Transcript What is Facilitated Communication?

Introduction to Supported
Communication
Pascal Cheng
Harvey Lavoy
Tracy Thresher
2014 Midwest Summer Institute:
Inclusion & Communication for All
June 23-24, 2014
Elements of Support for Communication
Adapted from Cardinal 2006
Visual attention (look
at keyboard)
Emotional
Support
Attitudinal and
behavioral
supports
Physical
Support
Communication
support
Positioning
Technology
and
Equipment
Partner skill
and training
Structured
Activities
Pointing skills of FC user
Topics
 Overview of
Augmentative /
alternative
communication
 Definition and
candidacy for FC
 Understanding
movement and FC
 Overview of the FC
training process
 Basic elements of the
technique
 Simulated practice of
facilitation technique
 Getting started
activities for new
facilitators
 Documentation of FC
user skills incl.
authorship
What is facilitated communication?
Strongest therapy for people with no
means of expression is sensational,
controversial, revolutionary, technically
subtle FC. It involves understanding
movement lapses of people and
providing physical support to help
overcome them. Plastic nature of users
of FC requires topnotch weaning of
support towards ultimate goal of
independence.
Larry Bissonnette
What is facilitated
communication/supported
typing?
 Facilitated communication or supported
typing is one of an array of augmentative
and alternative methods of expression for
people who cannot speak, or whose speech
is highly limited (e.g. echoed, limited to one
or a few word utterances), and who cannot
point independently or reliably.
Facilitated Communication (FC) or Supported
Typing is a form of alternative and augmentative
communication (AAC) in which people with
disabilities and communication impairments
express themselves by pointing (e.g. at pictures,
letters, or objects) and, more commonly, by
typing (e.g. in a keyboard).
Institute on Communication and Inclusion
Structured facilitator training process
 Background info on FC
 Simulated practice activities
 Modeling by experienced facilitator
 Initial practice with supervision from
experienced facilitator
 Regular practice with FC user and ongoing
supervision from experienced facilitator
Communication partner activity
1. Participants will break up into pairs. One will play
the role of the communicator. The other will be
the listener with normal speech. The
communicator will attempt to communicate a
message. DO NOT SHARE WITH LISTENER
2. The message can be:
- A comment about the day
- A question to the listener
- Some news about something they have done
recently
Activity directions:
2. The AAC user must attempt to
communicate the message without:
-speaking
-writing
-signing
-drawing
The communication partner will attempt
to determine what the message is.
Activity Directions:
3. After completion of the activity, the pairs
will share their experiences with the larger
group:
(Communicator) What was it like trying to
rely on limited means to communicate
your message?
(Partner) How easy/difficult was it to
understand the person’s message?
“The most important principles for
supporting people to communicate
have little to do with equipment or
elaborate instructional techniques.
They are the attitudes and skills of
the people they are talking with:
their communication partners…
“…The more supportive a
communication partner is of a
person’s efforts to communicate, the
more effective that person will be.”
Pat Mirenda
Guiding principles for supporting
communication
 Access to all forms of AAC including FC is
a basic civil right.
 Presumption of competence is the
starting point for supporting people who
have difficulty with communication.
The Right to Communicate
 The right to communicate is both a basic human
right and the means by which all other rights are
realized. All people communicate. In the name of
fully realizing the guarantee of individual rights,
we must ensure:
 that all people have a means of communication which
allows their fullest participation in the wider world;
 that people can communicate using their chosen
method; and
 that their communication is heeded by others.
TASH Resolution on the Right to Communicate, 2000
Presumption of Competence
Assume that a child has intellectual ability, provide
opportunities to be exposed to learning, assume
the child wants to learn and assert him or herself in
the world... Presuming competence is nothing less
than a Hippocratic oath for educators. It is a
framework that says, approach each child as
wanting to be fully included, wanting acceptance
and appreciation, wanting to learn, wanting to be
heard, wanting to contribute.
Douglas Biklen, 2012
Larry Bissonnette
“Fastening labels on people is
like leasing cars with the
destinations determined
beforehand.”
Anne McDonald, Annie’s Coming Out, 1980
“Unless someone makes a
jump by going outside the
handicapped person’s
previous stage of
communication, there is no
way the speechless person
can do so. Failure is no
crime. Failure to give
someone the benefit of the
doubt is.”
