Changing you, changing me

 

COVER STORY: INTERACTION

Changing you, changing me Andrea Ruck was looking for a therapy approach that would address attitudinall barriers of care staff and generally help her to be more attitudina positive in her work with adults with learning disabilities. Video Interaction Guidance, originally developed for work with families, proved transformational for her practice.

READ THIS IF YOU ARE INTERESTED IN • CHANGING UNDERLYING PERCEPTIONS • FOCUSING ON STRENGTHS AND POTENTIAL • USING VIDEO AND GIVING VIDEO FEEDBACK 

s a new graduate practitioner in the adults with learning disabilities field, my work was heavily reliant on traditional advisory methods such as writing reports and discussing recommendations with staff. I felt frustrated that my recommendations were often not followed, and

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the approach include adult psychiatry teams, health visitors, educational psychologists, behaviour support teachers and social workers. Whilst it is widely used by those t hose working with children and families, the approach equally lends itself to work with adults with learning disabilities.

It is very important that only positive video clips are used as a basis for reflection during the feedback. This positive video self-modelling has a long history of being used to radically reshape behaviours (Biggs, 1983).

that communication training workshops were not effecting any real change in carers’ communication behaviours. I realised a different approach was needed, which would allow me to address the underlying attitudes of staff. Another significant moment in my development was when a staff member said a report I had written was “too negative”, and I decided I wanted a more positive angle to my work. Having heard a nursing colleague mention Video Interaction Guidance (VIG), I attended the VIG International Research Conference in Dundee in 2005. VIG sets out to improve communication and relationships using video.  The approach appeared to combine everything that I was looking for, and I was instantly hooked. I have since used VIG in various ways

Whatever the client group, all VIG practitioners hold several basic assumptions in common: • People wish to communicate • People in troubled situations do want to change • People do really care about each other • Everybody is doing the best they can at the time • Every crisis is an opportunity for change • Change always comes from within the individual. As a Video Interaction Guider (VIGer) I film 5-10 minutes of interaction between a carer / support worker and an adult with learning disabilities. I then edit the material and return on another day to view and discuss several short

All films are micro-analysed and edited with reference to the Contact Principles (figure 2), a set of descriptive categories which include attentiveness, looking and tone of voice. When appropriate, higher order communication skills such as making suggestions, offering choices and solving problems together are also incorporated. This has the advantage that the VIG approach can be used with clients across the entire spectrum of learning disability. disabilit y. I have used VIG with staff and carers interacting with clients with: • severe learning disabilities and autism and / or challenging behaviour • severe learning disability and severe visual impairment • Down’s syndrome and a stammer

to benefit adult clients with a learning disability and their carers / support suppor t workers, and the process continues to influence my attitudes and day-to-day clinical practice.

video clips with the carer / support worker (figure 1). These feedback sessions take about an hour. Usually the participant rather than the VIGer decides when they want to stop, but 3 - 4 recording and feedback sessions are generally sufficient to effect a change in attitude and / or communication behaviour, or to make the carer feel confident that they can now independently use their improved communication skills.

• moderate learning disability and hearing loss. I have also used the approach directly with clients to change their communication skills.  This includes a client with autism, others with social skills difficulties, one with a stammer and a mother with a learning disability interacting with her young child.

A. VIDEO INTERACTION GUIDANCE – THE BACKGROUND “VIG emphasises that change can be achieved more effectively and in a more empowering way in the context of a ‘coaching’ relationship, which is collaborative rather than prescriptive, empowering rather than deskilling and conveys respect for strengths and potential.”   (http://www.cpdeducation.co.uk/veroc/vig.php (Accessed 22 January 2009)) Video Interaction Guidance is based on

Figure 1 VIG filming and feedback 

a model developedHarrie in theBiemans. early 1980s by a Dutch psychologist, Originally used with dysfunctional families in the Netherlands, VIG is now practised widely across the world. There are currently 800 accredited Video Interaction Guiders and 75 accredited supervisors in the UK. Professionals using

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Figure 2 VIG ‘Contact Principles’ of communication

 

