Werner and Kaplan's work was later expanded and edified into more refined therapeutic practice by the pioneer in deaf-blind patient therapy, Dr. Jan Van Dijk, and later refined by the work of Dr. Susan Bruce. Primarily of use in working with deaf-blind patients, distancing gradually leads the subject through a course of physical interactions which encourage a range of responses connected to the act.
At first, responses may be simple repetitions of pleasurable acts, but eventually events that take place in the present tense are replaced in the subject's mind with more complicated cognitive concepts, such as desires, requests or other expressions which reflect symbolic cognition and understanding of past events.
As the subject progresses through these stages, he is eventually able to move from communicating his desires simply (as in early childhood) to more complicated treatment of symbols in communication. Once the communication barrier is removed, more conventional therapies and educational methodologies are then possible.