Marte Meo and Video Interaction Guidance – similarities and differences. Landor, M. & Ljungquist, A.

Miriam Landor, National supervisor AVIGuk, miriam.landor@gmail.com

Åse Ljungquist, Licensed supervisor Marte Meo Sweden, ljungquist@icloud.com

INTRODUCTION

Marte Meo and Video Interaction Guidance (VIG) are closely related interventions; the aim of each is help people with their most important relationships, whether in their family, school, hospital, centre or workplace, through micro-analysing and reflecting on video of their interactions in everyday situations. This article has been co-written by Åse Ljungquist (AL; social worker, family psychotherapist, licensed (= VIG national) supervisor of Marte Meo in Sweden) and Miriam Landor, (ML; teacher, lecturer, educational psychologist, national supervisor of Video Interaction Guidance). We came together in November 2018 in Orkney, Scotland, when we co-delivered a Continuing Professional Development (CPD) event for accredited VIG guiders (i.e. practitioners using VIG with their clients) and VIG trainees, where Åse was the guest speaker.  We were fascinated by the similarities and differences between our two approaches, and wanted to share our reflections in the interest of building greater cooperation in the helping professions internationally.

How Marte Meo and Video Interaction Guidance began: Harrie Biemans, Maria Aarts and the Orion programme.

Following their interest in Professor Colwyn Trevarthen’s ground-breaking work on intersubjectivity and the building blocks of attunement, Harrie Biemans, a psychologist, and Maria Aarts, a family support worker, working with children and their families in the Netherlands, developed an intervention to help families develop or repair their relationships. It was at a time when children in care were being returned from residential homes to their birth families, and both children and families needed additional support to build or repair their relationships. This programme was called Orion and it was based on shared reflections and microanalysis of video-recorded everyday interactions. These videos were then edited to extract tiny moments of evident attunement, based on ‘principles’ of attuned interaction. The clips which were discussed in a meeting (called ‘review’ in Marte Meo and  ‘shared review’ in VIG) showed families visual ‘evidence’ that they were already achieving moments of successful interactions, even if fleetingly, thus giving them hope and also a way forward.

In around 1990, Orion then split into ‘SPIN’ in the Netherlands (with Biemans) – now translated into English as Video Interaction Guidance – and ‘Marte Meo’ (with Aarts) – which translates as ‘from my own strength’ or ‘of my own power’.  In 1991 Aarts began training therapists in Marte Meo in Sweden, and in the same year Biemans and colleagues presented SPIN to a conference in Scotland attended by several psychologists, from where training in Video Interaction Guidance cascaded in the UK and beyond.

Benefits for clients, and range of uses including Video Enhanced Reflective Practice (VERP)

Both Marte Meo and Video Interaction Guidance are strengths-based and solution-focused. This focus on showing clients only their moments of success, and none of their negative or ineffective behaviours, is a key difference between these approaches and some others. Our philosophy is that clients learn best from what is going well (even if it is an exception to the usual), and from studying what is already in their repertoire of communication skills; this means that they can learn from their own self-model to do more of ‘what works’.  These micro-moments are edited into brief video clips that show the adult’s sensitive attunement to the child’s need, by following the child’s lead or expression of need.

In Marte Meo the adult follows the child’s focus whether internally or externally directed; in Video Interaction Guidance the first ‘Principle of Attuned Interactions and Guidance’ (PAIG) is to give close attention. In both methods the client has a ‘helping question’ – a self-determined goal they wish to work towards. In family work, this is often about how they can better support their child – in their general development, learning, language, social skills or behaviour for example. Both Marte Meo and Video Interaction Guidance also apply the same principles and methodology when working in other contexts and with other age groups – in schools, residential homes, neonatal wards and so on.  When Marte Meo is used in these situations the person delivering the intervention is called a ‘colleague trainer’. In VIG this approach to supporting the professional development of others can be adapted to become Video Enhanced Reflective Practice (VERP), where participants select their own clips demonstrating their strengths in attunement from their daily work practice, following training.

