You will see in the following Case study, that Restrictions/Demands and Transitions can co-occur and overlap, and sections are categorised this way.
Case Study Three: Paul
Paul was a man, we visited for some years. He had brilliant humour, was very rhythmical and musical (maybe due to a heightened interest by his visual impairment) and communicated using repetitive phrases. Sometimes he added new phrases, and used words and vocalisations as well as expressive face and body posture to communicate. He had a learning disability, and we envisaged probably experienced some level of Post Traumatic Stress Disorder connected to his time in institutional living.
Overall Strategies:
- Agree across Interaction Practitioner Teams to treat his chair and chair area as an extension of his body, and the awareness that he seems to have trauma around proximity / touch / movement of his chair.
- To always proceed interactions with predictability, giving him as much choice as possible and only venture into more playfulness, humour and gentle sound-based surprises when he either says he is ready, or his body language and facial expressions clearly show it.
- Utilise music and singing as he had a clear affinity for it and seemed to be able to process it easier.
Example March 2022
When we arrived, we were told that paramedics had checked Paul out this morning, as his mouth had been bleeding, but that he was ok now. He seemed a little agitated at first so we reduced our words and responded to his tapping, by clapping/ tapping in response to his rhythms and later quacking in his rhythm (as he had previously enjoyed this sound). By tuning into his rhythm and using only this at the start, we handed the control to him. This can have a settling effect and as Paul would often test us, seeing if we still followed his rhythm when he changed it and laughing if we made a mistake, we had the sense that it was acting as a focus for him, and reducing his agitation.
Demands
Initially, any singing (a usual part of our time together) added to his agitation, and he began to bite himself. We use our observation skills and test singing and/or speech with caution as a lot of the people we see do not find it calming, and instead go from upset to sensory overload quickly. This makes sense as the nervous system is already busy, in this situation with being upset/unsettled by his sore mouth and we wondered if our singing had maybe triggered some old memories. It does not help to add sensory input on top of someone’s current experience so we left the room for 5 minutes. We had previously agreed this strategy as one that we would use if needed, and having these management tools in place alleviates any insecurities about decisions that delay helpful action.
When we returned, we tuned into his rhythms again, gradually introducing the guitar, but no voice! Using varied rhythms and our Spanish sounding tune, Luca continued to notice his taps, and Stephen began to smile. Gradually Luca introduced tapping and stamping rhythms whilst moving around Paul with the guitar. The intention was to add additional sensory vibes to the music, varying the rhythms to keep Paul’s interest. Paul laughed a lot, and leaned his head to where the rhythms were being made. We began varying the tunes and responding to Paul’s “Doo bee doo” vocalisations, claps and loud “Wahey” vocals. We introduced our voices very gradually, using them to notice Paul’s actions and sounds, he remained engaged and seemed joyful throughout the rest of the session, clearly listening, participating and smiling and giggling. He often said “lovely”, “beautiful” or “thank you” when we finished singing.
We then offered to share a story of Nicky’s boating weekend, checking if it was ok with Paul, he said “yeah”. Importantly we only introduced our non-singing voices back towards the end of the session, probably around 45 minutes in, and asked for his permission. He decides if he can cope with the additional sensory input of speech now, without being triggered or overwhelmed.
The story involved Nicky slipping down a muddy bank and falling into the mud, with some sound effects for falling, winding up locks on the canal, mud, boat engines and ducks. He seemed to enjoy all this, giggling and we think saying “Down she goes”!
We celebrated this utterance especially, adding a falling sound on the guitar string and repeating to maximise the humour of the event.
Paul seemed much more relaxed by the end of the session, shown in him having a relaxed facial expression, the quality of his voice being more gentle sounding, him humming, him having a relaxed body posture with his arms resting, instead of making fast repetitive movements.
