work in progress

a In

view
Even when enthusiasm, cooperation and support
from the top are available, changing a culture isn't
easy. Yasmin Shah reports on the successes and what
is still to be achieved following the introduction of a
Focused Interaction progralTlme to a Day Opportunity
SeNice for people with severe learning disabilities.
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003
if you are
offering training
managing change
.delivering amulti-
professional service
. ~ wo different but crucial needs are
often identified by speech and
language t erapiSTs:
1. the need fOf organisations to take
on board therapy programmes - to
'own' them -fOf successful outcomes.
2. the limited speech MId language
therapy services allocated to meet the needs of ser
vice users with speech and languag intervention
requirements.
Finding ourselves in this situatio , e developed
a Focused Interaction project wh-ch combines
Intensive Interaction and Ind- 'dualiied Sensory
Environment work.
Intensive Interaction as desaibed by Nind &
Hewett (2001, p.vi) is, 'A spe<i ic interactive
approach to facilitating the de ent of social
and communication abilities i pEG with severe
learning disabilities based on the model of caregiver
infant interaction.' The broad aim - 'or the service
user to discover the world outsi e of themselves
and to start to engage with others.
Individualised Sensory Environment therapy, as
developed by Karen Bunning (1 996), involves the
use of structured sensory stimulatio to develop
purposeful interactions with the en ironment by
the service user. In this context, environment
refers to the people, items, places a events that
motivate the service user. The ,!m -so provide
sensory stimulation that enco rages he service
user to make a target response_ rough the
course of intervention the se ice USEr learns to
make the target responses to get E desired sen
sory reinforcement. Even1ually he target
responses are generalised to SI a -om outside of
the Individualised Sensory Envir ment.
Focused Interaction refers to eve ing the abil
ity of people with severe lea - disabi lities and
severe social communicatioo d- -es to learn
about the world outside of th selves, from devel
oping engagement to lear iog spec- {communica
tion signals (signs, vocalisa -0 voros), through
using Intensive Interacti on or - - ualised Sensory
Environments. Focused Intera - is an umbrella
term that covers both Intens- ~ Interaction and
Individualised Sensory Environment work. So, for
those people who are engag- 9 - others in a dif
ficult to see, minimal, or u -onal way, an
Intensive Interaction approadl is used. When the
person is more interactive and engaged,
Individualised Sensory Environmen erapy is used.
The term Focused InteractJOn is used because the
overall goals of both In ensive
Individualised Sensory En -w - , ork are simi
lar, but differ in the degree 0 - posed structure .
This work has been dE\eIoped ' a large Day
Opportunity Service in Kent. proximately 140
servi ce users attend the service" ugh not every
day. The day opportu nity ~ has historically
had three-month blocks of speech and language
therapy support every 12-15 mo, Servi ce is now
provided one day a week.
Aware and commi tted
Ja.son Gerlack, the manager of the By opportunity
service, is very aware of the need speech and
4
ISSN (online) 2045-6174 www.speechmag.com
In progress
language therapy services and is committed to
developing and delivering a high quality pro
gramme for service users. In the day opportunity
service two sessions are run daily, led by Day
Centre Officers or Sen ior Day Centre Officers.
Care staff are generally assigned to those service
users who have more complex needs and have
one-to-one staff support. In this day opportunity
service, care staff generally work with one service
user in the morning, and another in the after
noon. Sometimes care staff are assigned to sup
port the running of sessions.
The Focused Interaction programme developed
following a referral for three service users who
had severely limited interaction and communica
tion skills. These service users, Larry, Nina and
Helen, attended the day opportunity service daily.
On assessing the three referred service users, it
was clear that they would benefit from an
Intensive Interaction approach to develop
engagement and connection with other people,
and that using an Individualised Sensory
Figure 1 Record f orm used in Focused Interacti on
Name of client
-
Name of staff
Date Location ._-_. ..
DID THE SERVICE USER ...
Give eye contact
Respond vocally
Initiate vocally
Reach I look towards you
Follow or move away from you
Use facial expressions
Use meaningful sounds
(This means sounds I words that can be translated,
for example "Oi" meaning "Come here!")
Show anticipation
Show they wanted more
Take turns with you in activity
What happened? (Describe the sequence)
What do you think was important about this
session?
How did it feel to you?
Environment approach later would be
an effective way of building up more
formal communication skills.
I was aware of the need for therapy to
be delivered as often as possible, and by
staff who were familiar to the service
user. Given that much time is spent
training carers to deliver a programme,
only for carers to leave or be re
assigned, and that as the speech and
language therapist it often is difficult to
ensure programme delivery, I proposed
a different model of service delivery to
the day opportunity service manager.
