Intensive Interaction fits within a ‘social model’ and not ‘a deficit model’ of impairment

In an eagerly anticipated*/dreaded* continuation of my last blog on Intensive Interaction being an approach that can ameliorate the level of a person’s apparent social impairment ‘in a socially mediated way’ (with the actual degree and form of social impairment itself also being co-created ‘in a socially mediated way’) ... I have been giving some further thought as to where Intensive Interaction sits philosophically within (or is parked alongside) our standard health service responses to people with learning difficulties and/or autism.

I have also spent some time wondering why Intensive Interaction still often isn’t even considered an appropriate ‘type’ of psycho-social intervention for many of the people we work with or support (despite psycho-social interventions being explicitly recommended by the UK National Institute for Health and Care Excellence  in their considered guidance for such service user groups).

One reason I think is that Intensive Interaction differs from most standard health/NHS interventions in that it isn’t seen to directly address a diagnosed or clearly defined problem (or deficit) that is identified as being of, or individualistically belonging to, the person themselves (which is most often the genesis of a referral into health or social care services).

Other interventions (many of them absolutely necessary and appropriate) do directly address some perceived problem (or deficit) in the individual person themselves e.g. psycho-pharmacological treatments, some behavioural interventions, some SLT interventions, physiotherapy treatments and sensory interventions (remember - many of them absolutely necessary and appropriate) do directly address some diagnosed or defined problem (or deficit) that is viewed as wholly residing in the individual ... and the individual is seen as just that, individualised and separate.

These types of treatments are, I believe, founded on a view of the 'person' as a bounded, individualised, cognitive, behavioural and/or sensory processing unit; with such a bounded, individualised cognitive, behavioural and/or sensory processing unit sitting between some kind of externally applied ‘stimulus in’ and some kind of processed and then expressed ‘response out’; i.e. physically, cognitively and psychologically separate, and thus physically, cognitively and psychologically separated from the rest of us.

This bounded view of a ‘person’, and their individualised problem (or deficit), is the one that dictates that each client or service user is required to follow an individualised treatment pathway or package. However this treatment pathway or package contrasts philosophically with a different view (and I think a view held by many of us Intensive Interactors) that human beings are not bounded and individualised, but are instead integrated and socially networked parts of a bigger social whole, and therefore the problem or deficit (and thus the socially mediated impairment) is diffusely situated within the social grouping, not simplistically located within the ‘individual' (i.e. as a personal characteristic of that individual).

However, many health, and I think many social care organisations can only see an individual as an individual … and perhaps this aspect of a systemic and reductionist health philosophy is actually a part of a bigger problem (or deficit) that needs addressing first!

p.s. Educational models of individualised 'learning' can also present with similar philosophical issues when contrasted with socially situated views of knowledge and skill acquisition and expression - perhaps I’ll try to touch on a bit of that in an up-coming blog ... 

Yes I know ... isn't it fascinating*/unfathomable*/too abstract by half!* 

(*delete as appropriate).

The social impairments due to Autism are co-constructed and socially mediated ... ?

At a recent training event for a Leeds schools autism support service, during an open period of discussion, I offered a rather poorly articulated view about the nature of the social impairment experienced by people with autism. The thought, again rather inelegantly expressed here, goes along the lines of:

'If an act of communication is defined as a coordinated and co-constructed activity (between two people, with a sender, a receiver, a means of sharing information and a shared topic), then surely any communication breakdown must in some way also be co-constructed (through communicative acts of either omission – things we don’t do; or commission – things we do do) i.e. the social impairment itself is to some degree socially mediated'.

Also, in trying to clarify this view I think I said something like: 

'It has become my view that the social impairments due to the developmental impacts of Autism are to some degree socially constructed, and are therefore socially mediated in their form and degree i.e. a person’s social impairment is either made more severe, or less severe, depending on the social expectations and behaviours (responsive or otherwise) of the other people they socially encounter.'

