By Cath Irvine (Specialist Speech and Language Therapist for Adults with Learning Disabilities and Independent Intensive Interaction Trainer/Advisor)
We’ve been using Intensive Interaction in Somerset now for eight years. We have 30 coordinators across the county who are trained to teach, support, monitor and evaluate the use of Intensive Interaction. Social Services are fully supportive and Intensive Interaction is written into people’s care and support plans and is an integral part of staff job descriptions. I have seriously done myself out of a job here!
The following is the story of how we achieved this. I begin with some background history then move onto the discovery of Intensive Interaction. Much of the success of the approach here is due the success of early implementation so there is a section on this – divided into two parts: - a research project and work with one individual with severe challenging behaviour. Following this is a section on the impact of this early implementation.
I hope this makes easy reading. There’s a lot of information not covered but I’m happy to answer any questions via email.
I joined the Speech and Language Therapy Team in Somerset in September 1994. The team already had a high and respected profile for their work in promoting inclusive communication strategies for people coming out of long stay institutions. They had pioneered what became known as ‘Somerset Total Communication’ and at the point of my joining the team this was effectively implemented across the county.
Most of services for people with learning disabilities were provided by social services with input from health professionals like speech and language therapists, physiotherapists, psychologists and psychiatrists (sadly no occupational therapists – and community nurses have been introduced since).
Social services staff began to express their dissatisfaction that no one seemed to be paying attention to the needs of people with profound learning disabilities. When our team looked at these claims – we had to admit they were right. We did make an effort but those efforts seemed to be pretty useless and unproductive.
I remember one particular gentleman called Simon, for whom I had drawn up a communication plan of which I was very proud. Simon had cerebral palsy and used a wheelchair. He had no formal communications that we could recognise so we began to teach him how to make choices using crisps and pieces of apple (I can hear the dysphagia therapists groaning! – A steep learning curve is my defence!). He actually managed to grasp the concept of choice quite well using these gastronomical and life-threatening enticements.
Rather than celebrate this success, as a therapist firmly committed to further developing the skills of the people I was working with, I began to draw up plans for the communication session to now incorporate not only the real objects from which to make choices but also colour photographs – thus taking Simon onto the next stage of symbolic representation.
After four weeks of running this session the day centre carer came to me asking for help – Simon wasn’t grasping it at all. I decided that if there was a problem, it was because the session wasn’t being done often enough in a variety of environments. I invited his key worker from home to come into the day centre and observe the session so that she too could be involved.
On the day the residential key worker came to observe the session I also had a student with me. So four people, including day centre key worker, ended up watching this ‘1:1 communication session’ take place!
Simon was fine at the beginning of the session whilst making choices from the real objects but once the colour photographs came out – his breath quickened, his eyes rolled towards the ceiling - then to out of the window and his shoulders dropped into a posture which screamed communication of ‘I’m p***ed off!’
I had a flash of understanding about my working practices. A communication session that ignored one of the two participants? How appalling! Also – I’d fallen into the trap of assuming that if a teaching strategy wasn’t working – it must be the fault of the person/the carers – rather than the teaching strategy (and the teacher!).
I had a referral for another man, James, who was attending sessions at a bigger day centre. This centre had a policy of integration for their students with profound learning disabilities so I visited James in a number of his sessions to watch him sleeping in the corner or engaging in repetitive, stereotyped behaviours in order to keep himself awake. He was mostly uninvolved in any session he was attending. This was hardly surprising as the staff running the session would be struggling to engage a number of students of different abilities whilst ensuring general safety from individuals whose behaviour could be threatening to others.
I came away from attempting to assess this individual with a lots of questions about quality of life – what did he have to communicate about? Who did he have to communicate with? And who was going to talk to him on a level that he could relate to? Who had the time and insight to understand any of his communicative attempts? Did he have access to ‘activities’ that could engage him rather than alienate him further? Furthermore – how many other people were there out there who were leading similar lives?
