Author: Isabella Bernardo, firstname.lastname@example.org
In this paper I will reflect upon my journey and experiences in delivering Video Interaction Guidance (VIG) interventions to families with complex needs who are known to a multi-agency Children Services team. I will reflect upon some of the difficulties I experienced in contracting VIG interventions and also on the benefits and challenges in working alongside other professionals with VIG. Reference will be made to mentalisation based approaches and links to working in a multi-agency manner.
What is VIG?
Video Interaction Guidance is an intervention which aims to improve communication and relationships for carers/parents and their children. Carers or parents work with a VIG Guider registered with Association of Video Interaction Guidance UK (AVIGuk) to review and discuss short video clips of their personal interaction. VIG aims to help carers/parents become much more aware of their effective communication through a process of viewing themselves and reflecting on what they observe on film. The Guider aims to empower participants in the process of change by exploring perceptions and assumptions, and building on their strengths. Relationships, interactions and behaviour can improve as carers/parents develop greater understanding and where appropriate adjust their communication style. Typically key ‘helping questions’, similar to hopes from the intervention, are named by the carer/parent and focused upon throughout. In working with older children, helping questions can also be gained from the young people themselves, involving them in the process of change by helping them to reflect on their communication and interaction style with their carer or parent.
The Family Recovery Project
The Family Recovery Project (FRP) is a multi-agency innovative team working with families with historical and recurrent complex needs, which may include school refusal, children at risk of going into care, substance misuse and unemployment. The project is funded by the local authority’s Troubled Families governmental programme, which is a national funded initiative (2012-2020) set up by Dame Louise Casey; please see link https://www.gov.uk/government/news/troubled-families-programme-annual-report-published for further information on the programme. The programme aims to support the families who are most marginalised in society and facing issues such as poor housing conditions, unemployment and parental physical and mental ill health.
FRP in the local authority I work in aims to build resiliency and long lasting change in families by developing a strong partnership with carers. The team consists of a large number of outreach workers who build up the key role with carers and children, and a number of multi-agency services including police, health visitor, adult mental health worker and child psychologist (my Educational Psychologist role). FRP emphasises the importance of not just building relationships with families but also building effective partnership working with professionals that are involved with the family, hence multi-agency working is at its core.
Evaluation of impact is key to the team’s role, given the funding for FRP is short-term. Managers have a key responsibility in using information gathered by the team’s two data analysts, to demonstrate positive outcomes and sustained impact on families.
The Child Psychologist role (part time to the team 0.5) provides support at training, consultation, assessment and intervention levels to the FRP team. One key development in the last two years has been the offer of VIG to families; this is now a key psychological intervention on offer.
The offer of VIG within a multi-agency team
Families known to FRP each have an outreach worker, acting as the key lead professional to the family. Outreach workers can deliver direct work with carers/parents on aspects of their parenting as well as help them to engage in community services. Each family has a Care Plan co-written between the outreach worker, carers and wider team. This is reviewed every 6 weeks, detailing what targets are being worked on by all in the network.
At the start of my VIG journey, I held twilight sessions and shared several resources to support my team’s knowledge and understanding of attunement principles and information on VIG. Together, the pathway below was developed to support and encourage VIG referrals:
I quickly learnt and experienced that it was through attending Team Around Family (TAF) meetings or even informal consultations with colleagues that VIG was identified for families, rather than colleagues directly requesting this support. Over time, as colleagues experienced VIG more, direct requests were made, which was encouraging and highlighted colleagues’ learning and appreciation of VIG.
In line with principles of FRP in effective multi-agency working, I started to think what this could look like in my team in regard to VIG but still be in line with VIG core principles and practice. Multi-agency working in FRP, helping the network to understand and respond to a family’s complex and sometimes confusing behaviour, underlies the team’s professional practice. The team has received substantial training on Adaptive Mentalisation Based Integrative Treatment (AMBIT), focusing on using mentalisation based practices to support understanding not only of a family but also of the professional network (Bevington and Fuggle, 2012). AMBIT is a team approach in working with clients, in FRP’s case, vulnerable families. AMBIT recognises that the dilemmas professionals have in working with clients with complex needs often generate high anxiety in the worker. AMBIT pays attention to both the worker’s ability to develop a therapeutic relationship with the client but also there is a strong focus on teamwork, incorporating a ‘team around the worker’ approach and not just ‘team around the child’.
Mentalisation refers to the imaginative activity of making sense of the behaviour of oneself and of others on the basis of intentional mental states such as desires, feelings and beliefs (Allen et al., 2018). Almost all aspects of social interaction entail the capacity to mentalise: to understand the other person’s behaviour in terms of the activity that has taken place inside their minds – that may provide a good explanatory model of their actions (Fonagy & Allison, 2012). In regard to many of the families working with FRP, often their behaviour can be very challenging and difficult to understand, therefore mentalisation can be a helpful framework to explore this behaviour and attempt to understand it from the person’s perspective in hope of identifying some ways forward. In addition, mentalisation of different aspects of a professional network is encouraged to support and develop multi-agency working e.g. why may be leading the social worker/school to take X action?
