'An increased emphasis ... upon process-based learning'

As a member of 'Researchgate' (this apparently being the largest/most 'active' academic social networking site in the world - where researchers and academics share their papers and network with each other), last week I was notified of a paper from the Scottish Educational Review. 

This paper (Rees et al, 2017*) looks at the implementation and evaluation of the South Lanarkshire Framework for Supporting Children with Severe and Profound Learning Needs. This Framework was set up to assist Scottish schools implement the 'Curriculum for Excellence' for this group of learners. In this paper (p.69) the authors state that:

'The most recent curricula developed by individual schools in England attempt to achieve a balance by adopting a developmental perspective to learning and life skills ... Emphasis is placed on providing a relevant and personalised curriculum, with a narrower range of key areas which enable pupils to develop skills in independence and communication. These areas include: Communication and Social Development, Cognition, Self-Care and Independence, and Physical and Motor Development. Whilst behaviourist approaches are still used widely to develop a pupil’s abilities to carry out new skills and to break down skills into smaller, achievable tasks (for example, self-care and independence skills such as putting on/taking off a jacket), an increased emphasis is placed upon process-based learning (where the interactive process between staff and pupils takes precedence over the outcome of the task).

Yet, in both England and Scotland, evaluations of current curricular approaches for this group of learners have been scarce (Lacey, 2011). In addition, although there is an increasing body of evidence highlighting the positive impact of ‘intensive interaction’ as a means of encouraging pupils’ interaction and communication (Firth, 2006), there are still very few evaluative studies of other specific teaching approaches.'

Now the 'bolding' of some of the text is mine - and the bits that I bolded (if there is such a word) are because:

a) the identification of 'process-based learning (where the interactive process between staff and pupils takes precedence over the outcome of the task)' is exactly what we in our Intensive Interaction community (and in particularly Dr Dave Hewett) have been banging on about (i.e. quite reasonably arguing for) for years!, and 

b) Intensive Interaction is correctly identified as the most evidenced of these 'curricula approaches for this group of learners' ... and in these days of 'evidence based practice' Intensive Interaction should surely be elevated to the very core of the curriculum above other, less well (or some almost entirely not) evidenced approaches to the teaching/learning of this important group of learners. 

*Rees, K., Tully, S. & Ferguson, K. (2017) “This is theirs” The implementation of the South Lanarkshire Framework for supporting pupils with severe and profound needs, Scottish Educational Review, 49(1), 67-88.

Intensive Interaction: an approach that sits across disciplines - its greatest strength ... and its greatest weakness?

With my most recent Blogs focusing on linking Intensive Interaction to established psychological theories and therapeutic models, it has increasingly dawned on me that I think that this highlights one of the approaches greatest strengths, but also one of its greatest weaknesses.

In other Blogs I have written about Intensive interaction being developed through the same practices, but successfully fulfilling different educational, social or therapeutic functions depending on the context or aims of its use e.g.: 

• a 'Social Inclusion' process* - evidenced in shorter term improvements in sociability as both recipient (e.g. a person with an LD, autism, or as is increasingly reported, people with late stage dementia) and practitioner develop and improve their social engagement and rapport.

• a 'developmental process'* - seen in the longer term acquisition/extension of social skills and understandings, as new social experiences are accommodated and new learning takes place.

• and, as I have written recently, a psychological or therapeutic process (Berry et al, 2013) which can help to develop psychological contact and emotional connectedness for people who are difficult to reach and/or in emotional distress. (Here in Leeds, when and where relevant, we include personalised Intensive Interaction guidelines into the ‘proactive strategies’ section of Positive Behaviour Support (PBS) plans i.e. to train staff/carers to work 'at the level of the antecedent', thus negating a person's need to resort to any challenging communication behaviours).

So, one approach, many uses - and as I allude to above, I think this is a great strength of the approach - with all these uses, aims, contextualised functions being obviously positive, and the outcomes highly plausible and increasingly well evidenced. 

