The Fruits of Reflective Practice

The main reason I promote the use of the 7 levels engagement is so staff have a shared language with which they can describe and analyse their practice.  In a recent consultancy I did for the Sheffield learning disability charity The Burton Street Foundation, one trainee said “Oh, I get it… the levels are about the depth of the interaction.” This is correct.  The levels are not describing some abstract quality that is only useful for recording… it is a way to describe the depth of an interaction, from fleeting awareness all the way to two-way-ness and the initiation of this two-way-ness. A clear understanding of the levels can really help staff to understand how to meet the needs of the people they support more effectively.
For example, at Woolley Wood school I have given a teaching assistant in each class the role of II Class Lead.  During the first half term their first as was to take a baseline for the two children in the class most in need of Intensive Interaction support.  To take the baseline the staff have to pair up and film some interactions and then watch the films back and record the levels every thirty seconds.  This is done several times for each child and the average is taken which gives a relatively robust baseline to which future interactions can be compared.
That this method gives a nice baseline is all very well and good but to be honest, I’m more interested in the social learning that takes place between the staff as they do the analysis, particularly with their new words to describe the practice.  I was very happy therefore when one class teacher gave me the following feedback:
“Last week the II Class Lead organised an after school reflection meeting during which we analysed one video of an interaction with one of the children.  We were discussing and noting the levels every thirty seconds and then, about three minutes in, we noticed that the levels dropped off.  We discussed the potential reasons why the the interaction no longer had the two-way-ness and that the person was only showing brief attention to what was happening socially and, after reviewing the video again, we realised that the staff had started to try too hard, being a little impatient because nothing had happened for 15 or 20 seconds or so.   We discussed how the staff could approach the interaction differently next time and how perhaps the staff could simply have waited to see what the child wanted to do next rather than to intervene or how it might have been a good time to end the interaction.”
The teacher who gave me this feedback was so enthusiastic for the work and it was great to see the fruits of reflective practice – how using a shared language to describe our shared challenge can help us to offer the joy of human interaction to isolated and difficult to reach people. My work here is done :0).

Musical Interaction vs Intensive Interaction

Every Tuesday I work at Wilsic Hall School in Wadworth, Doncaster.  The service is a residential secondary school for people with complex needs mainly arising from autism and learning disabilities.  My role is to offer Intensive Interaction and Musical Interaction sessions for the individuals most at risk of isolation due to their communication disability and also to train staff during the monthly induction training and also as part of an ongoing training programme I have devised for the service.
Currently I am working with two class groups and I am finding that Musical Interaction is a useful approach in this context.  I hope the following short explanation may go someway to explain how I understand the approach relates to Intensive Interaction.
The way I understand Intensive Interaction is that, to create rapport, the practitioner looks for offers in the person’s behaviour and then joins in with this behaviour, using 100% of their attention and celebrating the behaviour like it’s the best idea in the world.  If this results in a mutual understanding of each others behaviour then rapport can be experienced (Fig 2).

In musical interaction the music offers a further opportunity for rapport.  In this approach practitioner will often make the first offer – a song, pulse, tune or rhythm which the practitioner thinks might be be mutually understood by the both the musician and the person (or other participants if working in a group setting).  If this results in mutual understanding then rapport can be experienced (Fig 3).

I have made the diagrams in an attempt to clarify this short explanation.  They work for me… let me know they make the practice more clear to you too.
Oh and if you want to learn more about Musical Interaction then I will be offering training on Musical Interaction Training 20th November 2017.

A post a day for II week – Monday – Woolley Wood School

Every Monday I visit Woolley Wood School in Parsons Cross, Sheffield.  I have worked at the school for one day per week since 2013 and, according to our evaluation of the community of practice, the Intensive Interaction provision and skill base has steadily developed over this time.  This year I have finally put a strategy into place that has been something that I have wanted to initiate for at least two years now and I thought I would share how this is going so far.
Each class now has a teaching assistant appointed as the Intensive Interaction Lead.  The person was chosen for their enthusiasm for the practice as shown over the last three years I have been working in the school developing II. Their role is three-fold:

  • To motivate the staff team to do Intensive Interaction and to learn more about the practice
  • To lead reflective practice meetings with the staff team
  • To be responsible for the intensive interaction recording – initiating the baselines and keeping the records up to date

The support that I give to help the lead person to achieve these objectives is to offer:

  • Easy to pass on principles of the practice (Three C’s of Intensive Interaction and RECAPS, 6 observable qualities of intensive interaction).  More about these in a future post.
  • Twice half-termly reflective practice meetings with the nine class leads to model how to facilitate such a meeting in the classroom after school.
  • Training on the 7 levels of intensive interaction and how to take baselines and record.
  • In class support to the lead person to model practice, answer questions and support recording.