COVER STORY: INTERACTION

Andrea Ruck with John (see case example 2, p.6)

At another level VIG teaches the practitioner to give effective feedback to the carer / support worker. All work during training is supervised by a qualified VIG trainer. The VIG trainee brings micro-analysed video clips of him / herself interacting positively with the carer / member of staff to the supervision sessions (figure 3) and reflects collaboratively with the supervisor on use of the Contact Principles during feedback. This includes different initiative and reception patterns, what is being said and what is being conveyed without words. Because the VIGer is focusing on moment-tomoment pleasurable and successful interactions, s/he is perceived by the carer to create a positive atmosphere. As well as providing a scaffold for new thinking for the carer, s/he is also acting as a model for positive interaction. Looking at the different factors which may be contributing to the effectiveness of VIG, Vermeulen (2006, p.8) notes that Lambert (1992) identifies a positive carertherapist relationship as “one of the most important factors that t hat predict success in a programme.” Figure 3 VIG supervision

B. VIDEO INTERACTION GUIDANCE – WHY I FIND IT EXCITING AND REWARDING a) Carers change their perception of a client’ss communicative competence ent’ During the feedback sessions, the practitioner listens and responds to the participant’s own views, thoughts and feelings about the situation and vice versa. New shared meanings, possibilities and ideas for solutions appear (figure 4). Figure 4 New New perspectives develop

I filmed a carer with a client who had a severe learning disability and severe challenging behaviours in a residential setting. Initially the carer clearly overestimated the level of the client’s communication skills. She voiced the opinion that using close proximity and a sing-song voice with the client was “babyish”. She began experimenting with positioning herself closer to the client. On seeing the client’s positive response in the video clips, she engaged in a very open dialogue about the meaning of age appropriateness. Her perception changed in that “even adults like being silly and enjoy a bit of fun”. She also began to monitor and reduce the number of key words that she used with the client. She said that the recommendations in my report now “made

perfect sense” whereas beforehand she had simply disagreed with them. b) VIG generates positive effects in the carer’ss and client’ er’ client’ss environment Beyond the pure technical aspects of communication, VIG leads to various positive ripple effects each time I use it. These ripples affect the client’s daily routines, opportunities for communica communication tion and other physical environment factors, as well as the carer’s relationship with others around them, including ways of accessing support for themselves and for the client. Such associated positive outcomes often take place between feedback sessions, without the need for advice.  The carer carer finds finds their their own own solution solutionss to proble problems ms and starts putting them into practice. When I worked with a visually impaired client and her support worker Paul (case example 1), Paul talked to the other residential staff and persuaded them to switch off the radio while the client was indoors. It is worth wor th noting that the creation of a quiet acoustic environment had formed part of my recommendations for the last two years. c) VIG establishes collaborative relationships I sometimes use VIG with individual members of staff in situations where a staff group has failed to implement a communication programme due to difference attitudes or beliefs. Because VIGa focuses on in developing a collaborative relationship with an individual staff member, who gains a more realistic view of the client’s communication needs, the staff member may start to act as the client’s advocate and pass good practice on to other staff.

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COVER STORY: INTERACTION Following a client’s autism diagnosis, our local Learning Disability Team carried out some communication / autism training for staff, who remained unconvinced that the client had autism. I then carried out VIG with an individual volunteer member of staff. She picked up straight away from the video that the client had a verbal processing delay and revised her opinion about the diagnosis. After two VIG sessions, she reported that incidences of challenging behaviour had drastically reduced when she was on shift with the client. She asked me whether I could do another couple of VIG sessions with another interested member of staff. The two staff members drew up their own set of communication guidelines and we shared video clips with the rest of their colleagues. The next time I visited, I found the staff much more attuned to the client’s communication. d) I can work with clients directly I have also used VIG very successfully with clients themselves. Biggs (1983, p.119) states that, “for people with mental retardation, self-modelling has enjoyed considerable success – it is visual, rather than language based, and the ‘self’ element makes it engaging and concrete.” Video also readily enables clients with a learning disability to repeatedly view their own adaptive behaviours. Because all filming is done in a natural context, at the client’s Day Centre, at home or out in the community, using VIG with clients offers exciting opportunities to address the difficulty with generalis generalisation ation experienced by people with learning disabilities (Krantz et al .,., 1983).

