Using Intensive Interaction with learners or service users who present with some level of ‘engagement and/or task avoidance’

My Blog this week is admittedly quite long - but please stick with it as I think it addresses a vitally important but little discussed issue. Here goes:

The 2019 Intensive Interaction Weekend Workshop discussed using Intensive Interaction with learners or service users who presented with some level of engagement or task avoidance*. We collectively as participants thought that we saw a range of children or adults who fitted somewhere along ‘a broad spectrum of engagement or task avoidance’ with such generalised ‘avoidance’ often differing in its form and severity 

(*We purposively did not base our discussions on considerations of the apparent or claimed symptomology or diagnostic processes (or even legitimacy) of the condition known as Pathological Demand Avoidance (PDA), as we felt this would channel and constrain our thinking away from considerations of some of our own learners or service users, who we all felt did fit somewhere along ‘a broad spectrum of engagement or task avoidance’).

We asked ourselves the following questions: 

1. How might any such ‘engagement and/or task avoidance’ be presented?

2. Why might any such ‘engagement and/or task avoidance’ occur?

3. What factors might perpetuate someone’s ‘engagement and/or task avoidance’?

4. How might Intensive Interaction help ameliorate the impact of ‘engagement and/or task avoidance’ for such learners or service users?

The results collated from all the participants in the workshop activity:

1. How might a person’s engagement or task avoidance be presented?

• Having a ‘Melt-down’ e.g. shouting, crying, throwing things, jumping on tables, causing environmental damage, etc.

• Engaging in self-injurious behaviour e.g. hand biting, head slapping, etc.

• Becoming violent e.g. punching, kicking, etc.

• Engaging in inappropriate social behaviour e.g. swearing, abusing others, laughing (at unfunny things), grounding, masturbation, stripping, etc.

• Verbally declining (“no thanks”) or refusing (“No!”) tasks that the person has the ability to do, or has even historically liked doing.

• Ignoring or not responding to requests or the presentation of an activity.

• Closing down a conversation e.g. “its okay luv”, “Not just now” or giving apologies before not doing something.

• Steering a conversation or creating a distraction away from, any given demand.

• Hiding offers of activities e.g. destroying letters, leaflets or invites etc.

• Physically pushing things or people away, out of their immediate space.

• Physical isolation e.g. staying in bed, staying in room, not going out, etc.

• Physical withdrawal e.g. leaving the room, turning their back, etc.

• Social withdrawal i.e. retreating to an ‘inner world’ e.g. shutting eyes, avoiding eye contact, self-soothing.

• Regulating aural and/or visual input e.g. looking away, putting fingers in ears, etc.

• Incongruent verbal and/or non-verbal behaviour i.e. saying something verbally but doing the opposite behaviourally.

• Switching sleep patterns to avoid engagement or contact with others e.g. sleeping during the day, being up at night.

• Using prolonged engagement with technology (or other rigidly focused object orientations or activities) as a shield from external demands.

• Using rigid routines to control the level of potential demand in any given situation.

• Responding negatively to everyday requests (not just potentially novel or potentially ‘challenging’ things); even failing to choose between some offered positive choices.

• Responding negatively to positive comments or praise from others.

2. Why might someone be (or become) engagement or task avoidant?

• Chronic anxiety, including social anxiety and/or prolonged exposure to stress.

• A fear of the unknown, and a wish to avoid uncertainty; a fear of failure, of getting something wrong; a fear of being judged by, or of disappointing others.

• Needing to control a situation (possibly in response to some change or as a means of protection from something) and/or being unwilling to be controlled by others.

• A lack of understanding about what is being asked, leading to anxiety about their ability to complete the given demand.

• Previous or continuing negative experiences leading to trauma.

• A historic lack of positive interactions or feedback in any previous engagements.

• Low confidence or self-esteem and/or a negative self-view or self-worth.

• A lack of the necessary social skills to engage with others.

• A ‘power’ issue, seeking power over those around who historically or currently hold power over the person.

• Due to the onset of puberty and the resultant changes in hormonal levels and/or the menstrual cycle.

• Being in pain or having other medical or health related issues e.g. musculoskeletal, of the bowels, etc.

• Being in a constant state of exhaustion through maintaining a physical posture.

• Being on psychoactive or other medication (e.g. tranquillisers, anti-epileptics), thus reducing cognitive functioning.

• The result of some form of sensory processing disorder or other sensory issue.

• Not being cognitively, emotionally or physiologically ‘ready’ in some way.

• As a means of gaining and holding prolonged attention (even if that is negative attention) from others.

• Boredom with or not being interested in the potential ‘demand’ i.e. not being genuinely demand avoidant.

• Neurodevelopmental issues (incl. P.D.A. diagnosis).

3. What other factors might perpetuate someone’s engagement and/or task avoidance?

• The demands being made are too often too complex or unfamiliar or unpleasant or uninteresting.