To expand on this a bit: when attempting to socially engage with some people the social impairment of one individual with autism may be almost absolute (i.e. allowing for no social interactivity to take place), but with some other, more sensitively responsive people, the social impairment experienced by the same person may be much less evident, even at times seemingly negligible. So surely we must ask: ‘where does this social impairment lie?’ From this example, not entirely as an intrinsic and individual characteristic of the person with autism.

This is not an area I feel at all expert in, but this view has developed over many years using Intensive Interaction with people with autism (in my case generally also with a learning disability) i.e. that the social impairment caused by autism is something that sits between us, and that it is therefore at least partially socially co-constructed or mediated in from and degree (and is therefore not an absolute condition in and of itself – even when it is used as an individual condition defining, diagnostic criteria).

Indeed social environments, or more accurately the people in those social environments, can make that social environment potentially more attuned and therefore potentially more socially accessible to the individual with a social impairment (e.g. by the use of Intensive Interaction) or less attuned and less socially accessible, depending on the way the person reacts or responds to the person with a diagnosed social impairment.

To recap my initial contention: although autism is clearly a defined and diagnosable characteristic of an individual, the social impairment associated with autism is not a characteristic solely of the individual with autism; it is co-constructed, in the same way that any successful interaction between two (or more) people with, or without autism, is by its very nature co-constructed.

Again I must state that I have little real legitimacy to air this view from a personal perspective, but in my professional Intensive Interaction role, having seen the manifest social impairment suffered by many individuals with autism be significantly reduced through the use of Intensive interaction, this idea of the co-construction or mediation of either successful engagement or continued socially impairment and isolation, seems to me to have useful analytic (and potentially clinical) value.

It is not the responsibility therefore of the individual with autism to change (or be changed) in some manner, or for others to demand or effect change solely in that person (to overcome a diagnosed social impairment), but instead the responsibility lies with those potential social partners around the person to adapt their pro-social behaviour to be socially inclusive of the person with autism. 

If a social impairment lies in the space between people, then so does the responsibility to reduce the potentially socially isolating impact of this impairment. If there is something we can do to make a social environment generally more ‘person-centred’ in ways that allow social access to a person with autism, (i.e. via the use of Intensive Interaction) then we have a responsibility to act in ways that do just that.

Anyway, I can't decide if this general idea is something I should develop further and submit for publication in either the 'British Journal for Stating the Bl**ding Obvious' or the 'International Journal of things that are already widely known and accepted, apparently by everyone but you!'

Although just possibly it might be right at some time to submit it for publication in the 'Journal of potentially interesting ideas that are as yet only partially developed'  ...  Hhhmm, well I suppose that all depends on what other, more informed people, make of it!

Intensive Interaction: a growing body of published evidence

Intensive Interaction is clearly built upon genuinely socially inclusive and universal humanistic values; it is highly plausible in its developed practices and principles (they are based on the most successful communication development model that there is - the infant-caregiver model), and therefore it is clearly theoretically coherent. Oh, and it is also a pleasure to do! But also rightfully, in these days of 'evidence based practice', I think it useful for us all to know that the hard 'evidence' for the claimed outcomes of Intensive Interaction approach exists.

So, lets have a quick look at some of the most epistemologically (what a word that is!) 'robust' evidence: well, across the general body of research into Intensive Interaction (summaries of 36 research and academic papers are are included in our  Intensive Interaction: published research summaries 2018 document available on the 'Intensive Interaction Users' Facebook page) there are a number of common findings of increased or novel interactive responses found across the studies - this evidence coming from a reassuringly broad range of British, European and international academic and research journals that publish peer-reviewed papers on special education, learning disabilities, disability studies, autism, language therapy, nursing, dementia and psychology. 

Listed below are some of these ‘external’, observable and therefore measurable interactive outcomes associated with Intensive Interaction interventions when compared to initial baseline measures. 