Christy Brown – “My Left Foot”
“This is Christy
Brown, my son.
Genius. “
Christy’s father.
Understanding
Augmentative/alternative
communication and FC
What is AAC?
Augmentative and Alternative
Communication (AAC) refers to
all forms of communication
that enhance or supplement
speech and writing.
In simpler terms:
Vt. AAC Resource Guide
•Augmentative Communication
supplements or adds to verbal
and nonverbal communication.
•Alternative Communication is for
people with no verbal and
minimal nonverbal output.
Examples of AAC
 Gestures
 Body actions
 Head shaking
 Facial expressions
 Signing
 Use of
communication
board
 Use of electronic
device
 Eye gaze
Many ways to communicate
Total Communication
Approach:
A full system of strategies which might
include sign language, simple gestures
and facial expressions, single words and
phrases, and use of electronic devices.
Specialized forms of AAC
Sign language
Selecting through
touching, pointing, etc.
pictures, symbols,
words and letters to
communicate a
message
Specialized communication aids
What is the best physical access strategy ?
Using an eye gaze board
Pointing skills are often required to use
communication aids and devices.
What is Facilitated
Communication/Supported
Typing?
Facilitated Communication/supported
typing is a form of augmentative alternative
communication (AAC) in which people are
provided with physical support to help them
develop effective pointing skills for
communication using pictures, symbols,
letters and words.
The level of complexity of pointing skill
needed depends on what is being
communicated and what communication
aid/device is being used.
Choosing what methods or
modes of communication to use
Using multiple modes:
• I might greet someone with a hand
wave
• I might show them some pictures of
my vacation to share information
• I might point to a picture or word for
a snack I want
• I might make a comment or share an
opinion by spelling a message out
Larry – Speech and Typing
“Personally, my speech relays to others what my
stomach needs while my typing promotes what
my brain visualizes as intelligent thought.”
Within any activity, people will be
communicating for different purposes:
 Expression of needs/wants
 Sharing information
 Social Closeness
relationships
 Social Etiquette
social routines
What kind of communication happens
at a restaurant?
Who can benefit from the use
of FC/supported typing?
40
FC is helpful for those who cannot speak
or whose speech is highly limited (e.g.
echoed from others or limited to one or
a few word utterances) and for who
people who cannot point independently
or reliably.
Assessment
The assessment process for FC
involves determining if there are
specific physical/movement problems
affecting a person’s ability to point
independently or reliably and if so,
what physical support strategies can
help the person to overcome those
problems and improve their pointing
skills.
Examples of movement
difficulties
 Difficulty isolating an index finger
 Pointing without looking
 Pointing too quickly
 Difficulty with extending arm/hand
 Initiating movement to point
 Difficulty with new motor tasks, i.e. typing
novel communication
 Hitting the same selection or series of
selections, e.g. automatic words and
phrases, repetitively
Q W E R T Y U I O P delete
ASDFGHJKL
ZXCVBNM , .
space
Observe the person doing a
variety of activities involving
pointing. Look for physical
problems that might be
affecting pointing.
Point to the picture of “pizza”.
Can you point to the word, “milk”
Milk
Juice
Tea
Soda
Which drink comes from a cow?
Let’s try typing the name of the
town you live in…
Determine physical support
strategies that will help to remedy
the problems and improve the
person’s pointing skills
The person may not be able to isolate an
index finger and may need physical
support initially to develop this skill.
The person may also be unable to pull the hand
back after making a forward movement and/or
sequence forward and back movements unless
the pointing hand or limb is steadied and
supported….but not directed.
“The facilitator must slow me down and pull my
arm back to help me start again so that I can
point to the correct letter I am going for. I
would not be able to type the words I really
want without the firm resistance of the
facilitator.”
Independent typing is not always reliable:
LARRYFEELBETTERHAPPY
GOINGHOMEPINESTWINOOSKIVT
SITDOWNCHAIRTVONSUPPER
CORNSTACKPOTATOSION
PLAINSPEESICETEESPIE
BANANASMILKBEER
PRINT
In addition to physical support, the communication
partner may provide emotional encouragement, and a
variety of communication supports (e.g. verbal
prompts and feedback)
The goal of facilitated communication training
is independent communication, i.e. pointing
and typing.
