Intensive Interaction works. In my last post I reviewed Phoebe Caldwell’s book “Autism. Respecting Difference”. That book gives several examples of Intensive Interaction in action. Here is a brief example from my own experience;
I was working as an agency worker in a Primary School for special needs children in London. I arrived in the classroom to which I had been allocated. The children were arriving at the start of the school day. One boy, aged about 9 perhaps, came in and lay down on the floor next to the radiator. I was told he mostly spent the days there. Other children were milling about beginning to be engaged in activities. I lay down on the floor next to the boy and copied his breathing rhythm and fed it back to him. After about 5 minutes he got up and sauntered down the corridor.
I don’t want to give the impression that the point of Intensive Interaction is something to do with stunts. I also used the technique, where I learned it, at an FE College also in London. Here it was part of, but not the whole part, of a series of conversations I had with a largely non-verbal young man with severe LD and autism over several months. These conversations were really enjoyable. As well as Intensive Interaction, signing also played a part in our conversations. He had very few words, but I think he understood a fair amount of spoken input and picked things up quite quickly. The point is that when you ‘feedback’ a person’s own language to them, showing you are attending, modulating it, picking up on their modulations, and so on, you are having a real conversation. And that is pleasurable and meaningful in its own right. (As Dave Hewett concedes in Chapter 1 of the book Intensive Interactions. Theoretical Perspectives. [1]).
How does it work?
The explanation given by Phoebe Caldwell is something like this; people with autism have problems with sensory processing. Their senses function correctly, but the circuits from the sense organs or receptors to the parts of the brain where the signals are decoded and interpreted have deficits, which leads to sensory misdirection, sensory overload and sensory storms. In defence from the internal chaos and confusion, which is so easily exacerbated by environmental factors and by people, people with autism can retreat into an inner world. They self-stimulate using some kind of sensory input which they themselves generate. This is extremely familiar and it makes them feel safe. They shut off the outside world. However; they appear isolated. Approaching them with “normal” input will only trigger the sensory over stimulation or confusing sensory input which they are trying to avoid. However; if you approach them respectfully, leaving them with the power to refuse or accept your approach and then communicate with them using their familiar vocabulary things might turn out better. When you feedback their sounds or gestures to them this attracts their attention. The signals, for example a particular rhythm, are familiar to them, but are now coming from outside. This draws their attention outside and away from absorption in their inner confusion. In addition, because the signals are the ones they are very familiar with they do not experience stress. In this state of relaxation existing cognitive functions are now able to operate; for example – a person who is usually non verbal may speak. So; the person is now focussed on someone outside of them and is unstressed and relaxed. Already, we can see, this is the basis for an enjoyable social exchange. I want to add to this account the useful view of Suzanne Zeedyk. [2] Zeedyk suggests that we all have a fundamental need to be ‘heard’. When a person with autism hears or sees the sounds or rhythms or movements which they have generated being reflected back to them by someone else, they feel heard. A fundamental need for connection is being met.
Once connection is established one can develop the conversation, continuing to use the person’s own vocabulary as a basis but developing it. In the book already cited, Intensive Interaction. Theoretical Perspectives [1] several authors present a case that using the technique can lead to measurable educational outcomes especially in terms of the development of communication skills or the ability to participate in exchanges. In the work of Phoebe Caldwell the emphasis is on the happier lives which can be lived by the parents or carers and the autistic people she works with.
I mentioned in my last post that I am not convinced by the sensory processing deficit model for autism. I am, at least at this stage, inclined to think that an alternative model is more correct. This model is theory of mind. In this model there are many “modules” in the brain which handle different aspects of life such as language, face recognition, dead reckoning and so on. There is also one for “mind reading”, that is for reading or estimating the feelings and intentions of others – making inferences about what is going on in other people’s minds. Clearly, this is key for communication. It is this module which is in deficit in people with autism. In this view the problem lies with a specific part of the cognitive apparatus. The difference may be that the proponents of the sensory processing model of autism are still using an older and more simplistic model of cognitive faculties (short-term memory, attention, induction) which lacks the detail to be able to explain autism as a cognitive deficit. Let’s provisionally accept this model. How does that affect our explanation of how Intensive Interaction works?