Offering consultations to outreach workers, helping them to reflect and mentalise, often at times on a large and complex network, is a significant part of my day-to-day work. Over time, I became curious as to how VIG interventions on offer could support outreach worker colleagues in helping to mentalise further the parents’ inner worlds. Therefore I was keen to involve colleagues as much as possible in VIG rather than it being seen as a stand-alone intervention.
In VIG Shared Reviews, a key aim of the experience is for the VIG Guider to encourage the parent to mentalise him or herself as well as his or her child in the interaction. This is detailed by Item 12 on the Skills Development Scale, Naming and Receiving the Process. The VIG guider helps the parent to reflect and identify key emotional states, thoughts and behaviours from what is seen on video. However, what is important both in line with VIG principles and with mentalisation based theories is that we can only begin to mentalise when we feel emotionally contained and not at threat. Therefore in the VIG Shared Review, the Guider works hard to receive the parents’ responses, behaviours and emotional states in order to enable a secure and safe space to develop. This may involve naming internal states that the VIG Guider may be experiencing as well as naming responses observed in the parent. In essence, when the parent feels mentalised by the VIG Guider, he or she may be more likely to mentalise his or her child and their relationship.
Contracting VIG with families
In offering VIG now for over 2 years, I have experienced that the more families can identify how VIG may be beneficial for them at the contracting and consent initial stages, the more likely a safe and working space will be developed. FRP works on a consent based model, therefore it is not statutory that parents have to work with the team. However, families can feel ‘directed’ by their social workers or other referrers to comply in working with FRP. This can make it harder for FRP professionals to establish honest, safe and working partnerships with families, if families are feeling anxious and in two minds about working with an intensive home visiting service.
With regard to VIG, I have experienced the importance of gaining informed consent from families for the work providing a space to consider what may be the benefits and risks of engaging in such work. I have found the videos from Kent Psychology Service (https://www.youtube.com/watch?v=YRVaL_ZlxHs) and Bolton CAMHS (https://www.youtube.com/watch?v=dpSHHS_YMLE) really helpful in explaining VIG to families, perhaps more so than any recorded written information. I have found taking one to three sessions to explain VIG, ensuring parents and children have time to ask questions and address the practicalities of the work, very beneficial prior to starting the intervention.
Below are two reflections on cases I have worked with. All names have been changed for confidentiality reasons.
Anya and her three children were referred to FRP from Anya’s social worker due to concerns about some aspects of Anya’s parenting. Anya’s children were on a Child In Need plan due to physical abuse, having previously been on a Child Protection plan. A Child in Need (CIN) Plan is produced for a child who has need of extra support for his or her safety, health or/and development. This is underpinned by Section 17 of the Children Act 1989. Parents can decline access to this support as working with Children Services under CIN support is on a voluntary basis. A Child Protection (CP) Plan refers to the local authority’s assessment findings that a child is experiencing significant harm. A child would be defined under Section 47 of the Children Act 1989 as a child in need of protection; under CP, Children’s Services do not require parental consent for their involvement. The CP plan will name members of a core group of professionals and family members with the social worker as lead professional, setting out steps needed to safeguard the child.
Anya was engaging well with her outreach worker Emily at the time, the children’s school attendance had improved and Anya had started university. Anya could easily become stressed when parenting her middle son Ali, who she described as not being able to listen to her and not following her instructions. Anya’s ‘helping question’ (goal) at the start was for Ali to listen to her instructions more readily; we reframed this through our discussion as ‘How I can speak more calmly and be more calm with Ali?’ Importantly, Anya’s helping question was shared with Emily and the social worker at the time. The purpose of this was to ensure joint working in seeing how the professionals could support Anya working towards her helping question in their own work.
VIG took place within the home and consent was sought from Anya for Emily to take part in the Shared Reviews. In reality Emily was only present for the latter part of the Shared Reviews, as childcare could not be found for the other children so Emily was needed to support in this capacity. We used this experience, which seemed like a barrier at the time, for Anya to show to Emily her favourite clip at the end of our session and to reflect on her reasons together. In this way, I facilitated a space between Anya and Emily for their shared learning to grow. This became a powerful experience for Emily, seeing Anya on film being successful and using particular skills and qualities that were supporting communication with her son. I believe involving Emily in this way also reinforced several of VIG’s core values of trust, hope and cooperation. It also enabled Emily to further understand and make sense of Anya’s internal world e.g. her thoughts and beliefs as a parent, enabling mentalisation of Anya’s emotional states. Through supporting Anya to discuss her strengths, this enabled her to feel more empowered and instil hope that change is possible. Anya’s reflections and learnings were re-enforced in Emily’s direct session later in the week. Emily through her visits was also able to ‘look out’ for Anya’s helping questions and keep them at the forefront of her own work. One particular learning point Anya made was that speaking softly to Ali helped her to feel less stressed and also that repeating instructions to him would often escalate situations. Emily later worked with Anya on the importance of giving clear instructions to Ali and using simple language with him as a follow-up to this learning.
