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

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

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

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

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

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

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

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

'....[to] create the prospect of an evidence-based therapy for people who are unable to access traditional psychotherapies but may be in great need of experiencing psychological contact and connectedness'.

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

'Being with' - some more Intensive Interaction thoughts …

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

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

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

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

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

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

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

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

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

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

Does that help?
 

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

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

Integrating Intensive Interaction

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

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

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

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

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

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

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

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

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

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

Being 'mainstream' but not yet 'established' ... continued

At the start of last week I received a copy of a report about supporting people with profound and multiple learning disabilities. 

SUPPORTING PEOPLE WITH PROFOUND AND MULTIPLE LEARNING DISABILITIES:'CORE & ESSENTIAL SERVICE STANDARDS'
(by Dr Thomas Doukas, Annie Fergusson, Michael Fullerton & Joanna Grace)

Developed with the help of a diverse group of family members, professionals and academics 'these Service Standards are the result of a positive and passionate desire to ensure people with profound and multiple learning disabilities, regardless of age and circumstance receive excellent support and services consistently and are always respected as a person' (from the forward by Rt Hon Norman Lamb MP).

These standards outline a number of key objectives and principles that should be adopted by commissioners and service providers so that families and other representatives can be clear about what level and type of support and services they should expect for the person they represent. The report is available via the PMLD Link website, and so please go and download it for free at: www.pmldlink.org.uk/resources/#commissioning

The authors of the report hope that these standards will be adopted nationally - and this point reminded me of my previous blog (04/08/17) in which I made the point that Intensive Interaction is now a mainstream approach (and it is therefore included in this report), but not yet an established one - it doesn't happen as it should, as a matter of course! We still need to continue our work in the areas of dissemination and sustainable practice and service level development more broadly.

Anyway, back to Intensive Interaction, which is represented in four sections of this report:

Individual Standard 1: Communication
2b. Continuity of communication is demonstrated ... paying particular attention to gaining insight from those who know the individual best (e.g. family and familiar support staff) and then as many perspectives as possible, utilising as many avenues for understanding (e.g. Intensive Interaction, sensory engagement such as hydro, massage, music, responsive environment etc.)

3b. Supporting staff are skilled in delivering a total communication approach, e.g. sensory engagement, Intensive Interaction, routines and sensory cues, objects of reference.

Individual Standard 3: Meaningful/Quality Relationships. 
9. Staff understand the implementation and benefits of safe touch (functional use of touch vs. natural and emotional touch) and Intensive Interactions techniques.

Organisations Standard 3 : Staff development (skills and confidence)
2. All support staff receive regular in-house training, refreshed at appropriate intervals. Such training includes Total Communication, Manual Handling of People, Postural Care, Intensive Interaction or Sensory Engagement, Active Support, Safe Eating and Drinking skills, Supported Choice and Decision Making, involvement in services etc.

Finally I will leave you with a great quote from this report: 

“A person’s ability to communicate is not dependent on their being able to master certain skills, it is dependent on our ability to listen and communicate responsively” 

Jo Grace, The Sensory Projects

Intensive Interaction: is it ‘different paths, but with same goal’ or ‘the same path, but with different goals’ 

I was recently reading an online piece about my beloved football team 'Uddersfield Town. The obviously very clever (and/or very pretentious) sports journalist quite surprisingly quoted the renowned German philosopher Friedrich Nietzsche. He did this in respect of the different ways of playing football that the very successful 'Uddersfield Town manager had used with his team (be patient, this blog will eventually get around to Intensive Interaction at some point). 

Remember - after a few years in the footballing wilderness 'Uddersfield Town are now on a journey to the upper-reaches of the the English Premier League (and have recently beaten Manchester United - a team followed mainly by fans who journey from outside Manchester!)

Anyway,  the quote he used was this:

‘Many are stubborn in pursuit of the path they have chosen, few in pursuit of the goal’

All well and good, I hear you ask, but what has this to do with Intensive Interaction?

Well, I recently got a copy of a book on using Intensive Interaction strategies with people with late stage dementia. This book, called 'Adaptive Interaction and Dementia' by Dr Maggie Ellis and Prof. Arlene Astell, sets out their case on 'how to communicate without speech' with people with late stage dementia by referencing strategies set out by both Hewett & Nind, and Phoebe Caldwell in their respective books on the approach. 

