An NHS 'Observation' policy without mentioning how to interact? ... in 2019? Surely not!

I was recently sent a copy of a newly ratified (in July 2019) NHS policy on 'Procedures for Observation and Engagement' for staff of a NHS mental health and learning disability trust 'in all acute units, inpatient settings and residential areas where service users may be observed by staff'. This policy states that: 'Observation and engagement is a skilled clinical intervention' and that 'Effective observation is underpinned by continuous attempts to engage the service user therapeutically'.

All well and good I hear (imagine) you saying, but below I will list the number of mentions in this 'observation' (which gets 138 mentions!) and 'engagement' (which manages a paltry 19 mentions) policy of the possible 'Fundamentals of Communication' through which any 'engagement' could be developed for service users with communication or social impairments (e.g. because of a learning disability, autism or mental health condition):

So, for 'Interaction' = 0 mentions - so how about, in alphabetical order:

'Attunement' and/or 'tuning in' = 0 mentions 

'Enjoyment' and/or 'pleasure' = 0 mentions  

'Eye contact' = 0 mentions  (although having someone in 'eyesight' = 14 mentions!)

'Facial Expression' and/or 'Smiling' = 0 mentions 
'Joining in with' and/or 'mirroring' and/or 'echoing' = 0 mentions 

'Joint focus' = 0 mentions 

'Sequencing' (as in 'sequencing' communicative actions) = 0 mentions   

'Touch' or 'physical contact' = 0 mentions   

'Turn taking' = 0 mentions.  

Well then, how about 'rapport': well, that got 1 mention as 'therapeutic rapport', as opposed to normal, run-of-the-mill, sociable rapport. 

So how about 'sociable' and/or 'social' ... you're probably there before me = 0 for both!

Even the use of words like 'conversation' and/or 'talking' (i.e. for those who could use symbolic language to develop and sustain some sort of conversational exchange or engagement), for both (oh no, here we go again) = 0 mentions. 

However, 'Activity' does get 6 mentions in a half-page section called 'ENGAGEMENT' where 'Consideration should be given to the use of activity, discussion and distraction techniques ...'. Hardly much there in terms of any useful detail, I'm sure you'll agree.

Now obviously this is a necessary and important area of 'policy' if we want to create therapeutic 'engagement' (remember = 19 mentions) during periods of care requiring some level of service user 'observation' (=  138 mentions). However, to me this 31 page policy is woefully unbalanced in terms of not sufficiently pointing staff to proactive (= 0 mentions) social engagement, and lacking in any useful procedural guidance on how staff should use their 'fundamental communication' skills to enact some form of therapeutic engagement with service users with communication or social impairments. This made me think: 

a) it evidences a particular therapeutic (no, actually overly medicalised) NHS mindset that sees engagement as a specialised professional skill set not naturally available to all staff through the sensitive use of their 'Fundamentals of Communication' (either intuitively, or via some method of training or mentored support) 

b) it is such a missed opportunity to set out how to achieve more sociable 'engagement' and genuine 'rapport' with some of our service users who struggle to use language for sociable or therapeutic engagement (if the two can be truly separated) ... or due to the level of their impairments, have no access to the sociable use of language.

Now, I am in no way calling out any of the genuinely dedicated NHS staff who developed this policy (it is probably just a development of a previous one) ... but to me it evidences a de-personalising institutional perspective that can at times skew how we see (or 'observe' = 138 mentions!) and provided engagement for some of our most challenging service users. 

However, I am not utterly downcast by this. It is my experience generally (and more specifically in the adoption of Intensive Interaction by the brilliant staff on our learning disability inpatient units) that policy tends to follow positive develops in practice, and not the other way around (although often too slowly for my liking). Things are changing, and it is the staff who work directly on the units that are driving this change forward - and hopefully future iterations of this policy will acknowledge and then follow the successful adoption of the more proactive social engagement strategies of Intensive Interaction.

p.s. Wishing you a merry and interactive Xmas and New Year!