Transition/touch
- Paul’s wheelchair area is his safe space. We always ask him and count to 3 before we move his chair and we make sure to never bump into, move or lean onto his chair accidentally. The sudden movement or vibration for someone who is blind is sudden and unpredictable and goes with a loss of power and a feeling of helplessness. He may have unpleasant memories of being moved in a frightening or unpredicted way and we need to avoid recreating circumstances that caused anxiety in the past. This is especially important if he already seems on edge. We only cross its boundary with his permission, and then, only in a playful context later on in an interaction. When we do ask him, he sometimes answers with a clear “Yes.” or “No” and even though Stephen doesn’t ‘t seem to be able to express: “Please let me know before you move me or touch me, “We have noticed that he smiles more often and relaxes sooner if we let him know beforehand or ask him. He shows his appreciation of being treated in a considerate way with his body language and facial expression, and sometimes he says “thank you “.
- To ease Paul’s concerns around being moved, we have made sure that Paul’s home staff members move his chair into the perfect position long before we arrive. The additional transition of moving his chair within his own room, with the additional sensory input of “Oh visitors”” and “Oh visitors, they move me around” seemed too much.
- We have learned that singing our intentions is preferable to speaking them, and use this to reassure him that everything within the session is his decision, including whether we include elements of touch. It is vital to make sure to keep that promise always.
The aspects of our practice that have remained the most pertinent and effective for Paul are thoughtfulness, playfulness, patience, handing back control, and gentleness.
Conclusion
I think we need to remind ourselves to never fall into us and them thinking, as this creates an unnecessary rift and a possible danger of assuming that the responsibility, power and being in charge just lie with one side.
While it might feel scary to admit, we all are just a step/misstep away from disability/complex health issues/mental health issues. It is statistically the truth that most people will at least experience one of those during certain times of their lives or their lives might change drastically/unexpectedly for a prolonged time or forever.
Whilst we often hear “treat someone like you would want to be treated”, I feel like not everyone actually thinks through the situations the people we visit experience every day. I’m not sure we listen to them, try to adjust and adapt as much as possible so they can feel at home and at ease. We must be striving to create an environment for them that is as similar to our own experiences when we sink contentedly into our couch/bed at the end of the day.
Exploring in your mind and with your emotional intelligence what you would do if you just had limited access to something you really, really love; if you were in some pain or discomfort every day; if you lived constantly with unchosen housemates; were under a tight, never-ending schedule unbroken by weekends or holidays where you can be more spontaneous; not be in charge of your own hygiene routine; not being able to go out and find friends/hobbies, and feel the feelings you might have around loosing those independencies could create starting points for understanding and change.
Let’s choose to see the strength and power of disabled people, choose to show honest respect to everyone who has to face physical, mental and social difficulties/challenges every single day.
Let’s choose to see the humour, communication and self-expressions over the perhaps chaotic results.
Let’s choose to see clever coping mechanisms, often subconsciously developed for physical and emotional survival, instead of calling it a “behaviour”.
Let’s choose to see movement patterns we aren’t familiar with ourselves as an extension of strategies for the other person to feel better and for their body to stay as healthy as possible, instead of labelling it as “weird” or “That’s just what … does”.
Let’s choose to see self-regulating practices instead of “purposeful disruptiveness” (e.g. undressing for temperature regulation/sensory regulation).
Let’s choose to see attempts-for-building-a-connection for what they are, even if the approach/delivery is repetitive and might be causing tension.
Let’s choose joint exploration and a curiosity-filled try-and-error approach over restriction/limitation.
Let’s choose compassion over judgement for ourselves and the person we are with.
I feel like all of these build the foundation to be able to follow the people we see with Gentleness, Patience, Compassion, Humour and Playfulness all of which they usually have already in abundance and are happy to share and lead with.
“How many years has it taken people to realize that we are all brothers and sisters and human beings in the human race? I mean how many years does it take people to see that?” — Marsha P. Johnson
Luca Grys, Interaction Practitioner July 2026
Disclaimer: Us in a Bus cannot accept liability for any errors in this publication. No part of this publication can be reproduced, in any form, without the written permission of Us in a Bus