So from a number of Intensive Interaction research papers we get epistemologically (there it is again!) robust evidence of:

• increased social anticipation, initiation and/or engagement (Nind, 1996; Watson & Fisher, 1997; Kellett, 2000; Cameron & Bell, 2001; Kellett, 2003, 2004; Forster & Taylor, 2006; Anderson, 2006; Barber, 2008; Samuel et al, 2008; Zeedyk et al, 2009a; Zeedyk et al, 2009b; Jones & Howley, 2010; Fraser, 2011; Argyropoulou & Papoudi, 2012; Harris & Wolverson, 2014; Rayner et al, 2016; Calveley, 2017).

• increased toleration of, or responsiveness to physical proximity (Nind, 1996; Firth et al, 2008; Zeedyk et al, 2009a; Zeedyk et al, 2009b; Fraser, 2011; Harris & Wolverson, 2014; Calveley, 2017).

• increased levels of contingent smiling (Nind, 1996; Lovell et al, 1998; Leaning & Watson, 2006; Barber, 2008; Zeedyk et al, 2009a; Argyropoulou & Papoudi, 2012; Calveley, 2017).

• increased levels of eye contact or looking at another person’s face (Watson & Knight, 1991; Nind, 1996; Lovell et al, 1998; Kellett, 2000; Cameron & Bell, 2001; Kellett, 2003, 2004, 2005; Leaning & Watson, 2006; Forster & Taylor, 2006; Barber, 2008; Samuel et al, 2008; Zeedyk et al, 2009a; Zeedyk et al, 2009b; Fraser, 2011; Argyropoulou & Papoudi, 2012; Harris & Wolverson, 2014).

• increased use of vocalisation (Watson & Knight, 1991; Lovell et al, 1998; Kellett, 2000; Elgie & Maguire, 2001; Cameron & Bell, 2001; Argyropoulou & Papoudi, 2012; Harris & Wolverson, 2014; Calveley, 2017).

• increased levels of socially significant physical contact (Lovell et al, 1998; Elgie & Maguire, 2001; Kellett, 2000, 2003, 2004; Forster & Taylor, 2006; Firth et al, 2008; Barber, 2008;  Samuel et al, 2008; Argyropoulou & Papoudi, 2012; Harris & Wolverson, 2014; Calveley, 2017).

• improved levels of joint attention (Nind, 1996; Lovell et al, 1998; Kellett, 2000, 2003, 2004, 2005; Leaning & Watson, 2006; Samuel et al, 2008).

Within the overall body of Intensive Interaction research there also appears to be two different time related aspects to the social communication progress being made i.e.:

1. Evidence of relatively rapid change in social interactivity associated with Intensive Interaction 

Instances of rapid change in social interactivity are often anecdotally related by practitioners using Intensive Interaction techniques with people for the first time, particularly when employing the techniques of behavioural mirroring or vocal echoing. Also empirical support for such claims of rapid ‘social inclusion’ (Firth, 2008) comes from short-term research evidence e.g. Lovell et al, 1998; Zeedyk et al, 2009a; Zeedyk et al, 2009b; Argyropoulou, & Papoudi, 2012; Harris & Wolverson, 2014.

Indeed, in the study using ‘micro-analytic analysis’ of Intensive Interaction by Zeedyk, Caldwell & Davies (2009b), it was shown that for all the participants Intensive Interaction was: ‘… effective in promoting social engagement ... well before the end of the first full intervention session’, with some changes being seen to ‘occur within minutes’.

2. Evidence of gradual developmental progress in aspects of social communication associated with the extended use of Intensive Interaction 

In addition to the potential for rapid increases in sociable communication over short timescales, the use of Intensive Interaction over longer periods has been evidenced to support ‘developmental progression' (Firth, 2008) as an outcome of systematic and sustained approach adoption.

