Being 'mainstream' but not yet 'established' ... continued

At the start of last week I received a copy of a report about supporting people with profound and multiple learning disabilities. 

SUPPORTING PEOPLE WITH PROFOUND AND MULTIPLE LEARNING DISABILITIES:'CORE & ESSENTIAL SERVICE STANDARDS'
(by Dr Thomas Doukas, Annie Fergusson, Michael Fullerton & Joanna Grace)

Developed with the help of a diverse group of family members, professionals and academics 'these Service Standards are the result of a positive and passionate desire to ensure people with profound and multiple learning disabilities, regardless of age and circumstance receive excellent support and services consistently and are always respected as a person' (from the forward by Rt Hon Norman Lamb MP).

These standards outline a number of key objectives and principles that should be adopted by commissioners and service providers so that families and other representatives can be clear about what level and type of support and services they should expect for the person they represent. The report is available via the PMLD Link website, and so please go and download it for free at: www.pmldlink.org.uk/resources/#commissioning

The authors of the report hope that these standards will be adopted nationally - and this point reminded me of my previous blog (04/08/17) in which I made the point that Intensive Interaction is now a mainstream approach (and it is therefore included in this report), but not yet an established one - it doesn't happen as it should, as a matter of course! We still need to continue our work in the areas of dissemination and sustainable practice and service level development more broadly.

Anyway, back to Intensive Interaction, which is represented in four sections of this report:

Individual Standard 1: Communication
2b. Continuity of communication is demonstrated ... paying particular attention to gaining insight from those who know the individual best (e.g. family and familiar support staff) and then as many perspectives as possible, utilising as many avenues for understanding (e.g. Intensive Interaction, sensory engagement such as hydro, massage, music, responsive environment etc.)

3b. Supporting staff are skilled in delivering a total communication approach, e.g. sensory engagement, Intensive Interaction, routines and sensory cues, objects of reference.

Individual Standard 3: Meaningful/Quality Relationships. 
9. Staff understand the implementation and benefits of safe touch (functional use of touch vs. natural and emotional touch) and Intensive Interactions techniques.

Organisations Standard 3 : Staff development (skills and confidence)
2. All support staff receive regular in-house training, refreshed at appropriate intervals. Such training includes Total Communication, Manual Handling of People, Postural Care, Intensive Interaction or Sensory Engagement, Active Support, Safe Eating and Drinking skills, Supported Choice and Decision Making, involvement in services etc.

Finally I will leave you with a great quote from this report: 

“A person’s ability to communicate is not dependent on their being able to master certain skills, it is dependent on our ability to listen and communicate responsively” 

Jo Grace, The Sensory Projects

Intensive Interaction: is it ‘different paths, but with same goal’ or ‘the same path, but with different goals’ 

I was recently reading an online piece about my beloved football team 'Uddersfield Town. The obviously very clever (and/or very pretentious) sports journalist quite surprisingly quoted the renowned German philosopher Friedrich Nietzsche. He did this in respect of the different ways of playing football that the very successful 'Uddersfield Town manager had used with his team (be patient, this blog will eventually get around to Intensive Interaction at some point). 

Remember - after a few years in the footballing wilderness 'Uddersfield Town are now on a journey to the upper-reaches of the the English Premier League (and have recently beaten Manchester United - a team followed mainly by fans who journey from outside Manchester!)

Anyway,  the quote he used was this:

‘Many are stubborn in pursuit of the path they have chosen, few in pursuit of the goal’

All well and good, I hear you ask, but what has this to do with Intensive Interaction?

Well, I recently got a copy of a book on using Intensive Interaction strategies with people with late stage dementia. This book, called 'Adaptive Interaction and Dementia' by Dr Maggie Ellis and Prof. Arlene Astell, sets out their case on 'how to communicate without speech' with people with late stage dementia by referencing strategies set out by both Hewett & Nind, and Phoebe Caldwell in their respective books on the approach. 

