‘How adults with a profound intellectual disability engage others in interaction’ a 'conversational analysis' study.

Following up on last week's blog about 'epistemic asymmetry', I thought that I would report on the findings of the paper I was quoting from: I should warn you, it makes for some pretty depressing reading. The  paper was ‘How adults with a profound intellectual disability engage others in interaction’ by Antaki, C., Crompton, R., Walton, C. & Finlay, W. in the journal Sociology of Health & Illness (2017, 4/39, p. 581-598). 

The paper reports on a study (using video to record service user ‘initiations’ and subsequent responses by staff) of everyday life in a residential home in the UK for people with severe and profound intellectual disabilities [SPID].

The authors' stated aim was: 'to apply the methods of conversation analysis to the behaviour of people with severe or profound intellectual disabilities which either had the characteristics of initiations, or which were treated as initiations despite lacking the usual elements of such turns’. The authors identified these practices as 'sufficiently recurrent' ... that they were reasonably representative of practices that persons with a range of severe and profound intellectual impairments could and do use to engage with those around them'. 

They then describe how the staff responded to these non-verbal service user communicative initiations verbally - but in the authors' view 'inappropriately for people unable to comprehend, or to produce well-fitted next turns.' Indeed, the authors go on to state that: 'this mis-reliance on ordinary speakers’ conversational practices was one factor that contributed to residents abandoning the interaction in almost all cases’.

Also, equally depressing about the frequency of such attempted engagements: ‘In terms of a simple count in ...  over seven hours of possible interaction across about 40 days, there were 26 attempts by a resident at starting an engagement, sustaining four beyond the initial move. In other words ... aside from activity generated by the staff, residents had long periods of disengagement punctuated by them only very occasionally trying to initiate something’. They went on: ‘… most of their [the service user’s] efforts at establishing intersubjectivity with an interlocutor [the staff] – whether in the sense of co-producing a series of turns at interaction or joint attention, let alone agreement on the meaning of words – largely failed’.

The brutal truth is that, in over 7 hours filmed over 40 days: ‘Whatever means of engagement the residents attempted …usually failed’, and unfortunately, this service was described by the authors as 'not untypical of such services in the UK'.

When looking to explain this recurrent failure of the staff to make communicative engagements last over one turn (is that really a turn?), they state that: ‘untrained in any specific procedures for engagement with people with such serious cognitive impairments, they [the staff] necessarily fell back on using their ordinary skills of interaction.  The problem however, is that while these are effective for engaging with other neuro-typical people, they are not tuned to the needs and capacities of people with SPID’.

Now as they authors also make clear: ‘support staff … work under inauspicious conditions: poorly paid, liable to frequent job-turnover, obliged to consider health and safety as overriding priorities, and with the running of the residence’s domestic arrangements a constant pressure’. So should we be all that surprised? Remembering that this is a single case study, and I know that there are many services out there where Intensive Interaction is consistently used that aren’t like this – but in this case it wasn’t, and that is one case too many.

So what do the authors recommend (I hear you asking), well they did say this:

‘If there is a policy recommendation here, it is for staff to give time to be with residents in some activity that affords their doing something that would count not as merely responsive, but as positively initiating; and to reward any such initiations with patient responses and – though this edges into the challenging – for the staff member to channel their neuro-typical instincts into formats that the resident will understand’. Intensive Interaction, yes surely, it has to be Intensive Interaction!

... but there was no mention of Intensive Interaction, not in this whole paper, not even from the academics who wrote it, in 2017, slap bang in the midlands of the UK … and this depresses me, because it makes me ask: what are we doing wrong, or not doing right, that this is still happening?