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e) Clients show a high degree of involvement in their own therapy Probably more than anything else, I have been amazed by the way clients have involved themselves in decisions about their own therapy. All too often we as therapists decide on the number and content of therapy sessions. With VIG, clients usually take control over who they want to be filmed with and the pace of therapy, and they may request additional sessions. I worked with a client with a moderate learning disability and a severe stammer (case study 2). VIG therapy with the client was aimed at improving his confidence in talking to staff. We viewed and discussed brief video clips, which showed the client engaging in pleasurable and relaxed conversations with a member of staff. When I asked the client whether I could film him with another staff member, he initially admitted to feeling “very nervous” and was reluctant to be filmed. Two months on, he approached me, asking if I could help him to “feel proud” when he was talking to other staff. f) The unexpected happens Work with another client with autism whose comprehension was at a 3 Information Carrying Word level (Knowles & Masidlover, 1982) led to exploration of the Contact Principle of using a friendly voice. A pivotal moment was when the client engaged in some reflection. On noticing her ‘friendly voice’ on video (repeated playback), and on seeing the other person’ss reaction, person’ reactio n, she said, “well…maybe that’s a good thing!” and began to actively experi-

ment with her tone of voice. Seeing herself and others on video enabled the client to identify how her conversation partners felt during conversations, and whether they were interested or bored. Due to the client’s autism and poor comprehension ability, I would not normally have envisaged – or thought it possible – to target intonation in therapy. C. POSITIVE IMPACT ON MY PRACTICE i) New perspectives appear In my role as VIGer, I am constantly gaining new insights. I have come to appreciate how crises resulting from challenging behaviours can profoundly undermine staff’s self-esteem and belief in their own personal competence as communicators. For me, it has been extremely rewarding helping these staff to feel more positive about themselves, and to re-establish a mutual and positive trust between them and the clients in their care. ii) My interactions with other professionals have changed profoundly Approximately 4 - 6 months into the VIG training, I noticed on leaving professional meetings how they had gone extremely well and led to very positive outcomes. I realised this was due to effective carryover of the Contact Principles. When I enter into negotiations with other professionals and students, I now rely much less on persuading, convincing or arguing my point, and much more on listening, bringing out the other person’s resources and strengths and enabling them to come up with their own solutions to problems.

Case example 1: Vicky and Paul

Case example 2: John and George

Vicky is a woman with Down’s syndrome, a severe learning disability and severe visual impairment. She was at the pre-intentional / early intentional stage of communication development and presented with several challenging and self-stimulatory behaviours. I was first approached by Paul, Vicky’s new 1:1 support worker at

 John is 25. He has Down’s syndrome, syndrome, a moderate learning disability disability and a severe stammer. John frequently isolated himself at his Day Centre. He only engaged with his key worker and tended not to speak to other staff or join in with any groups. His brother reported that, at home, John did not usually talk to visitors and would often

the client’s residential home, as he felt unsure how to communicate with Vicky. I carried out four filming and feedback sessions over a four month period. At the beginning, Paul described communication with Vicky as “hard work”. He felt he would never be able to “have a longer conversation” with her. During the first feedback session, Paul became aware of the Contact Principle of using a ‘friendly voice’. He had been a football coach and used the terminology of “cheering Vicky on”, which I reinforced. Paul subsequently experimented with his tone of voice between filming sessions and reported back on his success: “I’m so thrilled – I now feel that Vicky knows who I am!”  The final film was done whilst Vicky and Paul were in a busy café. Normally Vicky did not tolerate such noisy environments and would start screaming. However, on this occasion, she calmly engaged in vocal and tactile turn-taking behaviours with Paul for 10 minutes. Paul noted that Vicky’s communication was now much more directed at him. The video revealed how, for the first time, Vicky touched Paul’s arm to gain his attention, as opposed to throwing objects or stripping off her clothes. Other staff also noticed a change in Vicky and reported that her challenging behaviours had decreased.