In chapter 3 of this book, 'I Hear You Now - Collaborative Communication', Ellis & Astell set out what they see as contrasting conceptualisations of Intensive Interaction, and the person with whom the approach is used. In referencing the works of Hewett & Nind they say that 'some practitioners consider the focus of II to be on teaching the 'pre-speech fundamentals of communication'' and identify 'the communication-impaired partner [as] the learner'. They contrast this view of of II with that of Caldwell, which posits 'the caregiver or professional as the learner, attempting to 'learn the language' of their partner'. Interesting views I'm sure you'll agree.

Where do I stand on this: well I see the merits of both positions. With any collaborative  social endeavour learning goes on on both sides - but, I think, possible so at different points in the II intervention. Initially I see a 'social inclusion aspect' of an intervention where the practitioner learns how to adapt to the communication impaired partner's preferred and available means of social expression. But then I hypothesise a developmental process subsequent to successful social inclusion* - and I don't discount this even potentially for people with late stage dementia. 

However I don't see any developmental aspect for people with late stage dementia as necessarily being reliant on any retention, via short term episodic memory, of recent engagements with II (which may effectively be absent for some people with late stage dementia). However I do see there being the potential that repeated practising, and therefore neural accessing, of previously retained understandings of 'pre-speech fundamentals of communication' through II, could have a cumulative effect of improved access to those social understandings and associated social functioning.

I think this because of a paper Intensive Interaction: to build fulfilling relationships, by Charly Harris  & Emma Wolverson (Journal of Dementia Care, 2014), which pointed to some small but noticeable cumulative  improvements in the duration and ease of initiation of social engagement, over time, for some people with late stage dementia when using Intensive Interaction (although admittedly from a  small scale study).

This brought to mind another philosophical quote that I have liberally used myself over recent years, this time by Plato (who's being pretentious now, eh!) who apparently said that 'The greater part of instruction is being reminded of things we already know'! - Teaching being mainly about building upon the current knowledge base i.e. in II building on the current but potentially latent social skills and understandings that a person already has, and which are not being used to the maximum potential.

So, perhaps the two potential paths of II are not actually separate then, perhaps they are just temporal stages on the same path, and after successful social inclusion it is a journey that we go on, and learn on, together. Surely it is the pursuit of the universal goal of improved social engagement and connectedness (over both the short and longer term) that is the thing that we should be most stubborn in pursuing!

(p.s. I think that philosophy must be the new 'rock & roll' - even non-pretentious, cheeky-chappy, cockney comedian Micky Flanagan quoted existentialist philosopher Kierkegaard on Desert Island Discs last week - so its not just me!)

(*see: Firth, G. (2008) ‘A Dual Aspect Process Model of Intensive Interaction’, British Journal of Learning Disabilities, 37(1), p.45-49.)

Looking under the bonnet of Intensive Interaction - thinking about the mechanics of social interactivity

Quite often recently I have found myself referring to the central contention of a paper by Philip Schweigert (communication consultant/instructional lead at the New Mexico School for the Blind and Visually Impaired). This paper, 'Understanding the importance of the Partner in Communication Development for Individuals with Sensory and Multiple Disabilities' was published in the journal Perspectives on Augmentative and Alternative Communication (2012, Vol. 21, 167-173).

In this paper Schweigert points us very simply (which is why I like it) to the four requirements for successful communication: 

1. a 'means of expression' to communicate with (for us IIers that's via the Fundamentals of Communication)

2. a sender of a communication (well yes, obviously)

3. a receiver of that communication (no s*** Sherlock!)

but then, most interestingly of all (I think) ... 

4. a 'topic' i.e. something of mutual interest to communicate about ... so now "hhhmm" I am thinking: what is our topic when engaging with someone with Intensive Interaction?  

This on the surface looks like a variation on the Means - Reasons - Opportunities model (Money, D. 2002) that is already very useful and widespread across learning disability communication training. But the more specific 'topic' aspect of Schweigert's paper is the part that I find most attractive: 

‘The topic is something to communicate about… experiences help the child formulate interests. They provide motivation and topics for interaction. It is important to remember that the experiences we are describing here do not initially develop in social isolation.'

So, when we are joining in with someone's activity, sociably reflecting back aspects of their behaviour or vocalisations, using touch and other fundamental communication channels, what is the topic of such a conversation?  

