Therapeutic relationships with individuals with learning disabilities ... an interesting paper!

Having last week taught a short introduction to Intensive Interaction on a Clinical Doctorate course for clinical psychologists in training, and edging into some discussions about the potential therapeutic outcomes of using Intensive Interaction with people with profound and multiple learning disabilities, I was reminded of an paper that I was pointed to (sorry but I can't remember by whom, but thanks anyway!) ... and about the central importance of relationship development between a therapist and their client in any psycho-therapeutic work - irrespective of the type of therapy being used.

So below I have set out some extracts from the aforementioned paper that look at the issue of developing and sustaining the vitally important 'therapeutic relationship' which sits at the centre of much counselling or psycho-therapeutic work (although the paper isn't about Intensive Interaction per se).

'Therapeutic relationships with individuals with learning disabilities: a qualitative study of the counselling psychologists’ experience' by Rachel A. Jones (2014), British Journal of Learning Disabilities, 42, 193-203.

‘Traditionally, psychological therapy has been concerned with working with individuals in isolation, on a one-to-one basis. The results of this study suggest that this practice is altered when working with individuals with learning disabilities ... Participants identified that developing a triadic relationship [i.e. with the staff or cares as well as the client] facilities comfort and reassurance ... [and] that the systemic relationships available to the individual should be involved in the therapeutic process to ensure that advances made during therapeutic work are reinforced and sustained after its completion’.

‘Individuals with learning disabilities are known to have limited experience of relationships, especially of those with an emotional focus ... the therapeutic relationship is often the first relationship of its kind for individuals with learning disabilities.  It is therefore suggested that as a result of their limited experiences, the therapeutic relationship has greater therapeutic impetus for individuals with learning disabilities’ (my underlining for emphasis).

‘There was a sense however that it was difficult for participants to introduce elements of their philosophical positions such as humanism, the therapeutic relationship and client-led rather than medical approaches ... resource limitations combined with the described setting culture were felt to significantly undermine the delivery of psychological therapy and the potential for positive therapeutic relationships’.

In summation the author states that:

‘The results [of this study] suggest that the therapeutic relationship with individuals with learning disabilities requires therapists to be flexible with some of the traditional assumptions of psychological therapy ... however, as suggested, one consistent factor remained fundamental, the significance of the therapeutic relationship’.

So in summation, I will also have a say, this being that for people with a severe communicative or social impairment, whilst acknowledging the difficulties presented by resource limitations and an encultured preference for 'medical approaches'), the development of a client-led 'therapeutic relationship' will undoubtedly have more 'impetus' when developed through the sensitive and responsive use of the 'humanistic' and 'client-led' approach called Intensive Interaction. 

But additionally it should be noted that this will not have the maximum therapeutic 'impetus' if it just done by developing a 'therapeutic relationship' with the person on a one-to-one basis; it needs to happen by working in systemically to make the social and emotional contact more universally encompassing i.e. by the full involvement of all the staff or cares, as well as the therapist. 

Intensive Interaction and Positive Behaviour Support

At a recent Intensive Interaction Forum meeting we held here in Leeds, we addressed some questions relating to the use of Intensive Interaction within or as part of the Positive Behaviour Support (PBS) formulation and planning process. 

Below are some of the notes that I took as we discussed the three questions I posed: 

Q1: What are the theoretical overlaps in the PBS and Intensive Interaction approaches?

• Both PBS and Intensive Interaction fit within a positive psychology theoretical framework, identifying positive aspects (or communicative strategies) of the service user's presentation as the basis of the proactive interventions, seeing these as the foundations on which to build improved engagement and developing an upward spiral in the development of positive and adaptive behaviours.

• PBS and Intensive Interaction are both about ‘getting it right from the start’, with PBS at times including Intensive Interaction (or the ‘adapted’ form of Intensive Interaction, and other communication and/or health/well-being approaches) to be used in a proactive manner to meet an individual’s identified psychological or psycho-social needs – rather than focusing on any resultant (and at times potentially challenging) behaviours i.e. they both address needs and issues ‘at the level of the antecedent’.

• PBS is a process (as is Intensive Interaction) which brings together an assessment and a formulation, and then incorporates both proactive and reactive strategies to address identified behaviours (more formally and predeterminedly structured in PBS, less formally and more reflectively and ‘in the moment’ with Intensive Interaction).

• PBS is seen as being a proactive and/or preventative approach (or process) that aims to support processes that are specifically designed to create the conditions for developing a good quality of life … (as does Intensive Interaction).

