Sensory involvement in Intensive Interaction - a straight forward and/or a difficult question?

Last week a current and very reflective trainee on our Intensive Interaction modular training course emailed me with a question:

The question: I was just wondering if you had any information around the different senses involved in intensive interaction (do they have names when one sense is more dominant and favoured etc)?

My (at the time I think unsatisfactory) answer:

Actually I have nothing specific in terms of written out information on 'the different senses involved in intensive interaction', but there are obvious sensory issues to be taken account of in how we look to use Intensive Interaction with someone who might have particular sensory needs or presentations (although I would say that all people have sensory needs that are personal to them) i.e. sometimes it can be more visual (e.g. when we physically mirror some aspect of someone’s behaviour), sometimes more via sounds (e.g. when we echo back the sounds they make or make verbal/vocal commentaries on some aspect of their behaviour) and sometimes it can be physical or tactile e.g. via rhythmical touch to the person or via shared movements together without touching which could include rocking together or running and twirling together. 

Sometimes some practitioners talk about meeting the service user’s ‘sensory needs’, which can be done via the sensory integration work of specially trained OTs or physios (which I don’t pretend to fully understand - like most things!), but when done within Intensive Interaction engagements we are really looking from improved social and psychological and/or emotional outcomes (e.g. improved connection, better interactive rapport and relationship building) by working through a service user’s sensory preferences (again that is something we all have).

Now I currently feel that I have short changed my trainee in trying to answer this question in a fairly concise fashion (within the time constraints I had that morning), and rather than setting out to trawl through all the Intensive Interaction literature to find something someone else has said that would concisely and more satisfactorily answer this both straight forward and/or quite difficult question (the source of which I am currently unaware), I thought I would put it out for all our II community to mull over and hopefully join a usefully reflective debate. 

Now obviously Intensive Interaction does rely on the sociable use of a person's senses, all of them to some degree (probably) and more so via certain preferred or more acutely socially attuned senses; but within Intensive Interaction it is done with the person, not to them, and it is not done to meet any apparently identified sensory need - it is done to make a psychological not a sensory connection (although obviously again the two will in some way overlap and quite possibly be mutually interdependent, and hopefully mutually supportive). 

So, understanding a person's sensory preferences as demonstrated within a social interaction (as opposed to how they present in a individualistic or neurological sensory assessment type way) can surely be of some help to all people trying to engage with someone with a communicative or social impairment - but then I find myself asking another question: 

Could an attempt to consciously and proactively differentiate sensory preferences within an Intensive Interaction engagement deflect the practitioner from responding in an intuitive and attuned way, 'in the moment', to the person as a integrated social  actor, if they are trying to frame their responsiveness to fit with any apparently identified sensory needs first? 

Hmmm, a really good question, and yes, perhaps more difficult than straight forward to try to answer. Anyone else want a go?

Behavioural imitation and its affect on empathy in adults with high-functioning autism

I came across an interesting paper a few weeks ago that looked to investigate how some form of behavioural mirroring can positively affect the expressed feelings of empathy in adults with high-functioning autism (HFA). Below I have reproduced some extracts from the paper's abstract (and I have enbold-ed the 2 most important bits). The paper is:

The effect of being imitated on empathy for pain in adults with high-functioning autism: Disturbed self–other distinction leads to altered empathic responding 

 by De Coster,  Wiersema, Deschrijver & Brass (2017) in 'Autism', 22 (6), 712-727.

'Autism spectrum disorder is a neurodevelopmental disorder that is associated with problems in empathy. Recent research suggests that impaired control over self–other overlap based on motor representations in individuals with autism spectrum disorder might underlie these difficulties. In order to investigate the relationship of self–other distinction and empathy for pain in high-functioning autism and matched controls, we manipulated self–other distinction by using a paradigm in which participants are either imitated or not by a hand on a computer screen. A strong pain stimulus is then inflicted on the observed hand.'

'Behavioral and physiological results in this study showed that overall affective responses while watching pain movies were the same in adults with high-functioning autism as in controls. Furthermore, controls showed higher affective responding after being imitated during the whole experiment, replicating previous studies. Adults with high-functioning autism, however, showed increased empathic responses over time after being imitated. Further exploratory analyses suggested that while affective responding was initially lower after being imitated compared to not being imitated, affective responding in the latter part of the experiment was higher after being imitated. These results shed new light on empathic abilities in high-functioning autism and on the role of control over self–other representational sharing.'

Now this very carefully controlled study, with all its dense and at times difficult to understand language ('self–other overlap' and/or 'self–other representational sharing' anybody?), is non-the-less really interesting. 

Although obviously much more research is required in this area, this study seems to be suggesting that by deliberately imitating some aspect of the behaviour of a person with high-functioning autism over an extended period of time ('secondary analyses showed that the effect of imitation was strongly modulated by time'), and thus being in some way visibly more like the person with high-functioning autism, we enable them to be more empathetic to our condition and our potential feelings or emotions. 

In this study the 'imitation' was somewhat contrived using a videoed picture of a hand being somehow hurt (yes I know, it sounds a bit of a CGI lab-rattish nightmare doesn't it), but even then ... 

'Adults with HFA showed an increase of empathic responding over time in an imitation condition and a decrease over time in a non-imitation condition.' 

... but imagine if we took this out of the white-coated laboratory conditions; yes, imagine the extra empathic effects that might have accrued if it had been a real human being, doing real Intensive Interaction, and creating real two-way empathic communication?

Making a difference …. perhaps ... eventually … with Intensive Interaction!

