‘What is not said’ to people - a persistent absence of meaningful and affirming communications

This blog isn't long or complicated - it is just a short passage rather lazily copied directly from a book (Firth et al, 2010, p.74), but this passage came back to mind when I recently became involved with an adult service user whose parenting in early childhood was, well shall we say (euphemistically), grossly and shockingly 'sub-optimal'.

'A[n] .... issue that is useful to reflect on is the possible lack of affirming and positive communications that a person with a social impairment might receive. It might be useful to ask at what other times, and during what other types of communicative exchanges [i.e. not Intensive Interaction], does someone with a social impairment have any affirming and positive things said to them, or asked of them, in a way that they can understand. Indeed, we could usefully ask ourselves how we would feel if these things were never said to, or asked of us, in a way that we could understand.

Not having certain things regularly communicated to us can say something very clearly to us about how other people value and view us. A persistent lack of affirming communications would, I believe, have a negative effect on most people, and a similarly persistent absence of any meaningful and affirming communications might significantly contribute to how a person with a social impairment comes to see themselves. This is not just my view, John Bowlby (a leading figure in the development of attachment theory) for example, writes about the importance of having a “lovingly responsive” parenting figure (1988, p. 124) for the development of a secure attachment and positive self view.

The reader may usefully reflect on how we might more often say affirming things to a person with a social impairment in a way that is meaningful to them. If, with the sustained use of Intensive Interaction, affirming and meaningful communications were presented more often, a person with a social impairment might have a better chance of constructing a more positive self-image. They may also come to see themselves as increasingly significant or appealing to be frequently engaged [with] in sociable communications, and also possibly come to see themselves as capable of initiating such communications.'

Firth, G., Berry, R. & Irvine, C. (2010) Understanding Intensive Interaction: context & concepts for professionals and families, London: JKP.
Bowlby, J. (1988) A Secure Base: clinical implications of Attachment Theory. London: Routledge.

Offering others 'Unconditional Positive Regard' through Intensive Interaction

Continuing on from the theme of my last blog (02/07/18) I thought that I might, as a non-psychologist, attempt to quietly purloin (well, point you the reader to) one of their psycho-therapeutic concepts, that of offering people 'Unconditional Positive Regard' (UPR).

This UPR concept is taken from the work of the American psychologist Carl Rogers and his ideas on Client or Person Centred Therapy. This is a well established form of structured psychological therapy that is designed to promote improved psychological well-being for people by helping them develop their self-knowledge and self-awareness. Such a UPR therapeutic process aims to both nurture a person's psychological growth, whilst also reducing their levels of emotional distress.

So just 'being with' someone with 'unconditional positive regard' (as Rogers would say), which is surely exactly what we aim to do when we do Intensive Interaction, should be seen as a legitimate psychologically therapeutic intervention that can help challenged and challenging people to more positively socially engage (also see blog of 28/12/17) ... and through such positive social engagement come to know themselves as potentially socially active, and potentially socially attractive people worthy of the positive regard of others. 

Below I have again purloined (with the best of intent) part of an illuminating blog on Roger's UPR concept by Dr Stephen Jones (an actual professor of psychology, health, and social care from the University of Nottingham):

First, Rogers’ theory was that human beings have an innate urge towards socially constructive behaviour which is always present and always functioning at some level. Second, Rogers’ believed that each person had a need for self-determination; and the more a person’s need for self-determination is respected, the more likely their innate urge to be socially constructive will take hold. For Rogers this provided insight into the best way to create nurturing environments at home, school, workplace and the therapy room.

Unconditional positive regard therefore means valuing the person as doing their best to move forward in their lives constructively and respecting the person’s right to self-determination no matter what they choose to do ... UPR can be misunderstood as being nice to people, smiling at them and nodding. But it’s not about what you do. UPR is an attitude. Get the attitude and the behaviour that expresses that attitude will follow.

So surely through the principles and practices of Intensive Interaction that we as practitioners embody and enact, we can tap into, open up and collectively explore a person's 'innate urge towards socially constructive behaviour' and their 'need for self-determination' ... and thus nurture their positive psychological growth! 

A bit of an issue with one of Nind’s 5 central features of Intensive Interaction

This blog is centred on something I don’t normally do; and actually something I feel quite anxious about going public on ... but I want to sensitively but reflectively challenge one of the central tenants of our Intensive Interaction theory and rationale.

