Chryssa Ekizoglou, Midwife, MSc; International Board Certified Lactation Consultant (IBCLC); Perinatal Psychologist; “Good Enough Parenting” Facilitator; V.I.G. trainee.
Research shows that children’s emotional development and the establishment of a secure attachment are promoted by an attuned mother or carer. Many studies present evidence of the harmful effects on the child of being parented by mothers with psychological difficulties. Thus, an early intervention in the perinatal period is essential for positive changes for the mother – infant dyad. Burgeoning evidence from research and clinical practice supports the benefits of Video Interaction Guidance (V.I.G.) as an early intervention tool. The goal of this article is to present the efficacy of Video Interaction Guidance as a supplementary or exclusive intervention for mothers with mild or severe mental difficulties. In this article, I describe part of the clinical work that is applied in Greece. The introduction includes the essential role of an attuned mother. I will then describe how the interaction between mother and child can be obstructed because of maternal mental problems. Subsequently, the facilitating role of the V.I.G. guider is mentioned and the method of Video Interaction Guidance is presented. In this case, the V.I.G. guider is a professional with a multidisciplinary background (midwifery, lactation consulting, perinatal psychology), who works with Greek primiparae mothers struggling with parenting, since their psychological status disturbs the interaction with their infants. Two indicative case studies are presented.
Keywords: video interaction guidance, mother – infant interaction, early intervention, perinatal psychology, V.I.G. guider, midwife, Greece.
The essential role of an attuned mother in the perinatal period
Numerous theories and studies have shown the importance of a mother who is attuned to her baby during the perinatal period since this period is essential for the welcoming of the new human being, first in the mother’s mind and second in the mother’s lap. Although the mother experiences one of the most challenging periods in her lifespan, comparable to adolescence and to menopause, the changes of the perinatal period help the woman to adapt to her new role (Tyaro et al. 2010).
Babies come into this world hardwired to form close attachments with primary caregivers and ready for learning with the vital support of the mother (Acquarone 2004; Baradon et al. 2005; Celebi 2014; Hobson 2002; Raphael-Leff 2015; Sakellaropoulos 2001). A parallel process takes place in the mothers’ psychic life. “Primary maternal preoccupation” as mentioned by Donald Winnicott is an expected ‘organized psychological state’ for the new mother, which lasts for few months after the baby’s birth and facilitates the bonding between them (Daws and Rementeria 2015; Gerhardt 2004; Holmes 2009, first published 1999; Raphael-Leff 2015; Winnicott 2003, first published 1965).
A “facilitator” mother – as she is classified by Raphael-Leff – usually adapts to her baby’s needs and celebrates the state of mothering (Tyaro et al 2010; Raphael-Leff 2015).
The mother’s ability to understand her baby’s signals, to put them into words and in some way to reflect them as a virtual mirror, encourages the child’s own ability to become aware of his own self and his own emotions (Bergman and Harpaz-Rotem 2004; Gerhardt 2004). When the mother is attuned to her baby, she is an unfading paradigm of interaction for the child’s future relationships.
Undoubtedly, nature facilitates the quality of this primary relationship between child and caregiver – usually the mother – since it is the fundamental factor in the child’s emotional, cognitive and social development (Gil et al. 2012; Moutsiana et al. 2014).
Additionally, a mother who responds harmoniously to the primary relationship with her infant is establishing the basis for a secure attachment – as the first experience of connectivity – and for good enough parenting (Howe et al. 1999; Holmes 2009, first published 1999; Zeanah et al. 2011; Celebi 2014; Raphael-Leff 2015).
Maternal mental difficulties obstruct the interaction between the mother – child dyad.
The expectant mother usually has ambivalent feelings about her new role as a parent. Experiences from her childhood may affect her parenting. If she has negative representations from her parents, she may repeat such behaviours. Additionally, her emotional state can influence her resilience (Antoniadou et al. 2015; Daws and Rementeria 2015). For instance, a mother with mild or severe mental health issues may face difficulties with her baby’s daily care and – mainly – with the baby’s non-verbal demands. A mother who is not aware of her own feelings finds it hard to understand her baby’s cues and become attuned to her baby’s needs (Gerhardt 2004; Salomonsson 2014).
The repetition of unsuccessful interactions and negative experiences in the mother-child dyad could be detrimental for the child. The developing brain of the infant can be damaged when exposed to events of neglect, abuse, trauma, stress and severe maternal depression (Acquarone 2004; Celebi 2013; Gil et al. 2012; Marioti 2012; Vik et al. 2009).
