By Rachel Pardoe, child and adolescent psychotherapist
With thanks to VIG trainees Nancy Shelton, Amanda Stirling and Jenny Griffiths for their commitment to VIG and for contributing data to this evaluation.
- Introduction and Aim
The report documents the findings from the evaluation of the use of Video Interaction Guidance (VIG) in CAMHS in Bristol and South Gloucestershire during the period 2015-2017.
VIG was introduced into CAMHS in 2015 by Rachel Pardoe, child and adolescent psychotherapist. Rachel had been using video feedback since 2011 in work with parents and pre-school children, using a psychoanalytically informed approach 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. VIG provided an opportunity to train in a structured approach with a good evidence base (see Pardoe, R. 2016 on integrating VIG and the psychoanalytic approach). Rachel subsequently trained as a VIG supervisor, supervising three primary infant mental health specialists (PIMHS) in CAMHS.
Aim: this evaluation of ongoing clinical work was carried out with the aim of convincing CAMHS management and commissioners to invest further in VIG training. Funding was not sought to for the evaluation; with hindsight funding would have provided the opportunity for use of further outcome measures (see Conclusions and Recommendations).
1.1 What is VIG?
VIG is a strengths-based, video feedback intervention in which clients are guided to reflect on video clips of their own successful interactions. VIG is used as a therapeutic intervention with parents and carers of children across all ages.
VIG aims to enhance parental sensitivity and attunement (Stern, 1977, Trevarthen, 1980), the parent’s capacity to mentalise about their own and their infant’s mental states (Fonagy, 1998, 2002), and to promote ‘mind-minded’ interactions (Meins, 2012). Kennedy et al (2011) gives a comprehensive introduction to VIG; Kennedy et al (2017) provides a summary of studies which have shown the effectiveness of video feedback with parents and infants.
VIG is recommended as an evidence-based intervention in the NICE Guidelines (2012, 2015), and is specified in the UK government-funded programme Children and Young People’s Improving Access to Psychological Therapies (CYP-IAPT):
- 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 2015)
- Social and Emotional Wellbeing – Early Years (NICE 2012).
1.2 What Happens in VIG?
VIG 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 VIG process is as follows.
- VIG practitioner meets with parent and child for engagement session(s), and to explain the VIG process. Together, the practitioner and parent think about how the parent might like things to change, and identify one or more goals.
- VIG practitioner takes a short film recording (5-7 minutes) of parent and child interacting/playing together in their ‘normal’ way.
- VIG practitioner microanalyses the film recording (the ‘video’) and selects clips of ‘best moment’ interaction which show exceptions to the usual pattern. The clips will usually seek to illustrate the parent’s attunement to the child (in particular the parent’s reception of the child’s initiative) and moments of emotional connection with the child. These clips may be as short as 10-15 seconds, or may even be a ‘still’ photo.
- VIG practitioner meets with parent in a ‘shared review’ where the video clips are explored. The VIG practitioner supports the parent to reflect on what they see, and to microanalyse the clips together to identify what the parent is doing that makes this interaction go well. There is a collaborative discussion on how to build on these strengths.
- This process of filming, selecting clips, and doing a shared review is called a ‘VIG cycle’. The usual length of intervention is 2-3 cycles, but sometimes significant progress can be made in just one cycle.
The VIG practitioner uses the AVIGuk Principles of Attunement (Kennedy et al, 2011) to support the parent in microanalysing their interactions with the child. The Principles provide a very helpful framework for this collaborative work.
2. Evaluation of VIG in CAMHS: Methods
The clinical work contributing to this evaluation took place from 2015-18. The majority of the work was carried out within the infant mental health service by Rachel Pardoe and three VIG trainees employed as primary infant mental health specialists.
Outcomes data (both quantitative and qualitative) was gained from therapeutic work with 39 clients, who had completed 1 or more VIG cycles. Two clients were mothers with adolescents, seen by Rachel Pardoe in the wider CAMHS service. Rachel moved to a new team in 2017 to work with the older age group. Unfortunately, pressures of workload at the time did not permit further VIG work with adolescents.
