Sensory Integration Education

This article was published in issue 63 of SensorNet in September 2024 and features an interview with Karen Forrest, a UK-based Occupational Therapist, Advanced Sensory Integration (SI) practitioner and certified EcoSensory therapy practitioner. Karen has a particular clinical interest in attachment and developmental trauma.

SensorNet: Tell us about your current role and how you implement SI in your practice. 

Karen: I am currently in independent practice, and I specialise in taking NHS one-off commissions for individuals deemed to be ‘stuck’ in the most restrictive of environments, so, in secure services and sometimes in conditions of confinement (also called seclusion or long-term segregation). I also mentor and supervise other therapists working in these settings.

SN: How did you develop an interest in SI, and where did your SI training journey begin?

Karen: This goes back a way to the early 1990s! I was working as a daycare assistant in an old-fashioned long-stay institution for people with learning disabilities, and we decided we needed to provide a service for all of the residents, not just the ones who could benefit from our traditional provision of crafts, games, etc. Our response was to build a Snoezelen® room. Not sensory integration, I know, but it was definitely the beginning of my interest in all things sensory.

I undertook my first sensory integration course in 2000 with Dr Sidney Chu and Professor Dido Green and the Sensory Integration Network (the origin organisation of Sensory Integration Education), in the days before the training was associated with university awards. I then completed the university-accredited modular pathway to Advanced Sensory Integration Practitioner level, before skipping on to the NHS England Advanced Clinical Practitioner route to gain my Master’s equivalent.

SN: How has the SI modular training pathway influenced your practice? 

Karen: Put simply, it supports my occupational therapy practice to be truly person-centred at the individual neurological level and enables me to make care and treatment recommendations that also reflect this. So, I might select an activity not only on the evidence for that activity, how it fits with my chosen model of occupational therapy, and the person’s shared preferences, but on how it fits with the person’s sensory profile and its potential for alerting, calming and connecting them, and for supporting their development at all life stages.

SN: You speak about utilising a sensory-informed practice approach – what does this mean in your setting, and what does it look like? 

Karen: It means knowing your neuroscience, neurodevelopment and sensory integration theory. It means assessing well and interpreting it according to this knowledge and possibly providing, where needed, a compassionate, accessible reframe for the person and those around them – just like Dr Ayres is remembered for doing. And it means making a sensory integration informed plan with the person – whether this is traditional Ayres Sensory Integration, environmental adaptations, or the provision of sensory equipment, prescribing a sensory diet to support regulation and connection to the body, ground, other people and the wider world (including nature); or use of therapeutic relationship and more of a social prescribing approach to support natural development through playful activity that presents a just-right challenge. Bringing other staff members on board with what you are doing and involving them is essential as you strive to support healthy relationships and manage the related risks.

SN: Assessment can be a difficult area to get right – what is your advice when completing an SI assessment in a forensic mental health setting? Any tools people should be aware of? 

Karen: Well, you should be aware of all the available tools, as this will help you select those that are best for your service users and practice! For me, there is no shortcut to getting a good developmental history – even if I have to trawl through masses of reports. Then, I tend to select whatever I think will work best for the person. For most people, it is best practice to start with one of the questionnaire-style assessments. I tend to select the Adult / Adolescent Sensory History (ASH) as this is standardised and examines each sensory system separately. Su and Parham’s 2014 research shows that this is more valid (even though it was associated with a different tool). However, the ASH also provides separate modulation and discrimination scores for each section, and I find this enormously helpful and relevant. What I am careful about though, with the ASH, is ensuring that the most accurate responses are inputted to the scoring programme, further description of this is probably outside of the scope of this article but it certainly includes gathering information from more than one source. 

I supplement the ASH with Kelly Mahler’s caregiver questionnaire for interoceptive awareness and the interoceptive awareness interview, as interoception is not considered by the ASH but is often very relevant, especially if coping skills approaches are being used. The Mahler assessments are not standardised but I like them because they consider homeostatic as well as emotional affect and I think that this is very relevant given the known health inequalities in this population group.

Observations can always be done, even if they are unstructured. I will complete structured clinical observations where I can, prioritising if I need to according to the ASH results. I find that they can be quite lacking when it comes to tactile discrimination, so I often have to supplement them in this respect. Then, of course, there are the standardised observational assessments (SOSI-M and COP-R, SIPT and EASI), if they are suitable for the person, and the latter two cover that tactile discrimination piece. Of importance, when using these tools with an adult population, we are, of course, using them out of age range and in an unstandardised way, so we must state this on reports and interpret results with caution. 

