The evidence-base highlighting the transformative impact of using Video Interaction Guidance (VIG) with families continues to grow. Educational Psychology Services (EPS) and Health Visitor (HV) Teams and other services across the UK are increasingly choosing this compassionate relationship-focused intervention to broaden and strengthen the support they offer to families (https://www.videointeractionguidance.net/). Across the UK, there is a range of services now well established in the use of VIG. For those services that are beginning or considering the use of VIG, this paper seeks to highlight early insights and learning from a project in Gloucestershire, where Educational Psychologists and Perinatal Mental Health Champion Health Visitors are working collaboratively, to develop the use of VIG in their respective contexts.
The following study was commissioned by Gloucestershire Educational Psychology Service (EPS), with two University of Bristol Trainee Educational Psychologists conducting the research, overseen by a Specialist Senior Educational Psychologist (SSEP). The SSEP’s specialism in mental health and therapeutic interventions, and longstanding interest in the critical role of relationships in promoting wellbeing, had led to the introduction of VIG in the EPS. This new tool was to be employed for its empowering, positive influence on relationships and strong evidence-base for effectiveness. Similarly – and rather fortuitously – the Perinatal Health Visitor Leadin Gloucestershire also had a strong interest in VIG, having heard of its impact from Alain Gregoire, the consultant psychiatrist who set up and leads Hampshire’s perinatal mental health service. The SSEP, following a successful bid from NHS Commissioning, worked collaboratively with the Lead Perinatal Health Visitor, to set up a small group of Educational Psychologists (EPs) from Gloucestershire EPS and 7 Perinatal Mental Health Champion Health Visitorsfrom Gloucestershire Health Visiting Service (GHVS), to train in parallel and deliver VIG in theirown settings. Alongside monthly AVIGuk supervision by Maureen Granger, an AVIGuk National Supervisor, were opportunities for peer supervision.
In future, the SSEP hopes the EPS will support the establishment of an area-wide multi-professional ‘team’ or network of VIG practitioners. To foster sustainability, training and supervision would eventually be available from home-grown AVIGuk practitioners from the EPS and GHVS. The following research was commissioned to capture the early experiences of those delivering and operationally managing VIG in Gloucestershire. It was hoped that these experiences may inform the planning and set-up of this broader, multi-professional VIG ‘team’ in Gloucestershire, and would also assist other services – EPS, Health Visiting or others – who might be considering setting up VIG elsewhere.
Following an investigation by the Children and Young People’s Mental Health and Wellbeing Taskforce in September 2014, Public Health England and NHS England developed Future in Mind(2015); this report presented a vision for transforming mental health and wellbeing support for CYP in the UK. The Future in Mind report summarises the key priorities for mental health and wellbeing. It highlights the importance of the promotion of resilience, prevention and early intervention, employing effective, evidence-based interventions, and developing the skills of the whole workforce to provide better support.
The role of the HV
In the last few years, HVs have taken on growing responsibilities for mental health and wellbeing. The Public Health England document, ‘Evidence into Action: Opportunities to protect and improve the nation’s health’ (2014), outlined seven priorities, one of which is ‘Ensuring every child has the best start in life’ (p.18). The document stresses the importance of prevention and highlights the effects of early experiences on the development of CYP. In addition to this, the Healthy Child Programme (HCP; DofH, 2009) provides guidance for commissioners and those delivering health services in Local Authorities and Primary Care Trusts. It includes a focus on providing support for parents to develop strong, healthy attachments with their children through attuned parenting (pp.10 -11) and places the HV role as the lead co-ordinating the HCP. It also advises the use of evidence-based interventions and structured programmes delivered by HVs to reduce risk factors.
Developing the role of Health Visitors to incorporate the use of VIG is also highly relevant for ‘The National Framework for Continuing Professional Development for Health Visitors: Standards for professional practice’ (iHV, 2015). Standard One focuses on ‘Working Therapeutically to effect change with children and families’ (p.21) and describes how Health Visitors need to have ‘excellent interpersonal skills and personal qualities’ to be able to do this. By training as a VIG Practitioner, not only are Health Visitors able to meet this standard by having a therapeutic intervention to use with their clients, but it may also develop their interpersonal skills more generally, benefitting their practice in the wider context.