In chapter 3 of this book, 'I Hear You Now - Collaborative Communication', Ellis & Astell set out what they see as contrasting conceptualisations of Intensive Interaction, and the person with whom the approach is used. In referencing the works of Hewett & Nind they say that 'some practitioners consider the focus of II to be on teaching the 'pre-speech fundamentals of communication'' and identify 'the communication-impaired partner [as] the learner'. They contrast this view of of II with that of Caldwell, which posits 'the caregiver or professional as the learner, attempting to 'learn the language' of their partner'. Interesting views I'm sure you'll agree.

Where do I stand on this: well I see the merits of both positions. With any collaborative  social endeavour learning goes on on both sides - but, I think, possible so at different points in the II intervention. Initially I see a 'social inclusion aspect' of an intervention where the practitioner learns how to adapt to the communication impaired partner's preferred and available means of social expression. But then I hypothesise a developmental process subsequent to successful social inclusion* - and I don't discount this even potentially for people with late stage dementia. 

However I don't see any developmental aspect for people with late stage dementia as necessarily being reliant on any retention, via short term episodic memory, of recent engagements with II (which may effectively be absent for some people with late stage dementia). However I do see there being the potential that repeated practising, and therefore neural accessing, of previously retained understandings of 'pre-speech fundamentals of communication' through II, could have a cumulative effect of improved access to those social understandings and associated social functioning.

I think this because of a paper Intensive Interaction: to build fulfilling relationships, by Charly Harris  & Emma Wolverson (Journal of Dementia Care, 2014), which pointed to some small but noticeable cumulative  improvements in the duration and ease of initiation of social engagement, over time, for some people with late stage dementia when using Intensive Interaction (although admittedly from a  small scale study).

This brought to mind another philosophical quote that I have liberally used myself over recent years, this time by Plato (who's being pretentious now, eh!) who apparently said that 'The greater part of instruction is being reminded of things we already know'! - Teaching being mainly about building upon the current knowledge base i.e. in II building on the current but potentially latent social skills and understandings that a person already has, and which are not being used to the maximum potential.

So, perhaps the two potential paths of II are not actually separate then, perhaps they are just temporal stages on the same path, and after successful social inclusion it is a journey that we go on, and learn on, together. Surely it is the pursuit of the universal goal of improved social engagement and connectedness (over both the short and longer term) that is the thing that we should be most stubborn in pursuing!

(p.s. I think that philosophy must be the new 'rock & roll' - even non-pretentious, cheeky-chappy, cockney comedian Micky Flanagan quoted existentialist philosopher Kierkegaard on Desert Island Discs last week - so its not just me!)

(*see: Firth, G. (2008) ‘A Dual Aspect Process Model of Intensive Interaction’, British Journal of Learning Disabilities, 37(1), p.45-49.)

Looking under the bonnet of Intensive Interaction - thinking about the mechanics of social interactivity

Quite often recently I have found myself referring to the central contention of a paper by Philip Schweigert (communication consultant/instructional lead at the New Mexico School for the Blind and Visually Impaired). This paper, 'Understanding the importance of the Partner in Communication Development for Individuals with Sensory and Multiple Disabilities' was published in the journal Perspectives on Augmentative and Alternative Communication (2012, Vol. 21, 167-173).

In this paper Schweigert points us very simply (which is why I like it) to the four requirements for successful communication: 

1. a 'means of expression' to communicate with (for us IIers that's via the Fundamentals of Communication)

2. a sender of a communication (well yes, obviously)

3. a receiver of that communication (no s*** Sherlock!)

but then, most interestingly of all (I think) ... 

4. a 'topic' i.e. something of mutual interest to communicate about ... so now "hhhmm" I am thinking: what is our topic when engaging with someone with Intensive Interaction?  

This on the surface looks like a variation on the Means - Reasons - Opportunities model (Money, D. 2002) that is already very useful and widespread across learning disability communication training. But the more specific 'topic' aspect of Schweigert's paper is the part that I find most attractive: 

‘The topic is something to communicate about… experiences help the child formulate interests. They provide motivation and topics for interaction. It is important to remember that the experiences we are describing here do not initially develop in social isolation.'

So, when we are joining in with someone's activity, sociably reflecting back aspects of their behaviour or vocalisations, using touch and other fundamental communication channels, what is the topic of such a conversation?  