When assessing, it is important to remember that Ayres Sensory Integration is an approach that relies on establishing a good therapeutic relationship to ensure success. Relationships with this particular population group can be tricky as they have often masked difficulties their entire life. This means that I will prioritise the relational aspects, even at the assessment stage, and will not expose differences in a way that is challenging for the person. I like structured clinical observations for this reason. They have the value of formal assessment but are not standardised, which means they might be easier to get right for some individuals. 

SN: Sensory regulation is often spoken about in terms of mental health – how do you consider this in your practice? 

Karen: In the way that you would expect really, but always based on good assessment information. So, understanding what signs and symptoms mean that someone needs to up or down-regulate and considering what might work for them. This is more nuanced than you would think especially when there is trauma (which there usually is) – I cannot advise additional training in attachment and developmental trauma enough. 

I would then work in partnership with the person and their supporters to ensure this is understood, creating adapted resources to aid this. From a sensory perspective, I will be thinking about the value of enhanced proprioception, deep touch and linear movement and, what regulatory value could contact with nature have? (This is the EcoSensory therapy influence, which is underpinned by a lot of evidence). I think the key thing about prescribing the use of regulating equipment or participating in a regulating activity is remembering the social aspect. I would be a very rich woman if I had a penny for every time I heard a narrative about a regulation measure working wonders during assessment, only to be discarded a couple of weeks later with some choice behaviour coming into play. It is my belief that the reason for this is that the co-regulation aspect during assessment was not appreciated. We simply can’t expect independence in regulation to be achieved just because we have issued a piece of equipment. None of us are truly independent in regulation, even if we are able to do this sometimes. We still also co-regulate pro and re-actively and the population group I work with can be horribly disadvantaged in this respect. Again, this understanding is thanks to additional training in attachment and developmental trauma.

I do not believe that sensory integration practice in mental health should be limited to addressing modulation and regulation though. I think that good sensory discrimination is also key to our ability to understand and connect with our bodies; the ground (a term frequently used in mental health but rarely considered from a sensory perspective); other people and the wider world. For me, this understanding and connection is a foundation of good mental health and can be supported through experiences of enhanced sensation.

SN: In your 2024 SIE Annual Conference presentation, you say, “There’s so much more to ASI outside of just the environment” – tell us more about this. 

Karen: I said this because I was asked to present on sensory-friendly environments in forensic services and secure settings and I think that there can be an assumption that environmental adaptation is the extent of sensory integration practice in these services and this, and other assumptions about sensory integration practice, can be a problem for us, and the people we serve, as it puts us on a path to quick (and cheap) fixes. This is not to detract from the excellent expert-by-experience-led publications available on this subject, such as ‘It’s Not Rocket Science’, which I highlighted in the presentation.

SN: Talk to us about the use of play in forensic mental health settings? 

Karen: I always find myself going back to Neumann’s (1971) description of play as being internally controlled and intrinsically motivated with a freedom to suspend reality. With this description in mind, and with a good partnership working with the individual, we are absolutely able to share in activity in a playful way. The right activities are usually considered to be leisure activities, but not always. I think about it more as exploring the possibilities of ourselves, the individuals we work with, objects and the environment. Adults play a lot and that playfulness relates to the freedom to suspend reality. This can also come with engrossment in the activity, if you (as a pair or group) have got the activity selection, environment and just-right challenge right – remember that true praxis absorbs us cognitively if we feel able to engage. It is really quite mindful. 

Play can also be scaffolded to be more make-believe (themed), depending on your relationship with the person you are working with and the level of engagement elicited. Only recently, I was talking to a mentee about using gardening to work on tactile hyper-responsiveness. We identified that one activity we could have ‘in our pocket’ was picking herbs and we wondered if we could get enough engagement to go on a flight of fancy pretending to be Christian Dior making a perfume! Now, you might be wondering in what possible way is this relevant or even appropriate in a forensic setting? Well, for the answer to that I turn to polyvagal theory. Carefully managed play is a great and natural way to work with someone to gradually and safely build tone on the ventral aspect of the vagus nerve, allowing the cortex to take control from the survival-dominated lower brain areas, which may be making the person prone to fight and flight behaviours. Play helps in the development of executive function, including inhibition, which is the healthy and mature alternative to dorsal vagal freeze.