COMPARING THE TWO METHODS

In Marte Meo the therapist selects the clip with the child’s needs always coming first, which they then connect to the parent’s helping question. The clip selected will be one where the child shares focus with the parent and gets his / her needs received in a supportive way. In Video Interaction Guidance clips are selected with a triple focus – the adult’s helping question, the child’s initiative and adult’s response, and examples of attunement as described in the Principles of Attuned Interactions and Guidance (PAIG).

We decided to jointly micro-analyse a piece of raw video in order to see how much difference – if any – these different starting points made in practice.

A. Micro-analysis of video

We checked how we each micro-analysed raw video by sitting down together with one which had been sent in by a Marte Meo trainee. The film was of a mother and her 18-month-old son (S), playing with blocks together. The mother’s ‘helping question’ was “We would like to not get into so many conflicts”. In the video the mother begins by trying to get her son to match the pictures on the blocks, but ends by stacking them for him to knock over. We found we micro-analysed the video for helpful clips in just the same way – even to the extent of often finishing each other’s sentences while we worked together, watching and re-watching micro-moments in the video. Our vocabulary was sometimes different; for example, in Marte Meo trainees look for the client to ‘confirm’ an initiative by the other – that is, show they’ve noticed or heard, repeat or summarise or name, before responding in an attuned way – which in Video Interaction Guidance is called ‘receiving ‘an initiative. Below are some excerpts from the transcript:

Starting out:

AL: I’m looking for her [trainee who sent video] to choose short sequences where the boy made an initiative and the mother confirmed it and…

ML: As well as looking for a moment where she’s following her child’s initiative, I’m looking for something which is a nice moment, that she’ll enjoy watching, where they’re happy, enjoying together…

AL: Yes an emotion…

ML: …and also I’m looking for a moment that is perhaps the exception to what she often does…

AL: we start the clip with a still picture where there is a real ‘meeting’ between them…

ML: … we have a similar advice – sometimes we tell them to look for just the Magic Moment, the moment that you think ‘oh isn’t that nice’, and then to microanalyse that and work out what made it so nice…

Interaction analysis:

AL: He looks at her and she makes a very big face and it…

ML: Yes she’s really receiving that look

AL: Yes she’s taking it in so that’s in a way a good picture

ML: and then he smiles, he gives a little smile and he moves forward to head-butt the bricks

AL: So perhaps the signal from Mum was yes it’s ok you can head-bump it

ML: yeah you can

AL: That could be something to ask the mother – if she thinks that he

read the signal ‘it’s ok’…  And he turns to…  he says nothing but she said ‘aah’ and she laughs and makes it nice and he’s smiling, he’s enjoying it …

ML: that could be a super clip

AL: from where we started – 122 to 126. You can start here

ML: Yes because by now he’s more interested in…

AL: He says ‘gaga’ and she reacts to that.

ML: That’s a nice short clip as well.

AL: And here S. takes up the block and looks at it…

ML: …and he tells her…

AL: something yeah

ML:… yeah because he isn’t just speaking to the block, he is telling her what it is

AL: yes. And then he

ML: ..throws it away

AL: with the foot, and she looks, and says yes take it

ML: yeah yeah ok so she is accepting that his method of giving it her is maybe not the best but it’s ok

AL: yes. So I think that’s enough for me because that is the crucial thing to show this Mum – that here this is him doing things.

Number of clips in a [shared] review:

ML: 3, 4. And maybe one of those is a still. And sometimes we say – especially if they’re new and they don’t know what to expect, if you start with the still which is easy and simple then that gets them to understand that they’re going to be looking for things which are going well and it gives them a voice and it’s easy to say something… so ok

AL: so that could be good …in order to get to the point where children understand, you have to be near, be following them so they know you are there for them.

ML: yes so I suppose for Video Interaction Guidance what I would hope is that by showing the videos, by getting the parents to see clearly what’s happening, to be able to put into words what’s happening, that I would have to judge how much help they needed to see how this could be applied to their problem [helping question]… and hopefully they might…  if you’re asking the right questions, if the parent is reflective, maybe they can see for themselves that ‘when I follow him it goes better, he is in tune with me I am in tune with him and then we don’t have conflict’.

