Does video feedback improve the relationship between mothers experiencing mental health problems and their babies? An emerging evidence review.
Stefania Pethica, Bangor University
The perinatal period is a time of vulnerability that is associated with the onset or aggravation of mental health problems (Berle et al. 2003). Recent public health policy in the UK has sought to tackle perinatal mental health as a way of reducing risk of poor outcomes for the children of women experiencing mental health problems. However, research shows that addressing maternal mental health problems alone will not improve the mother-baby relationship (Murray, Halligan and Cooper 2010), which is seen as a key factor in the inter-generational transmission of mental health problems. Video feedback is an intervention targeted at improving mother-baby relationships and attachment security, thus potentially reducing the vulnerability of the babies to develop mental health problems themselves and increasing parental well-being. This review is the first to present the evidence currently available from both qualitative and quantitative research for the use of video feedback interventions with mothers experiencing mental health problems. The evidence is still sparse, but video feedback appears a promising complement to current treatment. Recommendations for future research and clinical practice are made.
The perinatal period is a time of vulnerability often associated with the onset or aggravation of mental health problems (Berle et al. 2003). In this period, the relationship between mother and baby is established. This relationship is crucial for the baby’s physical, social, cognitive and emotional development. Experiencing a mental health problem can interfere with the parent’s ability to provide sensitive care to the baby. Not all parents experiencing mental health problems display this lack of sensitivity; however when it is displayed it can lead to adverse mental health and behavioural outcomes for the child.
Recent developments in UK policy have focused on providing mental health treatment to women in the perinatal period; however research suggests that addressing mothers’ mental health alone does not improve outcomes for babies (Murray et al. 2010). To improve mother and baby interactions an intervention is needed that focuses specifically on the quality of this relationship (Bakermans-Kranenburg, Van Ijzendoorn and Juffer 2003). Video feedback interventions have been designed to do just this and have been shown to increase maternal sensitivity and child attachment security across a wide range of populations.
This paper is, to the author’s knowledge, the first to review the current evidence for the effectiveness of video feedback interventions in improving the relationship between mothers experiencing mental health problems and their babies. This paper will outline the prevalence of perinatal mental health problems and the impact these problems have on maternal behaviour and child outcomes; it will provide a description of video feedback interventions and the models that underpin them and it will present the evidence from a quasi-systematic review of the literature on video feedback interventions with mothers experiencing mental health problems. Finally, recommendations will be made for the delivery of video feedback to this population.
Perinatal Mental Health
Perinatal “mental health problems” or “mental illness” refers to the development of a mental health problem during pregnancy or within a year after giving birth. Approximately 20% of women develop a mental health problem in the perinatal period (Bauer et al. 2014). Between 10% and 15% of women experience post-natal depression (PND) in the first year of their child’s life (Leahy-Warren and McCarthy 2007), the prevalence of which rises to 30% for first time mothers (4Children 2011). Other mental health problems developed in the perinatal period include postnatal psychosis (0.2%), eating disorders (5%-7%), obsessive-compulsive disorder (2%), anxiety disorders (8%-15%), post-traumatic stress disorder (2%) (Bauer et al. 2014). Some caution should be given to the interpretation of these figures, as the stigma surrounding perinatal mental health might influence its reporting (Sluckin, 1998; NICE 2012).
National guidelines recommend that women experiencing perinatal mental health problems have timely access to mental health services for high intensity psychological therapy, medication and monitoring of the baby’s wellbeing (NICE 2014).
Impact of Perinatal Mental Health on Mother-Baby Relationship
There are two ways in which perinatal mental health problems can impact on the mother-baby relationship. Firstly, parental stress during infancy, including experiencing a mental health problem, can lead to increased infant stress reactivity (Cottrell and Seckl 2009), and increased expression of negative emotions (Davis et al. 2007). A stressful pregnancy can result in infants who are more difficult to soothe. Secondly, parents experiencing significant stress, including mental health problems, can display less sensitive behaviours (Van Ijzendoorn 1995).