Such extended use of Intensive Interaction has been shown to facilitate gradual and sustained development in certain aspects of the social communication practices of people with severe or profound intellectual disabilities and/or autism e.g. Watson & Knight, 1991; Watson & Fisher, 1997; Nind, 1996; Kellett, 2000; Kellett, 2004; Jones & Howley, 2010; Fraser, 2011; Calveley, 2017. 

Have a look for yourself in our Intensive Interaction: published research summaries 2018 document available on the 'Intensive Interaction Users' Facebook page (https://www.facebook.com/groups/13657123715/)  - but you will need a bit of time as there is plenty of it!

Evidence based practice is where we all need to go ... and we have an extensive and increasing body of Intensive Interaction evidence!        

Intensive Interaction in adult services

Last week I was contacted by a teacher in Queensland (Hi Sue) who had 'only ever worked in schools', and who had local 'adult services' coming to her school to learn about Intensive Interaction. She asked me for 'any wisdom and advice about the challenges and complexity of doing II in Adult Services' - and so I quickly sent her my initial thoughts as copied below. 

However, since then I have thought that there is probably more to this than I have initially suggested - so I thought that putting my thoughts in front of our much wider II community (via this Blog) might start a broader consideration of this issue. Please have a look, and feel free to join the conversation:

• Intensive Interaction within adult services is often mostly about ‘being with’ type social support/inclusion for service users than looking for any educational progression i.e. the services/staff tend to have the shorter term aims of ‘getting on’ with service users in the short term ‘now’, than in looking for longer term cumulative social skill progression over time.

• Intensive Interaction in adult services is often more related to ameliorating (or ‘curing’) identified ‘problem behaviours’ of individuals (i.e. a behaviour that is seen as a personal characteristic of the individual, rather than as a response to inappropriate communication or an unresponsive social environment), rather than it being seen to be a general means of teaching/learning for a whole group/class of children – but even when an individual’s behaviour is the initial driver of considering Intensive Interaction, we try to keep our training or support much more general i.e. Intensive Interaction is about being ‘person-centred’, and thus about creating an individual social environment for the person (one that is appropriate for them).

• Sometimes social isolation for adult service users can be more ingrained (some have spent a lot longer experiencing institutionalised types of care), and the associated behaviours of social isolation can therefore be more severe and more chronic – so I often repeat the point of having realistic expectations for change – although in reality we often still see rapid change in the individual’s social presentation when Intensive Interaction is first used with a person, as they can still sometimes bring latent social skills quickly back from unused latency into their communication repertoire.

• We talk about being ‘stage appropriate’ with a person, and about us getting on a person’s level (we use a stepped model of communication development – Dr James McDonald’s 'Communication Steps') to counteract thoughts about being ‘age appropriate’ in socially engaging with their service user – although often denied, age appropriate thinking still dominates much in defining what is ‘appropriate’ or desirable in adult services.

• We present a positive view of all adult's communication means – and use a ‘Means – Reasons – Opportunities’ model (Money, D. & Thurman, S. 1994) to reinforce that message i.e. these are the three things you need to create positive social communication.

• We promote the ‘Strengths & Needs Analysis & Planning’ (SNAP) positive way of identifying the service user’s communication ‘strengths’ and their associated communication ‘needs’ (this being based on the work of Dr Penny Lacey & Dr Jill Porter).

• We use adult video footage for the staff/trainees to view (mainly taken from the DVD ‘Intensive Interaction in Action’).

• We generally don’t expect much in the way of adult support staff using videoing to record Intensive Interaction sessions with service users (unfortunately in adult services that tends to be the reality) as they tend to have harder issues of consent and information governance to overcome (or this is an excuse they often use more forcefully).

However, despite all these points though, the practices and principles of Intensive Interaction (and the Fundamentals of Communication) are still all the same, even if the service users are chronologically older, and sometimes a bit bigger – whatever a person’s age, their need for a truly responsive social environment is also still the same!

Any additional suggestions or thoughts?