We are very grateful to Anna Volkmer for sending us this blog, Lets Talk about Capacity…
She has just had an excellent book published –  Dealing with Capacity and Other Legal Issues with Adults with Acquired Neurological Conditions http://www.jr-press.co.uk/dealing-capacity-legal-issues.html. In it she describes how AAC methods, including Talking Mats, can be used to support people in expressing their decisions.

Prior to 1959 people who were considered “non-compus mentis” were cared for under the “parens patriae” principle. Literally translated this meant that they were ‘parents of the country’ and decisions to protect them and their property were made by the Crown (the Lord Chancellor). These people were often described as “Chancery Lunatics”. In 1959 the “parens patriae” jurisdiction gave way to the Mental Health Act. This Act instructed that “the judge may, with respect to the property and affairs of a patient, do or secure the doing of all such things as appear necessary or expedient…for making provision for other persons or purposes for whom or which the patient might be expected to provide were he not mentally disordered” (section 102 (1)(c)). Unfortunately, this Act did not make adequate provision for non-financial decisions such as medical decisions. During this period it was case law that guided professionals in supporting their patients who lacked capacity in medical decision making. It was not until 2005 that the first Mental Capacity Act was given Royal Assent, accompanied by the Mental Capacity Act Code of Practice in 2007.

I returned to the UK from a 5-year stint working in Melbourne, Australia, just after the Mental Capacity Act had been published. Mental capacity was on the tip of everyone’s tongues and as the speech and language therapist working on a multi-disciplinary team I became an integral part of this process. Patients I was seeing, often people with primary progressive aphasia or other types of dementia, were asking about how to make future decisions. They and their families were keen to understand how the mental capacity act worked, how to prepare for the future and how to have their voices heard. On the other side of the coin I was working on an inpatient ward where staff were concerned about ensuring we were fully assessing the decision making capacity of people with cognitive and communication difficulties, often holding best interest discussion to plan for the future of these individuals. Many of these decisions related to dysphagia, but others related to accommodation and finances.

What concerned me was the lack of evidence available across the speech and language therapy arena in this area. There was little to none in terms of written research, let alone written advice or even examples of good practice tailored to speech and language therapy clinicians. As I asked around I found an enormous disparity in the services that speech and language therapy clinicians were providing across different trusts. I had previously written a book on dementia, and had included a chapter on assessments of decision-making. At this stage some of the only research related to communication and decision-making had come from Talking Mats. This had demonstrated that using the talking mats tools can support families and caregivers in conversations with their loved ones when discussing decisions to be made. They found that conversation enabled people in understanding, retaining and expressing themselves in decision-making discussions.

Following a particular stimulating discussion with the publishers at J&R press, they invited me to submit a book proposal on this topic. As I was developing this idea I found the topic of mental capacity was raised more and more often at study days and seminars I attended. At these study days I started linking in with more like minded speech and language therapists such as Mark Jayes, Hannah Luff and Claire Devereux. These were clinicians who all agreed on the diversity of our potential role in supporting our patients around mental capacity issues. These common interests enabled a collaboration. Our book is now published.

Through these connections I became aware of other work being done; Mark Jayes holds a NIHR doctoral fellowship award and is conducting research in the development of a communication and capacity assessment tool kit. Claire Devereux is the chair of the Southern Psychiatry of Old Age Clinical Excellence Network, together we have held a workshop with the clinical specialists where we developed a consensus document on role of the speech and language therapist in capacity assessment. This is to be published in Bulletin magazine later this year. Hannah Luff is a clinical lead speech and language therapist at South London and the Maudsley NHS Trust and is currently a member of the review panel looking at the NICE SCIE dementia guidelines.