Even worse, I am going to try to sensitively but reflectively critique the ground breaking work of one Melanie Nind (yes, I know!) ... and one of her 5 central features of Intensive Interaction from her seminal paper 'Efficacy of Intensive Interaction' of 1996 ("stop now ... go no further" I hear you collectively shout!) -  these defining statements being something I use all the time in my training - and actually as the basis of all of my Intensive Interaction work.

So the thing I have an issue with, and this issue has been coming into sharper focus recently with my work with some very challenged and challenging service users, is Melanie's very first 'central feature of Intensive Interaction' this being: 'the creation of mutual pleasure and interactive games; being together with the purpose of enjoying each other’ (Nind, 1996, p.50)

I suppose the issue I have is that often, and certainly so in the initial stages of trialling different Intensive Interaction strategies with some severely challenged and severely challenging service users (some of this challenge being evident in their social withdrawal and demand avoidance) in that ‘mutual pleasure’ as an outcome seems such a long way off.

Instead I think in such cases the primary need is to actually look to create a sense of non-demanding mutual acknowledgement … and then subsequent to that some level of inter-subjective understanding of a person’s psychological isolation, and separateness, possibly even their pain and despair … rather than looking to prematurely expect any practitioner pleasing, and possibly superficial enjoyment (in both the ‘classic’ or ‘adapted’ with language forms of Intensive Interaction).

Intensive Interaction asks us to ‘be with’ people in an unconditional way (see blog of 18/12/17), feeling them in an emotional sense, making psychological contact with them at the most profound level. For some people this will be an almost instantaneously joyous experience, but for some of our most challenged and challenging people, it can open them to feelings and thoughts that might illuminate negative past experiences, their previous social failure, their separateness and their associated social anxieties into an even sharper focus!

This doesn’t mean we shouldn’t go there, and be with them unconditionally using Intensive Interaction - absolutely not, it is vital for such people that we do - but it does mean that for some people, before we can even contemplate ‘mutual enjoyment’, we should look at doing the foundational ground work of ‘mutual acknowledgement and understanding’ - seeing and feeling the reality of their lived, and for some very negative experience.

Maybe hopefully, and in my experience absolutely “yes” eventually, the prospect of mutual enjoyment can become real; but a genuine and honest understanding of the journey that starts where the person actually is, is perhaps a better and more realistic way to set out on the first steps of this sometimes difficult and challenging journey to genuine social inclusion.

Stereotyped behaviours ... and how they should 'be seen in the context of concern with the whole person'

Having recently set out some guidelines on working with someone with a range of potentially socially isolating self-involved or self-stimulatory or stereotyped or repetitive/perseverative behaviours (various people, from various backgrounds, can and do label these behaviours in various ways) and advocating that staff should find ways to positively join in with them, I then found myself re-reading some interesting stuff by Melanie Nind and Mary Kellett.

This really powerful stuff looked at professional's (whoever they might be) views of some people's 'stereotyped' behaviours; and also how those working through Intensive Interaction might alternatively see them, and more importantly how we (as II practitioners) might subsequently positively respond  to these behaviours - this I think being at the very heart of the, for some, very radical nature and values of Intensive Interaction. I reproduce some of it below:

'Traditionally, professionals working with individuals with severe learning difficulties who demonstrate stereotyped behaviours, such as rocking and hand-flapping, have viewed such behaviours as undesirable, inappropriate and in need of reduction or elimination. This perspective is influenced by notions of readying those individuals for mixed settings, educating, training or modifying them to help gain their acceptance. Intensive Interaction is an alternative approach for working with individuals with complex difficulties that responds positively to them and their stereotyped behaviours, sometimes using these as a point of connection.'

(Abstract: Nind, M. & Kellett, M. (2002) Responding to individuals with severe learning difficulties and stereotyped behaviour: challenges for an inclusive era, European Journal of Special Needs Education, 17(3), 265-282.)

They then go on to say: 'Intensive Interaction sets out to enhance social and communication abilities and not to reduce stereotyped behaviours. However, findings from two studies of Intensive Interaction ... show some reduction in stereotyped behaviours are reported and discussed' [in their 2002 paper cited above]. 

So, it is because we (as Intensive Interaction practitioners) show value to the whole person, and sensitively and positively respond to such stereotyped behaviours, that subsequent to that, they might naturalistically/indirectly reduce as joint, mutually enjoyable and socially interactive behaviours increase.