B. The underpinning principles

Both Marte Meo and Video Interaction Guidance use a framework of ‘principles’ to guide them in their selection of video clips for their client:

Marte Meo – Developmental Principles (Samspelets kraft 2012 Hedenbro Wirtberg) Video Interaction Guidance – Principles of Attuned Interactions and Guidance (2011 Kennedy Landor & Todd)
Common focus.   The adult seeks information about the child and where the child has his/her attention and/or what initiative the child makes                     1. Being attentive  e.g. Looking interested with friendly postureGiving time and space for otherTurning towardsWondering about what they   are doing, thinking or feelingEnjoying watching the other  
2. Encouraging initiatives e.g. WaitingListening activelyShowing emotional warmth through intonationUsing friendly and/or playful intonation as appropriateNaming what the child is doing, might be thinking or feelingNaming what you are doing, thinking or feelingLooking for initiatives
Confirming   The adult confirms the child – the child’s attention-focus, initiative and adds his/her own reaction   3. Receiving initiatives e.g. Showing you have heard, noticed the other’s initiativeReceiving with body languageBeing friendly and/or playful as appropriateReturning eye-contact, smiling, nodding in responseReceiving what the other is saying or doing with wordsRepeating/using the other’s words or phrases  
Tuning in   The adult awaits the child’s response / response to this reaction.   Naming   The adult is naming the child’s initiative, action, reaction, response and emotions in a way that is confirming for the child   4. Developing attuned interactions e.g. Receiving and then respondingChecking the other is understanding youWaiting attentively for your turn.Having funGiving a second (and further) turn on same topicGiving and taking short turnsContributing to interaction / activity equallyCo-operating – helping each other
Guiding   The adult takes responsibility for the interaction so that it is formed into several turn-takings and a rhythm that enables the child to actively participate in this interaction   Confirming   The adult confirms the child as it shows desired behaviour   5. Guiding e.g. ScaffoldingSaying ‘no’ in the ‘yes’ cycle (attuned limit setting)Extending, building on the other’s responseJudging the amount of support required and adjustingGiving information when neededProviding help when neededOffering choices that the other can understandMaking suggestions that the other can follow
Guiding, confirming, common focus – the adult’s responsibility   7. The adult triangulates the child to the outside world by naming persons, objects and phenomena 8. The adult gives clear start and end signals 9. The adult is responsible for the emotional climate   6. Deepening discussion e.g. Supporting goal-settingSharing viewpointsCollaborative discussion and problem-solvingNaming difference of opinionInvestigating the intentions behind wordsNaming contradictions/conflicts (real or potential)Reaching new shared understandingsManaging conflict (back to being attentive and receiving initiatives with the aim of restoring attuned interactions)
N.B. Sometimes you may see examples of every point in just one micro-sequence [clip]    

C. Review (Marte Meo) / Shared review (Video Interaction Guidance)

Marte Meo: reviewing checklist for the Marte Meo therapist or guider

  • Sit so you can see both the screen and the person you’re showing the clips to.
  • Always start by expressing or demonstrating emotional warmth both verbally and nonverbally.
  • Use the person’s name.
  • Give the context  – what you are going to do during the review.
  • Repeat the parent’s/staff member’s question and your starting-point for the intervention.
  • Name what you are doing and have a neutral tone of voice when you give the information.
  • Be attentive to any initiative, both verbal and nonverbal, made by parents/staff during the review.
  • Always stop the video when you or parent/staff are talking.
  • Use your tone of voice and a tempo that keeps the parent’s/staff member’s attention.
  • Make your interaction analysis very clear: let the picture speak.
  • Allocate the appropriate Marte Meo principle to the clip you just have been showing.
  • Wait for a reaction. Look at the person and try to create a dialogue.
  • Link your clip to the meaning it will have for the child’s development, both in general and more specifically.
  • Share any emotions which arise. Deepen the dialogue if possible and confirm [receive] strongly all self-reflections from parent/staff.
  • Don’t talk about the video-picture. Show it.
  • Agree upon a working point always connected to the helping question for the next video session

(From Marte Meo Basic Manual – see Reading list)

Video Interaction Guidance: the shared review

Preparation (points to check in no set order):

  • Are the chairs set in an ‘interaction triangle’?
  • Have I micro-analysed the video?
  • Have I checked that my client is ready to start?
  • Have I explained what I plan to do?
  • Have I negotiated the purpose of the shared review?
  • Am I ready to receive my client’s initiatives?

