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?

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.)