• PBS and Intensive Interaction are both processes that look to reduce, or somehow mediate, the impact of any demand avoidance on the part of the service user as they are structured in proactive ways to take account of any such issues.

 Q2: How does a combined PBS and Intensive Interaction process work in practice?

• After the Winterbourne scandal, PBS has been officially recognised as a more structured (and behaviourally informed) means of successfully embedding preventative and proactive strategies across services for people who present with challenging behaviour.

• PBS gives a more robust and evidenced analysis of behaviour (i.e. via the assessment and formulation aspects) of the underlying functions of certain behaviours (including the social engagement function).

• When recommendations (including Intensive Interaction) are included in a multi-disciplinary PBS plan, then it is more likely that this will be accepted as accurate and useful, and subsequently followed (to some level) by a service or staff team.

• PBS works by creating the potential for a positive spiral of more positive behaviours, and creating learning opportunities for service users to develop a broader positive behavioural repertoire (again, as does Intensive Interaction).

• However, the more structured process of PBS works well for some staff (and some staff teams) but less well for others; this being related to, and therefore dependant on, both the quality of management support, and the confidence levels of individual staff members.

 Q3: How does PBS help define with whom, when & where Intensive Interaction is used?

• The PBS assessment and formulation processed can help in identifying a person's social engagement needs through the use of specific social engagement trigger questions e.g. when contained in the behavioural assessment.

• PBS assessments can (although in practice often don’t) identify the social engagement needs for more cognitively able people who present with social impairments or demand avoidance issues.

• The PBS assessment should identify (although in practice sometimes doesn’t) those service users whose needs include the building of positive rapport, the development of trusting and supportive relationships (with support staff) i.e. prioritising ‘being with’ type practices before ‘doing with’, ‘doing for’ or ‘doing to ‘ type activities (see Blog of 18/12/17 for more details of these states).

• The PBS approach is focused on changing the support staffs’ or carers’ behaviour; this being the first order catalyst of change in the service user's behaviour i.e. creating a better and more responsive social ecology around the service user, not looking to change the behaviour of the service user directly 

i.e. “You have to lay the foundations [of the staff]… before you lay the foundations [for the service user]” Nick Guthrie (Intensive Interaction Coordinator).

I hope this helps other professionals using either Intensive Interaction or Positive Behaviour Support approaches (or both), and I would certainly be interested to hear any other points others might consider important.

Intensive Interaction: its place in my personal and professional history

A couple of weeks ago I attended a 40th anniversary 'get together' of old (well some of us) teaching staff who had worked at various incarnations of a special education unit for adult students with severe or profound learning disabilities.

It was great to meet up again with many old colleagues and friends, some of whom I haven’t seen in nearly 20 years. It was a wonderful night, with lots of catching up, and a fair bit of reminiscing about 'better times' - and for me, it also prompted some reflection about the difficult time I had when I started rejecting some of the then current (and sometimes still current) teaching strategies used by some of my colleagues, all of them highly committed and well-meaning staff members, and really nice colleagues to work with. However, the night also brought back to me a few difficult conversions I had when I started to develop some contrasting philosophical views about our role as teachers or facilitators of learning for our adult students.

It was during my time at this educational service that I intellectually and philosophically moved away from the teacher-directed and externally defined curriculum and pedagogical style that they were using (and previously I had also used as well), to incorporate more learner-centred and interactive classroom practices. I then went quite quickly on to fully embracing Intensive Interaction as both the content of my teaching (i.e. the curriculum content) and as my teaching style i.e. how the curriculum content was actually delivered to the learner. That in itself was, and still is interesting to me, that Intensive Interaction can be the knowledge and skills content of a lesson and the teaching method used to teach it, both at the same time i.e. it is what we are teaching, and it is how we are teaching it. Also it gives a process-central framework that helps shape the broad (but not SMART) learning goals! 

But also there was something about the values both embedded in Intensive Interaction, and enacted by it, that attracted me. There was something vital in how we value the learner as a legitimate adult student whose views, capabilities and motivational factors are fully accounted for in the classroom (i.e. they are fully involved in deciding, like all adults should, what they want to learn and how they want to learn it) ... and by responding to them (like adults) and following their lead, we show them their status as legitimate and equal actors in an inclusive social world.

When I was starting to use Intensive Interaction there was virtually no published research evidencing its effectiveness as a teaching and/or care approach (as there is now), but it was those values of equitable social inclusiveness that stood out. There was also the coherency of its theoretical underpinning i.e. its basis in the naturalistic infant-caregiver model of social communication development, and also how it fitted beautifully with my then growing understanding of social constructivist and socio-cultural views of the teaching/learning process.