I discussed the therapy needs of these
people with the manager, and suggest
ed that, for effective intervention, a
number of staff needed to be trained
1998; Nind & Hewett, 2001) . We then developed
our skills through role-play with each other and
observed each other working with one of the des
ignated service users. Della later attended a train
ing day in Intensive Interaction but we did not
want to wait for the formal training before we
were able to launch this project.
We felt that both objective measures of the ser
vice users' responses and subjective impressions of
the staff needed to be recorded, so we designed
a form that we hoped would be easy and clear to
use. This combined elements of forms developed
by Nind & Hewett (2001) and Bunning (1996).
Della and I then delivered staff training. This
consisted of a formal training session,
presented three times to cover all partici
pating staff, as well as session leaders.
Including session leaders was part of
involving all levels of staff in the project
so that they would be able to support the
staff who were carrying out Focused
Interaction. Within the training sessions
My role
would be to
design the
programme,
train all staff,
and to
support staff
on a regular
basis
to deliver the programme at least daily, and that,
preferably, a day opportunity service staff person
should coordinate and support programme deliv
ery. My role would be to design the programme,
tra in all staff, and to support staff on a regular
basis as well as the day opportunity service pro
gramme coordinator. The manager was most sup
portive and freed up a staff person from another
commitment to work with me on this project.
Simple and user-friendly
We decided to keep things as simple and user-friendly
as possible. The idea was that the programme
would start using Intensive Interaction and then,
as the skills of the service users as well as those of
the staff developed, Individualised Sensory
would be introduced. Much time
was spent on Intensive Interaction, partly for staff
to feel comfortable working directly with Larry,
Nina and Helen without using any equipment. I
have found that people can easily focus on equip
ment rather than the service user.
First, much time was spent with the designated
coordinator, Della Heaton, to teach her what
Intensive Interaction is and why it works. This was
supplemented by readings (Bunning, 1996; Irvine,
both knowledge and experi
ential skills were developed
through listening, observation
and role-play.
Following the formal staff
training session, Della or I
supported the staff as they
worked with Larry, Helen and
Nina. Staff were asked to
spend at least ten minutes
morning and afternoon
doing Focused Interaction,
and to then fill out the record
form. We felt that stipulating
a minimum t ime would result
in more success than specify
ing a longer period . We also
hoped that, as staff became
more comfortable, they would naturally
spend more time doing Focused
Interaction, and that the style of their
general interactions with these three
people would shift. We also tried to
schedule a formal meeting with staff
every si x to eight weeks to discuss any
issues and to share our experiences.
Project has changed
Focused Interaction has now been running in the
day opportunity service for ten months. The form
of the project has changed quite considerably.
Initially, more than 10 staff were involved. We
found that some were more comfortable working
in the Focused Interaction style than others. We
also found that staff were reluctant to fill out
record sheets. The feedback from staff meetings
was positive overall . Staff felt that they were see
ing changes in Helen and Nina, and this was
encouraging. Some feedback was also critical - for
example, some staff expressed their view that
they felt it was childish to mirror behaviour.
Della and I responded to the feedback by
1. redesigning (with staff input) the record form to
make it simpler to understand and to use (figure 1).
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 5
ISSN (online) 2045-6174 www.speechmag.com
work in progress
~ 2. asking staff to fill out a simple questionnaire
about their experience using Focused Interaction
and giving them the opportunity to withdraw
from the project. The five staff who returned
the questionnaire wanted to stay in the project.
So our staff group then stood at five, but all
five were comfortable delivering Focused
Interaction and felt that they could see the
benefits of it.
3. resolving to be more present with
this core group of staff. It became The support service I This means that the
clear that, without our regular trained core group of staff only
involvement, they felt they were
of the day
work with Helen and Nina
working in a vacuum, and perhaps when they relieve the contract
opportunity
this contributed to decreased motivation ed agency staff. Staff pointed
in delivering Focused Interaction. out in one of the group meet
service manager
They needed support and ings that this would really
encouragement. This meant that I impact on Focused Interaction.
has been a
would work with whoever was When staff worked all morning
delivering Focused Interaction when I
critical enabling
with Helen or Nina, they could
more confidence'. Helen is also signing 'want' to
request an object during Focused Interaction with
just a minimal prompt.
These are highly significant shihs for both Helen
and Nina, attributable to their participation in the
Focused Interaction.
Things have recently changed again. All individ
ual support workers are being supplied by an
agency. And Larry no longer
attends the day opportunity
was at the day opportunity service and
that Della would do so during the week. factor.
4. developing the skills of staff further.
We videotaped ourselves working
with Helen and Nina and later reviewed these
tapes with staff. The video camera was also
used to record staff as they delivered Focused
Interaction. The recordings were later reviewed
to identify areas of good practice as well as to
facilitate reflection by the staff on their skills.