The wonders and value of networking never ceases to delight, enthuse and inspire me! And you can purchase our book at the following website (there is currently a discount rate until 21^st February):

http://www.jr-press.co.uk/dealing-capacity-legal-issues.html

You can follow me on my blog https://annavolkmersbigphdadventure.wordpress.com/ or on twitter @volkmer_anna

Do you want a part time, time limited opportunity to work for Talking Mats based in the North West of England? We are appointing an  External Associate to extend access to resources and training in this part of the country. We would like this person to

• generate interest and business in the North West of England in Talking Mats with a focus on children and young people, particularly the promotion of the use of Talking Mats in the SEND(Special Educational Needs and Disability) reforms
• work with Talking Mats to promote a marketing seminar in the North West
• work with Talking Mats to run training and establish a base for a North West training programme
• increase sales in Talking Mats in the North West of England

If you have extensive experience of using Talking Mats to allow children and  young person to have a voice particularly in their education, health and care plans and are passionate about extending the reach of this framework to a range of services then please consider whether this opportunity maybe right for you. We are looking for someone with initiative ,enthusiasm for the role of Talking Mats, good local professional networks and great communication and networking skills.

Please down load the person spec, project role and how to apply here Talking Mats External Associate
Closing date is the 28th Feb with interview scheduled for the 7th March .if you want to discuss further then please phone the Talking Mats office and ask to speak with either Lois or Margo.

 We are very grateful to Tom Tutton from Autism Spectrum Australia for this interesting blog. 

Autism Spectrum Australia (Aspect) works with people on the autism spectrum and their families. We regularly recommend visual communication strategies because people on the spectrum often have strengths in visual learning. This is especially important in our work through Aspect Positive Behaviour Support where communication can replace challenging behaviour.

In the past, we applied a ‘hierarchy’ of visual representations based on how easily they can be understood.

Generally, objects are considered the easiest form of visual communication to understand; followed by miniatures, remnants, photos, line drawings and symbols and writing, in that order. Although this hierarchical understanding is held true for many people on the spectrum, there can be exceptions. Some individuals find line drawings easier to understand than photographs.

Aspect Practice continually reviews and applies the evidence base to our daily work. So, with the knowledge that the hierarchy does not fit for some people, we reviewed the research literature to see if we could refine our understanding and use of visual communication strategies.

We asked “What evidence is available about the hierarchy of visual representation which could explain how an individual could benefit more from line drawing supports than photos?”

To find the answer, we searched an electronic research database, prioritised 20 papers and then reviewed four papers in detail that seemed to answer our question (references below).

We found information that suggests the factors contributing to a person’s understanding of visual symbols is broader than a simple hierarchy and involves consideration of three main areas:

The individual’s experience

• The individual’s ability to learn
• ‘Iconicity’ of the symbol (more detail about this piece of terminology below)

Ideally, these factors should be considered for every symbol used with every individual. We learned that a symbol can be placed on a continuum in terms of ‘iconicity’. At one end, it can be described as “iconic” or “transparent”, meaning that it is very similar to the object it refers to (e.g. using a juice bottle to present the choice of juice). At the other end, it can be described as “arbitrary” or “opaque”, meaning that there is little or no visual similarity between the real item and the symbol (e.g. the written word “bird” does not look or sound anything like an actual bird).

The generally accepted hierarchy of visual representations aims to organise types of symbols by their level of iconicity, but misses some subtleties. This means that phrases such as “photos are easier to understand than line drawings” are often overgeneralisations.

For example, image 1 looks more like an apple than image 2, even though the second one a photograph. Image 1 would also be easier for an individual to understand if that symbol had been used extensively around them, if it was motivating and functional and if that individual had a strong ability to learn the association of that symbol and an actual apple. Therefore, a person’s ability to understand a symbol does not depend on its iconicity alone, but the ways symbols are used and learned.

In answer to our question, there are several possible explanations why a person may understand line drawings better than photos.

They may have been exposed to line drawings more than photos, meaning they can learn the associations between line drawings and things in the real world more effectively.

• The photos being used contained a background (and had lower ‘iconicity’), whereas the line drawings provided a simple representation on a plain white background.
• The person’s learning style may mean they learn each symbol individually, rather than learning how to associate symbols the real objects in a more general way. If a person who learns this way is exposed to more line drawings, they will learn more through line drawings.