The other day it suddenly dawned on me how change, often gradual and inconsistent, the 10 steps forward 9 steps back variety of change, can creep up on you ... and then 'Blam’ (or Batman type words of a similar nature) you suddenly notice just how radically things have moved on.

Since taking up my current role I have at times been asked to work with people in a local service for people with learning disabilities and challenging behaviour. I used to mainly feel like a bit of an outsider (because I was), but at times I also felt like a bit of an unwelcome visitor (although that might have been my own insecurities playing themselves out). My general sense was that what I said or did (obviously based on Intensive Interaction), or what I wrote in a person's guidelines or activity notes, didn’t make much of a difference in the general ways of working at a staff team level, even if it did help with specific service users (which it undoubtedly did, sometimes dramatically – but there’s me getting all big-headed now!).

Anyway, over many years I generally felt that Intensive Interaction and I were bit-part players in a much bigger, more medically and behaviourally oriented care narrative; but then the other week I met with their new OT (who had recently completed our Intensive Interaction training course) to discuss using Intensive Interaction with a number of their service users (nearly half of them) – and I then talked to one of the nurses and was asked for (and offered) some more detailed guidance on engagements with a particular non-verbal service user … and then I noticed:

• a dedicated Intensive Interaction noticeboard by the main entrance, with new/up-to-date general Intensive Interaction guidance e.g. on using Intensive Interaction with people with language, some simple Intensive Interaction dos and don’ts, etc …

• and then I remembered that I had recently had a meeting with the service manager about developing some dedicated Intensive Interaction paperwork for the service (including an ‘easy read’ Intensive Interaction handout) …

• and I also remembered that the senior matron (the overall service manager) has recently been very supportive of a staff member becoming a dedicated Intensive Interaction ‘Champion’ for the service …

• and that a couple of their service users had recently be supported to visit one of our Interactive Cafe sessions ...

• and that a student nurse (who will soon start as a qualified member of staff on the unit) has shown a particularly keen interest in the approach (and has talked about co-authoring a paper on the use of Intensive Interaction with people who challenge) …

• and that the general socially interactive behaviour now seen across the staff team (the majority untrained formally in Intensive Interaction) is more and more coming to include aspects of Intensive Interaction practice ... as if the whole culture of care has now moved decisively in the general direction of Intensive Interaction.

And so I do now think to myself, after all these years, "yes" things are certainly different ... change really has come; albeit gradually, inconsistently, the 10 steps forward - 9 steps back variety of change that will eventually effect a deep-seated working culture ... and perhaps that is the moral of the tale; when you continue to do the right thing (Intensive interaction), and do so with an emboldening sense of optimistic perseverance, eventually you will notice the accumulated positive outcomes ... 

p.s. I am now going to sign off from my Blogs for a 4 week break over the summer, but first can I just thank all those people who have read, reacted and commented (mainly positively) to my previous 48 blogs. Thank you, it would be a pointless exercise without that kind of positive feedback … and hopefully I will be back blogging again in September.

The ‘content’ or information transferred during Intensive Interaction exchanges

For this week's blog I will yet again unashamedly copy an extract straight from a book*, and it concerns what might actually be communicated between the participants during a often non-verbal Intensive Interaction exchange i.e. its 'content'. I have tried to translate the social aspect of the communication into symbolic words ... to give greater clarity to the co-constructed meaning. It may be one thing that is being said, or it may be a combination of many things, and perhaps you might like to comment on this blog to add your own views on this II 'content' issue.  

'The content or information that is transferred between people during a communicative exchange is often quite basic and (generally, although not always) uncontentious: how healthy we currently are; comments about a period of inclement weather; news of mutual friends or acquaintances; comments about last night’s TV or a sports contest; family or work related issues; where we would rather be at any precise moment, rather than where we are now! 

During such a seemingly mundane and commonplace communication there is an overt verbal exchange going on (e.g. the stuff about the weather), but also such an exchange can serve a more important ‘covert’ purpose – the most important thing not being the information conveyed about the weather, but instead perhaps it is about feeling connected with someone, re-affirming our relationship with that person, and possibly feeling validated by the person’s attention and response.

When engaged in a period of Intensive Interaction that is mainly or entirely non-symbolic, I often ask myself: ‘what are we actually communicating to each other?’, that is, what is the ‘content’ of such an interactive exchange? When I have asked this question, I have thought that, at various times during an Intensive Interaction, the content of such an exchange might be some combination of the following statements (although this is  by no means an exhaustive list):

‘I am listening to you – you have my full attention.’

‘Your behaviour or activity is interesting/important/significant and/or fun.’

‘You are interesting/important to be with.’

‘You are fun to be with and I am enjoying doing this with you.’

‘I want to be with you.’

‘I want to know you better/find out more about you.’

‘You can lead me, I will follow you during this interaction.’

‘You know what you are doing and I would like to know what you are doing as well.’

I also think that during an interactive exchange you are also implicitly asking questions of the person with a social impairment. These questions might be some combination of the following (although again this is by no means an exhaustive list):

‘What are you doing now?’

‘Can I do that with you?’

‘Do you want me to spend some time with you?’

‘Would you like to spend some time with me?’

‘Do you have something you wish to share with me/show me?’

‘Do you like it when I do this, or when I do that?’

‘What do you want me to do now?’

These questions will probably be asked in differing combinations at various points across an interactive episode, and in my opinion, they might well be viewed as the most significant content of the exchange.'

(* Firth, G., Berry, R. & Irvine, C. (2010) Understanding Intensive Interaction: context & concepts for professionals and families. JKP: London.)

‘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.