Thinking about the fidelity of Intensive Interaction practices

As more and more people are now finding out, Intensive Interaction gives us a process through which we can develop genuine social inclusion for people with communication and/or social impairments ... and then, by being engaged in that socially inclusive process,  supporting the development of a person's social communication and sociability; nothing difficult or contentious there then. 

But a question I have recently been asking myself is: how can we most precisely define the naturalistic, and often fluid, 'in the moment' and open-ended process of Intensive Interaction in way that can really nail its fidelity, so that when people (e.g. in research studies) say they are doing Intensive Interaction (and possibly trying to measure its subsequent outcomes), we can be sure (to the best degree possible) that it really is the best quality Intensive Interaction that could be provided (e.g. by someone who is a competent, experienced and reflective practitioner i.e. by someone who might be described as an 'advanced' Intensive Interaction practitioner? see last week's 03/1/18 Blog). 

Now Fidelity can be a tricky thing, but in very general terms it is defined as: 'the extent to which [the] delivery of an intervention adheres to the protocol or program model originally developed'*. So, we already have a very clear starting point there.

Therefore I think that any fidelity measures that might be useful in any Intensive Interaction research should combine two things; evidence of the use of the Fundamentals of Communication** (i.e. what the practitioner actually does) and Melanie Nind's 5 Central Features of Intensive Interaction*** (i.e. how the practitioner actually does what they do).

As most of us know, the 'fundamentals of communication' have been clearly set out by Hewett and Nind, most recently in the Intensive Interaction Handbook (2nd Ed, p.26) as: enjoying being with another person; using and understanding eye contacts; developing the ability to attend to that person; using and understanding facial expressions; learning to do sequences of activity with a person; using and understanding other non-verbal communications; taking turns in exchanges of behaviour; using and understanding physical contacts; sharing personal space; learning to regulate and control arousal levels; and vocalising and using vocalisations meaningfully (including speech).

Nind’s 5 central features of Intensive Interaction (set out in 'Efficacy of Intensive Interaction ...' 1996) are also referenced in the Intensive Interaction Handbook (2nd Ed, p.14) as:

1.  The creation of mutual pleasure and interactive games: being together with the purpose of enjoying each other (please also see my blog of 02/07/18 for a bit more on this one!)

2.   Staff adjusting their interpersonal behaviours in order to become more engaging & meaningful for the person

3.   Interactions flowing naturally in time: with pauses, repetitions and blended rhythms

4.   The attribution of intentionality: responding to a person’s  behaviour as if it were communicatively significant

5.   The use of contingent responding: following a person’s lead and sharing control of the activity

But, another thought: perhaps we should all be more thoughtful about the fidelity of our Intensive Interaction practices? Perhaps fidelity is a useful concept for us all to hold in our minds (and not just something for researchers to think about).

Perhaps we should all ask ourselves if we and our colleagues really are doing the best quality Intensive Interaction ... or something else, something with less fidelity 'to the protocol or program model originally developed' ... and therefore something potentially less truly intensively interactive? 

*Mowbray et al (2003) 'Fidelity Criteria: Development, Measurement, and Validation', American Journal of Evaluation, 24 (3), p.315-340.
**Hewett, D. Ed (2018) The Intensive Interaction Handbook (2nd Ed). Sage: London.
***Nind, M. (1996) ‘Efficacy of Intensive Interaction; Developing sociability and communication in people with severe and complex learning difficulties using an approach based on caregiver-infant interaction’, European Journal of Special Educational Needs, 11 (1), 48-66.

A new research paper on 'City Wide' Intensive Interaction training

I recently read a research paper published in the journal of Disability and Rehabilitation by researchers Judy Clegg, Rachael Black, Antoin Smith and Shelagh Brumfitt. The paper is called:

'Examining the impact of a city-wide Intensive Interaction staff training program for adults with profound and multiple learning disability: a mixed methods evaluation' 

[2018, but still only available on-line I think].

In this study, 7 staff were trained as ‘Intensive Interaction coordinators’; these coordinators then went on to train 120 staff working across a UK city's day centres for people with profound and multiple learning disabilities (PMLD). Some staff with a particular interest in the approach were then given further training, and one-to-one mentoring, and they were then signed off as ‘Advanced Practitioners’ (APs). These APs were then expected to support their colleagues to use I.I., as well as use it themselves. 

The results of this study showed that the Intensive Interaction training had a significant impact on the levels of staff knowledge about the approach, and that this then also changed the staffs' work practices. Indeed, 96% of the participants reported using Intensive Interaction, with 76% also wishing to use the approach with even more people. Using Intensive Interaction was also reported to help staff build better relationships with their service users, giving them more confidence and greater job satisfaction as well. 

However, the implementation of Intensive Interaction was seen to be about more than just having enough well trained staff - there was also a need for a consistent 'core team' of skilled and enthusiastic staff (the APs) who were committed to developing Intensive Interaction. The ‘Advanced Practitioners’ role was viewed as vital in this development and in maintaining staff’s focus on Intensive Interaction across the day centres. 

Support from managers and dedicated staff time to reflect on the use of Intensive Interaction were also valued, as was the completion of session and attainment records and external support from speech and language therapy services. 