As a general statement, it is clear that greater emphasis needs to be placed on the needs of the individual, as well as the properties of the individual symbol, rather than considering only a hierarchy.

Steve Davies (Positive Behaviour Support Specialist & Speech Pathologist, Aspect Therapy)

Dr Tom Tutton (National Manager, Aspect Practice, Positive Behaviour Support Specialist)

References

• Fuller, Lloyd & Schlosser (1992) Further Development of an Augmentative and Alternative Communication Symbol Taxonomy, AAC Augmentative and Alternative Communication, pp67-74
• Sevik & Romski (1986) Representational Matching Skills of Persons with Severe Mental Retardation, AAC Augmentative and Alternative Communication, pp160-164
• Stephenson & Linfoot (1996) Pictures as Communication Symbols for Students with Severe Intellectual Disability, AAC Augmentative and Alternative Communication, pp244-256
• Dixon, L. S., (1981) A functional analysis of photo-object matching skills of severely retarded adolescents, Journal of Applied Behaviour Analysis, 14, pp465-478

This article was inspired by a blog post written by Dr Joan Murphy, Co-Director, Talking Mats.
Click here to read original blog

Aspect Practice is an initiative where Aspect shares its evidence based practice through information, workshops and consultancies. To learn more about Aspect Practice, visit www.autismspectrum.org.au/content/aspect-practice.

Get your New Year’s resolution Talking Mat here!
Talking Mats is a social enterprise whose  vision is to improve the lives of people with communication difficulties. 2015 has been another exciting year for us. We have had great opportunities to work with a fantastic range of people and hear great stories: from wee ones in nurseries using Talking Mats to encourage active participation and decision making, to older people and their families through our dementia family training project. It is our core belief that good communication is fundamental to a quality service. Making sure there is space for active listening to views and concerns particularly, if individuals have difficulties communicating is central to effective interactions and individualised, person centered care. We are really grateful to all the people who have supported the work of Talking Mats; people with communication support needs, staff who work with them and organisations that we are privileged to work with on a consultancy basis.
It will not surprise you to know that as an organisation we like to set goals and then go for them so as our thank you to you all for your continued support , we have created our very own New Year’s resolution Talking Mats;
• What are you definitely going to go for ?
• What is in the maybe pile – or that could be for those things you are already doing and will continue
• What is not a goal for you in 2016 .
• Don’t forget to use the blanks to personalize it further!
• Plus take a photo so you can reflect back on where 2016 takes you and whether you achieved your goals .
So open and download it , cut it up and we hope you enjoy using the resolution Talking Mat with friends and family ! resolution pics
We wish you all every health and happiness from all in the Talking Mats team

Fika (coffee time)  in the Talking Mats office is always interesting.  Recently we got chatting about Christmas preparations and who had the longest ‘to do’ list.  There was a definite variation in enthusiasm for all things Christmas.  We needed to do a Talking Mat! This was done on our digital Talking Mats – it’s  easy to import your own images now and make a digital Talking Mat about any topic.

Eating , drinking and games and puzzles got the thumbs up!   (Lois is the games queen and was the most enthusiastic about that).

Holiday, partying and entertaining got consensus.

Extended family coming to stay? This moved around a bit, but was generally positive (say no more!)

Shopping was in the mid section-we all agreed.  Perhaps by now it would be less positive with last minute mayhem.

Gifts was added as a blank (how could the interviewer forget that) and not everyone was comfortable about the commercialisation of Christmas.

‘How do you feel about Juggling demands?’   We all agreed -not sure.  Again remember, Talking Mats is how a person feels at a certain point in time.  Ask us again on Christmas Eve?!

Christmas cleaning?  All agreed was a chore and some thought best not to get too bothered about it

Talking Mats supports a group conversation.  We all got our say

Merry Christmas one and all

What works well when implementing Talking Mats?