The role of the EP
There has been a growing body of literature reviewing the role of the EP, and the many ways in which it can provide help working towards the goals of the legislation outlined above. First and foremost, the main role of the EP can be summarised as “enhancing the children’s achievement and well-being, as opposed to identifying deficits, or problems, in functioning” (p. 15, Beaver, 2011). This places EP work within a positive framework and identifies wellbeing as a key focus. The Future in Mind report (2015), posits that the wellbeing of CYP is a factor that underpins their academic achievement and success in all areas of life. Secondly, the delivery of therapeutic interventions is an aspect of the EP role that is gaining interest and commonality. Burns et al(1995) demonstrated how many mental health services are not actually provided by specialist mental health sectors, highlighting the significance of education settings in meeting the needs of CYP in this area. Further to this, Squires (2012) describes how EPs can help meet CYP’s mental health and wellbeing needs by training in the delivery of specialist, therapeutic interventions for use in schools.
Therefore, there is a rationale to train EPs and HVs as VIG Practitioners, equipping them with specialist therapeutic skills that can help them intervene early and effectively.
Video Interaction Guidance (VIG)
VIG is a form of video feedback intervention (VFI) “where the clients are guided to reflect on video clips of their own successful interactions” (Kennedy, 2011, p.21). Through recognising their strengths in their interactions with a child, clients (parents, carers, teachers) are supported to develop their skills and confidence in their relationships. VIG is a strengths-based intervention built upon principles of attunement, intersubjectivity, empowerment of clients, reflection and self-modelling (Kennedy, 2011). It resonates with current legislation and guidance in supporting the mental health and wellbeing of CYP by improving attachments and relationships between children and their parents, carers or teachers. Fostering these positive connections can help to reduce incidences of mental health difficulties and improve wellbeing (Ttofa, 2017).
Additionally, VIG meets the requirements of the National Institute of Clinical Excellence (NICE, 2012) and current legislation in that it has a developing research base. Two meta-analyses of experimental studies found VFIs to be effective as agents for positive change (Fukkink, 2008; Bakermans-Kranenburg, Van-Ijzendoorn and Juffer, 2003). Smaller scale qualitative studies also found support for the use of VIG (e.g. Robertson and Kennedy, 2009; Savage 2005). However, the majority of these studies took place outside of the UK, and considered a range of VFIs, rather than VIG specifically.
Whilst information is available for managers on the Association of Video Interaction Practitioners UK website, the authors could find no research to date which examines the practicalities of delivering VIG. This was identified by Colley (2013) as an area in which further research is required:
It would be beneficial for readers like me to have a clearer idea of costings for the equipment used, and for there to have been some discussion about the practicalities for delivering VIG. I am thinking, for example, of the skills required to edit recordings, the software required, and even the position of cameras, one-way mirrors etc. (Colley, 2013, pg. 348-349)
Given the growing interest in the intervention, information about considerations when setting up a VIG service would seem beneficial. With this in mind, the current study explores the early experiences of HVs and EPs in one Local Authority. It examines the practicalities of using VIG, and the lessons that can be learnt for the future development of VIG services as a tool to support mental health and wellbeing strategies.
Having identified a lack of research relating to the initial set up of VIG, and considering the interests of the commissioning authority, the current research hopes to identify the lessons that can be learnt from the early experiences of VIG Trainee Practitioner HVs and EPs, at practitioner and Service Area Lead (SAL) levels. The SAL level VIG Trainee Practitioners, as well as delivering VIG themselves, were also responsible for the operational management of VIG within their respective services (for example, negotiating access to equipment and software with relevant departments). By including the SAL level VIG Trainee Practitioners in the study, it was hoped that the range of issues arising from setting up a VIG service, at practitioner and operational management level, could be reviewed.
The research questions considered are:
- How have the delivery and logistics of using VIG been experienced by EP and HV Stage One VIG Trainee Practitioners?
- How have the delivery and logistics of using VIG been experienced by the EP and HV SAL Stage One VIG Trainee Practitioners?
- How might these experiences inform the set-up of a multi-agency VIG service?
5 Perinatal Mental Health Champion HVs took part in this study. This included 4 HVs at practitioner level, and 1 SAL HV. 3 EPs participated, including 1 SSEP (the SAL). All participants were female and were currently in Stage One of their VIG training. This meant that they had all attended the initial two days of training together, and were currently receiving monthly supervision as they worked on their first cases.