Well I suppose the topic is the person themselves and our shared experiences (current and past) with them ... we are talking to, and with them, about them, and about our interest in them, and our interest in the things they are currently doing. Surely for most of us, 'we' and our experiences are the main thing we generally like to talk about. We like to engage in a process of sociable (but generally functionally useless) chit-chat: and we like to do this a lot, especially with those around us who are genuinely interested in us and our well-being.  

So if Intensive Interaction is the 'means of expression' it can also form the basis of the 'topic' as well ... two aspects in one, because it is the 'how' of how we are communicating, and it is the content (or topic) based on our 'in the moment' shared experiences, with these being a reflection of the person and their current (often pre-symbolic) behavioural repertoire. 

I also think that this can be in stark contrast to the situation where our people can so often be talked about ... not to or with ... but by other people, between other people.

Interestingly, also taking a more overtly developmental perspective, Schweigert states that: 

‘Before we can talk about symbolic communication for children with multiple and sensory disabilities, we must consider their presymbolic foundation and specifically their communicative intent. In order for such learners to develop an understanding of communication and their ability to influence others through their own behaviour, they must demonstrate a means of expression that others can detect and respond to. Means of expression must encompass not just the symbolic forms, but also the presymbolic forms. Behaviours such as a slight turn of the head, orientation of the body, change in respiration, or opening/closing of the eyes that are more subtle and difficult to detect also must be considered’.

I'm not sure if he knows it, but that looks a lot like Intensive Interaction!

x

'Developing best practice: developing best practitioners'

As I had repeatedly and shamelessly flagged up over the last few weeks, last Thursday we held our 13th annual UK Intensive Interaction Conference here in Leeds. I'd like to think that it lived up to it's reputation as a 'relaxed, friendly, meaningful' (Hewett, D. 2017) gathering of like-minded Intensive Interaction practitioners and advocates.

The focus of this year's conference was 'Intensive Interaction: Developing best practice: developing best practitioners' - which was a stroke of luck, as that was the title we'd given it on the flyer! I would just like to thank the chair and the speakers for their considerable efforts on what turned out to be a brilliant day. 

Thanks therefore to: Amandine Mourière (Chair and II Institute Associate), Cath Brockie (LD residential service owner), Ben Smith (specialist behaviour team leader), Lucy Golder and Julia Barnes (teachers), and Lynnette Menzies (Speech & Language Therapist).

Dave Hewett kindly remarked that: 'The expertise on display from the presenters was well, more than impressive, particularly since, apart from Graham, they were conference first-timers or with little experience on the podium. Praise them please, they uphold the finest traditions of what it is to be an Intensive interaction practitioner' - high praise indeed: it doesn't come much better than that!. 

If you would like to see a short illustration of the quality of their presentations, then go to: https://www.facebook.com/dave.hewett.71/videos/10154856997401123/ 

Here, I will give just a brief summation of the concluding point of my own presentation. It was my strong contention that to develop Intensive Interaction best practices and best practitioners:

We need to understand the value of structured and shared reflection in learning:

'learning from experience' should really mean ‘learning from reflection on experience’.

Without a clear process to support reflection on our Intensive Interaction experiences, we are unlikely to develop our Intensive Interaction practices, both individually and collectively, to their full potential. 

But learning from 'reflection on experience' doesn't happen by accident: we need to have, or make available, an on-going process of supportive, dare I say 'nurturing' (there I've said it), feedback to enable regular constructive reflection on our current practices - that's what will make us better at doing what we need to do, and to do it better (if that makes sense!).

p.s. I have also just got my NHS Intensive Interaction webpage back on-line. This is really important to me as my old one was cited in the UK Department of Health strategy document: 'Valuing People Now: a new three-year strategy for people with learning disabilities’. It was cited as one of only 2 places to go to get further information on the approach. (Mind you, you only get to the Intensive Interaction bit once you'd laboured past 7 voluminous pages of introductions, with glossy 'in my Sunday best' photos of 2 secretaries of state, 6 government ministers and a National LD Director!). Anyway, my new NHS 'branding & style format compliant' webpage can now be accessed at:

https://www.leedsandyorkpft.nhs.uk/advice-support/intensive-interaction/ ... why not take a look.