The reaction of the child during the “Still Face” episode as described in Tronick’s “Still Face Experiment” (1970) indicates the period of disruption and misunderstanding that a baby experiences under those circumstances (Bergman et al. 2004; Gerhard 2004; IJzendoorn et al. 1995; Music 2011). Further research mentions the impact of living with a depressed mother. Two year-old babies, for example, showed that even after their mother’s recovery, they had more sleeping problems, temper tantrums and separation issues (Music 2011).
Often, these kind of emotional and behavioural problems in infants may cause parents to feel a sense of despair, ideally leading to parents’ seeking help from professionals.
The facilitating role of professionals
The goal of professionals who work with parents and infants is to break the intergenerational cycle of insecure attachment and to enhance the development of parental mentalisation about their infant (IJzendoorn et al. 1995; Underdown 2013). Professionals need to be alert and sensitive offering their help when early warning signs of problems arise. Early intervention is crucial for conferring positive changes, firstly to the mother – baby dyad and secondly to the father and the siblings (Acquarone 2004).
Notably, short–term preventive interventions are more effective (apart from the evident cost-effectiveness) for parents and young children. Early intervention promotes parental changes and facilitates remedial behaviours for the child (Acquarone 2004; IJzendoorn et al. 1995; Salomonsson 2014). Video Interaction Guidance (V.I.G.) is a brief intervention with positive outcomes for all the participants (Kennedy, Landor & Todd 2011). The V.I.G. method is offered – usually – by a professional (e.g. psychologist, social worker, midwife, teacher), who is V.I.G.-trained, called a V.I.G. guider.
Describing the V.I.G. method in the perinatal period.
Video Interaction Guidance (V.I.G) is an evidence-based, non-pharmaceutical, brief intervention, which can be used safely and successfully – among other applications – in the perinatal period. Hence, the method is recognised in the UK by NICE (The National Institute for Health and Care Excellence) and by the NSPCC (National Society for the Prevention of Cruelty to Children) (NICE Guidelines 2015).
The method is based on the theories of “intersubjectivity” (Professor C. Trevarthen), “attachment” and “mediated learning” (Kennedy, Landor & Todd 2011). In the first place, the V.I.G. method was devised by Harrie Biemans (Netherlands) in the eighties and further developed in Scotland in the nineties by H.Kennedy, P.Forsyth and R.Simpson (Dundee). The V.I.G. method is guided by a trained practitioner (Kennedy, Landor & Todd 2011; NICE Guidelines 2015).
Following a parent’s concern – usually the mother’s – about parenting difficulties (eg. fussy child, lack of eye contact, breastfeeding problems etc), the V.I.G. guider facilitates the parent to have an interaction with the child in order to video it (Videoing session). Afterwards, the V.I.G. guider microanalyses and selects the exceptional moments of attuned interaction between the parent and the infant. The selected video clips or stills will be the material on which parent and guider are going to reflect. They watch carefully the “highlight” moment in order to discuss the changing point that facilitates the attunement. The helping question of the parent usually leads the session (Shared Review).
Usually, 3 cycles (6 sessions) are recommended. A cycle consists of two sessions (videoing and shared review). If it is required, more cycles can be offered (Kennedy, Landor & Todd 2011; NICE Guidelines 2015).
Practical implementation of Video Interaction Guidance in Greece for mothers with mental health difficulties and their infants.
The participants who are presented in this article are Greek mothers aged 35 to 40 years and they are married. They have a range of psychological difficulties from anxiety to bipolar disorder and psychosis (under medication after psychiatric diagnosis). They are primiparae and they have healthy children aged 3 to 18 months.
At the mother’s request, the health professional offered midwifery services for a few days or weeks following the baby’s birth. The initial home visit focused on feeding (principally breastfeeding) and on daily baby care, such as changing, bathing and sleeping.
A good working relationship between the mother and the health professional appeared to have been established. Weeks or months after the initial home visit, mothers called the professional (knowing her multidisciplinary background) with a worry or a specific request concerning their interaction with their children. In the cases where telephone-counseling seemed inadequate, the professional (who is a V.I.G. guider) suggested Video Interaction Guidance. A brief explanation about the process and the potential positive effects of the method were given. Before the sessions, the mothers were advised to watch the 3 minutes whiteboard explanatory video about V.I.G., in order to help them to have a better understanding of the method (“What is Video Interaction Guidance?” https://youtu.be/YRVaL_ZlxHs).
The sessions took place in the families’ own homes by mutual agreement. Usually, mothers were alone with their children. In some cases, as well as the mother and the V.I.G. guider, the father or the grandmother were also present, if they were curious about the process. In addition, they took care of the infant during the shared review, facilitating the discussion.
The V.I.G. guider videoed a few minutes of the mother – infant interaction during daily care and routine activities (e.g. breastfeeding, feeding solids, changing, playing etc.). The video usually focused on the mother’s concern. Indicative questions were: “The baby doesn’t look at me during breastfeeding”, “The baby is crying all the time. How can I nurture him better?”, “I get bored easily when I am playing with my child”, “How can you communicate with an infant who doesn’t answer you?” etc.
Two issues arose during videoing: on one occasion videoing was cancelled because the baby was sleeping, and on another occasion, the older child demonstrated more interest in the V.I.G. guider than in the mother.
The equipment used for videoing was a mobile phone held by hand or supported by a hands-free “lazy-holder”.
Both mother and V.I.G. guider signed a consent form about the use of the videos.
The V.I.G guider selected and edited short clips or stills of the parent – child interaction for the purpose of reviewing them with the mother at the shared review. A few days after the videoing, the V.I.G. guider and the mother met at home – ideally during the baby’s sleeping time – and they watched and ‘micro-analysed’ (frame by frame) together the selected clips. The shared review lasted more than 20 minutes and the mother was encouraged to recognise what she was doing positively that promoted the attuned interaction with her child.
Usually, the mother’s initial request changed from the first session to the ones that followed as she gradually felt more confident with her interaction.
The research on V.I.G. shows that three to four cycles (each cycle includes one videoing and one shared review) are effective enough for promoting good parenting. As well as providing an early intervention tool for new parents, Video Interaction Guidance can be applied in any other form of intrapersonal relationship (Kennedy, Landor & Todd 2010; Kennedy, Landor & Todd 2011).
Two case studies
Case Study M: ‘Lack of eye contact during breastfeeding’
M. had a 3 month-old baby girl when she called me asking for a visit for breastfeeding observation. Although the baby was a full term healthy infant, just a few weeks following her birth the mother faced various difficulties with her breastfeeding. Poor latching on, vomiting and annoying colics were mentioned by the mother. Maternal anxiety was mainly obvious after two episodes of the baby’s “still face”. Exclusion of anything pathological was confirmed after numerous medical examinations. The mother was worried about possible symptoms of autism. Particularly, she mentioned that the infant did not make eye contact with her during breastfeeding. Video Interaction Guidance was suggested to her on the basis that the video microanalysis could show that there was interaction between her and her infant, even though there was limited eye contact between them. After a breastfeeding observation, two V.I.G. cycles followed and helped her understand the non–verbal communication of her baby. The initial request changed since she became more attuned. No episode of the baby’s still face was repeated.
Case Study G: ‘I get bored easily, while I am playing with my child’
Both G. and her partner were under medication for bipolar disorder. We had met a few days after the birth of their baby boy for a midwifery postnatal home visit. Afterwards, she called me quite often asking for a second opinion on medical issues. Once she called me in desperation and with a worried voice asking advice about age-appropriate toys and activities for her 18 months aged child. He still had non-verbal communication. She was worried about his language development and additionally she felt guilty because she was easily getting bored with her child. She was letting him watching television instead of playing or interacting with him. The V.I.G. method helped her to enrich her creativity while playing. Also, she tried new activities that she used to carry out only when her partner was present. For instance, she took her child to the playground without her partner. Exceptionally, in this case study, I did something effective for the father that all the participants enjoyed: once, we arranged the shared review with the father –not the mother – watching the selected clips which showed attuned interaction with his partner and his child. Afterwards, we had a nice discussion. The father reflected on the clips, shared thoughts about his inadequate parenting and suggested ways to improve his interaction with his partner and his child.
This article presents the application of Video Interaction Guidance with a sample of Greek mothers and their infants as an early intervention in the postnatal period. Often, parenting difficulties threaten an adequate parental role and secure attachment. Health professionals who work with mothers and infants in the postnatal period usually come across maternal anxiety and ambivalence with their new parental role. The health professional promotes the empowerment of the new mother by counseling and practical support. When the health professional is trained in the V.I.G. method (as a V.I.G. guider) they can offer an alternative or supplementary intervention to the new mother. V.I.G. helps the mother to observe herself and to reflect on her behaviour, while she interacts with her infant. The image of an attuned interaction between mother and infant satisfies the mother and accredits her strengths and parental skills. Maternal anxiety decreases and parenting seems more joyful. This is confirmed from all the participants (Greek mothers) during the shared review, as an oral evaluation of the intervention. All the mothers mentioned how powerful were the selection of the video clip and the positive approach of the V.I.G. theory. The case studies illustrate the effectiveness of such a brief, client-centered and cost effective intervention that uses the video feedback technique. Moreover, we know that early intervention is essential as the plasticity of the young brain permits healing and adjustment. Hence, the V.I.G. method is an evidence-based intervention recognized by scientific society. Nevertheless, more research on V.I.G. is required to enhance the current bibliography and to facilitate the parents with their unique journey in parenting.
Acquarone, S. (2004) Infant – Parent Psychotherapy. A handbook. London: Karnac.
Baradon, T., Broughton, C., Gibbs, I., James, J., Joyce, A. and Woodhead. J. (2005). The practice of psychoanalytic parent-infant psychotherapy.Claiming the baby. London: Routledge.
Bergman, A. and Harpaz-Rotem, I. (2004). Revisiting rapprochement in the light of contemporary developmental theories. Journal of the American Psychoanalytic Association, 52: 2, 555-569.
Celebi M. (2013) Helping to reduce parental anxiety in the perinatal period. Journal of Health Visiting, 1:8, 438-442.
Celebi, M. (2014). How video interaction guidance can promote attuned interaction parenting. Journal of Health Visiting. 2:2, 2-7.
Daws, D. and Rementeria, A. (2015). Finding your way with your baby. The emotional life of parents and babies. London: Routledge.
Ekizoglou. C, (2015). ‘Psychological Aspects on Breastfeeding’ In I. Antoniadou and K. Sofianou (eds). Breastfeeding- Guide for Professionals. Athens: Institute of Child Health.
Gerhardt S. (2004). Why love matters. London: Routledge
Gil, S., Droit-Volet, S., Laval, V. and Teissedre, F. (2012). ‘Postnatal Depression and Emotion : The Misfortune of Mother-Infant Interaction’ In M. Castillo (ed). Perinatal Depression . Croatia: InTech.
Hobson, P. (2002). The cradle of thought. London: Pan books.
Holmes, J. (2009). John Bowlby and the attachment theory. Athens: Greek Letters.(Original work published 1993).
Howe, D., Brandon M., Hinnings, D. and Schofield, G. (1999) Attachment theory, child maltreatment and family support. New York: Palgrave.
IJzendoorn, M., Juffer. F. and Duyvesteyn, M. (1995) ‘Breaking the intergenerational cycle of insecure attachment: A review of effects of attachment- based interventions on maternal sensitivity and infant security.’ Journal of Child Psychology and Psychiatry ,36:2, 225-248.
Kennedy, H., Landor, M. and Todd, L.(2010) Video Interaction Guidance as a method to promote secure attachment. Educational & Child Psychology, 27: 3 59-72.
Kennedy H. Landor M. & Todd L. (2011) Video Interaction Guidance. Jessica Kingsley
Kennedy, H., Landor. M., and Todd. L. (2011). Video Interaction Guidance: A Relationship-Based Intervention to promote Attunement, Empathy and Wellbeing. London: Jessica Kingsley.
Mariotti, P. (2012). The Maternal Lineage. London: Routledge
Moutsiana, C., Fearon, P., Murray, L., Cooper, P., Goodyer, I., Johnstone, T. and Halligan, S. (2014). ‘Making an effort to feel positive: insecure attachment in infancy predicts the neural underpinnings of emotion regulation in adulthood.’ Journal of Child Psychology and Psychiatry **-*, **-**, doi: 10.1111/jcpp.12198.
Music, G. (2011). Nurturing Natures: Attachment and Children’s Emotional, Socialcultural and Brain Development. UK: Psychology Press.
National Institute of Health and Care Excellence (2015). Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care. (NICE) Guidelines. http://www.nice.org.uk/guidance/ng26.
Raphael – Leff, J. (2015). Dark side of the womb. London: Anna Freud Centre.
Sakellaropoulos, P. (2001). Mother – child relationship in the first year of life. Athens: Papazisis.
Salomonsson, B. (2014) Psychoanalytic Therapy with Infants and Parents. London: Routledge.
Tyaro, S., Keren, M., Herrman, H. and Cox. J. (2010). Parenthood and Mental Health.UK: Wiley – Blackwell.
Underdown, A. (2013). ‘Parent-infant relationship: Supporting parents to adopt a reflective stance.’ Journal of Health Visiting 1:2, 76-79.
Winnicott, W. (2003). The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. Athens: Greek Letters.(Original work published 1965).
Zeanah, C., Berlin, L. and Boris, N. (2011) ‘ Practitioner Review: Clinical applications of attachment theory and research for infants and young children.’ Journal of Child Psychology and Psychiatry , 52:8 , 819-833.