SN: Can you summarise some of your practical top tips for implementing SI in forensic mental health settings? 

Karen: I think a Swiss ball for both assessment and for use as a sensory strategy is a really beneficial piece of equipment for your toolkit. Provision of movement can be particularly challenging in these settings, and this is where Swiss balls come into their own. As with anything, a risk assessment is required, particularly with Swiss balls around the stopper and sitting balance – a peanut ball is a more manageable alternative. In sitting, Swiss balls can provide regulating up/down linear movement and a gravity connection and this regulatory function can be progressed to forward and backward movement, with the ball between a wall and the small of the back. With risk assessment, these can be used in confinement along with some weighted equipment, which I do find helpful for providing enhanced deep touch and sensory information that reinforces the detection of gravity (grounding). 

Hospital gyms are great too, especially outdoor ones, for proprioception and movement opportunities, e.g. rowing machines. When I trained in sensory attachment intervention, the potential value of ‘hanging’ was emphasised. Now, this is a scary word to use in these settings, but if we reframe this as ‘proprioceptive stretch with gravity’, then gym machines that simulate climbing have huge potential for enhanced sensation. In terms of activities, yoga and similar activities can provide enhanced proprioception, interoceptive breathwork and vestibular challenge.

SN: The evidence base is growing in this area. Do you have any key seminal papers or books you have found helpful and why? 

Karen: There is some useful evidence for the use of sensory integration-informed practice, rather than Ayres Sensory Integration according to fidelity, in forensic services and secure settings. Pure ASI research in these environments remains sparse. Some recent publications I have found useful include; 

• Pfeiffer et al.’s 2018 systematic review into cognitive and occupation-based interventions; adolescents' and adults’ perceptions of sensory-based interventions
• Miller et al.’s 2023 qualitative analysis on adolescents’ and adults’ perceptions of sensory-based interventions
• Parent and teacher education and coaching (Miller-Kuhaneck et al., 2018)
• The role of sensory integration in multi-element behavioural intervention (McGill and Breen, 2020). 

SN: Finally, how do you feel the area of forensic mental health is progressing in terms of training and using SI within this area of practice? 

There are certainly drivers in the system, meaning that more therapists from these settings are seeking this training but also those risks I mentioned earlier, around assumptions of what sensory integration is and the seeking of quick and cheap fixes. I think that the potential value of sensory integration is very broad, and it is still in its relative infancy in terms of being translated to more diverse practice areas like this one which can make it difficult for therapists to understand its huge potential in these settings and envisage how it can be used. So I really do encourage SIE learners to make the most of all the opportunities available during the modules to network and share learning with peers and e-mentors, to seek good clinical mentoring through the practice hours, to engage in ongoing supervision beyond the end of their formal training journey and to commit to staying up to date with the ongoing organic development of the field. Joining the SIE Lifelong Learning Programme is an excellent way of doing this. 
 

References

McGill, C., & Breen, C. J. (2020). Can sensory integration have a role in multi‐element behavioural intervention? An evaluation of factors associated with the management of challenging behaviour in community adult learning disability services. British Journal of Learning Disabilities, 48(2), 142-153.

Miller, D. C., Schoen, S. A., Schmitt, C. M., & Porter, L. M. (2023). Adolescents’ and adults’ perceptions of sensory-based interventions: A qualitative analysis. The American Journal of Occupational Therapy, 77(5), 7705205160.

Miller-Kuhaneck, H., & Watling, R. (2018). Parental or teacher education and coaching to support function and participation of children and youth with sensory processing and sensory integration challenges: A systematic review. The American Journal of Occupational Therapy, 72(1), 7201190030p1-7201190030p11.

Neumann, E. A. (1971) The Elements of Play. MSSI. New York. 

Pfeiffer, B., Clark, G. F., & Arbesman, M. (2018). Effectiveness of cognitive and occupation-based interventions for children with challenges in sensory processing and integration: A systematic review. The American Journal of Occupational Therapy, 72(1), 7201190020p1-7201190020p9.

Su, C. T., & Parham, L. D. (2014). Validity of sensory systems as distinct constructs. The American Journal of Occupational Therapy, 68(5), 546-554