Practitioner level VIG Trainee Practitioners took part in either a focus group (HVs), or 1:1 semi-structured interviews (EPs), based on availability. SAL VIG Trainee Practitioners took part in semi-structured interviews. Information sheetsand confidentiality protocolswere given to all participants, who signed a consent formconfirming their agreement to participate. The focus group and interviewswere recorded and interviews transcribed.
On the completion of data collection, thematic analysis was conducted. Transcripts were summarised and a Constant Comparative Method was then used to identify similarities and differences, and identify themes (Harding, 2013).
On completion of data analysis, six core themes were identified. It was noticed that for practitioners and SALs, many of the same responses were given across HV and EP groups. Where differences were found, these are highlighted in the following description of the themes.
All participants noted the time costs of VIG. This can be broken down into a number of different areas. Firstly, there were the time costs associated with attending the initial training, and with the monthly supervision sessions. The face-to-face delivery of VIG also had time implications. Participants noted that it had been difficult to organise their VIG activities around their other, often statutory, responsibilities. Some participants explained that they had needed to carry out VIG administrative tasks in their personal time to meet these requirements. Time restrictions meant that informal VIG peer support could not always be accessed. In addition, time needed to be factored in for the development of the relationship between the client and VIG Trainee Practitioner, prior to the start of the intervention. It was highlighted that it was important for managers to be fully aware of the time costs of VIG and to have a commitment to releasing staff to carry out their VIG activities.
The EPs and HVs at practitioner and SAL levels described the challenges of using new information technology (IT) and video recording equipment. Challenges ranged from choosing equipment and learning how to use it, to building an awareness of common problems, such as the video recorder accidentally entering standby mode. SALs additionally described the time required to make arrangements for IT provision that was compatible with other IT systems. The purchase of new equipment and enlisting technical support from an IT department also has cost implications.
Policy and procedural infrastructure
The initial establishment of a VIG service required clear protocols for confidentiality, data protection and information sharing. Practitioner level Trainees spoke about challenges in terms of having confidential spaces to micro-analyse video clips and negotiating with clients and other agencies the information that could be shared. Furthermore, SALs needed time and support to establish service policies and protocols on these matters, including processes such as storage for the videos. For the SSEP SAL, consideration was also needed regarding the pricing structure for delivering VIG in a traded context.
VIG Trainee Practitioner identification
All participants described their initial enthusiasm for VIG, stating that it aligned with their interests and values. VIG Trainee Practitioners appreciated the strengths-based nature of VIG and the fact it has a developing evidence-base. Several EP and HV participants welcomed the chance to increase their direct work with clients and undertake continuous professional development opportunities. Whilst sharing this perspective, SALs also considered their Service Development Plans. Their identification of staff to train was often logistical (i.e. training one staff member in each geographical base), and considered broader service priorities such as the HV service establishing Perinatal Mental Health Champions. A common discussion point related to the need for staff to be fully informed of the requirements of VIG so that they could make an informed decision before committing to training.
All participants experienced the initial two-day training as positive and inspiring and recognised the value of the subsequent supervision sessions in enhancing their skill development. Discussions with one of the EPs highlighted that many of the skills required for VIG were skills that EPs generally already have, but that training in VIG provided opportunities to develop and practise these skills. Some EP and HV participants described how they had been able to transfer the skills developed through VIG into other areas of their work and personal lives. However, other participants felt that it was too soon in their training to notice such effects.
Client identification was the main area of difference between the HVs and EPs. The HVs worked within a non-traded context and as such had increased and easier access to clients. Indeed, the HVs expressed they could potentially reach a point where they are unable to meet the referral demands for VIG. For the EPs, working in a traded context meant different issues arose. The SAL needed to consider how to inform potential customers (e.g. schools) about VIG and promote its effectiveness to generate custom. This led to an increased emphasis on the need to consider ways of measuring impact. Aside from the traded/non-traded dichotomy, a positive relationship between the client and VIG Trainee Practitioner was noted as essential. The attitude, motivation and wellbeing of the client were key factors in the intervention being successful.
It was noted earlier that supporting the mental health and wellbeing of CYP is a key focus in guidance such as Future in Mind (2015). A consideration of the roles of EPs and HVs revealed that both practitioner groups are well placed to use evidence-based interventions to work towards the goals outlined in this paper. VIG was identified as a form of support that could be utilised by EPs, HVs and other professionals in supporting CYP and their families. There is a developing research base which demonstrates the effectiveness of VIG. A smaller amount of research or consideration has been carried out into other factors related to VIG, such as its impact on professional development.