The staff at the centre believed that integration was what they should be doing but some were very aware that the sessions they were running were not meeting the needs of a number of people with profound disabilities. Also, personal care had become a ‘conveyor belt’ system in the mornings and at lunchtime in order to get people to sessions on time. Individuals with profound disabilities would sometimes be taken out of the group to do an individual communication session which consisted of engagement with an activity they had previously shown a liking for, i.e. hand massage, playing with play dough.
The session began by giving the person brief taster of one of their preferences. The ‘teacher’ then stops the activity, saying, “Stop” then asks, “Do you want more?” They wait for a signal that can be interpreted as ‘more’ before giving another brief taster, introducing it with….“One, two, three…ready” The cycle continues like this until the person looses interest
These sessions were thought to be beneficial because they: -
I was deeply uncomfortable with these sessions! There didn’t appear to be much generalisation of the skills learnt into everyday life and I hated the idea of finding things that an individual liked and then restricting access to these activities/interactions until a communication session. I also hated the cold, unemotional language and the degree of control the ‘teacher’ had.
I shared an office with physiotherapist Chris Pratt and we spent hours during 1995 discussing the situations and lives of the people we were working with. Our discussions led us to some ideas for more proactive work.
We devised a questionnaire for each student who had been identified as having profound learning disabilities - this was distributed to all day centre staff that provided sessions for these students. We asked whether they thought the sessions they provided met the needs of these individuals. Only 10 &percent; came back as appropriate in the eyes of the staff. The 10% consisted solely of (unsurprisingly) music.
Using the results of the questionnaire, we negotiated, cajoled and coerced the staff and management at the centre to allow us a six months trial project for 14 individuals with profound learning disabilities. We got our agreement, got four staff willing to work on the project – negotiated an extra member of staff for each day from residential, got a great room and planned to start our specialised project. If no clear progress was made within a six months period we would go back to an integrated service.
The one thing we hadn’t fully planned was what we were going to do! We had proposed some plans: -
We had two weeks before the project was due to begin to finalise our plans.
At about the same time the speech and language therapy team were invited to apply for specialisms within Adult Learning Disability. I became the specialist for people with profound and multiple learning disabilities. Suddenly I was expected to know how to work with a whole group of people for whom the Total Communication approach was inadequate.
In a state of near panic at becoming the ‘specialist’ in profound learning disabilities, I rang one of my old university lecturers who had loads of experience with this client group. Juliette Goldbart is a respected expert in the area of working with people with profound disabilities and her advice was fantastic. There were two parts of the advice that were most emphatic. The first was to read ‘Access to Communication’ by Mel Nind and Dave Hewett and the second was to go to a conference in Manchester the following Friday to hear Dave Hewett give the keynote speech.
By some fantastic synchronicity, I went into the Speech and Language Therapy office and found two copies of Access to Communication – no-one knew who had ordered them or how long they had been there – certainly no-one had lifted them off the shelf since they had been placed there immediately following delivery! I started reading the book and became a bit of a recluse whilst doing so (I still went to the pub – but I took the book with me!)
By hook or by crook I was going to get to Manchester too – despite the AA and RAC warnings of heavy snow and only travelling if your journey was essential!
The reading of ‘Access to Communication’, the key note speech by Dave and the rest of the conference turned my training and my previous experience of working on its head.
I drove back from Manchester with my head buzzing with questions
I did an hour feedback from the conference to the staff who were to be working on the project – they were enthusiastic. We agreed that we’d all learn together – using video footage and regular reviews of our skills. We shot a video of us all playing with a baby in order to compare our styles when interacting with an adult.
We began our project in 1996 by having a six-week observation period – whilst still experimenting with the use of Intensive Interaction.
The staff were initially horrified by the idea of doing an observation period – they had worked with these students for a long time and felt they already knew them well enough. However, at the end of the six week period they had learned so much more that they asked for the observation period to be extended for three of the individuals – feeling that the process could be more valuable with more time.