Photos – Institute on
Communication and Inclusion
Levels of support
Independence
The effect of movement
difficulties on communication
Writing Exercise
 Write while moving opposite foot in counterclockwise direction on floor
 Name and address
 Your favorite activity to do in the summer
and why
 Copy this sentence exactly:
 I am tirred of beeing misunderstandoo.
Sue Rubin
“Movement issues for me are a connection
difficulty. I hear you ask me to complete a
task, but my legs stay put. Through the use
of FC I have been better able to get my body
to engage in a task. Typing requires thinking
and focus. My body has been trained to
focus on movement when asked to do
something or asked to respond. “
“Movement is essential to
communication. I am unable to speak
because of apraxia, a movement
disorder. I can type because the
movement of one finger going up and
down is much easier than speaking or
sign language. Adding a series of
movements as in sign language would
be dreadfully frustrating for me. Even
simple movements are trying at times.”
“It is a grounding of both my physical issues
with where my body is in space and telling my
motoring to type to go slow. Pay attention to
the output with trusted touch. I am less
anxious. Therefore I can truly type my own
thoughts. That is the basis of the physical
support to create a functional typing rhythm.”
Physical support can help with:
 Regulation
 Control
 Body awareness
 Organization
 Connection
 Focus
Tracy Thresher:
My impulse control problems, my way of
going too hard at the letters and my
problems with perseveration, are things I
need help from my facilitators…
Basics of support
 Physical support
 Communicative support
 Emotional support
Physical Support
 Provides physical support in response to
specific hand function/movement issues
 For example, slowing down a person who is
pointing too fast or molding a person’s fingers
back from their index finger
 For low muscle tone/strength, pulling a
person’s hand back above their board or
device so that that they can reach selections
Physical Support
 Pulls hand back from the communication
device to a neutral position, ie. not side to
side
 Provides backwards resistance only, does
not move co-actively with the person
Physical Support
 Provides minimal level support
 Creates opportunities for pointing with
less physical support
 NO GUIDING - waits for the person to
initiate the movement
Physical Support
 Positions the communication device at an
accessible angle and height for the
person
Physical Support
 Regularly monitors whether the person is
looking at the communication device
 Monitors pace and rhythm of person’s
pointing movement and adjusts physical
support to accommodate changes:
Physical Support
 uses more backwards pressure to slow the
person down if they begin pointing too
rapidly
 pulls the person’s hand back and brings to
a pause to interrupt the pattern of hitting
the same selection over and over
(perseveration)
Communication Support
 Provides skill reminders to the person
about their movement, e.g. “Slow down”,
“Reach more for the letters”
 Provides prompts and cues to help a
person get started, maintain their focus or
continue an interaction, e.g. “What’s the
next letter?”, “Keep going”, “Look at what
you are doing”
Communication Support
 Provides feedback on what pictures,
words, letters a person has pointed to,
e.g.”G-O-space-N-O-W, go now”
 Provides feedback on content of messages
and asks clarifying questions, “So you
want to go now?” “Yes”, “Tell me where
you want to go”
Emotional Support
 Conveys high expectations and belief in
the person’s competence, “I know you can
do this”
 Maintains a calm and respectful attitude
 Offers encouragement and positive
feedback to build confidence
What kind of training activities
are used when getting
started?
Set Work
Set work is any structured
activity which where the
responses are predictable and
the information is shared
between the facilitator and
communicator.
Set Work
 Builds confidence in both communicator
and facilitator
 Allows facilitator to learn the movement
patterns of the communicator
 Helps facilitator to “get a feel” for the right
support technique
Set Work
 Very structured activities will be used with
new FC speakers and new facilitators.
 The speed at which one moves from
predictable to open communication will
vary across FC users and facilitators.
Flexibility is critical.
Guidelines for using set work
 Method of structuring activities from
ones which require very predictable
responses, e.g. spell the word, “cat” to
ones where the responses are very open,
e.g. “What would you like to talk about
today?”
The Language Ladder
(adapted from Rosemary Crossley)
 Conversation
 Self Expression
 Open ended Questions
 Less Predictable
 Predictable work
Set Work
 Set work does not mean doing the same
activity over and over such as typing name
and address
 Ideas for set work can be found in
everyday activities, e.g. reading a story
and answering comprehension questions,
practicing spelling words, doing a
crossword puzzle, making choices from a
menu, etc.
 For school age individuals, the use of FC
can be incorporated into many different
academic activities
Can you point to the word______”
Acrobat
Violinist
Lawyer
Accountant
Which person performs in a circus?