Our last blog highlight how  the Wigan Pathfinder Project selected Talking Mats from a range of tools to consult with pupils who have Education, Health and Care  plans (EHCP) . They reported that Talking mats provided :

• An objective, neutral space – a thinking tool- ‘Children and young people are able to consider their priorities when setting targets’.
• Opportunities for change – ‘Children and young people are able to make changes to their initial thoughts and have time to decide and reconsider options’.
• A truly person centred approach
• It was fun!

Additional factors they commented on which worked well  when consulting with pupils about decision making and goal setting were:

• Good liaison with parents and staff who know the child well before the session
• Adapting the length of the session to the child’s needs
• Ensuring a suitable room without too many distractions
• Using the teaching scale
• Putting the child’s name on the mat
• Placing all topics in one envelope for easy access
• Allowing time to sort symbols and discard irrelevant ones.
• Reducing the number of symbols used depending on the child’s needs
• Changing the top scale symbols to support the child’s understanding where necessary
• Keeping a verbal record where appropriate
• Working in pairs whilst learning the approach
• Using the effectiveness coding framework (all case studies scored above 75%, therefore considered effective using this measure)

The Talking mats training focuses on teaching how to establish a consistent and appropriate top scale, maintaining a clear topic and using the effectiveness framework. It also presents a model for thinking about who can and cannot use the mat and for what types of questions and discussions

We are grateful to Emma Atkiss, one of our accredited trainers for this interesting report.

The purpose of The Voice of the Child pilot project carried out by the Wigan Pathfinder team was to obtain pupil views using a viable tool.  The team selected Talking Mats as a framework to support pupils to express their views in decisions regarding their lives.  They were working on the principle that engaging with the young person and his/her family would lead to better outcomes

The project team considered that Talking Mats met the 5 criteria of Shier’s model of participation (2001)

1. Children are listened to.
2. Children are supported in expressing their views.
3. Children’s views are taken into account.
4. Children are involved in the decision-making processes.
5. Children share power and responsibility for decision-making.

Click on diagram to enlarge.

The pupils in the pilot ranged from 7 to 17 years with a range of disabilities.  During the pupil interviews the team found that the Talking Mats Health and Well being resource provided a practical framework for decision making and target setting

Talking mats provided :

• An objective, neutral space – a thinking tool- ‘Children and young people are able to consider their priorities when setting targets’.
• Opportunities for change – ‘Children and young people are able to make changes to their initial thoughts and have time to decide and reconsider options’.
• A truly person centred approach
• It was fun!

For example :   A seven year old child with Autistic Spectrum Disorder identified both her cognitive strengths and areas for development using the Learning and Thinking domain.  She provided feedback regarding her difficulty in attending when faced with too much information or choice and also her strength in planning skills.  Thinking skills targets and interventions can be developed using this information as a starting point.

Their report states that the information gained from Talking Mats can be used, as part of the Education Health and Care planning and review cycle, to inform both decision-making and goal setting for children and young people   i.e. It identifies strengths; It identifies areas to develop; It identifies the child / young person’s response to a range of experiences; It informs day-to-day decision-making ;  It informs both targets and interventions for Individual Education Plans and it supports transition planning.

Ref :  Engaging the voice of the child / young person at an individual level  – Emma Atkiss,Senior Educational Psychologist and  Caroline Gomez,     Educational Psychologist, Wigan council

Stirling Council hosted a meeting this morning (2^nd October) to discuss Stirling’s response to the Syrian refugees crisis. It was a great meeting with good speakers outlining the Scottish response and also the Stirling response to welcoming families from the refugee camps. There were about 150 people in the hall buzzing with ideas and we were given plenty of time to discuss in groups our thoughts and ideas.

One of the key issues overlying those such as housing, education, health, faith and community support was communication. How we can help people whose first language is not English and who may also have difficulty expressing themselves because of trauma?

Already there have been responses from translation services, the local Islamic Centre and the University. Another possibility is the use of Talking Mats to help people consider their options and express their views. We have used Talking Mats in other situations where English was not a first language, for example in clinical situations with Polish patients and also in our work in China a few years ago. We found that once the person understood the basic structure of Talking Mats we were able to communicate amazingly well. We have a number of symbol resources that might be helpful and, as a social enterprise, are keen to offer our services.