Frameworks:

The Association of Video Interaction Guidance UK (AVIGuk) is in the midst of moving from the previous framework ‘Seven steps for a shared review’ to piloting a series of competencies called ‘Skills Development Scale’ (SDS).

The Seven steps are:

  1. Naming what you are about to see and explaining purpose. Looking at the video-clips
  2. Open tentative questions or sharing what you see
  3. Watching and creating space for the client’s response
  4. Reception of the client’s response. Mindful response to your own feelings. Respond naming your own thoughts or build on the client’s ideas
  5. Checking for reception of your statement. Support the client to think about it
  6. Continue giving and taking short turns between you, your client and video-clip
  7. Deepen discussion by exploring thoughts and feelings. Moving to possible new narratives about self, other and relationship

At each turn you judge if you want to give information or give space, or activate, possibly using video-clip.

The SDS are currently being piloted and may be amended at the end of this period; they currently cover: Identifying attunement principles / microanalysis*; establishing and revisiting the purpose of the shared review; use of video technology to maximise client activation*; embodiment of AVIGuk values and beliefs*; attuned dialogue*; attuned guiding*; pacing; naming and managing emotions in shared review; working with power; reviewing the shared review; co-constructing new meanings*; naming and receiving the process; widening the context (* = core SDS).

It should be understood that (at time of writing) Video Interaction Guidance itself has not changed; the principles behind it, methodology and values and beliefs stay exactly the same. All that is changing in this pilot is the training programme (see next section) and the wording of the frameworks for evaluating Video Interaction Guidance skills.

D. Differences in education / training model

The main differences between Marte Meo in Sweden and Video Interaction Guidance in the UK lie in what in Marte Meo is called ‘education’ and in Video Interaction Guidance is called ‘training’.

Marte Meo education

For Marte Meo trainees in Sweden, four terms over two years are taken up with monthly full-day group supervision sessions. The ‘reflective team’ method is used, whereby each trainee has a turn to work one-to-one with the supervisor on the video they have brought, whilst the other group members observe and reflect back to the group, thus maximising the learning of all.

Each term has a different focus. In the first term trainees work with video taken in families where interaction is normal and where there is no helping question. They practise microanalysis to identify clips that begin with the child making an initiative to the adult, with the adult responding in an attuned way – confirming (or receiving) the child’s initiative. In the second term the trainees start their work with families who are seeking treatment or have been recommended by the social services. For these beginning stages video clips are always shared with the supervisor before being taken back to the family for the review meeting.

As part of their final accreditation trainees write a paper reflecting on one or more concepts from their training period and describing how they use them in their work. The trainee has to work with at least 5 different casework families during those 4 terms. At their certification [accreditation] they have to show 2 of their casework families in an edited video-presentation and also deliver 5 written reports of their work with families or staff.

Video Interaction Guidance training

Trainees registered with the Association of Video Interaction Guidance UK usually work 1-1 or in pairs with their supervisor, often at monthly intervals.  Three stages of training, usually taking about 18 months, each with a pre-stage training session and a post-stage transition or final accreditation meeting, have recently been replaced with a pilot scheme of a shorter training period. The new Video Interaction Guidance pilot training uses the SDS as evaluation and consists of a minimum of 15 hours supervision with a mid-point review day and final accreditation.  This training can be followed with an optional ‘advanced’ stage.

Conclusion

Once we had clarified the meanings of some of our different terminology we were surprised to find how similar Marte Meo and Video Interaction Guidance remain after all these years – in the aims, philosophy and methods we both use. This has been a fascinating twinning exercise across the North Sea!

Reading list

Marte Meo method for school: supportive communication skills for teachers, school readiness skills for children 2006 Josje Aarts. Eindhoven: Aarts Productions.

Marte Meo Basic Manual, revised 2nd edition, 2008 Maria Aarts. Eindhoven: Aarts Productions.