Fill in the blank/ predictable:
A large astronomical body that
revolves around the sun is called a
_______ (planet).
Fill in the blank/open:
One of the planets in our solar
system is ______.
Multiple choice/ closed choices:
“Do you want strawberry,
chocolate or vanilla ice cream?”
Multiple choice/limited range:
“What is your favorite flavor of
ice cream?”
Open Questions/Shared Knowledge: “Tell me what is
happening in the picture.”
Participation in everyday conversation
Documenting progress with
communication skills
87
Authorship
Who is the author of a message
produced through facilitated
communication?
Message passing
The FC user conveying information that
is unknown to their facilitator
Research
 Negative studies in the 1990’s all used
message passing as the method to prove
“authorship”
 Most FC users in these studies fail to pass
messages successfully
 Double blind studies show facilitator influence
 “Conclusive evidence that FC is not a valid
communication technique”
Research – Studies that have
demonstrated authorship
 Used diverse research methodologies
 Message passing
 Video eye tracking (2001)
 Linguistic analysis of FC user typing (20012009)
 Evidence of speech before and during typing
(2001, 2009)
Studies with successful message
passing
 Weiss, Wagner, and Bowman (1996)
 Cardinal, et al. (1996)
 Sheehan and Matouzzi (1996)
What we have learned about
message passing:
 FC users can do message passing successfully







under the right conditions
Not presented as test of competence
Practice over time with a task
Occur in natural environments
FC user choice in message passing tasks
Feedback to FC user on performance
FC user performance can be variable
Facilitator skill is critical
How can a person
demonstrate authorship
of their communication?
Understanding Message Passing
 For many FC users it’s a “test” of their




ability to communicate
Singled out and put on the spot
Through message-passing we connect
with others, reliable people, truth tellers
Learned over time with practice
Requires specific skills
Special Issues for FC Users
 Lack of experience
 Passive observers
 Familiar routines with little change
 Thrown into situations and expected to
perform
 High risk stakes
 Systematic practice of message-passing
skills
What can facilitators do to support
FC users to be in control of their
communication
Minimizing Negative Influence
 Provide backwards resistance only
 Pull back to a neutral position
 Provide the minimal amount of support
necessary - work towards independence!
Minimizing cuing and control of
responses through FC
 Wait for the FC user to initiate movement
 Avoid trying to anticipate what words a FC
speaker might use
 Always clarify responses that you are not
sure about
Minimizing cuing and control of
responses through FC
 Encourage FC user to control the flow of
conversation
 Develop awareness of how and when a FC
user might be looking for cues
Minimizing cuing and control of
responses through FC
 Teach FC users protest strategies where
they can inform their facilitators when
they are being influenced or when they
want to change their words
 Work with other facilitators to compare
your technique
Guiding principles for the use of
FC
 Specific guidelines and standards are
needed to support the use of FC.
 Evaluation of a person’s progress with FC
can be done through observation and
documentation.
Documenting progress and
success
 Evaluation of a person’s progress with FC
can be done through observation and
documentation of the content of their
communication and their actual pointing
and typing skills over time. This can be
part of a communication portfolio.
Pointing and related skills that
can be improved through the use
of FC
 Index finger isolation





and extension
Visual focus
Accuracy of pointing
Upright seating
position
Development of
deliberate rhythm
Maintaining slow, even
movement
 Decreasing impulsive
or automatic
movement
 Initiating movement
 Organization of
movements –
arm/hand positioning
 Attention to task
Portfolio Approach to
Documentation for FC
 Structured way of collecting information
over time on an individual’s progress with
FC focusing specifically on authorship, and
independence
 FC user is directly involved in the portfolio
documentation process
Portfolio Approach
 Is best done when there are adequate
supports in place for FC for an individual,
e.g. multiple, trained facilitators; regular
opportunities to use FC
 Methods of collecting info can include the
use of forms, logs, transcripts and
videotapes
What is documented?
 Instances where the person has done
successful message passing, i.e.,
conveying information unknown to the
facilitator
 Demonstrations of independent pointing
and typing
What is documented?
 Patterns of unique typographical errors
and creative/phonetic spellings; unusual
syntax and expressions
 Similarity of communication style across
facilitators
 Correlation between speech and typing