Intensive Interaction emotional development and emotional well-being: by Melanie Nind

For my blog this week I am again summarising a chapter from the book 'Intensive Interaction Theoretical Perspectives' (Ed: Hewett, D. 2011) that I have been rereading recently. This time it is the chapter by Professor Melanie Nind: 

Intensive Interaction, emotional development and emotional well-being 

In this chapter Melanie Nind (now Professor of Education and Director of the Centre for Research in Inclusion at Southampton University) sets out a perspective on Intensive Interaction being concurrently both educational and therapeutic in nature, addressing the important and interrelated issues of emotional well-being and development. 

Initially Melanie relates a little history, pointing to the fact that their students’ emotional well-being was not one of the issues they were thinking about when Intensive Interaction was first developed. However, she then goes on to point out the recent emergence of the concepts of ‘emotional intelligence’ and ‘emotional literacy’, and states that emotions are ‘a crucial and integral component of self development’, and are seen ‘to emerge in the interactions between children and their social surrounds’. She also states that ‘emotions are embedded in the interactive space’ and this explains ‘how intertwined the emotional, social and communicative essentially are’, and therefore Intensive Interaction ‘unconsciously yet actively fosters emotional development’.

Melanie points us to 'theories of emotional development in infancy', referencing Dr Suzanne Zeedyk who argues that ‘intense emotional engagement between mothers and infants is regarded as the best foundation for later development’. She then goes on to draw on studies in developmental psychology, including Dynamic Systems Theory, which doesn’t define emotions as ‘discrete states’ but sees them as dynamic ‘coherent emotion patterns that support infant’s meaningful relationships with others’.

According to Garvey & Fogel (2008) emotions emerge through communication and ‘help punctuate the dynamic flow of communication by opening (or closing) opportunities for individuals to experience themselves in relation to others’, hopefully in ‘a mutually enjoyable and satisfactory experience’ (i.e. via Intensive Interaction). Therefore, through being active agents in interactions, both parties can reciprocally foster ‘a sense of connection with and differentiation from others’, thus building an emotional repertoire. 

Melanie then points to a social-biofeedback model (Gergely & Watson, 1999) which sees infants becoming aware of their emotional dispositions through ‘social mirroring’ i.e. contingent reflections of their own emotions by caregivers ‘modulating the infants affective states before the infant develops mechanisms to do so’. Melanie points to Zeedyk again who, when considering the Intensive Interaction strategy of contingent imitative responding as a powerful means of creating emotional intimacy, states that ‘imitation provides the closest correspondence between self and others!’. She then goes on to discuss the role of touch, which Montagu (1986, 1995) identifies as ‘fundamental to health, well-being and cognitive development’; touch having ‘a deep emotional and psychological significance’ and is ‘a primary means for providing comfort and for communicating empathy’. 

Melanie also looks at 'Attachment Theory' (Bowlby, 1969), stating that the attachment experiences of an individual are 'hypothesised to impact on the individual’s later relationships’, as individuals build ‘internal working models’ of their primary relationships (and how to regulate their associated internal states), with good attachment states creating a ‘relational place of safety’. She then relates how Intensive Interaction has helped parents feel ‘newly connected to their children’, and also advises a ‘team approach’ to prevent potential attachments that, if broken, might cause ‘isolation and hurt’. 

Melanie sets out a holistic view of promoting emotional well-being, so that instead of looking at ‘individual problems’ it is better to look at ‘environments’ and ‘positive capacities’ rather than ‘problems and deficits’. The building of an Intensive Interaction ‘culture’ is seen as being particularly effective where a community can ‘foster productive, pleasant relationships, teamwork [and] mutual responsibility...’. Indeed, she identifies Intensive Interaction as helping create ‘emotionally healthy environments’.

Finally, Melanie argues that Intensive Interaction has a clear place among the other more traditionally identified 'therapeutic approaches' (and therefore it is not solely educational), and also argues (correctly in my view) against those who take a position in which teaching/learning and emotional well-being are seen as separate or discrete issues.

It is well worth a read!