• A continued lack of trust in others e.g. due to previous ‘false promises’ e.g. “it’s gonna be okay”.

• A confusing lack of consistency experienced across previous engagements with others.

• Continued experiences of simply not being listened to by others.

• A physical or cognitive deterioration in the person.

• Too much language used, too little processing time.

• Both the person and their carers getting stuck in a negative cycle of perceived and expected failure.

• There being a hierarchical power issue i.e. a battle for control between the person and their carers/staff.

• The use of over-enthusiastic and/or non-genuine initiations or invitations to join in with an engagement.

• Some response from third party reinforcing the behaviour.

• Not addressing a need to alter a current sensory environment.

4. Strategies used within an Intensive Interaction intervention to ameliorate the impact of a person’s engagement or task avoidant avoidance:

• Pausing a lot, and for longer; allowing the person extra processing time.

• Being indirect with requests or invitations e.g. “Bet I can get my coat on before you” will be better than “put your coat on” … or “I’m going now”.

• Being careful when using language e.g. at times more, at times less; using comments and/or statements instead of questions or requests e.g. “you can join me if you want” or “I don’t know where this goes”.

• Sometimes providing reassurance e.g. “we’re all ok”.

• Consider reducing the volume of vocalisations: try whispering!

• Providing ‘failure free’ (i.e. unstructured) tasks or activities, led by the person.

• By staff initiating an activity and allowing the person to just observe, before they then choose to join in (if they want to).

• Reducing the availability of eye contact, if this adds to a perceived level of demand.

• Creating some kind of ‘joint activity’ out of less obvious ‘joint activity’ situations when led by the person.

• Do things alongside or in parallel, but actually not with the person (and sometimes at a distance).

• Presenting the person with ‘Unconditional Positive Regard’ (UPR) irrespective of any level of engagement.

• Being taskless; just seeking ways of equitably ‘being with’ the person.

• Making any necessary adjustments to the sensory or social environment (possibly to tone it down?).

• Being thoughtful about too much, or too little proximity i.e. not being too far away/too close in.

• Being open-minded and genuine, whilst persevering and demonstrating empathy.

• Looking to match the mood and presentation of the person in the current situation… let the person lead.

• Knowing when to stop (i.e. when they’ve had enough), whilst also trying to wind down when things are still going well i.e. ending on a positive.

• When stuck seeking help and/or peer support e.g. by using video analysis for constructive feedback and new ideas.

• Re-labelling ‘avoidance’ to something like ‘engagement and/or task avoidance’ (as in this document) so that we do not get confused with the approaches used with those whose avoidance is diagnosed as ‘Pathological’.

Finally, some potential outcomes of the use of Intensive Interaction with people with engagement and/or task avoidance:

• Improved social engagement with staff or carers.

• Improved relationship development.

• Improved psychological well-being e.g. in mood and self-esteem.

• Improved staff rapport and morale.

• Improved emotional well-being.

• Improved access to educationally enabling activities and engagements, increasing the potential for all future educational and social outcomes.

• Greater independence for the individual.

• A generally improved quality of life!

Intensive Interaction: Bringing the laggards on board!

My Blog this week is based on notes taken at our recent Leeds Intensive Interaction Regional Support Group meeting which had the title of: 'Intensive Interaction: Bringing the laggards on board!'. Below is what we came up with:

In order to better understand why Intensive Interaction isn’t used with all potential beneficiaries, in all circumstances, by all staff or carers, at our meeting we discussed the kinds of arguments or issues that potentially might be felt or voiced by individual staff or carers, and which might then make them less likely to do Intensive Interaction.

Below are our collated thoughts on these potential Intensive Interaction restraining issues:

• Some staff or carers who might appear disinterested or unenthusiastic towards a change that includes more Intensive Interaction practice (labelled here as ‘Laggards’) are often focused on, or reacting to, or constrained by multiple other distracting systematic issues and pressures. 

• Some staff or carers may feel a need to look busy, and to fill any silences, driven either by their own need to be ‘doing something’, or wishing to be seen to be ‘doing something’ by others; making pausing, waiting, or ‘being with’ someone feel inappropriate or time inefficient. 

• Staff or carers may feel a sense of embarrassment, or may feel uncomfortable when out of their normal ‘comfort zone’. Some new members of staff might also be hesitant and/or worried about making a fool of themselves in front of other, more established staff (or managers). 

• Staff or carers may feel they don’t have enough time, and therefore Intensive Interaction may be seen as ‘another thing’ to do, on top of the other more observable tasks they have to carry out. 

• Staff or carers may not have enough training to be sufficiently confident in their own Intensive Interaction practices. Also many staff are not paid for any ‘outside working hours’ training, restricting access to training and suggesting a lack of importance in training some staff. 

• Without sufficient training (or mentoring) in Intensive Interaction, some staff or carers simply cannot pick up the ‘Fundamentals of Communication’ social cues coming from their person. 