The current study aimed to explore the practical considerations needed when setting up a new VIG service in response to the aspirations of Gloucestershire EPS in setting up a multi-professional VIG team. As noted by Colley (2013) this is an area lacking in guidance and information, which may be of use to others.
Through the literature review, guidance for managers to consider when implementing VIG, published on the VIG UK website, was discovered. This guidance resonates with several of the themes identified in the current research.
The most salient theme noted was that of time. Consideration was needed of how time would be managed to allow VIG Trainee Practitioners to carry out the range of tasks associated with the intervention: building relationships with clients, preparing equipment, carrying out the client face to face sessions, analysing video clips, engaging in supervision, and writing policies. Difficulties with time featured in all our interviews and our focus group. The HV group hypothesised that using VIG as an early intervention, as promoted through Future in Mind (2015), would mean that time and money would be saved in the future. Additionally, this fits with the HCP (DofH, 2009), which HVs are commissioned to deliver. Services will need to consider how they might manage and track this.
Similar findings were found in the ‘Through Each Other’s Eyes’ (Chakkalackal, Rosan, & Stavrou, 2017) paper. This paper looked at the implementation of VIG in a Health Visitor service in Haringey. The research found many positives for the use of VIG, including reduced stress and anxiety and increased confidence in the parents, and the Health Visitors and managers felt the intervention was very effective in terms of developing practitioner skills and having it as a therapeutic tool. However, they also noted the practical challenges of the intervention, such as the differing referral routes and the impact on caseload and need for team support to manage this.
As well as time, the current study identified that services need to consider how they would manage the development of the policy and procedural infrastructure, e.g. with respect to confidentiality, data management and trading agreements. Technical considerations were also needed to ensure that staff members were fully equipped to deliver VIG, both in terms of equipment and technical skills. Other themes included the identification of Trainee VIG Practitioners and clients, and the skills of the Practitioners.
On reflection of all the themes, a commonality was identified. It was noted that, for all the challenges of delivering VIG to be met and for staff to be supported properly, a full commitment to VIG was required across all system levels.The following outlines how this might be achieved:
- Collective Strategic Direction
A collective strategic direction needs to be held by all, beginning with national legislation and initiatives and extending through to local operational managers. Where missing links occur in this direction, it is likely that issues such as managing time demands and supporting policy development may become increasingly challenging.
- Principle of Attunement Across all Systems Levels
The values and beliefs of VIG include being attuned to others, recognising strengths, and believing that people are doing the best they can. Ideally, across all systems levels, this view is taken of clients, VIG Trainee Practitioners, SALs, and others involved in the direct support of VIG, in order that they will be best supported to meet the practical challenges. Indeed, the VIG training and supervision model ensures that the VIG ‘Principles of Attuned Interactions and Guidance’ are developed in clients, trainee Practitioners and supervisors alike.
- Capacity and Collective Drive for Change
As Fullan (2005) identified in his paper which outlines the Tri-Level Solution approach to change, capacity and collective drive for change needs to occur at three levels of a system for improvements and success to happen. With regards to this study, this would mean “building capacity” at the bottom level (those delivering VIG), the middle level (LAs, Health Commissioners) and top level (National legislation and guidance). There needs to be accountability at all three levels and a collective belief in the purposes, efficacy and utility of the intervention.
Recommendations for a self-sustaining multi-agency VIG intervention
On the basis of this study, the following issues could be considered by services exploring the set-up of a VIG intervention:
- All involved in the strategic planning and delivery of VIG need to understand and demonstrate a commitment to the practical issues related to VIG (e.g. Time, Technical Infrastructure, Policy and Procedural Infrastructure, Trainee Practitioner and Client Identification) and its overall ethos and values.
- Time for all staff involved to implement all aspects of VIG. This will likely require flexibility and reassessment of work responsibilities including the provision of cover to release staff from their other responsibilities in order that they may complete their VIG activities effectively.
- Clear and precise policies and procedures will be needed at an early stage, considering matters such as data storage and confidentiality (e.g. selecting the videoing equipment and software to support it; deciding on data protection processes; time planned in to train and support practitioners in using the equipment; the sharing of sample ‘IT solutions’ from other services would be helpful).
- Staff will need confidential spaces in which they can analyse and edit clips.