Even though we are only half way through the first half-term, this strategy is already proving to be a big step forward for my role as consultant because I now have a group of staff to liaise with, each of whom is responsible for the practice in their class.  As you can imagine, this is much more practical that one person attempting to facilitate the practice in nine classes with only one day per week to do it.  I’ll write more about this strategy as the year progresses.
I will attempt to write a post a day for Intensive Interaction Week, each post referring to the context I work in on that day.  Tomorrow will be the Hesley Group service Wilsic Hall School in Wadworth, Doncaster.

What's in it for you?

Once up on a time I believed that all practitioners (and potential practitioners of intensive interaction) would share the same motivations – to help the person they are supporting to develop fundamental communication skills or to offer experiences of social inclusion and help the person become less isolated as a result of their communication disability.  While these motivations are very important and are often the priority for teachers, educators and therapists, after working for several years with support workers at the Hesley Group, I found that this other group of practitioners were, on the whole, motivated by a different set of reasons and outcomes.
This realisation is very important, particularly when working to develop a community of practice.  In Etienne Wenger’s social learning theory, the concept of ‘identity’ explains why a person will be motivated to take up a practice.  Put very simply, if the benefits of a new practice cover enough of the person’s ‘identity’ that they see the benefit to themselves; that they see why working harder tomorrow will be worth it, then they might give it a go (Interestingly, Etienne explained to me that the concept of identity hasn’t entered the mainstream understanding of ‘communities of practice” which may explain why it is an often neglected part of the theory).  Much of the explained benefits for Intensive Interaction tend toward looking at the impact upon the person we are supporting but, in my personal experience, while this is an important factor, it seems that this objective is not enough to motivate all people to do more intensive interaction… staff need to see “what’s in it” for them.
So, with this in mind, here are some of the most common motivations that I have found support workers to have for doing intensive interaction.  I have found that emphasising ‘what’s in it” for the practitioner to be very effective is supporting a staff member to try intensive interaction.
To find “this is why I came to work” moments – The wonderful thing about support work is that these moments are available every day.  All intensive interaction practitioners know what I mean when I say “this is why I came to work”.  It was this feeling, and the mutual feeling of the person I was supporting, that made me an advocate of II in the first place.  From conversations with people on induction with the Hesley Group, it seems that outside of care work people typically have these moments of job satisfaction in relation to promotion or when somebody offers them praise.
To calm the supported person to baseline – This benefit is a recurring theme with the support workers at Hesley Village.  The reason is obvious – the support workers have a difficult job supporting people whose behaviour can put both themselves and the staff at risk of harm.  Staff will certainly value a technique that can calm a volatile situation, reducing the risk to both the staff and the supported person.
To get a good shift – One staff member now describes the practice as “working for the eye contact” after she found that, if she joins in with the persons offers and gets good eye contact at the beginning of a shift then she tends to have a good shift.
To create rapport – Many staff feel unhappy when don’t get any positive feedback from the person they are supporting.  Staff are often relieved to find an approach that can create rapport, which both gives the positive feedback, because rapport works both ways, a positive feeling for the staff too.  One staff member now describes the practice as “working for the eye contact” after she found that she
To build a relationship – This is my core message to new starters.  Good relationship with the person you support = good job.  Bad relationship = bad job.  Rather than developing a relationship through trial and error, Intensive Interaction immediately brings a sensitivity to the needs of the person and will mean that the relationship develops quicker.
To make the supported person happy – The reason why support workers at Hesley have a good shift is more often than not because the person was happy.  Staff therefore find a lot of value in a simple approach that can lead to more happiness.
The community of practice at Hesley only started to develop once I started considering the motivations and needs of the community of staff I was working with.  Rather than trying to explain the practice in terms of the value I saw in it, I began to consult with staff to understand their perspective so that I could adapt my explanations to their needs.  This approach has had far reaching impacts and it all started with answering “What’s in it for them?”