Mother and baby are both active participants in the creation of their relationship. By impacting on the infant’s stress reactivity and the mothers’ ability to participate in sensitive interaction untreated mental health problems have profound effects on women, their families and their developing children by interfering with parent-infant attachment (Hipwell et al. 2000; Wan and Green 2009), thus increasing the child’s vulnerability to experience mental health difficulties themselves (Pawlby et al. 2009).
Mental health problems interfere with the mother’s ability to interpret the baby’s signals accurately (Stein et al. 2006) and respond promptly and appropriately, behaviours crucial to sensitive care (Stein et al. 2012). Lack of sensitive care can lead to mistiming of maternal responses which distresses infants (Braarud and Stormark 2006) and can result in poor emotional and behavioural infant self-regulation (see below). Understandably, parents experiencing mental health problems are often worried about the impact of their difficulties on their child’s wellbeing (Wang and Goldschmidt 1994).
Outcomes for Children
Children of parents experiencing mental health problems constitute one of the most at risk groups for developing mental health problems (NICE 2012), and the younger the children are when their parent experiences a mental health problem and the longer and more severe the mental health problem, the worst the outcomes for the child (Murray and Cooper 1997; Luoma et al. 2001; Pilowsky et al. 2008), making infants of mothers experiencing perinatal mental health problems the most vulnerable (Goodman et al. 1994).
Overall, babies of mothers experiencing mental health problems are more likely to have an insecure attachment (Jacobsen and Miller 1999) and display poor behavioural and emotional self-regulation, which can lead to poor cognitive development, interpersonal skills and school attendance (Murray et al. 1996; Trevarthan and Aitken 2001; Murray et al. 2010). However, during this period the infant is also responsive to positive input, maternal behaviour can change this process and increase the infant’s resilience and reduce stress reactivity (Sharp et al. 2012).
Evidence indicates that where psychotherapeutic interventions do not focus specifically on the parent-child relationship but only on the mother’s mental health problem, the quality of the relationship will not improve: the mother may recover but parenting stress remains elevated and the attachment poor (Neilson-Forman et al. 2000). This means that treating the maternal mental health problem alone does not translate into increased maternal sensitivity and secure attachment (Forman et al. 2007; Bakerms-Kranenburg et al. 2003). What is needed is an intervention that can support mothers in providing sensitive care to their infants (Bliszta, et al. 2012).
NICE guidelines (2012, 2013, 2016) recommend that interventions aimed at improving atttachment be evidence-based, tailored to the family, goal oriented, delivered in the family home and use video feedback.
Video feedback involves two steps. First, the filming of a short video-clip of mother-infant interaction by a health or social care professional. Second the review of the video-clip by the professional and the mother to analyse her interactions with her baby and support her in reflecting on the mother-baby relationship.
Video feedback is usually part of a multimodal approach, embedded in parenting programmes or psychotherapeutic treatment and can vary from the location of the filming to the nature of the review. There are two distinguishable approaches to video feedback interventions:
- Behaviour-orientated approaches focus on the interactive behaviours of parent and child and aim to increase parental sensitive behaviour. Video-clips are recorded in the family home, the professional selects from the recording naturally occurring moments of sensitive interaction and then shows these clips to the parent in the review. This approach is based on theories of self-modelling (Dowrick 2012) and self-efficacy (Bandura 1977). In the UK this approach is called Video Interaction Guidance (VIG; Kennedy, Landor and Todd, 2011).
- Psychodynamic approaches focus on the parent’s representation of themselves, the child and their relationship. Video-clips are usually taken in a therapeutic setting, then immediately shown to the parent. The video-clips are used to support the mother in accessing memories of her own childhood or ‘ghosts’ from her past (Fraiberg 1975) which intrude upon her capacity to establish an attuned relationship with her infant (Cramer 1998). The aim is to ‘free’ the infant from the ongoing impact of the mother’s past, and to increase maternal sensitivity.