In the same journal issue Melanie and Mary also responded to some other academics' responses variously critiquing [both positively and negatively] their articulation of the Intensive Interaction approach (crikey they must have been busy!); again I shamelessly reproduce some of this below: 

'We do not regard concern with stereotyped behaviours as redundant ... but we do maintain that the behaviours need to be seen in the context of concern with the whole person ... The worth of people with learning difficulties is neither negotiable nor dependent upon any particular set of behaviours ... The pressure felt by staff, supporting children and adults in ordinary community settings, to have them behave ‘normally’ is very real to them ... We have to live with the tension of valuing people as they are and wanting developmental change for them; how we respond to them as people is how we show our value of them. The issue is one of unconditional positive regard; people who have stereotyped behaviours should not have to alter them to gain our positive regard*'

Nind, M. &  Kellett, M. (2002) 'Response' by Melanie Nind & Mary Kellett to 'Commentary on: Nind & Kellett (2002)' by  Goldbart, J./Harris, J./Hogg, J. in Eur. J. of Special Needs Education, 17(3), 299–300.

*My underlining for emphasis! ... and I think I need say no more!

Intensive Interaction and Conventional Interventions: what is Different?

I was recently asked by a colleague for a copy of a piece of work that I have variously used across a number of different training presentations - this work looks to set out what is different about Intensive Interaction when compared with other more conventional 'interventions' (i.e. ways of working which would have previously been seen as more standard practice) used when working with, or supporting people with communication or social impairments. 

This 'What is different?' list is the work of the most estimable Dr Mark Barber (he of Intensive Interaction Australia), and I think this list is both useful and interesting, especially so in helping define what Intensive interaction actually is in terms of it's general rationale; and I shamelessly share it with you below (as possibly the easiest blog I've ever done):

What is different? Conventionally, an intervention begins by assessing the person to identify what skills are absent or problematic, or which areas of the person’s performance require intervention.

-  Using Intensive Interaction, observation is aimed at identifying strengths and preferences, so that these become the context for social encounters. 

What is different? Conventional styles of intervention and teaching are characterised by practitioners deciding on a predicted outcome or objective.

-  Intensive Interaction is characterised as open ended – the outcome of an encounter is not predicted or aimed towards. 

What is different? Conventionally, the practitioner leads and controls an interaction, engaging the person in a planned ‘teaching’ or ‘learning’ session.

-  Using Intensive Interaction the practitioner makes themselves available for social activity: Intensive Interaction = partnership. 

What is different? Conventionally, the practitioner leads by providing the focus of interest, attracting the person’s attention into joint focus [usually around an object or structured activity].

-  Using Intensive Interaction the practitioner looks for and responds to the person’s focus of interest by actually joining in with it. 

What is different? Conventionally, the practitioner has control over the place, the subject and any reward associated with an experience.

-  Using Intensive Interaction the choice of place depends on the preferences of the person, there’s no need for a reward –because the activity [or subject] of the interaction follows what s/he is already doing there’s no need for a reward……..its enjoyable for the learner [that’s why s/he is doing it] 

What is different? Conventionally, stereotyped or self-involved behaviours are seen as negative or ‘inappropriate’, and can become the focus of an intervention.

-  Using Intensive Interaction stereotyped or self-involved behaviours are viewed as probable ‘access points’ or indications of a means to enable ‘social’ activity. 

What is different? Conventionally, interventions focus on assisting the person to elicit developmentally helpful behaviours from those around them [usually staff].

-  Using Intensive Interaction contingent interactions are a starting point, although the goal of progress up an ‘interactive spiral’ is the same [Nind & Powell 2000]. 

What is different? Conventionally, interventions frequently focus on teaching new skills or developing a new behavioural repertoire.

-  Using Intensive Interaction practitioners engage the person by joining in with their existing behaviour, encouraging them to use skills they already have.

There, I told you it was both useful & interesting! and you can view more of Mark's work at:

www.drmarkbarber.co.uk

Using Intensive Interaction with people with language in residential settings: Some Simple Dos!

Following on from last week's blog about the 'Simple dos' when using Intensive Interaction with people with language in educational settings (04/06/18) developed by those attending our most recent Intensive Interaction Weekend Workshop, here are some 'simple dos' that can be used to inform practitioners when using Intensive Interaction with people with language in residential settings:     

                 

·    Do join in with the person’s interests, actions and vocalisations as a vehicle for an Intensive Interaction engagement – including the use of repetitive words, and see any spoken language as an additional element of the Intensive Interaction, but not the main focus or aim of the Intensive Interaction.

