“It’s striking to realise how much of a role the spontaneous responses of other people play in helping us to create ourselves. People who love us can close us right down or open us right up, without ever meaning to. That’s one of the key messages that comes out of the study of human development: even our physiology is shaped by the way that other people treat us” (Zeedyk, 2014).
In 2012, the Scottish Government outlined its ambition for “Scotland to be the best place in the world for children and young people to grow up” (cf. Consultation Document, 2012). Today the Children and Young People Act (2014) along with other policy initiatives, such as Getting It Right for Every Child (GIRFEC), the Curriculum for Excellence, the National Parenting Strategy (2012) and The Early Years’ Framework (2009) define the child as the centre of learning and care (cf. Wellbeing, Autumn 2013).
The child as the focal point really is crucial. How best we meet the needs of the individual child engenders more success than a focus on the delivery of specific programmes or tools per se. Families need to be empowered to gain awareness, knowledge and confidence in their own abilities to create the right conditions for successful communication and interrelationships rather than to depend on tools or skills which they assume reside in the visiting professional (or a manual) alone.
The purpose of this document is to set out the argument for Video Interaction Guidance (VIG) as effective provision for the training and guidance of midwives and health visitors in Scotland. Four key questions will be posed:
- Why VIG?
- Why target midwives and health visitors specifically for the implementation of VIG?
- Should we target beyond the mother-baby dyad?
- What are the potential service-level impacts of economic, practical and time constraints on VIG implementation?
Pregnancy, birth and infancy are times of tumultuous change. Primary and secondary attachments are beginning to take shape, with Internal Working Models (IWMs) becoming a platform from which babies base the tenor of their subsequent relationships. Equally, at this time, the attunement of relationships impacts on language development, socioemotional stability and the development of self (e.g. Gerhardt, 2010). Unsurprising, therefore, that Governmental initiatives, such as Pre-Birth to Three (LTS, 2010) and The 1st 1000 Days study started in 2013 (NCT, 2016) highlight this period as more crucial to the child’s long-term future than any other subsequent time. Importantly, most parents say that they experience some of their most challenging moments at this time, too. This means that professionals involved from the offset, who have a strong understanding of and commitment to child development, health (including maternal mental health), community and family dynamics become pivotal to the implementation of techniques which can enhance families’ foundations to become attuned and communicate meaningfully from within. Midwives and health visitors crucially help to establish a process whereby successful interrelationships, trust and confidence in social interaction and parenting are achievable.
At the same time, programmes need to be economically-efficient and mindful of the wider context. VIG is the most widely available training package across the UK (NICE, 2015) and is recommended as an intervention to facilitate attachment as well as positive socio-emotional development in the early years (NICE, 2012). Studies (e.g. Robotham & Frost, 2005) suggest that health visitors are particularly successful in gaining acceptance of families across the board, including those who are likely to be harder to reach (e.g. homeless families, travellers, and mothers with mental health issues). Their interventions are valued highly by families (cf. Mitchell & Wilson, 2016) and other professionals see them as lynch pins within the preschool framework, liaising with midwives and school nurses amongst others.
Thus, midwives and health visitors already engage in early social care situations, have engagement with families and communities facing severe challenges, and cooperate in programmes such as early nutrition as well as parental smoking cessation (Universal Health Visiting Pathway in Scotland, 2015). This supports the research mentioned above related to gaining the trust of families and establishing good rapport. VIG could be offered as a natural progression within these situations as and when required. Being strengths-based and proactive, VIG presents opportunities to ameliorate pressures on skills, tools, and professional availability by encouraging and enhancing the long-term family’s integral role to success rather than focusing on a perpetual cycle of professional intervention which may never become embedded in the family culture itself.
What is the argument for implementing VIG through the midwifery and health visiting services?
How VIG works
Video Interaction Guidance (VIG) provides positive improvement by guiding individuals through a process of awareness-raising, recognition, understanding and application of what they do well in their everyday relationships and interactions with important others (Kennedy, Landor & Todd, 2011). These positive events may be fleeting but by isolating their occurrence, VIG can provide a platform for hope and for successful progress even where the overall feeling is one of despair (e.g. parents of children with complex developmental conditions; parents with mental health issues). VIG practitioners guide parents to see and acknowledge what they are doing right, and they name these instances of quality interaction so that parents can identify and reflect upon them at any time. As a result, VIG has an enduring impact by altering internal cognitions and anxieties, enabling parents to accept that they have decent competencies and can cope with situations and events even when things are not so good (through self-modelling and self-efficacy techniques) (Bandura, 2000). The intergenerational transmission of faulty attachment patterns (e.g. v IJzeendoorn et al., 1995; Seskin et al., 2010) can be intercepted and retuned to more positive patterns of interacting and relating (thereby potentially having an impact on how Internal Working Models are formed (cf. Baby Bonds, The Sutton Trust) and longer term development of executive functioning in the child (Bernier et al., 2012)). By guiding parents to a more confident and aware perspective of parenthood, they will accept that the locus of responsibility and control is with them – not with a professional who holds some mystical training or skills. Potentialising parents’ skills in this way is a positive goal.