Both approaches use guided self-observation (Egelan and Erickson 2004) and have some degree of technique crossover (Cramer 1998). Overall, video feedback is used to focus the treatment on the mother-child interaction and provide immediate feedback showing the impact of parental behaviour on the child. Video recordings allow parents to observe themselves at a distance, with time for reflection (Zelenko and Beham 2000), which can aid objectivity, insight and memory (Gasman 1992) as well as challenging the parent’s beliefs about themselves and their child.
Evidence for Video Feedback with Mothers Experiencing Mental Health Problems
A quasi-systematic methodology was used to collect studies for this briefing. The PsychINFO and Google Scholar databases were searched using the search criteria from Fukkink’s (2008) meta-analysis of video feedback interventions: (self-model* OR self-confrontation OR self-observation OR feedback OR playback OR parent* training OR intervention OR treatment) AND video* combined with terms for particular family populations (parent* OR family OR child* OR marital OR infant OR baby OR mother* OR father*). The titles and abstracts were screened for papers in English which evaluated a video feedback intervention aimed at improving mother-baby relationships in mothers experiencing mental health problems with normally developing infants below 24 months of age. Due to the lack of research in this field, studies were included irrespective of methodology and time of publication. This search identified 6 papers (2 quantitative); further reference list search yielded an additional 5 papers (3 quantitative); see Tables 1 and 2.
Qualitative research findings
Qualitative research and case studies are particularly suited for the early stages of research on a topic (Eisenhardt 1989); they allow for exploration of acceptability and feasibility of an intervention. Given the relative novelty of using video feedback within perinatal mental health settings, a review of these qualitative and case studies was deemed appropriate.
Sluckin describes the cases of two women both experiencing a persistent lack of emotional connection with their babies and severe mental health problems requiring hospital admission (1998). The outcomes were positive and long-term for both cases. One mother reported referring back to the video feedback experience at three-year follow up; the other stated that the video-clip provided evidence that clearly contrasted with her self-beliefs and played a key part in her recovery. Zelenko and Beham’s case study (2000) describes the treatment of a woman with a severe and complex mental health problem and her baby. Outcome was positive for both child and mother at two-year follow up.
Unlike the aforementioned papers, Vik and Braten’s case studies (2009) answer specific theoretical questions. This is a high quality case study. In all three cases the authors use both transcripts of conversation and behavioural observation of changes in the way mothers held their babies as evidence. After the intervention, mothers increased sensitive behaviours, held their babies more closely and actively sought to soothe them when distressed.
Tilley and Chambers’ study (2004) uses discourse analysis to explore the experience of two women diagnosed with PND and receiving VIG in the community. Both women were interviewed and video recordings of the review sessions were analysed. Results suggest that during the VIG process the mothers were able to reflect on and reclaim more positive aspects of their identity that the mental health problem had overshadowed.
Vik and Hafting’s study (2006) aimed to describe the mothers’ experiences of PND and VIG. It collected data from interviews with mothers, video recordings of review sessions, video-clips of mother-infant interaction, observations and reflective notes. Three themes to VIG emerged:
- The importance of mothers experiencing their own coping and self-image (VIG focuses on showing parents moments in which they are sensitive to their children)
- Increasing engagement in mutual dialogue between mothers and infants, due to reported increase in self-confidence gained.
- The importance of mothers having their suffering recognized, which resonates with Tilley and Chambers’ findings.
