Visual support for your client

What it is

Visual support means that you make visible what you would otherwise only say or write. You do this with a picture, a photo, an object or a card. In care for people with an intellectual disability, this is part of total communication: you communicate in several ways at once, with and without words. You then support spoken language with things someone can see, such as pictograms, drawings, objects, written text or gestures. Pictograms are simple pictures with one fixed meaning, such as a plate with a knife and fork for food.

In care and support, it is often about a few common forms:

• An appointment card. One card with what kind of appointment it is, the day, the time, where, with whom and what to bring.
• A daily plan. What someone does in the morning, the afternoon and the evening, with a picture for each part.
• A step card. A task in small steps, each with a number and a picture. For example: opening a letter from the municipality, reading it and putting it in the right folder.
• Time you can see. A clock that shows how much time is left.
• Pictures to talk about. Photos or cards that someone uses to show what they mean, when talking is hard for a while.

Who it works for

• People who find reading hard. In the Netherlands, that is about 3 million people aged 16 to 75. A picture with the text makes the message clear more quickly. Also read Recognising and discussing low literacy.
• People with an lvb (in Dutch: licht verstandelijke beperking; a mild intellectual disability). They find learning and everyday situations very hard, more than most people their age. In the Netherlands, this is an estimated 1.1 million people. They often find it hard to keep their day organised.
• People with autism. Like people with depression, they can find it hard to remember appointments or to stick to their daily routine.
• People under stress. Capacity to act (in Dutch: doenvermogen) is the ability to make a plan, take action, keep going and deal with temptations and setbacks. Stress puts this ability under extra pressure, for example for someone who has just lost their job, or is in the middle of a divorce. Capacity to act is different from thinking ability, and it is only partly linked to education: many highly educated people also regularly struggle with it.

You don’t need to know whether someone has a disability to use visual support: clear communication helps most people. People forget a large part of what you tell them in a conversation, and they remember part of it differently from how it was said.

Why it matters

With a good card, your client doesn’t have to remember everything, and can look again at home to see what was agreed. They know what is going to happen, with whom and when, and that can give peace of mind. And if they can look at their own card, they need to ask less. This fits with self-direction: staying in control of your own life, even when you get help with it.

For you as a care worker, it can save repetition, missed appointments and misunderstandings. A card you make together also shows whether you have understood each other.

How to do it

1. Look at what your client needs. Ask where things go wrong: forgetting appointments, not getting through the day, not finishing a task, or not being able to say what is wrong. Also ask what already works, such as a calendar on the fridge or an alarm on their phone. Build on that.

   People can feel ashamed when you bring out pictures. So suggest it as something ordinary: “Shall we write it down, so you can check it again at home?” If your client says no, you don’t do it.

2. Choose one goal per card. An appointment card is for one appointment. A step card is for one task. If there is too much on one card, it becomes hard to follow.

3. Choose images your client recognises. Concrete images usually work best. If it is about money, show coins and notes. If it is about a consultation hour, show a clock with the right time, and if you are explaining a route, show the map. Photos often work better than drawings, and many people find graphs and flowcharts hard to understand. A photo of the real front door of the community centre often says more than a pictogram of a house.

4. Put the text with the image, not instead of it. Write a few words under each picture. Write the day and the date in words, such as “Tuesday 6 October”. Keep sentences short.

5. Make it together. Let your client choose the pictures, or take a photo themselves. Ask whether it should be on paper or on the phone. Someone is more likely to use a card they made themselves. Also read Designing a digital tool together with clients.

6. Go through it together, and check that it is right. Read the card aloud and point to the pictures. Then ask your client to tell you in their own words what you agreed. If the answer is not right, explain it again in different words.

7. Give the card a fixed place. Agree where the card will hang or lie, for example on the fridge or next to the keys.

8. After a few weeks, see how it is going. Is the card being used? Is there too much on it, or too little? Change it, or stop if it doesn’t help.

Which tool fits

• Appointment card maker. You choose what kind of appointment it is, and each kind has its own picture. You fill in the day, the time, the place and the person, and tick what your client needs to bring. You print the card in large letters and give it to your client to take home. It helps to add what time your client needs to leave, not just what time the appointment starts.
• My day. Your client chooses what they do in the morning, the afternoon and the evening, with pictures, and prints their day. In an empty space, they write or draw something themselves. Start small: one day, with a few things per part of the day.
• Visual timer. A clock on which a green part gets smaller and smaller until the time is up. Useful when “a little longer” means nothing to your client. For example during a conversation (“we’ll talk for another ten minutes”) or at home with a task someone would rather put off.
• Questions for your appointment. Your client writes down beforehand what they want to say and ask, and prints the list. This helps at an appointment with the GP or the municipality, where someone under stress forgets things.
• Talk Cards. Photos with a question. Your client chooses a photo that fits what they want to say. A talking picture or conversation card like this helps to make something easier to talk about, when someone finds it hard to say what is on their mind.

Example: a step card for the post

A man with a mild intellectual disability lives on his own and often misses appointments with the debt advice service. Together you make an appointment card for the next appointment, and a step card for the post with four photos: open the envelope, see who the letter is from, put it in the folder, put the folder on the table for the next appointment.

After a few weeks, the second step turns out to be hard: he often doesn’t know who a letter is from. Together you add the logos of the organisations that write to him most often to the card.

Points to watch

• Check that your client understands the picture the way you mean it. A picture can mean something different to your client than to you.
• Choose images for adults. No childish pictures, and don’t talk about “your picture book”.
• Keep it small. A daily plan with twenty pictures is hard to follow. Start with one card and a few parts, and add more if it works.
• Think about who else sees the card. Visitors also see an appointment card on the fridge. Ask whether your client is okay with “debt advice” or the name of an organisation being on it. A neutral picture and “appointment with Sanne” also works.
• Look at what the rest of the team uses. If several people work with the same client, use the same pictures and the same place. Two different systems make things unclear. Also ask whether your organisation already has a standard set of pictograms, so your client sees the same ones everywhere.
• Consult others if your client still gets stuck. If someone gets stuck despite the card, there may be more going on. Then ask a behavioural specialist or therapist to think along with you.

Questions

Isn’t paper old-fashioned? Doesn’t everyone have a phone? A reminder on the phone can work well. But a phone can be flat, lost or full of notifications. A card on the fridge doesn’t have those problems. You can also do both: the card for the overview, the phone for the reminder.

Does this also work in a conversation? Yes. During the conversation, put a sheet of paper on the table and draw or write as you talk.

Find out more

• Recognising and discussing low literacy
• Writing at B1 level for your clients: if you give text as well as images.
• Making accessible documents: letters, leaflets and PDFs that everyone can read.
• Self-direction and digital tools
• Choosing a digital tool for your client
• Communication with people with an intellectual disability at Kennisplein Gehandicaptensector ↗ (in Dutch)