Midwives and health visitors’ key role in family and community health make them a positive conduit for disseminating the VIG technique, especially as they can involve other key attachment figures in the training. This paper suggests that VIG intervention and training for these health professionals will have a positive impact in several ways:
VIG enhances the opportunity for achieving sound, trusting partnerships due to the following principles:
- it is a genuinely collaborative process, allowing for active listening and engagement strategies to activate the parent’s (& practitioner’s) thinking as well as to consolidate positive development in that thinking;
- it promotes development through highlighting aspects of self – this includes awareness of self-efficacy, self-awareness, self-confrontation, and self-modelling.
As such, the dynamic between the VIG practitioner and the parent becomes more attuned, more evaluative, and more reflective as the work unfolds both within the individual and the dyad group.
In other words:
- VIG can enhance the relationship between the mother and child, especially in circumstances where the pregnancy and/or birth is sub-optimal (e.g. unwanted pregnancy, young mother, violent act leading to pregnancy, PTSD re birth, depression, difficult birth, disability);
- VIG can enhance the relationship between the father and child, facilitating the father’s awareness of the infant’s individuality and personhood at the earliest stages, enhancing his awareness of the pregnancy & birth process from a less directly biological/physiological perspective;
- VIG can enhance the relationship between birth partners (mother & father, mother & grandparents, mother & step-parent, etc.). Involving birth partners, especially fathers, in the early stages of pregnancy, birth and post-natal days can be crucial to the quality of the mother’s health (Bloch et al., 2010; Mesman et al., 2012; Ramchandani et al., 2013), the relationship between parents (Doss et al., 2009), as well as between father and child (e.g. Alio et al., 2012). VIG can provide a platform for enhancing these relationships by focusing on the positive value of involvement and care of all key partners;
- VIG can enhance the midwife/ health visitor’s professional practice by facilitating self-awareness and evaluation.
Ensuring fathers do not feel left out
Recent headlines such as “Dead behind bars – my son didn’t think he was lovable” (BBC News, 25th April, 2014) as well as The Sutton Trust report (“Poor parent-child bonding hampers learning” (BBC News, March 21st, 2014) reflect the importance of giving parents support at critical times. However, parents, especially fathers, can feel detached from the forthcoming child as they have far less biofeedback than the mother. The Transition to Parenthood initiative therefore is vital in providing parents a means to discuss the changes they are undergoing, both as individuals and as a couple. Again VIG is an ideal intervention strategy with this regard. It is non-threatening. Considering research, such as that by Doss et al. (2009) who found that 90% of couples had a deterioration in their relationship after the birth of a first child, and Dex & Joshi (2005) who found that approximately 14% of couples separated before their baby was born, interventions which enhance these partnerships prior to birth and continue to maintain them afterwards, have a real role to play in social change on a larger scale.
The role of the midwife and health visitor: why they are well-placed to use the intervention
Midwives are involved in a period of ante-, peri- and postnatal care. In line with GIRFEC they often take responsibility for being the “named person” for the neonate until the health visitor succeeds them around 10-14 days after the birth. The health visitor may then continue as the “named person” until the child commences formal education (e.g. Scottish Borders Council: Guide to Early Years Services). As such their roles are clearly diverse and complex and have a significant impact upon the parents’ lives at a critical time. The Royal College of Midwives describes the midwife role as one that includes responsibility “for providing care and supporting women to make informed choices about the services and options available to them” (RCM). This raises two questions: which services and options should mothers expect during this period of great change; and does a focus on the mother and child fail to reflect on the impact of key others in the dynamic?
Midwives and health visitors need to create a close nurturing partnership that enhances and develops the parent’s inherent skills and abilities to provide optimal care – and to be able to evaluate what is being offered to them. Achieving such a partnership requires patience, trust and mutual respect. These skills develop through experience and expertise – but a programme of development, aimed at providing the tools to enrich and sustain this development, needs to include the foundational principles of successful engagement and reflection for long-term change to occur. VIG provides both this enhancement and awareness even though parents may receive on average only 3-4 direct input sessions from the practitioner. In terms of effectiveness and efficiency, once training is completed, the allocation of professional time and resources becomes very productive.