disappear to his room. I filmed John interacting with George, a less familiar staff member from the Day Centre. First, I did VIG with George. G eorge. Following Following one film and feedback, George reported how John had talked to him in the corridor, asking him how he was. Another breakthrough was when  John joined in with George’ George’ss Art Group. George had set up a table at the back of the art room especially for John and came over to speak to him at regular intervals. I then carried out some VIG therapy with John himself. To my surprise, John soon started talking about his thoughts and feelings about having a learning disability. To him it meant he was “rubbish at talking”. I showed John several video clips highlighting laughter and him feeling relaxed during conversations. No severe stammering episodes were shown. The VIG therapy gave John a real sense that both he and George had fun and enjoyed talking to each other. Towards the end of therapy John thought differently about his learning disability: “My learning disability is alright. Talking to George is fun!” After three filming and feedback sessions, there were signs that John’s communication behaviours started to change and that these changes were carried over into different environments. Staff noticed that he spoke to other staff members at the Day Centre more often. At home, John began to socialise so cialise more with visitors.

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COVER STORY: INTERACTION iii) My observation and reporting skills have shifted towards the positive When I observe staff now, I find myself focusing on the positives, however small. I no longer say to students or colleagues that certain staff members are “poor communicators”. I also no longer only work with wit h staff who are “good “good communicators” because I carry a strong conviction that everybody can communicate well, given the right support. I now adopt much more positive language in my reports, highlighting strengths of both staff and clients. D. LIMITATIONS WHEN USING VIG WITH ADULTS ADUL TS WITH LEARNING DISABILITIES DI SABILITIES Where the videoing forms part of the client’s treatment, I need to ensure that I follow consent procedures as outlined in the Adults with Incapacity Scotland (2000) Act. Filming clients in group homes or other group situations can also be tricky, as it is important to seek everyone’s consent prior to the filming. At a practical level this means that the camcorder has to be switched off each time a client who has not consented, or is incapable of giving consent, walks into the video. There are also several drawbacks to using old-fashioned VCR equipment of television with video playback and remote control: • Having to rely on clients’ VCR recorders when most households no longer have them, and  / or carrying around bulky equipment • Clients may get confused by seeing film rewinding on a VCR recorder and this may lead to less efficient feedback sessions • Some clients with autism greatly benefit from viewing the video clips in slow motion; this is not possible with VCR equipment. In my experience, a laptop computer and a digital camcorder are essential pieces of equipment which can overcome many of these problems. E. FAST FORWARD As a recently qualified VIG supervisor, I remain enthusiastic about the approach. I continue to learn about it through networking meetings

with other VIG practitioners and through supervising other trainee practitioners. My current supervisees are a health visitor and a community learning disability nurse colleague. I would like to see VIG used more widely by colleagues in my own multidisciplinary team and ultimately across the service as a whole. I am also interested in research on the effectiveness of using VIG with adults with learning disabilities. I feel I am just at the beginning of the process of exploring VIG’s wide range of applications, and look forward to using it in many creative ways, for example with clients with dementia and their carers. For those who wish to find out more about VIG and / or training to be a VIG practitioner, visit the VERoC website, http://www.cpdeducation. co.uk/veroc, or please contact me.  Andrea Ruck is a specialist speech  Andrea speech and language language therapist in Edinburgh with NHS Lothian, e-mail [email protected]. Acknowledgements My special thanks to Sandra Montgomery, Educational Psychologist and VIG UK supervisor, to my speech and language therapy colleagues Siobhan Mack and Tracy Paterson and to Anne Edmonstone, Head of Speech and Language  Thera  Th erapy py,, for for the their ir enc encour ourage agemen mentt and and sup support port in writing this article. Thanks also to John for agreeing to me sharing his story and to Susan Scotland for her insights during supervision sessions. SLTP REFLECTIONS • DO I RECOGNISE THAT FACILITATING SMALL CHANGES IN ATTITUDES AND BEHAVIOUR CAN BE ENOUGH TO START A RIPPLE EFFECT? • DO I APPRECIATE THAT THE RELATIONSHIP I HAVE WITH SUPPORT STAFF AND CARERS IS ONE OF THE MOST IMPORTANT IMPORTANT PREDICTORS OF THERAPY SUCCESS? • DO I BELIEVE THAT EVERYONE EVERYONE CARES ABOUT OTHERS, DOES THEIR BEST AT THE  TIME AND  TIME AND HAS THE PO POTEN TENTIA TIAL L TO CHA CHANGE NGE  THEMSE  THE MSEL LVES WIT WITH H THE RIG RIGHT HT SUP SUPPOR PORT? T?