So, now, five day opportunity service staff were
involved in delivering Focused Interaction. Della
and I continued to try to support staff regularly,
but were not able to do so as ohen as needed. We
also found that staff were not delivering Focused
I nteraction as ohen as we had asked and hoped
for. This was partly explained by staffing short
ages within the day opportunity service as staff
were ill or took summer annual leave.
Nina and Helen have continued to make slow
but subtle changes. Both young women have
been attending the day opportunity service for
several years. Nina used to become quite agitated,
and would butt her head against her chair and
scratch others. She would leave group areas fre
quently. She is now calmer, head butts and
scratches less and stays in group settings, tolerat
in.g being close to others far more. It is also clear
that she is engaging more with others both dur
ing the Focused Interaction sessions and outside
of them. This engagement is demonstrated by
smiling, staying close to staff and looking at, or in
the direction of, staff.
Helen has}lways been more responsive to oth
ers than Nina and at home would talk to her
mother, but her language was not reported to be
functional - that is, she did not use speech to
answer questions or to get her needs met. At the
day opportunity service Helen rarely used her
speech spontaneously, and never in a functionally
communicative manner. Now she occasionally says
the name of the staff member she is with when
engaged in Focused Interaction, sings Iines of
songs and is reported by her mother to, 'have
choose their time to do Focused
Interaction. Perhaps more sig
nificantly, the relationship that
had developed between Nina
and Helen and the staff would obviously be affect
ed now that they were only to spend ten-minute
periods together.
Back to the drawing board
So again it has been back to the drawing board.
We have also analysed the forms with respect to
frequency of delivery of Focused Interaction
expressed as a percentage of sessions in which
Focused Interaction was delivered per month.
The resul ts were disappointing. We have been
getting return rates of 13-51 per cent per month
for the nine months that the data has been
analysed, this in spite of the positive changes in
the skills of Nina and Helen. We have shared with
the day opportunity service manager the prob
lems of delivering Focused Interaction only in
break times, and also the poor rate of delivery.
The plan now is that all the agency staff will be
trained in Focused Interaction through two for
mal sessions and support to the individual agency
staff. The delivery of Focused Interaction will be
written into their contract and the manager will
discuss this with the agency manager. In addition,
all staff in the day opportunity service will be kept
appraised of Focused Interaction through updates
in weekly staff meetings. Della and I will also sup
port staff in delivering Focused Interaction. I will
do so weekly and Della one to three times per
week.
This project continues to be 'a work in progress'.
It is very exciting to see how two service users are
making clear gains as evidenced in increased t ol
erance of others, decreased challenging behav
iour, increased use of words, and the develop
ment of use of a single sign to communicate a
request. The quality of life experienced by both
Helen and Nina has been enhanced.
Unfortunately Larry, the other service user, is no
longer at the day opportunity service.
Critical enabling factor
The support of the day opportunity service man
ager has been a critical enabling factor. He has
freed up a staff person to coordi nate the day-to
day running of the programme and has made it
known to all staff in the day opportuni ty service
that this work is important a d needs to be car
ried out. He has also sent the coordinat or to be
trained in Intensive Interaction, an conti nues to
be supportive as evidenced by ping into place
measures to ensure that the programme of
Focused Interaction is delivere!L
Another key factor has been that both Della and
I have needed to be flexible and responsive to
staff and also to the needs of the day opportunity
service as changes happen. his has meant, and
cont inues to mean, considerable time on a constant
basis for the weekly support of staff, coll ection and
analysis of records, and regular staff meetings.
We also have to just go wi th the flow of all that
happens in the day opport nity service.
Personally I am taking a very long ie . I hope
that over the next year or so some of he hiccups
will be ironed out so that this programme will run
smoothly and an increased numbe of service
users will become involved.
Eventually I envisage that this programme will
become part of the fabric of service delivery at the day
opportunity service, without the intensi e involve
ment of speech and language therapy services.
Yasmin Shah is Senior Speech and Language
Therapist, Advisor in Challengi ng Be aviour, with
the Community Learning Disability Team, Speech
& Language Therapy Department, East Kent
Coastal Primary Care Trust.
References
Bunning, K. (1996) The rinci ples of an
'Individualised Sensory Environment'. Bulletin of
the Royal College of Speech & Language
Therapists 52, 9-10.
Irvine, C. (199B) Addressi 9 e Needs of Adults
with Profound and Multi ple earni ng Disabilities
in Social Services Provision. In: Hewett, D. & Nind,
M. (eds) Interaction in Action - Reflections on the
use of Intensive Interacti on. London: David
Fulton.
Nind, M. & Hewett, D. (2001 ) Practical Guide to
Intensive Interaction. Pl ymouth: BILD
Publications.
Reflections
Do I have a clear vision to work
towards?
Do I see changes that are
beyond my control as a barrier
or a cha lIenge?
Do I provide training in a
variety of ways to maximi se its
impact?
SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 6
ISSN (online) 2045-6174 www.speechmag.com