2.1 Setting Goals
A single outcome measure was used in this study: the AVIGuk Goal evaluation form. Parents were asked to give pre- and post-intervention ratings in relation to goal(s) set up in collaboration with the VIG practitioner. Examples of parents’ goals in this study included:
What am I doing to help her feel closer to me?
What am I doing to build a bond between us?
What am I doing to help him keep calm?
What am I doing to help her to be less frustrated?
During the VIG intervention the parent rates their goal(s) on a scale of 1-10 (10 indicating that the goal had been achieved), at the following points.
- At the start of the VIG cycle: where they think they are now in relation to this goal
- Where they would like to be after this VIG cycle
- After the VIG cycle: where they think they actually are.
At the end of the VIG intervention, a parent may be asked to complete a ‘Traject Plan’ with the practitioner, which documents how the VIG intervention has impacted on areas of the parent’s life (eg daily life, contact with the community etc). Quotes from the parents’ Traject Plans and end of intervention feedback are given in section 2.4.
2.2.1 Client population and completion of VIG cycles
A total of 39 clients were included in the study. 35 of the parents were mothers, and three fathers; in addition, VIG work with a nursery staff member, working with a referred child was included (see section 2.5 for a discussion on using VIG in this setting).
Table 1.1 shows figures regarding the client population, and completion of VIG cycles.
INSERT TABLE 1.1 AND NOTE * ABOUT HERE
Table 1.1 The client population and completion of VIG cycles.
|No. of Clients|
|Average age||2.4 years*|
|Under 2 years||8|
|Total no. of Mothers||35|
|Total no. of Fathers||3|
*Average age of infant mental health cases, not including the two 14 year old girls.
It is a challenge to clinicians to retain clients across 3 cycles, given the often stressful and eventful lives of families with small children (illness in parent and child, parental mental health problems, parental relationship breakdowns and conflict etc). Hence, at the time of reporting, 3 cycles had only been achieved with 5 of the 39 clients.
Figure 1.1 illustrates the number of clients who completed each cycle.
INSERT FIGURE 1.1 ABOUT HERE
Figure 1.1: Number of clients in each VIG Cycle
2.2.2 Goal rating change across VIG cycles
Table 1.2 shows average goal change across VIG cycles. The data shows highly positive results, even following a one-cycle intervention. The average goal change in 1 cycle (2 CAMHS sessions) is 3.1; the average change across 3 cycles (6 sessions) is 5.
INSERT TABLE 1.2 ABOUT HERE
Table 1.2 Average change in goal rating across VIG cycles
|Average goal change||Average overall change across all cycles||Average change for clients who completed 3 cycles|
Where a client has more than one goal this can impact on outcome data, for example if considerable change occurs with one goal but not with another. Figure 1.2 shows just the goal which showed the biggest change.
INSERT FIGURE 1.2 ABOUT HERE
Figure 1.2: Average change in goal rating (across all goals) by VIG Cycle
Figure 1.3 shows that the cumulative effect of VIG cycles is positive: the greatest change on average is shown by those clients who had 3 cycles
INSERT FIGURE 1.3 ABOUT HERE
Figure 1.3: Average biggest goal change across all VIG Cycles
Figure 1.4 shows the number of clients/cases in each age range. The greatest change occurs in the infants under 1 year old, and the 14 year-olds. Note that the data for the 14 year olds is only based on 2 cases and therefore is less reliable.
INSERT FIGURE 1.4 ABOUT HERE
Figure 1.4: Average change by age
2.3 Feedback from Parents: Qualitative Data
At the end of the VIG intervention, clients were asked to comment on their experience and how things had changed. As the quotes below indicate, there was high satisfaction with the VIG process, outcomes, and the support provided by the VIG practitioners.
A 4 year old boy was referred by the Health Visitor due to aggression towards his mother and two siblings; mother had a history of depression and OCD. She was expressing very negative feelings towards C, who was struggling with intense separation anxiety (indicative of an insecure attachment).
CAMHS work enabled mother to disclose domestic abuse (from mother to father), and, with social care involvement, to become more aware of the traumatic impact on her children. VIG enabled mother to see C, and herself as a mother, in a new light, despite these difficulties.
I just thought before: “You’re just a naughty boy that drives Mummy crazy.. Whereas now I think, No, you’re actually a hurt and scared little boy”
“I can see I am helping him” [representation of self]
“I can see he enjoys being with me” [representation of child]
“I feel closer to all 3 of my children”
A mother whose 2-year-old boy was referred for pica (consistently eating non-food stuffs) and aggression towards his mother and sibling, said after just 1 cycle of VIG:
“I feel better now. I can see I’m understanding him. I always thought I was doing something wrong: why is he like this? It must be me.. I look at it different now. I don’t think it’s me.. and watching the video I could see there was nothing wrong, nothing different about him.. he’s a good boy”
The total intervention with this client was just 4 sessions. The outcome was a significant reduction in aggression, and greatly reduced pica as mother now understood his eating non-food stuffs as a way of bringing her in (seeking negative attention in the absence of positive attention and attunement). Once the mother found a way to enjoy him, he no longer needed to do this.
A 4 month old baby girl was referred to CAMHS to support her early attachment to her mother, due to significant difficulties with the mother’s mental health. At the time of referral, they were both in a mother and baby in-patient unit. P was under a Child Protection Plan and mother was not allowed unsupervised contact with her.
The first VIG cycle took place when P was 7 months old, living back at home with dad, with mum having supervised contact. Five sessions of parent-infant therapeutic work (exploring mother’s difficulties in the parent-infant relationship) had been done prior to starting the VIG intervention.
“I know when she was born and I just didn’t want nothing to do with her … if I didn’t get to know her in the first place then everything that would have come after wouldn’t have bothered me”.
After first VIG cycle:
“I’m looking at her now and that’s more than I did 6 months ago … she can look at me now … because even though I used to avoid her, she wouldn’t ever look at me … she always wanted me more than I wanted her … and I can now sit close to her”
“I don’t look upset or anything when I’m holding her, do I? I’m not scaring her, am I?”
After 2nd VIG cycle:
Honestly … I wouldn’t ever have thought I would have been able to be this way with P … let alone after just 6 months … if you would have shown me that [the video] 6 months ago I’d have probably just laughed, like “there’s no chance!”
A further cycle was achieved with this client following the evaluation study. The outcome was that P was no longer under a Child Protection Plan and mother was having unsupervised contact. VIG was a crucial intervention in helping mother to find the positives in her relationship with P, despite the acute difficulties for them both.
A mother whose 1 year old was Child in Need with safeguarding concerns (infant suffering from chronic constipation under treatment from the community paediatricians and specialists), said after just 1 cycle of VIG:
“VIG helped me to understand feelings, and ways to help and comfort A. I understand her more and her need for space. I’m now comforting her and talking to her when she’s in pain; I get her need for closeness.”
Baby E’s mother had severe PND following death of her first born baby. She felt she could not bond with E, and grandparents did the majority of the care. She was concerned that E would not know she was his mother and she felt she could not be a good enough mother to him. VIG had a powerful impact on her.
“Seeing the clips lets me see I am being a mum, what I am doing is ok, that we are ok”
A 2 year old girl, F, was referred due to her mother feeling that she had never bonded with her. Six months before F was born, mother suffered the trauma of her 9 month old baby dying (SUDI). Mother reported after VIG:
“We do look like we are really playing. She looks as if she is enjoying it. I never thought we could do that. I didn’t think I could play with her like I am in the clip.”
A 15 month old boy, K, was referred due to difficulties in mother bonding with him. She was recovering from alcohol dependency and had suffered severe domestic abuse. Her children were under a Child Protection plan when CAMHS became involved. When K’s little sister was born, mother felt close to her and she realised that this had been missing with K. After 2 VIG cycles her relationship with K felt easier; mother felt calm and more confident.
“Wow! Is that me?! Wow! Look at K! He didn’t lose his temper. I worried he would, but he didn’t, he kept playing with me. If I had not seen that in your clip, I would not have thought he could do that.”
“Without this (VIG) I would never have got off the (Child Protection) plan. This made it possible. It helped me know what to do and made me work hard.”
N at 2 years old was having ‘big tantrums’, and her parents were worried about her future if this continued. Mother, in particular, found N very challenging and felt there was ‘something wrong with her’. Each parent did 1 cycle of VIG (they were expecting another baby so time was limited). Both parents responded very positively, and N became calmer and began to sleep through the night. Mother became aware of the need to give N space and follow her lead, and how this could be enjoyable for them both. Father, who lacked confidence in himself as a Dad with N (his first child) was struck by seeing N’s evident enjoyment in being with him
“At home it can be ‘overwhelming’ for N (busy family life with older half-siblings) – this quiet time is good for both of us. Nice to see us being close, both of us smiling..”
When prompted by the practitioner as to what might be seeing N when she looks at her father’s smiling face, he responded: “Security, I would imagine”. His mental representation of himself was changing to a sense of a father who can provide security and closeness for his little girl.
A 14 year old girl on the autistic spectrum, with high anxiety and complex somatisations, had been under CAMHS for several years. One cycle of VIG with J and her mother set in motion a positive change in their hitherto difficult relationship. The mother had been feeling very low in confidence, and as if her relationship with J was of little consequence. They had been spending very little time together.
I’m surprised.. it’s better than I thought. I think I’m really good! I can see how giving her space and time is helpful and enjoyable for us both.”
K herself, realised that she could wait for Mum to give her time, rather than demanding it at in appropriate times and ending up in conflict and stress. 18 months after VIG, the improvements in their relationship had been sustained.
2.4 Themes in the Parent Feedback
The case vignettes and parent feedback in section 2.3 show how VIG can be very powerful and emotionally moving: the clients voice their surprise and pleasure in what they see, and their new-found belief in themselves as parents. Some themes included:
- gaining a new, positive perspective on themselves as a parent (positive shift in representation of self)
- gaining new insights into their infant/child through greater understanding of behaviour (positive shift in representation of child)
- recognition that the parent-child relationship is closer and more positive than previously thought, along with a reduction in self-blame or blame of infant/child.
The parents comments reflect meaningful and significant changes (for the positive) in the parent’s mental representation of themselves as a parent, and their representation of their child. The feedback indicates an increasing capacity for mentalization, parental attunement and sensitivity; these capacities and parental behaviours are key to secure infant attachment.
2.5 Using VIG Across Different Settings
One of the cases in our study involved work with a member of staff at a nursery. The CAMHS PIMHS received a GP referral for a 4 year old girl, M, who was selectively mute at her nursery, where she also did not eat, drink or use the toilet. These difficulties did not present at home.
Staff at nursery were anxious about how to support M. The paediatrician, PIMHS and Educational Psychologist recommended a gentle approach, to support and encourage M’s confidence, and developing trust.
The PIMHS worked with the mother and child, but also carried out a VIG cycle with a member of staff at the nursery. VIG provided a wonderful opportunity for M’s key-worker to see how much M did enjoy being with her, how they communicated effectively and what a good relationship they had together. This empowered the keyworker and helped allay her own anxieties about how she was supporting M.
The quantitative goal rating data shows highly positive results, even following a one-cycle intervention. For VIG to produce an average change of 3.1 in 1 cycle (2 CAMHS sessions) and an average change of 5 points across 3 cycles (6 sessions) is clearly a very positive result.