Like everyone in this morning’s meeting, we look forward to welcoming and supporting the Syrian families who are coming to Stirling.

At the end of a recent training session, we asked the trainees to tell us how they planned to use Talking Mats as part of their work. Their comments were as follows:

• This tool will be useful in helping some residents make decisions, informed choices and express their needs. It will take time for some residents to feel confident in using this tool.
• I’d like to use it with some residents to be able to adapt Talking Mats more to their understanding.
• I’d like to use this tool for resident’s reviews to find out what the residents likes/dislikes are.
• Talking Mats will be great for service evaluation.
• Talking Mats will be great for asking residents about things they want to do.
• Updating Care Plans regularly from outcomes of Talking Mats.
• It can be used to get to know people’s needs and wishes more.
• Share the findings with colleagues and joint services.
• Hopefully through its use I’ll learn to pass it onto others.
• A gardening set. Service evaluation and well-being assessing stress levels/anxiety/emotional state?
• I’d use it to promote choices of activities.
• Care Inspectorate forms. Finding out how people enjoy time at the service and how to improve on it.

Can you let us know how you use Talking Mats as part of your work?

We are very grateful to David Brennan, a Dementia Support Worker from Ayrshire for this powerful blog.

Over the years our service has supported many people with a diagnosis of Dementia, now and then we encounter individuals whose cognitive difficulties have greatly affected their ability to communicate. This can (in some cases) result in distress for the services user and their families, distress that could be reduced or even avoided if the individual had a way of being understood by those around them.
As a service we welcomed the opportunity to engage in the Talking Mats Training and as a Dementia Support Worker I was eager to have a tool that could help me overcome communication obstacles, having experienced situations where those I support become so frustrated because they desperately want to relay a piece of information, but simply cannot find the words to express themselves.
I saw talking Mats as a communication system for those who struggle with speech. However, after using the practice in a practical environment I realise that I have had underestimated its potential, for it has much wider applications in our role.
My first experience of using Talking Mats was when producing the video for the second training session. I enlisted the help of a gentleman from the neighbouring Day Care centre.
We had never met prior to the session. The Gentleman had no communication difficulties that I was aware of.
Using the Talking Mats acted as an instant ice breaker, giving two complete strangers a reason to sit down and interact together, quickly striking up a rapport. The Gentleman appeared at ease and was happy to talk in detail about the tiles for the chosen subject of ‘Leisure Activities’
The activity revealed more than expected though. Through the course of the conversation he voiced feelings on things he was perhaps not happy with. I discovered he was unhappy that he did not get out in the open air enough due to poor mobility and that he would have preferred to see musicians coming into his Day Care Centre. This was crucial feedback
It occurred that Talking Mats also had an effective use in the assessment and quality assurance process that exist within services, providing crucial feedback for continued person-centred planning.
Taking this on board I considered examples of service users within my current caseload where the activity could prove beneficial.
I have been working with one gentleman for many months. He could be described as a Man’s man, someone who often replies to attempts at conversation with short responses, even when speaking with his wife. He may struggle to remember the names of people and places but he typically has little other difficulty in communicating.
I attempted the same topic with this man. Much of the answers were as expected. He spoke about football and his favourite team, but the structure of the Talking Mats encouraged him to open up about some of the smaller details that until now he hadn’t felt the need to disclose.
In the most recent example I was asked to take part in a colleague’s Talking Mat video for her training. She is one of our newest members of staff and although we have already developed a good working relationship the activity allowed her more insight to the nature and history of her co-worker.
For my experience, as someone who can struggle with sensory stimulation, it allowed me to express some of my needs and obscure preferences (around the office and in general) in a safe environment where I felt able to communicate what would normally be very personal information. And to have someone listen and thoughtfully consider this was a rewarding experience too.
As a service, new to the Talking Mats system, we are just scratching the surface of how we can best implement this into our roles, but the possibilities are already multiplying at a rapid pace, almost as much as the benefits we are seeing.

David Brennan
Dementia Support Worker