·    Do sociably ‘join in with’ the person’s language – as opposed to just reflecting it back!

·    Do playfully explore the language; the sounds, the emotions, the interaction, the feel, the vibration, the mouth movement and the meaning – but don’t focus on the literal meaning of the language, or on expanding on the literal meaning of the language.

·    Be aware that the words might not have the same meaning for the listener as they do for the speaker - the subjective meaning of words is not always as obvious as the meaning behind some behaviours … but sometimes do offer an extension when the word apparently has clear meaning …

·    Do use your knowledge of the person to know how much language to use (possibly using language only minimally) … and do provide sufficient processing time for the person to fully participate (again by possibly using language only minimally!).

·    Do closely observe the person for feedback as to whether ‘joining in’ the conversation by saying the person’s words back to them would be okay (i.e. not be interpreted by the person as in some way demeaning). We might say back some key words (from a longer utterance) as we  take a turn – but not the whole utterance.

·    Do make the language one of the fundamentals of the communication (e.g. the same as with an object) and follow Melanie Nind’s 5 key elements of Intensive Interaction (from her seminal 1996 paper 'Efficacy of Intensive Interaction' -  more about these in an upcoming Blog!).

·    Do consider the person’s sensory needs and their arousal levels or levels of anxiety … so consider the need to possibly offer a stimulating or calming type activity at the start or end of a session, or consider the inclusion of a sensory item to facilitate a calm, alert state of arousal.

·    Do get Intensive Interaction into communication passports, funding reports, care plans, etc. and do discuss the benefits of Intensive Interaction with management, CQC, etc.

·    Do keep it simple, and do follow your interactive instincts!

So thank you again to all our II Weekenders yet again for all their insightful efforts!

p.s. - you can now 'follow' this blog by clicking the 'follow' button on the top left - somehow Sheridan got there before I even put it up - why not join her and click on 'follow'!

Using Intensive Interaction with people with language in educational settings: Some Simple Dos!

At our recent Intensive Interaction Weekend Workshop in Malham (UK), all the weekenders contributed to writing up some simple 'dos' i.e. practical pointers that can act as accessible advice on how to use Intensive Interaction with people with language; the list below being developed by those working within educational settings (the next blog will have a similar list from those working in residential settings - although there are obviously many overlaps).

So: Some simple 'dos' when using Intensive Interaction with people with language in educational settings:

·   Language should be seen as an additional communicative “vehicle” through which to develop and sustain an Intensive Interaction engagement, with any language use seen as additional to, and not a distraction from, the use of the ‘fundamentals of communication’ (e.g. vocal intonation, facial expression, eye contact, posture and body language, etc).

·   Use good observation and reflection to gain insight into the student’s language use (including scripts); use this insight to inform the responsive use of language with them, remembering that sometimes it might be right to use no language!

·   Allow the student to lead the interaction; be available and respond when an interaction is naturally initiated or develops, and ensure that mutual enjoyment is the ‘focus’ of the interaction (and not any activity or linguistic agenda).

·   Be interested, enthusiastic and flexible in your use of language, but keep the tempo of language attuned to the tempo of the student’s language use and emotional state - allow for processing time; be comfortable with pauses and silence.

·   Enjoy verbally playing with sound, rhythm, volume, and intonation, as well as any words or phrases – and at times, when it feels right, look to gently and sensitively extend (i.e. spiral up) the language use.

·   Ensure that the language use does not put demands or expectations of language performance on the student (e.g. to respond in certain ways), nor create an external agenda that detract from the ‘taskless’ nature of the interaction.

·   Remember the language use may not have any clear or shared symbolic meaning i.e. a student’s language may not be used in a literally symbolic manner, and it may also not be directly indicative of or related to their current emotional state.

·   Use activities or objects of specific interest to the person if they create a familiar and safe social context, and an open-ended structure within which to scaffold the interaction, but always keep the focus on the sociability aspect of the interaction.

·   When appropriate provide sensitive ‘verbal commentaries’ (on shared activity or on any shared visual or auditory focus) to extend sociable language use.

·   Initially have one practitioner build up a trusting relationship with the student; they can then share their Intensive Interaction experiences and practices with others (via workshops, etc) to ensure consistency of approach in all settings.

·   Provide specific training and coaching through the use of videos, modelling, and discussions and make explicit reference to Intensive Interaction in all appropriate documentation e.g. ECHP, IEP, and Communication Passports.

So thank you to all our 'II Weekenders' yet again for all their insightful efforts!