|Table 1. Qualitative research summary|
|Author||Design||Maternal diagnosis||Approach||Edited video|
|Case study||Multiple comorbidities
|Zelenko and Beham 2000
|Case study||Multiple comorbidities||Psycho-dynamic||No|
|Vik and Brate, 2009
|Tilley and Chambers 2004
|Vik and Hafting 2006||Pre-post interviews||PND||VIG||Yes|
Quantitative research findings
The earliest quantitative study using video feedback with mothers experiencing mental health problems is Stein et al.’s (2006) randomized controlled trial of video feedback to improve the relationship between mothers with bulimic eating disorders and their infants. 80 mothers and their infants were randomly allocated to two treatment conditions. 40 mothers were allocated to a VIG-inspired intervention. 40 mothers were allocated to an active treatment that did not address the mother-infant interaction directly. Both groups received treatment for their eating disorders. After the intervention mother-infant pairs in the video feedback condition exhibited significantly less conflict compared to the control group. Odds ratio estimated a 73% reduction in the odds of a marked or severe conflict episode in the video feedback group. Further benefits of video feedback included greater child autonomy at mealtimes, greater maternal facilitation of infants and a higher level of appropriate non-verbal responses to infant cues. The two groups did not differ regarding infant weight, maternal symptomatology after treatment. This was a high quality study, however, it did not assess attachment security per se but relied on other markers of maternal sensitivity.
VanDoesum, Riksen-Walraven and Hosman (2008) assessed maternal sensitivity and attachment using a gold standard assessment measure: the Attachment Q-Set Questionnaire (AQS; Waters 1995). 85 mothers experiencing elevated depressive symptoms and their babies were randomly allocated to an experimental group (n=43) who received a video feedback intervention or a control group who received a minimal intervention (three telephone calls). All mothers were receiving psychological therapy for depression. The experimental group significantly improved in maternal sensitivity (η2=0.28), maternal structuring of interaction (η2=0.16), child responsiveness (η2=0.10), child involvement and attachment security (η2=0.13), and children in the experimental group were significantly more socio-emotionally competent at follow up. These results were independent of depression chronicity and severity. As in Stein et al.’s study maternal symptomatology decreased over time for both groups. Unlike Stein et al.’s study, the video feedback in this study was not focussed on successful interaction, but highlighted times in which the mother had not been sensitive and provided modelling of sensitive care. Additionally, the experimental group’s intervention had elements of other interventions (e.g. baby massage, also known to improve sensitivity; NICE 2012) and received significantly more contact with a professional, which might confound the results.
Bliszta et al. (2012) randomly allocated 74 clinically depressed mothers admitted to a mother-baby inpatient unit and their babies to three groups, one receiving video feedback (n=25), one receiving verbal feedback (n=26) and one receiving standard care (n=23). Most participants received simultaneous pharmacotherapy, psychotherapy and intensive parenting support. Video feedback sessions had a didactic element and as in VanDoesum et al.’s study focused on moments of low sensitivity and encouraged the mother to think of different ways to respond to infant cues. Verbal feedback focused on the same elements without video use. Results showed that participants receiving verbal feedback and standard care gained more confidence than those receiving video feedback, effect sizes were not reported. Video feedback participants reported finding the sessions useful but uncomfortable. This study sets itself aside from the positive results of others; it is also the only study to rely on self-report outcome measures alone. The authors reflect that the limited length of stay of women in the unit dictated a brief assessment and limited time for the therapist to build a relationship with the mother. Of interest is the focus of the video feedback on moments of failed interaction, rather than moments of sensitivity and the impact that might have on women experiencing acute mental health problems.
Another study (Kenny et al. 2013) conducted in an inpatient unit compared the mother-infant interactions of 49 mothers admitted to a mother and baby unit (MBU), with those of 67 community-based mothers experiencing severe mental health problems, and 22 mothers with no psychiatric diagnosis. The MBU group was in receipt of psychotropic medication and video feedback sessions. The community-ill and the healthy groups were used as a sample of convenience recruited from different studies, the community-ill mothers were diagnosed with depression and comorbid personality disorders. Comparison data was drawn from a single videotaped play session. The MBU group was filmed for assessment before and after the intervention. The analysis involved coding all video tapes of parent-infant interaction using the CARE-Index (Crittenden 2004) a robust procedure for the assessment of parental sensitivity. The MBU mothers showed significantly improved sensitivity (η2=0.12), responsiveness (η2=0.22) and infant co-operation (η2=0.23) at discharge compared to admission. At discharge the MBU group did not differ from the healthy group, they were more sensitive and responsive and their infants more co-operative and less passive than those of the community-ill group. Inadequate knowledge of the treatments received by the community-ill group, and the variety of sample size are limitations of this study. Nonetheless, it is not possible to disentangle the effects of the MBU treatment as a whole from the effects of video feedback.