But this is where I think it sometimes gets difficult. This breadth of use and function could I think be identified as a weakness for Intensive Interaction, in that the approach is therefore not 'owned' i.e. defined, developed and disseminated, by one key discipline. Instead it sits across many disciplines - special education, speech & language therapy, social or specialised care, psychology, occupational therapy, LD nursing, disability studies, etc.; with no discipline being the focused intellectual hub for, and thus the key driving force behind, the approach.

However, all of the discipline or domains mentioned above are actually human intellectual constructs that help us individually give order to what in reality is a complex, interrelated and conceptually overlapping human and social world. Sometimes that constructed conceptual ordering (which takes place inside our heads and is projected out onto the world) gives us a cognitive framework within which we can create meaning; but sometimes it tricks us into thinking that there are clear intellectual boundaries between all these domains of understanding - and of course, in the 'real' real world, as opposed to our individual cognitively constructed world, there aren't.  

Intensive Interaction sits between all these disciplines because our work, and the needs of all our different people, sit between them - it is our job as Intensive Interaction advocates and practitioners to think outside our constraining disciplinary boxes, and look at the bigger picture. We therefore need to continuously and actively work together to counteract the lack of a single disciplinary focus (which remember, is also a great strength), and collectively make the approach more accepted and understood whenever and wherever it is need.

*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.

Intensive Interaction and psychological therapies

In my most recent Blogs I have been focusing on how Intensive Interaction could, and I believe should be usefully conceptualised as a psychological intervention for those people who have intellectual disabilities (and/or autism) who are unable to access traditional (i.e. talking) psychotherapies, but as Dr Ruth Berry stated: 'who may be in great need of experiencing psychological contact and connectedness' (Berry et al, 2014). 

These people (our Intensive Interaction people) are currently often (and in reality, almost entirely) excluded from being able to access traditional psychological therapies simply because such therapies rely on two-way exchanges of some form of 'symbolic' meaning as the means for addressing psychological difficulties and emotional distress.

Well as it turns out, in the 2015 UK report on psychological therapies for people who have intellectual disabilities (carried out for the Faculties for Intellectual Disabilities of the Royal College of Psychiatrists and the Division of Clinical Psychology of the British Psychological Society and edited by Professor Nigel Beail), there is clear evidence that this issue is starting to be more clearly and thoughtfully considered. In their imaginatively titled report 'Psychological therapies and people who have intellectual disabilities' there were indeed several references to the use of Intensive Interaction as part of variously framed psychological interventions. 

These references included: 

Chapter 7: Solution-Focused Brief Therapy - SFBT (Helen F. Lloyd, Alasdair Macdonald & Lauren Wilson p.88).

‘Case studies of direct SFBT work with those people with ID with little or no language are emerging. Bliss (2012) describes using SFBT principles with ‘Beth’, a resident in a home for people with Autism Spectrum Disorder. She self-injured, engaged in flicking, rocking, screaming and playing with saliva. As ‘Beth’ did not speak, staff voiced the preferred future for ‘Beth’ and gave examples of times when she responded positively. Exception-seeking was combined with behavioural observations of ‘exceptions’ and Intensive Interaction techniques as described by Firth (2006)’.

(Ref: Firth, G. (2006) ‘Intensive Interaction: a research review’. Mental Health and Learning Disabilities Research and Practice, 3(1), 53-58).

Chapter 9: Group Interventions (Rowena Rossiter, Celia Heneage, Nicky Gregory & Layla Williams (with thanks to Paul Willner & John Rose) p.118).

‘There are published case examples of group work, such as Leaning & Watson (2006) … who describe group therapy with people who have ID.’

(Ref: Leaning, B. & Watson, T. (2006) ‘From the inside looking out: an Intensive Interaction group for people with profound and multiple disabilities’. British Journal Learning Disabilities, 34, 103-109).

Chapter 10:  Art, Drama & Music Therapies (Simon Hackett , Kate Rothwell, & Chris Lyle, p. 132).