This paper identified some implications for future service wide Intensive Interaction interventions: 

• Training staff in Intensive Interaction promotes successful social inclusion for adults with PMLD.

• With Intensive Interaction training staff can identify changes (i.e. positive developments) in the interactive and communicative behaviours of their service users. 

• However, staff need continued support and training to sustain their use of Intensive Interaction. 

• Also, services need to reduce the barriers of staffing, management and organisational structures to enable staff to sustain their use of Intensive Interaction. 

So, I think that this study provides us with clear and robust evidence that a well structured and well supported service level Intensive Interaction programme can be effective in increasing both the social inclusion and communicative progression of people with profound and multiple learning disabilities.

Many thanks then to researchers Judy, Rachael, Antoin and Shelagh. But we need more of this; more research, and more well structured and well supported Intensive Interaction interventions!

Opportunistic vs. Timetabled Interactions - a study of the pros and cons

Recently I was fortunate enough to receive a copy of Rachel Johnson's Master's degree study: 'Using a Phenomenological Approach to Develop Intensive Interaction as a Communication Technique in a Secondary SEND School and to Identify How It Can Impact on Pedagogy and Student Engagement' (Nice pithy title!). Rachel completed this study for her MA in 'Action Research in Education' at the University of Huddersfield.

Below I have set out some extracts that focus on some of the pros and cons of using I.I. in either 'prescribed' or timetabled sessions, or 'opportunistically' as opportunities for I.I. more naturally arise across a day - this being a topic of interest to me, and others in our Intensive Interaction community.

Extracts on: Opportunistic vs. Timetabled Interactions

'Firth et al. (2010) reason that sessional or timetabled interactions can mean that I.I. is more likely to happen with regularity and reliability, as it can be realistically managed within the timetable and working context. Nevertheless, if sessions are too prescribed, the learner might not be willing to engage ... Opportunistic interactions can be achieved at the most productive and favourable times for the learner. They can be integrated into basic care routines and happen at more unprompted and repeated times of the day.' 

'[However] If I.I. is left to be purely opportunistic, there is the risk of practitioners not taking responsibility for actioning it, or of not engaging in it with the required focus and intensity for the desired outcomes. Structured interactions can reduce external variables which might affect the learner’s response, including time of day, location, presence of other people, light conditions and temperature. A learner with SLD or PMLD may be more responsive in a familiar environment, where it is quiet, cool and has sensory stimuli, compared with attempted interactions in the morning when they are tired and have just experienced transition to school ...'

'Opportunistic interactions are favourable to experienced practitioners like Hewett, Firth, Barber, Harrison & Williamson (2011) as they adhere to the natural momentum of I.I. and can be done at any time of the day. Opportunistic sessions take advantage of the most preferred times for the learner and occur in a more unprompted manner. On the contrary, relying on opportunity can mean that no one practitioner takes ownership of the practice. In addition, time limitations and staff availability can restrict or cut short an interaction, especially in an educational setting where there are timetabled lessons.' 

'Considerations of engagement success can include the location, where an important consideration might be whether the student would be more or less willing to interact inside or outside of the classroom. The classroom is often a familiar and safe space but can also have many distractions, such as other staff and peers, noise (from inside and outside of the classroom) and interruptions from other students. There are arguments for I.I. taking place in more staged environments, where the practitioner can control such variables (Firth et al., 2010), but there is also support for I.I. taking place more naturally in a student’s familiar environment. Certainly, opportunistic interactions can be more favourable to the learner and therefore more student centred.' 

'This evidence ... indicates that distractions are less of an issue as the learner becomes more familiar with the practitioner and aspects of the interactions. Here, Firth at al. (2010) argue that whilst structured I.I. sessions can lead to more regular interactions, opportunistic sessions take advantage of the spontaneity that works well with I.I. Liken this to a typical verbal conversation between two people – if the interaction is timetabled, it tends to be formal and take place with the structure of an interview-type script. Naturally occurring conversations are more likely to be impulsive. This is reflected in the data, where the learners seem to display higher levels of engagement with increasing trust in the practitioner and familiarity of environmental factors.'

In conclusion, Rachel goes on to say:

'The key to creating the most successful situation for I.I. ... seems to be allowing opportunistic interactions to take place in partially-structured settings. For the sensory classes, this is quite easy to implement, as the timetable includes ‘continuous provision’ sessions, where there is more unstructured time for staff and students to focus on individual learning targets. Where there is a shared understanding of the benefits of communication approaches like I.I., staff are more open to interactions taking place ‘as and when’, (Hewett et al., 2011). This is more likely to create a suitable environment where the learner can initiate and control an interaction. For the supported and independent learners, this would look quite different and embedding I.I. within timetabled lessons may be the most effective way forward. Stern (1985) suggests that the key to engagement is through ‘varied repetitiveness’, where each interaction is part-new and part-familiar to the learner. This is relevant to creating more scheduled I.I. openings within the usual learning environment to take advantage of freer/opportunistic interactions as the learner chooses'.

p.s. Rachel will by now have gained her MA ... with a distinction! Well done and much deserved; and thanks again for some really useful 'food for thought' in how to get the 'opportunistic vs. timetabled interactions' balance right to deliver the most effective Intensive Interaction for all our learners or service users.

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.