Working for the eye contact

Communities of practice can operate at various levels in a care setting.  When I began working in the capacity of Social Learning Mentor at the Hesley Group, the most obvious communities of practice involved the members of staff in a particular area or on a particular team, or a group of staff in the same role (eg. Speech and language therapists).  For these communities of staff there was existing management, collaboration and time for the group to get together.  For me, with the role of facilitating social learning of Intensive Interaction, it was natural to begin with these existing groups.
As I started teaching on the 3 week induction course I found that the new starters had an energy and passion for the practice that often exceeded that of the people already in the job because their perspective was not inhibited by preconceptions or scepticism.  My experience is that, on the whole, new support workers see immediately how communicating responsively is going to make a difference to their job tomorrow and so they are receptive to the teaching, are enthusiastic to try it out and are looking for opportunities to develop the new skills.
After the induction session I make an effort to follow up with the new starters to see how they are going.  One such support worker gave me the following feedback:
“I attended the August Induction training and I would never have thought of copying someone’s behaviour if it wasn’t explained to me in the video and by Matt.  Now whenever I support someone new to me I look at their behaviour for ways to connect.  I find that if I get positive eye contact then this usually leads to a good day.  For example, when I supported one individual I was told that he only likes his regular staff.  When the other staff saw me doing the Responsive Communication that Matt taught us they asked me if I was an assistant psychologist!  I told that I was just doing what I was trained to do on induction.  Now I work for the eye contact and this leads me to moments of this is why I come to work… It makes me smile everyday.”

Three Pieces of Advice – Part 3

As I explained in the other parts of this series, the first two pieces of advice to people starting an interaction with a person with a communication disability is first ask “What are the offers here?” and then join in with the offers and Do What You See.  The purpose of this method is to see new opportunities for interaction and then hang out with the person, sharing their space and beginning to develop a rapport.  There is one more thing  however that newcomers to the practice often miss and this is where my third piece of advice comes in.
To mirror a person’s behaviour closely a practitioner must be able to improvise and follow the person’s lead.  This requires the practitioner to let go of his/her objectives or goals and be more mindful of what is happening in the moment.  My third piece of advice relate to not this letting go, but to what we actually add to the interaction, what we bring.  This is what I call Celebration.
When you have observed the offers and joined in with them by Doing What You See, don’t just copy the behaviour… copy the behaviour and celebrate it like this is the best idea the person has ever had and there is nothing that you would rather be doing right now.  What is really interesting to me is that a practitioner can choose to celebrate or not and that it feels nicer for the practitioner to celebrate something even if reluctant and the celebration is done on purpose.
Celebration is a key factor in developing rapport and is something that is often missing from my staff obervations.  Of course some people are very celebratory by their very nature and this is not something they have to work on but for others, particularly those working in stressful conditions, the emphasis on celebration has really helped them to find connections and also more job satisfaction.

Three Pieces of Advice – Part 2

In the first part of this series I explained my first piece of advice to new support workers – to observe a person’s behaviour and ask “What are the offer’s here?”.  The purpose is to open the practitioner’s eye’s to new behaviours that could be a starting point for an interaction.  The second piece of advice is what to do next.
After asking what the offers are the next step is to “Do What You See”.  Look for the offers and then join in with them.  Other ways to describe this step include copying, reflecting and mirroring.  I prefer “joining in” because the word “join” suggests two things being brought together to form a single relationship while “copying” and “reflecting/mirroring” describe one person doing something to another. For similar reasons I tend to avoid the word “mimicking” which suggests one person making fun of another.
What is the purpose of Do What You See?  Simply to hang out and share the space, showing the person that we love to do what they are doing and that we are a fellow rocker, tapper or singer.  This is first step to creating the rapport upon which playful/emotional communication is based.