Maria was also referred to FRP by her social worker. Her son Tom was on a supervision order following being on a Child Protection Plan due to Maria’s history of substance misuse. Maria had made great changes to her life as part of her personal recovery enabling Tom to still be in her care. Maria’s confidence as a parent was very low and her concerns about building a positive warm bond with Tom were at the forefront of her mind, given she had lost an older child to the care system. Maria suffered from depression and was keen to ensure her low mood did not interfere with her son’s ability to interact with her. Maria’s helping question was ‘How can I show more playfulness with Tom?’
Maria gave consent for her outreach worker Lisa to be present at the Shared Reviews. A separate consultation was held with Lisa to identify her role in the Shared Reviews. Through this we contracted that Lisa would keep a listening ear to Maria’s reflections and then add her own observations when directly asked. The purpose of keeping to this structure was to ensure Maria’s reflections and ideas were highlighted first, in line of VIG values of respect and cooperation. This structure was overall successful. It was interesting that Lisa’s third pair of eyes always added an additional different reflection and observation. Through the Shared Reviews, Maria’s low confidence about herself and low self-esteem in regard to her physical body came through. The Shared Reviews allowed a space for Maria’s worries and anxieties to be a little more understood by Lisa. As a result, Lisa was able to follow up on these concerns through in her sessions in a sensitive and perhaps more person centred manner as Maria’s thoughts and beliefs about herself were more understood by Lisa. This enabled a more thoughtful and considered approach in identifying support for her in this area, rather than just ‘signposting’ her to services.
Evaluation of the VIG intervention highlighted that Maria felt more confident in her parenting skills and was able to literally ‘see’ that she had a positive and warm rapport with Tom.
In both cases both parents gave consent for their outreach workers to be present throughout the VIG intervention and fed back that this was a positive and supportive experience to them. From the outreach workers’ perspectives, attending the VIG Shared Review sessions helped them to learn more about the parents’ strengths as well as on the parents’ own internal world and that of their children. Both colleagues fed back this helped to give a focus for their own sessions either following up certain areas (such as with Anya, in developing ways to give clearer instructions) as well as addressing new issues that had not yet come to light in their work. These case studies highlight the effectiveness of multi-agency practice when professionals work together to support the parents’ helping questions.
In working alongside my colleagues I was mindful of doing my best to ensure parents could decline having their outreach worker present. I attempted to explore both the benefits and disadvantages or worries in having their outreach worker present prior to the VIG intervention and to support the parent to make their own decision. I felt this was important to address, as some parents could have felt obliged to consent to this. It is possible that despite my attempts, this may have nevertheless occurred for some parents.
Another challenge I encountered in one case was the outreach worker shifted from participation in the Shared Review process, to a potential ‘Guider’. This then meant the session became less in line with VIG Shared Review principles. This highlighted the importance of holding a pre session or sessions individually with the outreach worker helping him or her to identify their role in the Shared Review.
In some situations I felt having separate time alone with the parent and then inviting the outreach worker at the end of the session worked best. It would be interesting to gather further VIG guiders’ experiences in involving other professionals in Shared Reviews and perhaps to gather some feedback on different structures from VIG participants.
VIG evaluations in FRP have been very positive. Feedback from not only parents and their children but also outreach workers and social workers has been gained in line with FRP’s principles of multi agency working.
Several of these families have struggled to engage in community services; therefore the ability to offer VIG in the home and flexibly has been a strength. It is an example of community psychology in action, being flexible in working with parents and families adapting to situations as they arise. In addition, I have experienced that the use of video as a concrete resource has supported parents and their children to reflect, by giving a medium for them to communicate with me. Often, these families have struggled to engage in more traditional talking therapies and models including attending CAMHS sessions. It is as if the video acts as a safe object helping to bridge the relationship between the parent and child but also between myself as a professional and the parent.
In this paper I have commented upon my use of VIG with families involving other professionals in the Shared Review Sessions. Multi-agency working and ensuring interventions are not carried out in silo are I am sure principles most VIG Guiders would believe in. However, the process of involving professionals in VIG can be complex and touches upon ethical issues of consent and power dynamics. I have also reflected on mentalisation based models and its strong links to VIG, in particular the Shared Review Process. Gaining further reflections and experiences from VIG Guider colleagues working in multi-agency teams would be helpful to further develop evidence-based approaches in this area.
Allen, J., Fonagy, P., & Bateman, A. (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Press.
Bevington, B. and Fuggle, P. (2012). Supporting and enhancing mentalization in community outreach teams working with hard-to-reach youth: The AMBIT approach. In Midgley, N. and Vrouva, I. (Eds.). Minding the Child: Mentalization-Based Interventions with Children, Young People and their families (p. 163-186). East Sussex: Routledge
Fonagy, P. and Alison, E. (2012). What is mentalization? The concept and its foundations in developmental research. In Midgley, N. and Vrouva, I. (Eds.). Minding the Child: Mentalization-Based Interventions with Children, Young People and their families (p. 10-34). East Sussex: Routledge
Further information on Troubled Families agenda:
Gibson, H. and Marczak, M. (2018). Video Interaction Guidance- Skill Development Scale (VIG-SDS)