 'One amongst many' = a 'Community of Practice'?

In my last blog I talked about how proud I felt to be 'one amongst so many' during our International Intensive Interaction Week 2017 i.e. being a part of our growing world wide community of Intensive Interaction practitioners*. Indeed this very Blog has now been accessed from 29 different countries, the latest being someone in Cape Verde, which if I'm being honest I had to locate via Google-Maps (its a small group of islands in the mid-Atlantic), so thank you for that! 

Anyway, in this statement I deliberately alluded to the concept of a 'Community of Practice' (sometimes 'CoP' for short), and did so because I think that such a 'CoP' is manifest across those of us who use or advocate for Intensive Interaction (albeit a defuse 'CoP' community i.e. spread widely by role, discipline and geography).

To put some theoretical flesh on this description, a ‘Community of Practice’ was an educational concept developed by academics Jean Lave and Etienne Wenger who defined a ‘Community of Practice’ as a self-defining, but open and supportive group of people ‘who share a concern, a set of problems, or a passion about a topic, and who deepen their understanding and knowledge of this area by interacting on an on-going basis’ (Wenger, 1998). 

Such a ‘Community of Practice’ should have three distinct and defining aspects: ‘mutual engagement’, ‘joint enterprise’ and ‘shared repertoire’ (Wenger, 1998: 72–3):

1. Mutual engagement: through participation in the ‘CoP’, individual members build relationships that bind the group together as a social entity.
2. Joint enterprise: through a process of continuous discussion and clarification, members of the ‘CoP’ build a shared understanding of the issue(s) that bind them together.
3. Shared repertoire: in the pursuit of their joint enterprise members of the ‘CoP’ collectively develop a set of shared practices or ways of working.

Lave & Wenger actually made the claim that such a 'CoP' grouping was 'an intrinsic condition for the existence of knowledge’ i.e. it was in such dynamic social learning groups that knowledge and understanding in particular disciplines is actually advanced. 

Within the Intensive Interaction 'CoP' we tend to feel that new or novice Intensive Interaction practitioners are best nurtured [or even actively mentored], and their skills and understanding of the approach developed, with the help and support of other more experienced Intensive Interaction practitioners (the 'old-timers'); and I think that this fits well with the general understanding of the theoretical 'CoP' concept. 

The way a ‘Community of Practice’ works is in marked contrast with more hierarchical ways that people (and organisations) have often chosen to share certain skills and knowledge (or not share them) in a top down and sometimes potentially non-inclusive manner.

Therefore to conclude: an Intensive Interaction ‘Community of Practice’ should deliberately set out to have certain defining features*, these being that:

• We are a group of people who share a common interest in the practices and theory of Intensive Interaction.
• We work together in a mutually encouraging and supportive manner in pursuit of our common interest e.g. the dissemination of good quality Intensive Interaction.
• We continuously look to collectively develop our shared skills and knowledge.
• We are collectively accessible to help ‘novice' practitioners develop their Intensive Interaction skills and understanding at whatever pace, and to whatever extent as individually appropriate. 

(*see the 'Intensive Interaction Users' Facebook group at https://www.facebook.com/groups/13657123715 for the evidence about how wide spread the Intensive Interaction community has now become). 

(**adapted from Firth, G. in 'The Intensive Interaction Handbook', Hewett et al, 2011, p.143)

   

What an 'II Week' its been so far ... after just one day!

I have waited until near the end of  the first official day of 'International II Week 2017' before doing my weekly blog - and I must say that I waited with a bit of baited breath (I think it was a bit baited) to see how well things were doing  ... and as usual I have been mightily impressed and delighted to see just how much stuff has already been posted on Facebook about what is going on around the world (e.g. in Greece, Russia, Finland (well done Dave!), Wolverhampton). Even just saying 'around the world' sends a shiver down my spine.

Anyway, there has been so much social media traffic so far on Intensive Interaction that I don't want to add anything that might deflect from from the combined efforts of our international and ever growing Intensive Interaction 'Community of Practice': indeed this blog has actually been viewed in 26 different countries, the latest being East Timor - so thanks for that!