Well I suppose the topic is the person themselves and our shared experiences (current and past) with them ... we are talking to, and with them, about them, and about our interest in them, and our interest in the things they are currently doing. Surely for most of us, 'we' and our experiences are the main thing we generally like to talk about. We like to engage in a process of sociable (but generally functionally useless) chit-chat: and we like to do this a lot, especially with those around us who are genuinely interested in us and our well-being.  

So if Intensive Interaction is the 'means of expression' it can also form the basis of the 'topic' as well ... two aspects in one, because it is the 'how' of how we are communicating, and it is the content (or topic) based on our 'in the moment' shared experiences, with these being a reflection of the person and their current (often pre-symbolic) behavioural repertoire. 

I also think that this can be in stark contrast to the situation where our people can so often be talked about ... not to or with ... but by other people, between other people.

Interestingly, also taking a more overtly developmental perspective, Schweigert states that: 

‘Before we can talk about symbolic communication for children with multiple and sensory disabilities, we must consider their presymbolic foundation and specifically their communicative intent. In order for such learners to develop an understanding of communication and their ability to influence others through their own behaviour, they must demonstrate a means of expression that others can detect and respond to. Means of expression must encompass not just the symbolic forms, but also the presymbolic forms. Behaviours such as a slight turn of the head, orientation of the body, change in respiration, or opening/closing of the eyes that are more subtle and difficult to detect also must be considered’.

I'm not sure if he knows it, but that looks a lot like Intensive Interaction!

x

'Developing best practice: developing best practitioners'

As I had repeatedly and shamelessly flagged up over the last few weeks, last Thursday we held our 13th annual UK Intensive Interaction Conference here in Leeds. I'd like to think that it lived up to it's reputation as a 'relaxed, friendly, meaningful' (Hewett, D. 2017) gathering of like-minded Intensive Interaction practitioners and advocates.

The focus of this year's conference was 'Intensive Interaction: Developing best practice: developing best practitioners' - which was a stroke of luck, as that was the title we'd given it on the flyer! I would just like to thank the chair and the speakers for their considerable efforts on what turned out to be a brilliant day. 

Thanks therefore to: Amandine Mourière (Chair and II Institute Associate), Cath Brockie (LD residential service owner), Ben Smith (specialist behaviour team leader), Lucy Golder and Julia Barnes (teachers), and Lynnette Menzies (Speech & Language Therapist).

Dave Hewett kindly remarked that: 'The expertise on display from the presenters was well, more than impressive, particularly since, apart from Graham, they were conference first-timers or with little experience on the podium. Praise them please, they uphold the finest traditions of what it is to be an Intensive interaction practitioner' - high praise indeed: it doesn't come much better than that!. 

If you would like to see a short illustration of the quality of their presentations, then go to: https://www.facebook.com/dave.hewett.71/videos/10154856997401123/ 

Here, I will give just a brief summation of the concluding point of my own presentation. It was my strong contention that to develop Intensive Interaction best practices and best practitioners:

We need to understand the value of structured and shared reflection in learning:

'learning from experience' should really mean ‘learning from reflection on experience’.

Without a clear process to support reflection on our Intensive Interaction experiences, we are unlikely to develop our Intensive Interaction practices, both individually and collectively, to their full potential. 

But learning from 'reflection on experience' doesn't happen by accident: we need to have, or make available, an on-going process of supportive, dare I say 'nurturing' (there I've said it), feedback to enable regular constructive reflection on our current practices - that's what will make us better at doing what we need to do, and to do it better (if that makes sense!).

p.s. I have also just got my NHS Intensive Interaction webpage back on-line. This is really important to me as my old one was cited in the UK Department of Health strategy document: 'Valuing People Now: a new three-year strategy for people with learning disabilities’. It was cited as one of only 2 places to go to get further information on the approach. (Mind you, you only get to the Intensive Interaction bit once you'd laboured past 7 voluminous pages of introductions, with glossy 'in my Sunday best' photos of 2 secretaries of state, 6 government ministers and a National LD Director!). Anyway, my new NHS 'branding & style format compliant' webpage can now be accessed at:

https://www.leedsandyorkpft.nhs.uk/advice-support/intensive-interaction/ ... why not take a look.