The final study identified looked at the application of video feedback in groups for mothers experiencing PND (Rackett and McDonald 2014). In this within-group study 22 mothers participated in weekly play-sessions aimed at promoting mother-baby interaction, videos were taken of mother-baby interaction during the play session, and video review was conducted individually. All women were experiencing depressive symptomatology as assessed by the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden and Sagowsky 1987). Most mothers reported progress on their self-set goals, increased confidence and found the intervention helpful and most mothers showed some improvement in their depressive symptomatology. However, no statistical analysis was reported. It was also unclear whether the mothers’ improvements were due to the video feedback or the group aspect of the intervention.
|Table 1. Qualitative research summary|
|Author||Design||Maternal diagnosis||Approach||Edited video|
|Case study||Multiple comorbidities
|Zelenko and Beham 2000
|Case study||Multiple comorbidities||Psycho-dynamic||No|
|Vik and Brate, 2009
|Tilley and Chambers 2004
|Vik and Hafting 2006||Pre-post interviews||PND||VIG||Yes|
Literature on the use of video feedback with mothers experiencing mental health problems is sparse (Bakermans-Kranenburg et al. 2003) and has several limitations. One major limitation is the variety of diagnosis, with most research being conducted with women experiencing PND due to its higher prevalence. This paper has tried to illustrate all the available evidence on this topic; it has presented findings from studies with populations with different diagnoses, thus assuming that different mental health problems compromise mother-baby interactions in the same way by interfering with sensitive caregiving (see Kenny et al. 2013). However, more research is needed to support whether this is the case and whether video feedback is more effective for specific diagnostic categories.
Although video feedback’s versatility is a strength, it is also a limitation; by being easily integrated in a variety of interventions it is harder to isolate as a key ingredient for change. Furthermore, studies evaluating video feedback interventions use research methodologies of varying quality and different outcome measures, thus further confounding results.
Another limitation of video feedback that has emerged from this literature is its lack of an independent effect on maternal mental health problem, which conflicts with previous expert reports, suggesting that interventions directed at mother-infant relationship may relieve the mothers’ distressed state quite rapidly (Cramer 1993). However, future research could explore whether video feedback enhances outcomes of treatments focused on maternal mental health problems.
Video Feedback has been found to be effective across a variety of settings (community and inpatient), populations (European, American, Eastern European, Israeli, ethnic minorities, refugees) and has been successfully delivered to mother, fathers, foster and adoptive parents and whole families (Kennedy, Landor & Todd 2011). Overall the emerging evidence suggests that video feedback is a promising intervention for mothers experiencing mental health problems and their babies. Most studies have demonstrated that video feedback is a feasible, acceptable and effective way of increasing maternal sensitivity in mothers experiencing mental health problems. However, such evidence is preliminary and in most studies video feedback was provided within a larger package of care, which was directly addressing the mothers’ mental health problem. Video feedback was not found to have an independent effect on perinatal mental health problems. The longer-term effects of video feedback interventions remain under-researched.
- Video feedback can be an effective way of improving mother-infant relationships.
- When delivering video feedback interventions, the literature reviewed suggests taking an approach which focuses on moments of sensitive care, as mothers find it more acceptable and comfortable.
- To ensure evidence quality, research into video feedback interventions should use random allocation, behavioural measures of attachment and maternal sensitivity and not rely exclusively on parental report.
Stefania Pethica, Bangor University firstname.lastname@example.org, Tel: 0044 (0)7510144837, North Wales Clinical Psychology Programme Bangor, University Bangor, Gwynedd LL57 2DG
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