There is just one thing that I would like to add - and that is just how proud it makes me to be 'one amongst so many' of our world wide community of Intensive Interaction practitioners and advocates. Our combined efforts and dedication are surely the most important resource we all have.

Evaluating the effects of Intensive Interaction ... hmmm, yet more twaddle musing!

At a recent evaluation meeting I attended, one of my colleagues reminded us all of the potential for basic 'type I and type II errors' that we should always remain wary of. A 'type I error' (for some reason they always seem to use roman numerals for this) comes from the measurement of, and subsequent belief in, an effect that isn't actually present (a false positive): so this means that you end up thinking that what you're doing is working, when it isn't. A 'type II error' is a failure to detect some kind of effect that is actually present (a false negative): so this means that you end up thinking that what you're doing isn't working, when it is. 

All well and good so far - especially if what you are measuring is clear in its nature, relatively easy to observe, and straightforward to quantify. However, these kinds of errors are less easy to take account of if what you are looking to measure is potentially unclear (or multifaceted) in its nature, and far from straightforward to quantify.

This lead me to muse a bit on the potential for these kinds of errors being at play in any evaluation of our Intensive Interactions work: both formally (via some kind of structured recording/evaluation system), and informally (by we ourselves forming subjective judgements on the effects of our practice). 

But, whilst thinking about the evaluation of Intensive Interaction, it is my view that while the practice will be the same (enacted via the Fundamentals of Communication, being 'process central', following 'Nind's 5 central features', etc), the effects of Intensive Interaction may actually lie in  at least 3 different domains, and that is just for the recipient (it also has significant outcomes for the practitioner as well). I have previously used the term 'Dual Aspect Process Model' to describe Intensive Interaction (British Journal of Learning Disabilities, 2009*) to differentiate the outcomes into two domains or aspects:

1. Social Inclusion - this being evidenced in short term improvements in sociability as both recipient and practitioner develop and improve their social engagement (often via the reclaiming of latent social skills and understanding on the part of the recipient).
2. Developmental Progression - evidenced in the longer term acquisition or extension of social skills and understandings as new social experiences are accommodated by the recipient and new learning takes place.

However, I now also think that there is a third potential outcome of Intensive Interaction for some recipients, and this is a 'therapeutic aspect' (Berry et al, 2013*). This paper states that Intensive Interaction can be used to 'establish psychological contact with people who are difficult to reach'. Being in 'psychological contact' with someone is obviously going to be a positive psychological experience, and the lack of that kind of affirming contact is potentially damaging to anyone's psychological well-being. Indeed in the above paper the authors see the potential for '... an evidence-based therapy for people who are unable to access traditional psychotherapies but may be in great need of experiencing psychological contact and connectedness'. 

So, back to where I started - the evaluation of Intensive Interaction therefore becomes potentially problematic in that we need to be clear in which of these 3 domains we wish to measure any outcomes, before we even set out to find suitable systematic methods with which to make those measures, otherwise we may be liable to type II errors - not detecting the positive outcomes we may be facilitating by our use of Intensive Interaction. Finally I have one last thought on this issue of evaluation ... that whilst firmly believing in the rigorous use of robust systematic methods for gathering evidence of the effectiveness of interventions, I always have one profound worry, which is this: 

Do we, across all disciplines and services, knowingly prioritise and therefore more readily  legitimise less plausible interventions (i.e. those that are often more abstracted from the natural model, or somewhat removed from truly person-centred ways of working), simply because these interventions lend themselves more easily to more hard-edged, quantitative methods of evaluation (than say Intensive Interaction)? ... and if we do (which in reality we do do), is that right and proper? 

*Firth, G. (2009) ‘A Dual Aspect Process Model of Intensive Interaction’, British Journal of Learning Disabilities, 37(1), p.45-49.

*Berry, R., Firth, G., Leeming, C. & Sharma, V. (2014) ‘Clinical psychologists’ views of Intensive Interaction as an intervention in learning disability services’, Journal of Clinical Psychology and Psychotherapy, 21 (5), p.403-410.