It is worth noting that the average change in Goal Based Outcomes (GBO) in national CAMHS data (CORC Routine Outcome Monitoring) is 4.1 between Time 1 and Time 2, ie 6 months later or at discharge, whichever is earliest.
It is a challenge to clinicians to retain clients across 3 cycles, given the often stressful and eventful lives of families with small children (for example, illness in parent and child, parental mental health problems, parental relationship breakdowns, conflict etc). Hence, at the time of reporting, 3 cycles had only been achieved with 5 of the 39 clients. The rate of change after just one VIG cycle, however, is extremely encouraging and shows that VIG can be highly effective even in a very brief intervention.
Setting goals, and rating them, can be a complex task. The parent may wish to focus on specific behaviours of the child, eg wanting her to stop having angry outbursts. The VIG practitioner needs to receive these concerns and explore them with the parent. During the VIG process the practitioner will seek to co-construct new shared goals which focus on the parent-child relationship (Kennedy et al 2011, p27), helping the parent to understand the impact they have on their child, and how changing their responses to the child could be key to positive change in the relationship.
There is always the risk that parents will be reluctant to portray themselves in a ‘bad light’ by reporting low ratings on VIG goals. One interesting outcome of this can be an apparent negative shift during the VIG work: a parent’s initial self-ratings may be higher than in subsequent cycles. At the start of VIG the parent’s self-ratings may be exaggerated and/or their expectations of their progress in VIG (‘Where I’d like to be after this cycle’) may be unrealistic, particularly if the family is involved with social care and feeling the need to prove that their parenting is good enough. The VIG practitioner seeks to have a collaborative discussion with the parent to identify realistic goal ratings for each cycle.
As the parent’s trust in the practitioner and the VIG process grows, the parent may become able to give a more honest and realistic view of themselves. The parent’s goal ratings may then be lower at the end of a cycle than at the start of that cycle, or lower at the start of the next cycle than at the end of the previous cycle. This discussion and goal rating re-appraisal may need to happen over several cycles.
The apparent negative shift may be followed by a positive shift, as a genuine positive change is recognised by the parent, and goal ratings increase. Overall the VIG goals scorings may thus apparently shift minimally or not at all, eg from 6 at the end of cycle one, to 4 at the end of cycle two, and to 7 at the end of cycle three. The overall minimal shift in ratings may belie the actual progress: the parent’s increased awareness of the need to attune to their infant, greater realism about their own capacities to attune, and the need for further therapeutic work. The shift in goal rating may be minimal, but the shift in the parent’s capacity to mentalise (Fonagy et al, 1998) about their own feelings/thoughts and their infant’s may be significant.
For example, in this study a mother whose infant was a Child in Need with safeguarding concerns (see Case A below), rated herself 7 at the end of the first VIG cycle, and 5 at the end of the second cycle. The lower score was a more honest and realistic rating. Her positive comments on the VIG work, despite the lower rating, reflected her new understanding of her baby daughter, her new awareness of attunement, and an increased capacity to mentalise.
In terms of evaluating outcomes, when looking at overall progress these incidents will lessen the effect, although in reality the outcome may be very positive. This highlights one of the drawbacks of client self-ratings, without a clinician rating alongside, and the complexities of measuring outcomes in parent-infant relationships.
- How Does VIG Effect Change?
There are a number of factors contributing to the positive change evoked by VIG.
- Video feedback, using ‘best moment’ clips, provides evidence of strengths: for example, the parent sees the child seeking closeness, and their own positive response; the parent sees themselves evidently enjoying their child.
- The video acts as ‘a witnessed present reality rather than a remembered past’ (Jarvis, 2011). This reality is shared by practitioner and parent, and is less subject to doubt or the differences in recall which are common to therapeutic work.
- Experiences of positive feelings are strengthened through VIG: when the parent feels moved and/or pleasurable feelings while viewing the video clips, the parent also experiences the VIG practitioner’s pleasure at his/her pleasure (Tucker, 2016). The new shared understanding is an emotional experience strengthened by being shared.