Meeting professional needs
In March 2010, The Commission on the Future of Nursing and Midwifery produced a guide for good practice – outlining how midwives might play a greater role in ensuring better equality in outcomes for parents and neonates irrespective of their social and economic situation. This document sets out the premise that VIG as an intervention strategy is better at supporting these aims due to the ethos underpinning it. Thus, success is more likely:
- through genuine collaborative engagement that is founded on attuned interactions;
- by empowering parents through enhancing their strengths and focusing on what they do right rather than what is wrong (giving them a vocabulary to explore, reflect, appraise, and challenge the thoughts, emotions and experiences they have during this period of adjustment);
- through focusing on the relationship between the parent and child by supporting the construction of warm emotionally responsive and attuned interactions.
Are there alternatives to VIG?
There are many different intervention strategies available and many with merit (e.g. infant massage; PEEP’s Reflective Parents’ programme, Incredible Years; Baby Father Initiative). However, VIG does present a package (with the potential to involve both mothers and fathers) to develop individual skills and cognitions as well as providing a method of working together dynamically and in a respectful and genuinely collaborative manner. Whilst other programmes may offer methodical procedures, which can be evaluated and measured, the locus of control can be of issue. Parents who believe that they are being told what to do by someone more knowledgeable, with more training and with more skills do not necessarily internalize the impact they and their behaviour have on their offspring and vice versa. If the programme fails, it can be viewed as due to the programme itself, not to how individuals have an influence on what occurs.
Impact on practitioners as well as participants
Empowerment through active, sensitive guidance can produce long-term changes and can facilitate improvements in breaking the defective intergenerational attachment patterns that occur. The enhancement VIG brings is that professionals who use VIG are also much more aware of self-evaluation. They too take ownership for changes as a consequence of interaction rather than due to the objective materials. This is a crucial point when evaluating the impact of any intervention process. We tend to overlook the dynamic and power of interactive engagement per se. And yet, we are cognisant of our need for successful relationships in all walks of life. How do we measure this success if we do not reflect upon how we engage with others and evaluate how we can improve?
Evidence of impact from academic sources
Studies have shown that VIG evinces positive outcomes. There are sound reasons as to why this is the case, including: its fundamental embedding in knowledge of how positive attunement, intersubjectivity, attachment and communication work; and the clarity of its training programme to achieve these goals by helping families internalise the process for themselves. Doria et al. (2014) have recently published findings which suggest that VIG “improves family happiness, parental self-esteem and self-efficacy, and [promotes] attitude–behavior change”. They argue that this is due to specific elements fundamental to the VIG paradigm. These centre on the fact that VIG assists in developing a mindful (and thereby aware and evaluative) approach, is success-focused, and provides unequivocal support for the positive change taking place through video evidence. Further evidence is presented by v Haaften (2011) who found that interaction improved between parent and infant, partly due to increased sensitivity to the child’s cues and also due to less negativity overall (the latter especially in circumstances of first time parents).
Training in VIG techniques involves guidance to become self-aware and self-reflective. As such, it involves self-engagement on all levels whether participant or practitioner. It does not require extensive travel to specific centres for delivery and is not time-intensive in terms of group allocation.
Conclusion and thoughts for future study
As VIG can be particularly useful in circumstances where fathers have felt less engaged at the birth or in instances where there are paternal mental health issues there is real impact on the family unit. VIG seems to establish real psychological and behavioural change via embodied, in-situ and dynamic interpersonal and intrapersonal change. By rolling out a larger exploration of how it impacts on early bonding and relationships, it will be better to establish mediating and moderating factors in its success, especially if there is a focus on ALL the relationships involved in birth and infancy (not just mother and baby).
In addition, VIG has an impact on practitioners. Many, who have experience of other strategies and approaches but come to work with VIG, say they are profoundly changed by it (Parker, 2011). It appears to become integral to them, not only in a professional capacity, but in terms of their personhood, too. VIG appears to be less of a process than a life-changing ethos. It is effective, easy to set up (in terms of equipment) but it requires commitment and an open mind to become self-aware and evaluate in a positive, success-oriented environment. Studies of comparison methodologies could highlight why VIG has such a profound effect (e.g. on cognitions related to working practices, to clients, to self).
In sum, VIG has strong ecological validity. It is rigorous, has a clear definition of the process it intends to evaluate and develop, and is structured to facilitate desired outcomes. By targeting its intervention with the neediest of participants and/or communities, it should be clearer to assess how it impacts and to distil key features which might be used as ‘top ups’ or concentrated approaches in other contexts.
What’s not to like?
Lorraine Howard was formerly Associate Lecturer in the Faculty of Health & Life Sciences at Northumbria University. Contact firstname.lastname@example.org.
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