Review of Conference Workshop: VIG with Mothers and Babies, Natasha Gray Hertfordshire Community NHS Trust
By Rachel Pardoe (Child and Adolescent Psychotherapist, VIG supervisor)
Natasha Gray (clinical psychologist, advanced VIG supervisor) and her colleague, Emma Custance (mental health nurse and trainee VIG supervisor), presented an evaluation of VIG work with mothers and babies, which was both impressive and inspiring. Natasha had set out to provide evidence to commissioners of the effectiveness of VIG with this client group, and she certainly achieved it: one highly positive outcome is the funding of a new half-time post in the Hertfordshire perinatal mental health team, with the aim of furthering use of VIG in the perinatal service. Natasha is taking up this post in November 2018.
At the time of the study, Natasha was working in Child and Adolescent Mental Health Services (CAMHS) in a service ostensibly providing a service to 0-19 year olds, but in reality not offering any service to under 2s. This is not uncommon in CAMHS. In Bristol, where I worked in CAMHS for 25 years, we were unusual in having an infant mental health service (set up by Dr. Paul Barrows, Child Psychotherapist in 2004). I introduced VIG to this service in 2015, and provided evidence in 2018 of its effectiveness with infants, pre-school children and their parents. This evaluation has helped to promote VIG in CAMHS and in the perinatal service (Pardoe, R. 2018, paper submitted to Attuned Interactions).
Natasha was innovative in seeking funding from the CAMHS Transformation Fund for a 4-month pilot study for one clinician to work with 10 parent-infant dyads. The VIG clinical work and the evaluation were set up carefully, with considerable personal time and effort. The assumption was an average of 7 appointments per intervention and 2.5 appointments per day for the clinician – quite a challenge, given travel time, client documentation etc. The pilot was so successful that the commissioners provided further funding: 2 clinicians, 1 day per week for 7 months. Emma Custance then joined the project. A total of 25 client interventions were evaluated.
Outcome measures: Natasha used both quantitative and qualitative pre- and post-intervention measures. The main criteria for selecting measures was that they need to be “quick, easy, and free” (in addition to having been tested in the research field for reliability and validity). Unfortunately, many measures in the field of parent-infant research are neither quick, easy or free, and are therefore harder to use in clinical work. In particular, it is difficult to find an easy-to-use objective measure which evaluates the change in the parental representation of the parent-infant relationship, ie the expectations and beliefs the parent has of themselves as a parent, their infant, and their interaction/relationship. A positive change to this representation, and an increased capacity in the parent for mentalization (Fonagy, 1998) are the key goals of parent-infant therapeutic work, as both increase the likelihood that the infant will develop a secure attachment (Bowlby, 1969; Ainsworth, 1978; Main, 1989). The evidence is building that video feedback approaches impact positively on parental representations and mentalization, hence VIG is recommended in the NICE Guidelines (2012, 2015).
The quantitative measures Natasha decided to use in her study were: the widely-used mental health measures PHQ-9 (Patient Health Questionnaire, depression module), and GAD7 (Generalised Anxiety Disorder); the MORS (maternal representations of the infant, Oates, J. 2005); Karitane Parenting Confidence Scale (Crncec et al, 2008); and VIG goals identified in collaboration with each client. She also used qualitative measures, including a referrer feedback questionnaire, a modified VIG Traject Plan, and audiotaped feedback of mother’s experience of VIG. The latter was particularly powerful for us at the conference, and for the commissioners, who, while viewing stills of parent-infant interaction, heard the voice of the mothers. VIG can speak with a strong emotional voice and can cut across barriers, funding being the main one. I think Natasha chose a very effective way of getting the message across.
Natasha’s view is that clients were remarkably honest in their reporting on outcome measures. As I found in my CAMHS Evaluation (to be published), there is always the risk that parents will be reluctant to portray themselves in a bad light by reporting low ratings on certain scales, or with regard to the 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. As the parent’s trust in the practitioner and the process grows, the parent may become able to give a more honest and realistic view of themselves. This discussion and goal rating re-appraisal may need to happen over several cycles. Despite this negative shift occurring with some clients in Natasha’s study, the overall change was very positive.
The quantitative measures in Natasha’s study yielded statistically significant results showing clear improvements across all measures. This is very impressive. Natasha commented (in person to me) that marked progress was made even in just one cycle. This has also been my experience in CAMHS where my study of 39 families yielded an average VIG goal change of 3.1 after the first cycle. Given that the average change in national CAMHS Routine Outcome Measures Goals is 4.1 after up to 6 months of treatment, VIG is proving to be a very effective, brief intervention.
Natasha’s work with mothers and babies has convinced commissioners and senior clinicians in Hertfordshire that parent-infant services are needed, and that VIG is an intervention ideally suited to this client group. Not only has a new parent-infant post been created, but funding has been allocated to train staff in VIG.
The challenge for Natasha (and for me as a newly appointed Parent-Infant Therapist in the community perinatal team in the Bristol/South Gloucestershire/North Somerset area) is to work towards a more parent-infant focused service. Perinatal services, many of which are staffed largely by adult psychiatrists and mental health nurses trained to work with adults, can be oriented more towards adult mental health than parent-infant relationships and the family system including, crucially, fathers. ‘Keeping the Baby in Mind’ (cf Barlow, J. & Svanberg, P. 2009) is an essential task. VIG can have a powerful impact on clients, but also on clinicians, whether or not they themselves are training in VIG. VIG provides emotionally moving evidence of change, and an insight into the importance of working with the parent-infant dyad and the parent’s mental representation of the parent-infant relationship.
To end with a quote from one of Natasha’s clients that reflects this vital positive change: “I have got more patience with my baby. I have started understanding him better than before. I am more confident that I am a good mum.”
Ainsworth, M. (1978) Patterns of Attachment: A Psychological Study of the Strange Situation. New Jersey: Lawrence Erlbaum.
Barlow, J. & Svanberg, P. Eds. (2009) Keeping the Baby in Mind: Infant Mental Health in Practice. Routledge.
Bowlby, J. (1969) Attachment and Loss. Vol 1, Attachment. London: Hogarth.
Črnčec, R., Barnett, B. & Matthey, S. (2008) Karitane Parenting Confidence Scale: Manual. Sydney: Australia.
Fonagy, P. & Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues, 8(1), 87-114.
Main, M. et al (1985) Security in infancy, childhood and adulthood: a move to the level of representation. Monographs of the Society for Research in Child Devt. 50 (1-2), 66-104.
Oates J.M., Gervai J., Danis I., Tsaroucha. A: Validation studies of the Mothers Object Relational Scales Short Form (MORS-SF). Poster presented at the XIIth European Conference on Developmental Psychology. La Laguna, Tenerife, Spain: 2005.
NICE (2012). Social and Emotional wellbeing: early years, PH40. https://www.nice.org.uk/Guidance/PH40
NICE (2015). Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care, NG26. https://www.nice.org.uk/guidance/ng26
Pardoe, R. (2018) Evaluation of the use of Video Interaction Guidance in CAMHS – paper submitted to Attuned Interactions, Autumn 2018).