- The practitioner’s attunement and emotional containment of parent and child: feelings of fear, rejection, anger and helplessness are explored within a trusting therapeutic relationship, alongside the positive, hopeful feelings engendered by VIG.
The last point is common, hopefully, to all therapeutic approaches, but the power of VIG lies in the ‘evidence’ provided by the video, and how the parent’s responses to this evidence can be explored to gain new understanding, shared between practitioner and parent.
3. Conclusions & Recommendations
Future of VIG in CAMHS and Other Services
This CAMHS data provides further evidence that VIG is an effective therapeutic intervention. Our experience as VIG practitioners leads us to believe that the interventions are faster and more effective than our interventions without VIG.
As stated above: the average change in Goal Based Outcomes (GBO) in CORC ROMs is 4.1 between Time 1 and Time 2 (6 months later or at discharge, whichever is earliest). Our VIG data shows an average change of 3.1 in 1 cycle (2 CAMHS sessions), and an average change of 5 across 3 cycles (6 sessions). This is clearly a very positive result in a short space of time.
Increasing pressures in the NHS and elsewhere for effective brief interventions make VIG an obvious choice where there are parent-child relationship difficulties.
VIG can be very powerful and emotionally moving: the clients voice their surprise and pleasure in what they see, and their new-found belief in themselves as parents. As Kennedy (2011) states, in VG: ‘Clients are not taught how to interact better, but rather to learn through experience how they can actively develop more joyful relationships’ (p 25). This emphasis on enjoyment is reiterated in Kennedy et al (2017): ‘Parents and infants thrive when they are able to enjoy getting to know each other, to read each other’s signals and to develop together’ (p 14).
In this study, VIG appears to have been very effective in changing for the positive the parent’s mental representation of themselves as a parent, and their representation of their child, and increasing the parent’s capacity for mentalization, parental attunement and sensitivity; these capacities and parental behaviours are key to secure infant attachment.
It is disappointing that we only worked with 3 fathers during this evaluation period. The limited number of fathers reflects both the nature of referrals (largely from Health Visitors and GPs) which tended to focus on the mother-child relationship, and the challenges involved in engaging fathers in therapeutic work. These challenges may include availability, for example if the father is working, and/or a perception by clinician and father that his involvement is unnecessary, particularly if the dialogue to date with professionals, including the referrer, has largely or solely involved the mother. Fathers can feel, and actually be, excluded from the arena of the mother-infant pair, and yet the research evidence and infant mental health literature suggests that both mothers and fathers need emotional support in the transition to parenthood (Clulow 1982, Cowan et al 1985, Parr 1996, Barrows 2009).
Furthermore, the infant’s security of attachment depends on the relationship with key caregivers (Bowlby, 1969; Ainsworth, 1978, Fonagy, 1995). Where there are two parents/carers, it is therefore essential to work with the ‘baby in the mind’ of each parent, and to consider the impact of the parental couple relationship as the ‘emotional matrix in which the infant develops’ (Barrows, 2009, p84). The feedback from the fathers in this study indicated the value and importance of the VIG work to them, both in terms of their perception of themselves as fathers, and their relationship with their infant/child. Further work with fathers has been carried out in CAMHS since the evaluation, but there is clearly a need to focus more on fathers, and on the parental couple.
Our recommendation to our NHS Trust was that VIG should be used in CAMHS as one of the standard therapeutic interventions. More work should be done with older children and young people. The positive findings here with the mothers of two 14-year-olds indicate a potential for effective work with adolescents.
We also recommended introducing VIG into other services including: perinatal, autism, learning disability, positive intensive behavioural support, and looked after children. VIG training is underway in the specialist community perinatal service.
No funding was secured for this project. With further resources, the evaluation could have been extended to incorporate additional parental measures (such as the PHQ-9 and GAD7) and CAMHS Routine Outcome Monitoring data. Further outcome studies should include this additional data.
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