, the interviewer was his old keyworker, and this would have made critical comments about the service he received even harder for him to offer.
We hope that, notwithstanding these limitations, something of the quality of the relationship was communicated. Of course, no case is being made for any direct causal link between Thomas’s positive outcomes and the influence of AMBIT on the team he worked with. Rather, we hope that this case study illustrates some of the principles and practices promoted by AMBIT, and explores one young man’s experience of these.
We are very grateful to Thomas for his time and generosity in helping us to write this chapter.
Falkenstrom, F., Granstrom, F., & Holmqvist, R. (2013). Therapeutic alliance predicts symptomatic improvement session by session. Journal of Counseling Psychology 60: 317–28. doi: 10.1037/a0032258Find this resource:
Maslow, A. H. (1943). A theory of human motivation. Psychological Review 50: 370–96.Find this resource: