Integrating Video Interaction Guidance (VIG) and Psychoanalytic Psychotherapy in Work with Parents and Infants

Note: This article was originally published in the May 2016 Bulletin of the Association of Child Psychotherapists. For more information about the ACP, see:

http://www.childpsychotherapy.org.uk

I have been working in CAMHS as a qualified CPT since 1997, specialising in psychotherapeutic work with parents and infants, having been inspired during my training by the Tavistock Clinic Under Fives workshop, led at that time by Dilys Daws, Juliet Hopkins and Lisa Miller. (See Emanuel & Bradley, 2008, for details of the Tavistock approach.)

I have been using video feedback as part of my therapeutic approach since 2011, along the lines of Beebe (2003) and Jones (2006), to help the parent/carer to gain insight into their interaction and relationship with their infant/child. As Beebe writes: “psychoanalytic intervention links the ‘story’ of the presenting complaints, the ‘story’ seen in the videotape, and the ‘story’ of the parent’s own upbringing”. She adds that video feedback facilitates the mother’s ability to “see” and to “remember” (Beebe, 2003).

I suggest that this external observer position, facilitated by using video, enhances the crucial development of Britton’s triangular psychic space where there is a third (internal) position from which the subjective self can be observed (Britton 1989). Seeing yourself on video is an emotionally powerful experience, as I myself have discovered through VIG training.

An Example of Psychoanalytic Parent-infant Psychotherapy using Video Feedback

In 2014, I presented a ‘clinical teach-in’ at the WAIMH Congress (and subsequently in 2015 at infancy conferences at the Tavistock Clinic and in Bristol) illustrating the power of video feedback in facilitating change in the context of a well-established, supportive therapeutic relationship: during the 8th session a mother of a 3 year-old boy was upset and shocked to see herself withdrawing her hand when her little boy touched her (“Now I’ve seen it on the film I can see it… I would never have believed it”). She was able to recognise the detrimental impact of her non-verbal distancing, and she became determined to consciously change her interaction with him, and to actively demonstrate affection. This resulted in a remarkable shift to a benign cycle of mutual affection.

I believe that the evidence provided by the video clip was a key instrument in this change. As psychotherapists we witness parents’ behaviours/interactions and we try to help them to ‘see’ these behaviours, asking them what they noticed, and felt, sensitively feeding back our own observations. However, the parent’s own ‘seeing’ can be very difficult to achieve, particularly where there are complex defences in place against unbearable feelings. Jones (2006): “The video camera, like a microscope, can now allow us now to see .. defensive processes in action.” The analysis of the video clips with the client provides a way forward.

VIG

At the World Association of Infant Mental Health (WAIMH) Congress in 2014, I met Hilary Kennedy (Educational Psychologist and Director AVIGuk) who played a central role in introducing VIG to the UK from the Netherlands in the 1990s.

VIG is a strengths-based intervention which highlights and builds on positive points in parent-infant interaction. Parents are supported by a VIG Practitioner to view and discuss short edited clips of ‘best moment’ interaction with their child. Parents are asked: ‘What is it that you are doing that is making a difference?’ Through this process of active engagement and reflection parents become aware of, and build on, their skills in attunement. The theoretical underpinnings of VIG include the concepts of attunement, (Stern, 1977) and intersubjectivity (Trevarthen, 2001).

When I first encountered VIG, I was doubtful about the focus solely on ‘strengths’. I was concerned that this might result in ‘glossing’ over difficulties, leading to an idealised and unrealistic view (potentially by both parent and therapist) of the parent-infant relationship. I discussed my psychoanalytic work with Hilary Kennedy, and she in her turn was concerned about the potential negative impact on parents of seeing ‘difficult’ moments on video – possibly lasting images which could undermine their sense of themselves as parents. Given the uncertainty around any lasting neurological and emotional impact of images, this may be a sensible precaution.

I decided to train in VIG to find out more. I am very fortunate in having Joanna Tucker as my VIG supervisor (former Clinical Director, OXPIP), given her background in psychoanalytic psychotherapy and her active seeking in her own clinical work to integrate VIG with the psychoanalytic approach.

What I Have Learned

The VIG training has been a fascinating process for me. An essential part of the training is videoing yourself and the client in discussion of the parent-child video clips. The same ‘Principles of Attunement’ are used by the therapist and supervisor to analyse and reflect on this ‘Shared Review’, and the therapist’s attunement to the client – a truly reflexive process.

Throughout the years of training and practice as a Child Psychotherapist I had not had the opportunity to analyse my own non-verbal behaviour and responses to the client. Beebe (2003) identifies increased awareness of nonverbal behaviour as a central goal of video feedback work; what is central to VIG is that this awareness is increased in both therapist and client.

VIG has significantly increased my awareness of non-verbal behaviour – in the parent, infant/child and therapist. Although I have always sought to track the client’s emotional state, I feel that my skills have been enhanced by seeing on video when I do manage to achieve this, and the times when I don’t (leading to reflection on why? – for example, due to dealing with difficult counter-transference feelings which may be leading me to ‘guide’ and advise rather than to encourage the client’s initiatives and to fully receive their initiatives emotionally).

In using VIG I have learned to focus more on ‘encouraging and receiving initiatives’, to activate the parent, rather than compensating by offering suggestions/comments. This can be hard to do when the parent is withdrawn or dismissive, and does not respond to activation. In VIG, as in any effective therapeutic approach, it is necessary as a therapist to bear the difficult feelings of helplessness and frustration.

Case Example: 2 year-old boy, L

(Referred for eating non-food stuffs, and emotional distance in the parent-infant relationship. Extract from VIG record of 3rd CAMHS appointment.)

Deepening the Discussion: I ask her an open question about how she thinks L feels at that moment when she has understood him? “I think he feels like I get it.. like I understand what he’s doing.. what he’s trying to say”. I validate her.

I ask her how the VIG experience felt for her overall? She says “I feel like I’m not doing too bad now” then laughs and makes eye contact “Just from watching..[hand across mouth].. it’s not that bad actually!” I smile warmly and encourage her to be more positive. “Yeah? I think the hardest part is just thinking.. oh my God.. Like from someone else’s point of view [indicates an observing position] I always think.. people looking.. but now it feels like I’m someone else looking in on it and yeah, he’s actually being good..”

VIG has helped this mother to experience and articulate, for herself (given space and encouragement to do so by me as her VIG Guider) the value of the ‘third position’ in coming to a more benign view of herself and her little boy.

Through my VIG supervision, I am becoming much more aware of parallel processes between my client and myself. This client was consciously working hard not to direct/intervene – to give her child space to explore; I am also consciously trying to give her space to explore and to come to her own understanding.

Case Example: 4 year-old boy, C

(Referred due to aggression and his mother’s negative feelings towards him; during the work a history emerges of several incidents of domestic abuse of father by mother.)

After the 3rd ‘VIG Cycle’ of videoing and holding a Shared Review, I reflect with mother on her changed perception of C. “I think a lot more about how he feels nowI was just thinking: you’re a naughty little shit and getting on Mummy’s nerves! … Whereas now I think, No, you’re actually a hurt and scared little boy”.

We reflect on her experience of VIG: “I think it makes you realise you are doing well.. ‘cos you don’t see it normally. I feel like I’m doing something right”. This client had had the strength to admit to me that she feels she’s “the baddy.. I know I lose my temper.. I see [the children’s difficult behaviour] and think: I’ve done that .. That’s why they’re like that”.

For parents struggling with very critical internal parents, the video evidence of doing something well is enormously powerful, and helps to counteract the intense feelings of guilt which in themselves can work against change.

Jones (2005) comments that video facilitates a ‘benign observing ego’. My client had minimised the impact on the children of her aggression; through our supportive work (and her experience of me as a non-judgmental ‘parent’ figure) she is becoming more able to acknowledge the children’s fear and anxiety – a recognition that hopefully acts as an inhibitor of future aggression.

Evidence of the effectiveness of the work lies in mother’s increasing capacity to take in something positive and use it for herself, eg the recognition that waiting and giving space helps C to be calmer and builds their relationship, plus the value of thinking about and naming feelings. She is increasingly able to repair difficult interactions, and C is talking to her more, coming to her with his upset feelings, and seeking proximity and affection.

The Power of VIG

I think these two case examples illustrate the power of VIG. VIG has helped me to focus on strengths – not in any trivial, denying sense, but a focus which helps the parent to move from a negative view of themselves and their child, to something more positive and hopeful: a new beginning. At the more extreme end, the parent may move from a position of defensive attack (‘There’s something wrong with my child’; ‘You’re no good as a therapist’) to recognising that as a parent they are offering something good to their child, and that this has been witnessed by both parent and therapist. Growth can occur from this fragile starting point by developing further confidence in themselves as a parent.

The ‘Best of Both Worlds’

Both VIG and psychoanalytic psychotherapy work towards increasing parent/carer capacities for mentalisation and attunement, in order to a promote a positive relationship between parent and infant (building secure attachment).

At the WAIMH Congress in June 2016, and the AVIGuk ‘VIG and Psychotherapy’ conference in September 2016, I suggested that an integration of the two approaches may offer ‘the best of both worlds’. Psychoanalytic thinking helps the therapist to understand unconscious anxieties and defences, to retain a realistic view of the parent’s capacities (though understanding the often traumatic impact of intergenerational transmission), and to work with the counter-transference to ‘deepen the discussion’ in meaningful ways for the client.

VIG offers an intensive learning opportunity through a reflective process (significantly enhanced by detailed use of positive video clips of both therapist and client) which facilitates taking a ‘benign observer position’ in relation to oneself, and reaching ‘new shared understandings’. This recognition of the ‘best moments’ can make it more bearable to acknowledge the difficult moments and to learn from them.

Beebe (2003) is clear that a crucial role of the psychotherapist is to highlight the positive, functioning as a benign viewer: “One of my essential functions is to admire the pair whenever possible .. [and to] understand what may be preventing the parent from fully “seeing” the interaction with the infant.”

It seems that VIG and psychoanalytic psychotherapy have very important things in common: a valuing of what is good in interpersonal relationships and a recognition of the need to build on these positives to promote emotional growth, whilst keeping in mind areas of concern, and finding ways to address these sensitively within a therapeutic relationship.

 

Acknowledgments: I would like to thank Joanna Tucker for her insightful and very supportive supervision, and our creative conversations around integrating VIG and the psychoanalytic approach. I would also like to thank Hilary Kennedy for her energy, enthusiasm and support of my VIG training, and now my training as a VIG Supervisor.

 

Rachel Pardoe

Child and Adolescent Psychotherapist

CAMHS, Avon and Wiltshire NHS Partnership Trust

 

References

Beebe, B. (2003) ‘Brief mother-infant treatment: psychoanalytically informed video feedback’. Infant Mental Health Journal, 24 (1): 24–52.

Britton, R. (1989). ‘The Missing Link: Parental Sexuality in the Oedipus Complex’, Steiner. J. (ed.) The Oedipus Complex Today: Clinical Implications. London: Karnac Books.

Emanuel, L. & Bradley, E. (eds) (2008) What can the Matter Be: Therapeutic Interventions with Parents, Infants and Young Children, The Tavistock Clinic Series, London: Karnac Books.

Jones, A. (2005) ‘The Process of Change in Parent–infant Psychotherapy.’ Unpublished doctoral dissertation, Tavistock.

Jones, A. (2006) ‘Levels of change in parent-infant psychotherapy.’ JCP Vol. 32 No. 3, 295–311

Kennedy, H., Landor, M. & Todd, L. (2011)Video Interaction Guidance: A Relationship-Based Intervention to Promote Attunement, Empathy and Well-being’. Jessica Kingsley.

Stern, D. (1977) ‘The First Relationship’. Cambridge MA: Harvard University Press.

Trevarthen, C. & Aitken, K.J. (2001). ‘Infant Intersubjectivity: Research, Theory, and Clinical Applications’ Journal of Child Psychology and Psychiatry, Vol 42(1), 3-48.

Tucker, J. (2016). ‘Seeing is Believing: using video-feedback in parent-infant psychotherapy to help change parents’ and babies’ negative representations of themselves’. Unpublished paper, presented at AVIGuk conference September 2016.

 

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