Three Pieces of Advice – Part 1

Part of my role for the Hesley Group is deliver induction training to new support workers. The autistic people they will soon be caring for have a reputation for being challenging to support and so the new starters are anxious to develop a good relationship as quickly as possible. Responsive Communication and Intensive Interaction is a very effective place to start and at the end of the training session I leave the inductees with three pieces of advice when starting an interaction with someone.
The first piece of advice is to ask “What are the offers here?”. Everything that the person does could be an offer to join in – tapping, rocking or singing for example. The first thing that the practitioner has to do is to see the behaviour as an offer. Observing carefully and taking time to ask what the offers are can often help the practitioner to see new opportunities for interaction.
Mel Nind expressed this principle as “imputing intentionality” i.e. we impute (assume) that the person intended their behaviour as meaningful communication. While useful and technically precise, this expression is directed at a particular audience (namely that of educators, speech and language therapists and researchers) and I have found that the language often requires further explanation. Expressing the same principle more simply has helped the people I train to “get it”.

Experiences of Intensive Interaction and Dementia

It was quite natural for me to try intensive interaction and responsive communication as a way to connect with people with dementia. I think the first time I tried was in 2011 – at the time I was working at an autism care setting with the people that were the most difficult to reach and I had just started a new care home project for people with dementia. Only a couple of weeks into the project I encountered some older people who were unable to participate in small group interactions due to their dementia and communication difficulties. Observing such people before entering into a one-to-one interaction, I couldn’t help but be reminded of responsive communications with people with autism and severe learning disabilities. I was faced with people who were exhibiting non-verbal behaviours: tapping, singing, murmering, walking… all of which were treated as obstacles to communication by those looking through the lens of the verbal communication that we are all so used to. But from the perspective of intensive interaction and responsive communication, reminded as I was by my experience in autism services and special schools, these behaviours were offerings, ways-in and opportunities for the precious shared experiences that can lead to relationship.
And so I remember my first few encounters. We met people in the living room of the residential care home and one lady was sat back in her chair, her body rigid. Her gaze was fixed, her face tense in a fixed anguished expression. She was frequently vocalising – a low pitch monotone ‘ahhhhhhhh’. I sat with her and joined in with her behaviour, vocalising with her, starting when she started and stopping when she stopped. The whole time I attempted to ‘just be’ without expecting anything or making any demands. In hindsight (and having now worked in various acute mental health units for people with dementia) this lady was living with perhaps the most advanced dementia I have seen but as I sat with her I felt that she relaxed, her facial expression changed and her gaze moved toward my face. I felt a connection with the lady which, according to care staff was unusual.
I found this first experience enlightening and I felt that further investigation was worthwhile. So one week I turned to a gentleman who had so far hummed along to a few tunes when I had been engaging the group in some singing and music making. He was in his late fifties and, once I was with him one-to-one, I found that he could engage in verbal turn-taking but only half his words were clear and his sentences did not make sense to me. He would say something with all the non-verbal body language of somebody who had said something very meaningful but I was unable to understand. Trying to talk to him in a traditional sense would therefore be tricky, staff would ask what he means or would turn-take saying ‘ok’ or ‘right’ when he stopped talking. His dementia was not as advanced as the first lady but I thought it would be appropriate to try joining in with his verbalisations and body language. The results were interesting. He would vocalise a jumbled up group of syllables and smile and I would repeat the syllable and smile back. His response was to smile back and affirm what I had done. We had some rapport. We continued our enjoyable verbal turn taking and I imagined that, if foreign person who did not understand english had entered the room, they would have thought, from verbal exchanges and positive non-verbals, that myself and the gentleman engaged in an enthusiastic and meaningful discussion.
For me, these two examples highlight some interesting points for consideration when using intensive interaction with people with dementia. If we define intensive interaction as a responsive, taskless and mindful approach to communication whereby the practitioner joins in with and celebrates the behaviours of their partner with the aim of sharing a positive experience of social inclusion, then using such an approach with a person with advanced dementia like the lady in the first example (a person who seems to have lost the ability to self reflect) can result in the sort of positive meaningful interaction that is familiar to anyone with experience of using intensive interaction with people with learning disabilities or autism.  Due to her dementia it seems that the lady had lost her ability at the fundamentals of communication and is in a similar position to a person with a severe learning disability who may be yet to learn such fundamental social skills. Therefore our approach may look the same. What we do with a person with less severe dementia may be have to look different however.
After the interaction with the gentleman in the second example I did question whether, due to his milder dementia, he was reflecting on what I was doing and whether he was sometimes asking meaningful questions, however indecipherable, and hoping for meaningful answers from me beyond my joining in with his sounds. For much of the time we interacted I felt my intervention was appropriate but it was quite possible at times that he was wanting a meaningful verbal response in which case my intervention could have been counter therapeutic with the gentleman getting frustrated that I was not understanding them. A sensitive interaction in this case might might not therefore look like a ‘classic’ intensive interaction with one person copying the behaviours of the other.
What should we do then in this situation? Well, we just need to go back to the principles rather than the applications. I defined intensive interaction above as a responsive, taskless and mindful approach to communication. We can still do this without directly copying a persons behaviour… in this situation I often involve music and dance as structures for responsive, creative communication but, since describing this will require another post then I suggest just thinking about the principles… put down your agenda, remain totally mindful, be ready to respond at any time and celebrate the person you are with. See what happens… it can only be positive.