'Art psychotherapists working with people who have ID often use a flexible, adapted and individualised approach in their work. When working with people who have limited verbal communication, adaptation can include using picture symbols and other communication aids within the therapy. Additional communicative techniques such as Intensive Interaction may also be used'. 

So there is an obvious pattern developing of a growing number of therapists/psychologists using Intensive interaction across the UK as part of their psychological intervention toolkit - and from the report above, often in imaginative and (perhaps for some of us) unexpected ways e.g. as part of group or arts based therapies. 

But what now, and what next - how can this increasing recognition of the psychological use of Intensive Interaction be brought together? And how can those who work in this way be further supported to continue this important (no lets be frank - 'absolutely vital') psychological work for those people who until this happens will remain 'in great need of experiencing psychological contact and connectedness'.

'Being with' and 'making psychological contact'- fostering the development of the person’s sense of self?

Writing last week about the term 'Being with', which was used by Ben Smith in the new book Integrating Intensive Interaction (2017, Routledge),  well it made me think about the conclusions that were drawn (mainly by Dr Ruth Berry) in our 2014 paper: ‘Clinical Psychologists’ Views of Intensive Interaction as an Intervention in Learning Disability Services’, Berry, R., Firth, G., Leeming, C. & Sharma, V. (2014) Clinical Psychology & Psychotherapy, 21 (5), 403-410.

In our research we interviewed some Intensive Interaction minded clinical psychologists to gain insight into their views on and use of the approach. One of our findings was that:

'... the participants were using Intensive Interaction to establish psychological contact with people who are difficult to reach ... as one participant emphasised: ‘you can’t overstate the importance of communication: without it you can’t interact and without interactions you can’t have a relationship’.'

Also: '[The] participants talked about using Intensive Interaction with people who are difficult to reach and their comments about its benefits can be understood in Person Centred Therapy terms; they described it as a means for establishing psychological contact.'

Now apparently (and please remember, I am not a psychologist) Person Centred Therapy (also known as Rogerian therapy as it originated from the work of the American psychologist Carl Rogers) is an established form of therapy that is designed to  promote improved psychological well-being by helping a person develop their self-knowledge and self-awareness. The therapeutic process aims to both nurture psychological growth, and also through the therapeutic process reduce a person's emotional distress.

So just 'being with' someone, and doing so with 'unconditional positive regard' (as Rogers would say), could justifiably be seen as a humanistic psychological intervention to help those people who, for a number of reasons, are difficult to socially engage. Extrapolating that thought, surely Intensive Interaction could therefore also be seen as a therapeutic tool that, by developing unconditional inter-subjective communication, directly fosters psychological contact and thus has the clear potential to promote emotional well-being.

So perhaps there needs to be more work (in 2018?) directly linking Intensive Interaction conceptualisations to established psychological theory? As we (well Dr Ruth really) say in our paper, we need to do this:

'....[to] create the prospect of 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'.

Rogers C. (1957) ‘The Necessary and Sufficient Conditions of Therapeutic Personality Change’ Journal of Consulting and Clinical Psychology, 21, 95–103.

'Being with' - some more Intensive Interaction thoughts …

As I said in my last blog, I am currently reading the new Intensive Interaction book 'Integrating Intensive Interaction' - I'm a really slow reader! 

The bit that is making me think this week (it's like I can only have one thought a week - and to be honest, that is probably just about enough for me) comes from the chapter: ‘Intensive Interaction: from Einstein to Lady Gaga’ by Ben Smith (what a title Ben, that's brilliant!). 

In this chapter Ben, a team leader in the West Wales Specialist Behaviour Team, recounts how Intensive Interaction changed his focus from just behavioural modification to also look at relationship development and emotional well-being. Ben’s re-evaluation came about through his work with a socially isolated man called Mick, but he also talks more generally about using behavioural approaches with service users.

'...utilising often powerful reinforces and incentives to get ‘control’ over or suppress other human beings behaviour in order to attain participation and activity engagement goals or ‘better quality of life’ feels somewhat adrift of the care values statements of many service or care providers (p 104).