• Some staff or carers intuitively view the caring role as essentially task-orientated, and such care is therefore not really social in nature; Intensive Interaction is therefore potentially judged on the basis of: tangible ‘jobs to be done’ vs. intangible ‘being with’ or even ‘messing around’. 

• Staff or carers may assume that the person they are working with is not capable of socially engaging through Intensive Interaction (i.e. having too low an expectation of the person): or conversely assuming that they should talk to the person they are with, even if that person doesn’t use symbolic language expressively (i.e. having too high an expectation of the person). 

• There being a wide range in the ‘level of need’ presented within a classroom or service location, subsequently Intensive Interaction never becoming a mainstream ‘norm’ for staff or carers to practice in their given care or working context. 

• For some staff or carers working with older children or adults it may personally feel uncomfortable (or even potentially disrespectful) to engage with their people in such a responsive, developmentally pertinent Intensive Interaction way. 

• There may be ‘mixed messages’ coming from an organisations own training or policy, or even service level values i.e. structured and SMART target teaching and routines vs. unstructured Intensive Interaction engagement, etc. e.g. if Intensive Interaction is timetabled within the organisation, it then stops when it is not within the timetabled times. 

• Staff or carers may not be easily conversant with the particular Intensive Interaction language used by others to explain the approach i.e. using words like ‘phatic’ rather than ‘being social’. 

• There being too much ‘defensive’ organisational emphasis placed on ‘Safeguarding’ (including issues of physical contact or potential sexualised behaviour), this then becoming a perceived barrier to engagement for some staff or carers i.e. the general management tone is defensively risk averse and therefore ‘service centred’ rather than ‘client-centred’. 

• Some staff or carers might not be able to recognise incremental ‘progress’ made by the person they support, and therefore may not see the vital need to continue with Intensive Interaction. 

• Staff or carers may be unaware of the positive overlaps between what they would class as ‘work’ and what they would class as ‘play’, and holding some non-Intensive Interaction supporting assumptions about the differences (and overlaps) between them. Indeed, some staff or carers may not actually know how to ‘play’ (in an unstructured way) with other people i.e. they themselves might lack the skills and knowledge of social play ‘rules’, this leading them to focus on some kind of structured, end-point defined ‘activity’. 

• Some staff or carers may have quite rigid professional or hierarchical boundaries as to what a job entails, and whose responsibility it is to carry it out e.g. Intensive Interaction.

After collating all the reasons listed above for staff or carers not wanting to do Intensive Interaction, we then discussed what support processes, or pieces of nurturing advice could be made to counter such individually held, non-Intensive Interaction friendly points of view?

• We should recognise that ‘laggards’ are usually not just lazy or uncaring people, but instead we should think that current circumstances may be conspiring to make it unlikely that they will enthusiastically embrace Intensive Interaction.

• We should adapt our language when introducing Intensive Interaction to a new audience, taking account of and using the staff or carers’ current working language (with English not always being a first or home language), whilst also reducing the level of Intensive Interaction ‘jargon’.

• Intensive Interaction training at various levels (from complete ‘novice’ training to that focused on more advanced practitioner’s reflective practice) needs to be prioritised in the service … and staff should be paid to attend if it is outside of their normal working hours.

• We should present Intensive Interaction as something that can be done opportunistically whilst doing other tasks i.e. it doesn’t need to be in a ‘session’, and you don’t need extra time to do it. Indeed, we could create video examples of ‘doing Intensive Interaction whilst doing other routine daily activities’ e.g. care tasks, to counteract a seemingly implied message in current Intensive Interaction DVDs that Intensive interaction is only properly done sessional, in 1:1, with experts.

• Senior staff and/or experienced practitioners should purposively model Intensive Interaction in visible areas, and therefore lead by example and legitimise its practice for all to see e.g. doing Intensive Interaction in the foyer, in the corridor, in the classroom, etc.

• We should look to nurture and build the confidence of reluctant or novice practitioners; on all possible occasions we should point out and celebrate positive Intensive Interaction moments with all staff and service users, but especially so the less confident ones! Also don’t scare them off; don’t add to their workload at the start (maybe introduce recording sheets and video later).

• We should explain the benefits of reduced challenging behaviour when Intensive Interaction is used proactively with some people - rather than staff relying on reactive strategies that are often overly (and sometimes inappropriately) used.

• We should not just assume a common or shared cultural understanding amongst everyone of the positive nature of all aspects of Intensive Interaction practices e.g. parents and/or carers may hold culturally divergent views on physical contact, gender roles, etc.

• We could initially ask some staff and carers to do a different job that better matches their (non-Intensive Interaction) skill set e.g. videoing sessions or updating the Intensive Interaction noticeboard, and for some staff and carers doing this in the long term (until they leave!).

• Finally, be proactively positive: tell them – “You can do it!”