References What therapy tools have changed you Biggs, S.J. (1983) ‘Feedforward and self-modelas well as your clients? Let us know via ling’, in Dowrick, P.W. & Biggs, S.J. (eds.) Using the Spring 09 forum at http://members. Video in the Behavioural Sciences. London: Wispeechmag.com/forum/. ley, pp.109-126. Knowles & Masidlover (1982) The Derbyshire Language Scheme. Matlock: Derbyshire County Council. Krantz, P.J., P.J., MacDuff, G.S., Wadstrom, O. & McClannahan, L.E. (1983) ( 1983) ‘Using video with developmentally disabled learners’, in Dowrick, P.W. & Biggs, S.J. (eds.) Using Video in the Behavioural Sciences. London: Wiley, pp.256-266. Vermeulen, H. (2006) ‘Video-Interaction Guidance in Pedagogical Family and Child Support Programs (VHT) in Relation to Effectiveness and Positive Behaviour Change’, Video Interaction Guidance: International Research Network Conference. Conference. University of Dundee, 19 May.

Respect for what is working Like Andrea Ruck in ‘Changing ‘Changing you, changing cha nging me’, Jane J ane Young Young rates Video Interaction Guidance highly.. Here she explains briefly the highly advantages of its use with parents of children with speech, language and communication needs. I have had the special opportunity of a rigorous and lively multidisciplinary training in the use of Video Interaction Guidance (VIG), a way of reviewing, with clients, video clips of successful communication. Video Interaction Guidance is very much in harmony with Hanen. Based on the premise that theofkey to future itdevelopment is in the quality interactions, creates a heightened awareness of the verbal and non verbal communication skills which promote positive interaction. It is proving to be a dynamic way to support change, as it has a deep respect for basic communication and never underestimates its value. My use of it at present is with parents of children with speech, language and communication difficulties. We look at selected clips of a film of their interaction with their child. Based on the Contact Principles of VIG, I share what I have seen and discover what they have seen to create a mutual understanding of what is working. It is amazing the difference only looking at what has gone well can do to build confidence and bring a dramatic d ramatic increase in the parents’ response to their child’s initiatives. It has strengthened my belief that people want to communicate well and that people in trouble want to change. Even in the most unpromising situations there is always something - however fleeting - which is happening in a positive way between the parent and the child. Review meetings can often be intimidating or dispiriting experiences for parents. I am now encouraging them to show their video clips at such meetings as a way of developing confidence - and sometimes independence - and to sustain change by engaging them as equal partners in the process.  Jane Young Young is a speech speech and langua language ge therapis therapistt in

Recommended reading Hodgkinson, P. (1998) ‘Communication in ALD – what do carers think?’, Speech & Language Therapy in Practice Spring, pp.4-7. Kennedy, H. & Sked, H. (2006) ‘Video Interaction Guidance: A bridge to better interactions for individuals with communication impairments’, in Kennedy, H. (ed.) VIG (ed.) VIG Handbook. Dundee: Handbook. Dundee: University of Dundee, pp.1-19. Nicoll, A. (2005) ‘Speaking skilfully’, Speech & Language Therapy in Practice Autumn, pp.18-19.

early yearsupon with Tyne. Community Children’s Services, Newcastle Resources • Hanen, see www.hanen.org • Video Interaction Guidance, see www. cpdeducation.co.uk/veroc/.

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