He goes on to say: '... simply ‘being with’ each other has equal if not more significance than ‘doing things’ with each other and if the ‘being with’ is done well, it can be immensely mutually satisfying and pleasurable. (p107).

'Being with' is a term I seem to hear more often now, and I have previously tried to usefully define this state of ‘being with’ someone in an Intensive Interaction way (initially in 'Firth, G., Berry, R. & Irvine, C. (2010) Understanding Intensive Interaction: context and concepts for professionals and families, JKP: London), where I refer to it being synonymous with more prosaic phrases such as: ‘tuning in with’, ‘attuning to…’, ‘going with the flow’, ‘just hanging out with…’, ‘chilling out with’, ‘sharing quality time with…’. I go on to say that: 

Just ‘being with’ someone can only happen if we put to one side any agenda of physical care, behaviour modification or educative development, enabling us to share moments with people in a way that is truly non-directive. (p.58)

However looking at this now, I think that it defines 'being with' as some things or qualities that it isn't, and perhaps it would be better to also define it by the characteristics it actually possesses. So, my most recent attempt to pin it down (rationalised with the help of my most estimable colleague Dr Jon Wain) is that the state of ‘being with’ someone is a social state that is: 

Purely equitable, two way, task-less,  contingent, emotionally attuned, negotiated in structure, open ended, and purely social in nature. 

(Please see the colour-coded diagram below which sets 'being with' apart from other social (or non-social) contexts that people in support roles may also need to enact) 

Does that help?
 

A new Intensive Interaction book & a new Intensive Interaction thought …

I am currently reading the new Intensive Interaction book recently published by Routledge:

Integrating Intensive Interaction

(edited by Intensive Interaction coordinators Amandine Mourière & Jules McKim).

Generally, as I read books that I feel I should fully understand, I take brief notes of any noteworthy points, statements or passages that I think illustrate something of particular significance or that are particularly insightful or thought provoking (and also that I think I might quote at some point later to make myself appear intelligent and well-read).

So here I will share just one statement from this book that stopped me a bit in my tracks, and set me musing for a while. This was from the chapter ‘Building an emotional connection through Intensive Interaction’ by Lucy Hankin. Working with Vincent, a 7 year-old boy who was ‘difficult to reach’ and ‘socially isolated’, Lucy relates how her Intensive Interaction practice developed hand in hand with the progress of Vincent’s abilities to connect with her.

At one point Lucy writes about watching some video of her Intensive Interaction with Vincent and noticing that ‘as Vincent was walking past he would gently touch his hand on my arm in an affectionate way: it was his way of keeping in contact with me as he moved around the room’.

And that observation led her on to make her next statement: and the bit I have underlined is what struck me as an extremely simple but also a profoundly insightful concept:

‘As this emotional connection [between herself and Vincent] continued to grow, the way he used touch also developed a further fluency as Vincent developed it alongside other fundamentals of communication…’

That bit about Vincent gaining ‘fluency’ (i.e. the ability to express himself more easily and more articulately) with touch … or more specifically gaining ‘fluency’ in the communicative and social significance of sharing touch with someone else … well I thought, what does that really mean for Vincent, and more broadly, for us?

I am still musing on this, because if we can help develop someone’s fluency in a pre-verbal means of fundamental communication, does that then directly equate touch as a means of sharing some form of inter-subjective meaning, and therefore it being an identifiable ‘language’? And does that idea of fluency also pertain to exchanges of eye contact and facial expression?

Well yes, I think it does, if we conceptualise the intentional sharing of touch, or eye contact or facial signalling, in a ‘language’ kind of way… and I’m still musing on the further issues of what does conceptualising touch (or eye contact or facial signalling) as a meaningful ‘language’ in which we can become more fluent mean for us, for children like Vincent, and for many other people who are ‘difficult to reach’ and ‘socially isolated’?

We teach foreign languages as specific ‘compulsory’ subjects in schools, but not fundamental communication for those who aren’t yet fluent [unless the school ‘voluntarily’ uses Intensive Interaction]: why is that? 

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