Let’s posit the following. R. has a deficit in the cognitive module (ToMM in the literature). He cannot make any sense at all of the intentions, desires, wishes, hopes or feelings of others. He rarely looks at them in the face because there is no point. It doesn’t help in the slightest. This makes communication very difficult. This needs some more work but my thinking is that to e.g. build something out of Lego with another person even without words requires a lot of glancing at the other and reading their intentions; is he going to put a brick there? So, R. can’t play normally with other children, (R. is 5), because without the ability to “read their minds” he isn’t capable of cooperative play. If he is allowed into the classroom where other children are playing he might just grab a toy, or he might, if he sees something like a tower another boy is building, knock it over. He is frustrated. He still has all the normal needs of a 5 year old. He wants to play with his peers. He would like to sit next to the teacher and read a story together, turning the pages as the teacher gets to the end because he can ‘read’ or sense that the teacher is looking for him to do that. In fact, as regards the last one, R. has developed a way of partly meeting his need. He has memorised the words from a couple of story books and he can sit next to the teacher and follow as the teacher reads, knowing when to turn the pages because he recognises the words. R. is however, mostly, very remote and aloof. He stays in his own world. He interacts with toys in his own way and on his own, but does not play with toys with others or an adult as “normal” children do. When an adult practiced Intensive Interaction with R. not much happened. There were no “instant results”. However; after this at one point R. did engage quite successfully in a turn taking game with me, building something. I can’t, though, say if this was the result of my attempts to practice Intensive Interaction with him. How might IA work with R. if we assume that R. has a deficit in the ToMM, assuming it might? In this model, R. has withdrawn into himself, not because of a chaotic sensory world, but because the human world, is inaccessible to him. It is painful for him to be in this world which he lacks the necessary equipment to take part in. Human encounters are frustrating for him. He has long since stopped trying. (You wouldn’t look at the view if you didn’t have any eyes to look at it with). When someone does IA with him, they are not presenting a strange face to him, an alien face, one that might as well be a whitewashed square piece of cardboard, they are presenting something different to him. It is, at least, recognisable and familiar. If we allow that he has functioning “mirror neurons” they might be firing. [I am not yet really able to talk about neurons and ‘brain science’. Need to do some reading]. He may feel “heard”; this is Zeedyk’s point, mentioned above. Just as in Caldwell’s model, this attracts his attention outside of him. The exchange is low in demand and this also means he can drop some of his habitual defences. He is relaxed and can trust the partner. He will be more open. Existing capabilities which are normally shut down can come into play.
Neither model really explains how Intensive Interaction is compensating for the supposed deficit. It seems that in both models, the main idea, is that Intensive Interaction is used to break through the isolation which has built up as a defence given the initial difficulty and then, once attention is diverted outwards, to sustain a conversation which is undemanding and unstressful partly because of the way it uses familiar vocabulary (and possibly familiar neural networks), and partly because of the spirit or respect and attentiveness with which the practitioner conducts themselves. But IA is credited neither with modifying sensory processing difficulties directly, nor with overcoming challenges arising from “mind blindness”, – lack of a ToMM. It seems that Intensive Interaction can enable a person to drop some of the secondary defensive mechanisms which they have adopted and open the way to communication, but it does not address the fundamental deficit which the person experiences.
Phoebe Caldwell has developed her practice by adding Sensory Integration to Intensive Interaction. Sensory Integration is a practice which addresses the sensory issues which autistic people have, and which Caldwell believes are central to autism. What could one add to Intensive Interaction which would specifically help people with “mind blindness”; if we accept this model of autism? (Given that I have only begun to think it terms of there being an issue with the ToMM in the last couple of days, there is a danger of running before I can walk). The immediate thought is rather obvious; if a person has difficulty or cannot at all, “read the minds of others”, that is, make reasonable inferences about their feelings, intentions, wishes and hopes, then, one needs to actively communicate these to the person all the time. Rather like, if one is working with a blind child, one can say “there is a wall here, there is a step here”, we can actively communicate our intentions, feelings, wishes and so on to them. Clearly, if they can understand words that might be relatively straightforward. For those without words, possibly, cartoon drawings might work? But, there might be an issue here that either they might lack the capacity to decode the semiology of the signs or the signs might suffer the same fate as your face; they might just not be readable. Words and gestures perhaps. (In our last post [3] we noted how Caldwell makes a point of communicating her intention to enter someone’s room by pointing).
Notes
- Intensive Interaction. Theoretical Perspectives Sage 2012
- ibid. Chapter 4
- Autism. Respecting Difference. Phoebe Caldwell.