The observation period was valuable because we had rarely had the opportunity to sit back and just watch. Also some of the strategies we were using were new to these individuals. Choice making was something I’d introduced in order to build in good practice for the future – I had no expectation that the individuals would begin to make choices so soon after their introduction. It became evident that many of the students had never been offered choices before – the belief had been that they couldn’t understand the concept.
The individuals had been chosen for the project following assessment of their communication abilities – they had all been assessed as ‘pre-intentional’ communicators. After the six-week observation period I began to query whether any adults we work with are pre-intentional. Once we began to look at communication outside the box of formality – we began to see communications happening all the time.
Following the lead of the students, we found ourselves on the floor and playing. The staff began to bring in toys and materials that appealed to the individuals. We videoed regularly and reviewed the videos monthly.
After four months I had a sudden realisation that, due to the fact that we were following the lead of the students we were probably breaking some policies like age appropriateness and physical touch. Fortunately the Social Services senior manager who was, at that time, responsible for policies was located in the same place as the research project and was familiar with most of the students. His reaction to my confession was wonderful,
“The progress of the students is astounding so the policies need ripping up and re-writing to accommodate the use of Intensive Interaction”
In reality – we could find no policy on Age Appropriacy. It seemed that the concept had been carried by word of mouth and regularly distorted along the way. We thought we’d better write one: -
Age Appropriateness
Age Appropriateness was a concept introduced mainly to improve respect and status for people with learning difficulties.
In practice the adherence to age appropriate philosophies can lead to:
Encouraging play does not need to diminish the respect for the people we work with
The project has been written up more fully in ‘Interaction in Action’ so I will summarise only briefly here.
The progress was wonderful in 11 of the 14 students. 1 student didn’t like the environment – preferring to be out and about (this was subsequently arranged and Intensive Interaction is now used ‘on the move’ with him) and 2 students in wheelchairs had made much less progress than the others – perhaps because we had come to expect so much that we were getting overly ambitious within a relatively short period of time.
At the same time as the project was running we were using Intensive Interaction with a young man in a different part of the county.
David was rather famous across the county due to the difficulty in placing him. His lifestyle was such that he was difficult to work with, to live with and to live next door to. He occupied his time by fast pacing, thumping his head with skull-echoing intensity and constant screaming. He arrived at a house that I clinically supported - after yet another breakdown of his previous placement.
We had been experimenting, with great success, with Intensive Interaction at this house. They also had the advantage of having no neighbours! We immediately went into interactive mode with David, pacing with him, vocalising back to his screams and mirroring his self-injurious behaviours by hitting whatever was to hand – if there was nothing around, we hit our thighs. Within an extremely short time (memories vary – somewhere between 10 minutes and half an hour) David realised that he was getting a response and he paused in his behaviours to wait for it. This meant that we could playfully delay the response as well as reducing the intensity of the hitting.
Two days later one of the staff discovered David’s fantastic sense of rhythm. Instead of slapping her thigh once, she did a little rhythmic sequence – and was thrilled when David echoed it back precisely. She continued to experiment and they both began to laugh and play with their new discovery.
The change in David was very fast and dramatic. The effect this had on county policy can never be underestimated. (Remember he was famous for being difficult to place.) At a county conference I did a workshop on Intensive Interaction and showed some video of footage of David. Some of the managers present had known David for years and despaired of ever getting through to him. Those videos of the new, settled, engaged and happy David were probably responsible for the financial and time commitment that has been given for the expanding use of Intensive Interaction across the county.
Within a few months of using Intensive Interaction, the staff involved began to hear comments like:
It’s alright for you – you just sit around with your students all day doing nothing!
These kind of comments, quite naturally, upset the staff so we thought we’d better do something about it. The Locality Service Manager decided that all staff in the network should attend Intensive Interaction training - starting with the managers.