- Consideration is required for how VIG will be utilised in multi-agency cases, such as how information will be shared, and how other agencies will be supported to understand VIG. Agreements will need to be in place from the beginning of multi-agency partnerships.
- Prior to committing to training in VIG, staff will benefit from being fully informed about the time and extent of involvement the role of the VIG Practitioner requires.
Limitations and Considerations
- The researchers are aware that the participants were very new to their delivery of VIG. Therefore, the views and opinions shared during the focus group and interviews reflect their very early and initial thoughts. The researchers wondered whether results might have been different had the study occurred later on in their training in VIG, and whether responses might have been affected by the passage of time. It would be interesting to compare responses at these two different times. For example, IT challenges are likely to be more of an issue in Stage 1 of training, whilst practitioners are still coming to grips with using the camera and editing.
- Another consideration was how the training routes for EPs and HVs may have impacted upon their views and opinions. For example, perhaps the initial professional training for EPs, which includes training in consultation and solution-focused approaches, may have better prepared some VIG Trainee Practitioners. This may need to be a consideration for other agencies looking into the set-up of a VIG service.
Potential Areas for Future Research
- Further research into the effectiveness and utility of VIG may be helpful in providing more insight for relevant commissioners into how the intervention works.
- It may also be helpful to consider how the effectiveness of VIG can be demonstrated to stakeholders across the variety of organisational levels, in order to promote investment, enthusiasm and commitment to the intervention across multiple system levels.
VIG is an intervention that resonates with the current national drive to support CYP and their mental health and wellbeing. It has potential to be used by a variety of professionals and appears to sit well within the EP and HV role. However, for successful early implementation of VIG, services need to be fully aware, prior to commitment, of the practical matters relating to the delivery of the intervention. This study has identified key themes in the early experiences of VIG Trainee Practitioners and has made suggestions for how these challenges may be navigated.
It also points to a potential area of further work within AVIGuk: the clarification of the requirements that need to be fulfilled in order for VIG to be introduced into a service. For example, local services need to consider meeting with senior management and training departments/staff to make the case for VIG, liaising with IT departments and writing or adapting data protection policies. Sample data storage policies to be used by services could be made available on the AVIGuk website, and an outline of the time requirements could be presented.
Arguably, for VIG to be successfully delivered, a collective strategic direction is required at all levels, from national through to local leadership. VIG practitioners see almost immediately its positive impact. They appreciate what clear benefits can be achieved for families and professionals alike, so are motivated to overcome operational barriers because of their commitment to and enthusiasm for this method. The challenge for management is to ensure that adequate practical support is available, in both time and resources, so that practitioners’ enthusiasm is fully harnessed and best possible outcomes are achieved for our families.
Amy Bushell and Pauline Cooper are Trainee Educational Psychologists at the University of Bristol, who were on placement at Gloucestershire Educational Psychology Service, when they conducted the research.
Dr Oonagh Davies is a Specialist Senior Educational Psychologist for Gloucestershire Educational Psychology Service and passionate Trainee AVIGuk Practitioner, who initiated and coordinates the use of VIG by Health Visitors and Educational Psychologists in the county.
Amy and Pauline would like to express their thanks to Dr John Franey, for all his support, guidance and sense of humour throughout this commission. They would also like to thank Dr Oonagh Davies for all her energy, enthusiasm and vision for the research.
Oonagh would like to thank Catherine Whitcombe (Perinatal Health Visitor Lead), Dr Deborah Shepherd (EPS), Helen Ford (Lead Commissioner CYP and Maternity, NHS Gloucestershire/Gloucestershire County Council), and Laura Phipps (Commissioning Manager), without whom this joint project would not have got going! For keeping it going, in the face of not inconsiderable challenges, a very special thanks to our supportive supervisor Maureen Granger, and especially all the VIG EPs andVIG Health Visitors.
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EP Services who are reported to be well-established in the use of VIG, include Cornwall, Glasgow, North Lanarkshire, East Lothian, Kent, Hampshire and Camden. Also see Manchester Child and Parent Service, Wessex Perinatal Service (Mother and Baby Units and Community), and SWIFT (Specialist Family Service) in East Sussex, and the NSPCC has a number of projects in different areas of the country.
A copy of the interview questions and prompts, which related to experiences of the initial training and information received about the intervention, to experiences of delivering VIG, and to the issues and difficulties that had arisen, can also be made available if requested.