When a demand is not a demand (I'll choose the place, you choose the time)

My ideas for blog posts come directly from my conversations during mentoring and training. To explain things to a new trainee I often have to find a different explanation and sometimes I think that it might be useful for other people to hear this too.  This happened this week when I was mentoring the new group of staff on my course.
The situation was that a child was playing with a wooden train set on a table.  His pattern of behaviour was as you might expect, adding bits of track, pushing the train down the track and also, because there was sand on the table too, blocking and burying the trains in sand.  The teaching assistant reported that when she had tried to play with him in the past he would often push her away and that she was finding it difficult to engage with him.
I began by advising that perhaps she could try to share his space by being less direct and just playing with the trains herself in the same space rather than trying to engage him directly.  The result of this was that the child was happy with her being alongside him as a fellow train-player and the teaching assistant found that she could share his space for longer than before.
When we looked back at the video of the interaction the teaching assistant noticed one of her direct attempts to engage the child that hadn’t worked well.  She had added a few pieces of track herself and had then asked the child if they wanted to push a train down the new piece of track.  The child just ignored her.  When I asked the teaching assistant what had worked well she noticed that just sitting beside the child playing with trains had resulted in the child choosing to reach out and engage with her.  My way of explaining what was happening went something like this.
The key here is to understand the difference between an instruction and an offer.  I am giving an instruction if I am choosing the time I want my partner to respond ie. by saying “it’s you turn” or “do you want to push the train now?”. Given such an instruction (which can also be non-verbal), my partner is left with only two choices: to do what I have instructed or to refuse.  In my experience of people with communication disabilities I find that a common response is to refuse, ignore or react negatively, responses which do not seem to be helpful when we are hoping for our partner to choose to be with us. Often such a partner may be called demand sensitive but is it the demand they are sensitive to or us and our habitual ways of interacting?
An offer however is different from an instruction in that we leave the timing up to our partner. We do something that allows our partner to choose what to do.    In the context of the example above we might, in response to something our partner did, just move one of the trains a little closer to him. Our partner is then free to choose what to do with it.  If our offer is too close it might be seen as a demand, if it is too far away they might not notice it.  If it is just right then our partner might choose to reciprocate our offer.  Other things that the TA could have done include changing her position, amplifying what was happening by joining in with her partners actions using her voice (e.g. saying ‘wheeeeeeee’ when he moved the train), making a pile of sand, building a tower of trains etc.  All of these are not direct attempts to ‘engage’ but responsive offers that leave the child with choice.
This explains why picking up our partners hand and hitting a drum with it during a music session often doesn’t seem to have the desired effect.  Or saying ‘it’s your turn to dance, Mavis’ on a dementia unit.  The reason that we haven’t been successful is that our attempt to engage the person, even with the best will in the world, has been seen as an instruction because our partner feels they have no choice.  In these examples just offering the drum and playing yourself, or playing some music that Mavis might like and dancing a little bit yourself may work as offers that may just be taken up by your partner as they make a self motivated choice to be with you.
To find just the right offer for a person to choose to interact with us and play can take a little time and investigation.  What worked for one person as a good offer may be seen as an instruction by a more sensitive person so our reflective practice is importance in order to discover how to be the person that our partner needs us to be.
So this is why I say that we as practitioners we might be choosing the “place” (how and when we choose to approach for example) but, by understanding how to offer, we let our partner choose the time…