The change in my teaching, and it seemed very radical then (in the 1990’s), seems quite distant and historic to me now ... yet the reasons I changed to Intensive Interaction, it's  values and its theoretical coherence, are still as powerfully convincing to me now as they were then (even if Intensive Interaction now seems less radical - it isn't).

It was great to see so many old colleagues ... some, but not all of whom came on a similar journey as I did with Intensive Interaction (i.e. learning with and learning from our truly memorable student body); nonetheless it was lovely to find so much mutual pleasure in sociably interacting and talking about our shared interests and experiences (did you see what I did then!).

The inter-related nature of Intensive Interaction attainments

Last week, when looking for something else, I came across a piece of work I did for my then Open University course in 'learning about the processes of learning' i.e. education. At the time I was a regular and I think okay practitioner, but I was just starting to try and think a bit harder about the underlying theory of Intensive Interaction, and through the course, the teaching-learning process more generally. 

An assignment in one module asked us to think about the 'Key Attainments' achieved within an aspect of learning that we were focusing our studies on, and of course I chose to focus on the learning that accrued for my then students with severe or profound learning disabilities through their engagement in Intensive Interaction; I ended up drawing out the diagram below:

When I look at this diagram now (trying to see past the somewhat arresting/off-putting colour scheme), what I see much more clearly than I did then is the complex and inter-related nature of all the fundamental social communication attainments - even when grossly simplified to the externally observable elements as in this diagram e.g. any increased use of eye contact is dependant on: 

• increased levels of stimulation or arousal ...
• also simultaneously on an increased use or understanding of facial signalling ...
• also on developing the ability to sequence any social signals with another person ...
• also alongside improved toleration of some else's physical proximity ...

with each of these other attainments also being inter-related to several other fundamental communication attainments, these subsequently feeding back into the initial attainment of 'use of eye contact' ... and all this happening in a complex, inter-related and circularly supportive fashion. 

So what about all this 'complex, inter-related and circularly supportive' malarkey I hear you ask ... well because all these individually conceptualised social communication attainments (e.g. 'increased use of eye contact') are in fact all inter-related and circularly supportive of each other across the very broad front of social learning - I think that the pressure to develop SMART teaching targets (i.e. S= Specific, M= Measurable, A= Achievable, R= Relevant, T= Time-bound targets) are at best a distraction from the process based, experiential learning that develops the skills and knowledge of the fundamentals of communication, but at worst I think they will become an actual barrier to genuine learning of the most important attainments we try to offer our learners, service users or family members.

The neuroscience behind 'getting more social' ...

In a comment on one of my most recent blogs - 'Sensory involvement in Intensive Interaction - a straight forward and/or a difficult question? (10/09/18) someone mentioned American psychologist Abraham Maslow (thanks Rachel) who was best known for creating Maslow's hierarchy of needs (obviously, that being his name), this hierarchy setting out the basis of his theory of the prioritisation of human psychological need fulfilment (and the associated motivational drives to act in ways to fulfil such needs). 

Maslow, in his seminal and still much referenced paper ‘A Theory of Human Motivation’ (Psychological Review, 1943), concisely defined this hierarchy of such human psychological needs (starting with the basic physiological needs of the body): 

· The basic needs: the physiological needs of the body (at the hierarchy’s base)

· The safety needs: the need for physical and social security

· The love needs: the need for love and belonging

· The esteem needs: the need for self-esteem and respect

· The self-actualisation need: the need to realise one’s individual purpose and inner potential i.e. in his own words: ‘What a man can be, he must be’ 

This mention of Maslow then reminded me of something I had seen a while ago (although I can't remember who pointed me to it - but thanks anyway); it was a wide-ranging and very powerful TED talk by neuro-scientist Matthew Lieberman that contested the ordering of Maslow's hierarchy. In his talk ‘The social brain and its superpowers’ Lieberman says that being socially excluded is analogous to feeling physical pain (i.e. that 'social pain is real pain') and therefore social inclusion and connection is vital for our very survival – and states that 'being social' should be at the base of Maslow’s Hierarchy of Needs i.e. below and supportive of access to the other, higher level physiological needs.

As well as somehow mentioning the world champion of 'Rock, Paper, Scissors' (as an example of 'social thinking') Lieberman says that 'social connection is the best predictor of happiness and well-being', and also that for all of us, “getting more social is the secret to making us smarter, happier and more productive”. Here, here, I say. 

Why not have a look at it at: https://www.youtube.com/watch?v=NNhk3owF7RQ 

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?