One of the aims of the course was to ensure people understood that this was a way of working that had been validated by research. We wanted people to understand what we were doing – even if they weren’t going to get the opportunity themselves.
What happened as a result of this massive input of training was that other staff got very excited and went away to experiment with the approach themselves. Indeed, many of them said that they’d been working this way for years but had only done so behind closed doors due to the fear of being observed to be breaking policies.
Gradually the whole network changed from using a relatively controlling approach to a more interactive approach. This was most obvious within the day centre where the project was taking place and the house where David lived.
A group of staff approached me about setting up a similar service for people with challenging behaviour. I had been very involved in the project for people with profound learning disabilities and the work with David and other clinical demands had been relatively neglected for a period of time so a new service really needed to be owned by the staff rather than under my clinical management. I agreed to help set up the service – with them, and monitor it periodically.
It was proposed that this service would provide for 12 students who did not fit into other groups because of their behaviours. They had a rather negative press within the network because they were difficult to occupy in activities and threatened the feelings of security of other students.
We began a study group to look at individual needs and at the model we would use. The staff were very keen to use Intensive Interaction. Developmentally (in terms of cognition, communication and sociability) the students we had in mind were very similar to 2-3 year olds so we began to look at parenting styles with this age group.
As a result of our studies, we ‘tweaked’ Intensive Interaction a little, built in some boundaries and created a range of appropriate activities and communication support strategies. After six months the number of violent incidences had reduced by 61% and the individuals involved were much happier, independent and had a much more positive profile within the service.
Once the results of the project had been published in 1997 and word had spread about the work with David, everyone wanted Intensive Interaction. I was spending more and more time travelling around the county delivering training and, as mentioned earlier, my clinical workload in other areas was being either squeezed in or neglected.
We began some negotiations about who could take Intensive Interaction forward. Secondments appeared to be out of the question. Anyway – who should be responsible for Intensive Interaction? I happened to have introduced the approach into Somerset, but that didn’t mean that Speech and Language Therapy should be responsible for it’s expansion – we didn’t have the time.
An Intensive Interaction working party was formed in 1997 to look at the future implementation. The working party consists of myself, a Social Services Service Manager, A Network Manager from each location, a psychologist and a representative from the training department.
The working party’s remit was to: -
The recommendations from the working party were that 16 social services staff be seconded for 2 days a month to work on Intensive Interaction. They would need to be very carefully selected, intensively trained and supported for a year before they could undertake this role. I would be responsible for devising selection criteria, the actual training (not the organising of the training!) and the initial clinical support.
The selection criteria and the training are too complex to go into - in what was supposed to be a quick review of Somerset’s Intensive Interaction! If anyone wants to know more specifics – feel free to contact me!
From 2000, we had 16 good, passionate about Intensive Interaction coordinators able to support to extending use of Intensive Interaction.
Because Intensive Interaction was also being extended to a wider client group, i.e. people with autism, mental health problems, challenging behaviour, people with verbal skills who still needed support with interaction and sociability, we soon found that 16 coordinators were going to be kept very busy. Already many of them were working more than the anticipated 2 days a month – some of them now full-time in Intensive Interaction. In 2002 we trained a further 16 people to fulfil the extending needs for support and training.
In 2004 we began to offer a further 2-day course for people wanting more experience in hands-on use of Intensive Interaction. This course is run by the coordinators and the local Specialist Speech and Language Therapist for Adults with Learning Disabilities.
Somerset now has a fantastic service for people with profound disabilities – and it’s great to know that what we’ve learned through working with this group of people has been extended to add a real quality of life to other people within our service.
Dave Hewett was an immense source of knowledge and encouragement in the early days. Despite the fantastic progress we have made he still gets to visit us sometimes – as a motivator, head-patter and to provide the occasional challenge about the quality of our training videos/DVDs!
Many, many thanks Dave.
Printed from www.intensiveinteraction.co.uk on Friday, 9th May 2008
For further information on Dave Hewett visit www.davehewett.com
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