Samspelets kraft 2012 Hedenbro Wirtberg

Marte Meo and coordination meetings: MAC. Cooperating to support children’s development. 2013 Ingegerd Wirtberg, Bill Petitt, Ulf Axberg. Tryck: Palmkrons förlag.

https://www.weforum.org/agenda/2018/02/how-you-talk-to-your-child-changes-their-brain/

‘Video Feedback Intervention With Children: A Systematic Review’ 2016

Stina Balldin, Philip A. Fisher, and Ingegerd Wirtberg. In Research on Social Work Practice 1-14, Sage.

‘Video Interaction Guidance (VIG) in Scottish schools’ 2011 Miriam Landor. In Verbondenheid in beeld: 10 jaar School Video Interactie Begeleidung (Connected through pictures) Retro Perspectief volume 3. ed. Hans Jansen. Amersfoort: Uitgeverij Agiel.

Video Interaction Guidance: a relationship-based intervention to promote attunement, empathy and wellbeing 2011. Eds. Hilary Kennedy, Miriam Landor, Liz Todd. London: Jessica Kingsley Publishers.

Educational Psychology in Scotland. Special issue: Video Interaction Guidance, 15:1 2104. Ed. Miriam Landor.  Leicester: The British Psychological Society. 

Video Enhanced Reflective Practice: Professional Development through Attuned Interactions 2015. Eds. Hilary Kennedy, Miriam Landor, Liz Todd. London: Jessica Kingsley Publishers.

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Reflecting on the importance of being present through use of Video Enhanced Reflective Practice (VERP): Tucker and Soni

Reflecting on the importance of being present through use of Video Enhanced Reflective Practice (VERP)

by Megan Tucker and Anita Soni

VERP is an application of Video Interactions Guidance (VIG), and is now more frequently termed VIG with professionals. It is a strengths based approach which enables professionals to analyse their practice to reflect on ways to improve their communication, therapeutic or teaching skills through shared review of video clips of attuned interaction in their everyday practice (Kennedy, Landor and Todd, 2015). VIG and VERP are based on the values of respect, trust, hope, compassion, co-operation, connections, empathy and appreciation, and both utilise the same principles of attuned interaction and guidance. The principles emphasise the importance of waiting attentively, encouraging initiatives from the child and following the child’s lead through receiving their initiatives as the basis to intersubjectivity. It is anticipated the child-learning mentor relationship and the VIG guider-client relationship mirror each other in terms of communication within an attuned relationship.

Meg and Anita started using VERP as a way of reflecting on practice in January 2018. Although Anita had used VIG with parents, this was Anita’s first experience of using VERP with a Learning Mentor in a primary school and Meg’s first experience of VERP. Meg as a Learning Mentor provides support and guidance to children and young people to help them overcome social, emotional and behavioural problems which act as barriers to their learning. She bridges academic and pastoral support roles, through building professional helping relationships with pupils, ensuring that individual pupils and students engage more effectively in learning and are participating in the life of the school.

The following account has been written to reflect on the idea of ‘presence’ and what this came to mean to us, both for Anita as a VIG guider and Meg as a Learning Mentor.

Anita: I had been keen to develop the use of VERP within a primary school. The Headteacher encouraged me to present information about VERP within a staff meeting, and then for staff to choose to volunteer. Two staff offered to try using VERP, and due to difficulties with cover for both staff at the same time, it was agreed to work with them individually.

Meg: My focus was within the context of individual mentoring sessions. I had been seeing children in small groups and individually for 18 months but felt unclear as to how effective I was being.

Anita: I was excited to work with Meg as I have been using group supervision with Learning Mentors for the past six years, but felt it was time to develop new ways of working. VERP seems to offer a valuable opportunity for Learning Mentors to reflect on their communication and attunement to the children they work with.

Meg: The VERP process provided the opportunity to assess my interactions more objectively and positively, as my tendency is towards a negative view of the way I work. It also gave me an opportunity to consider the responses and cues of the children I was working with.

Anita directed me to the positive features of the clips we looked at. It’s strange that something so simple can be such a revelation. After the initial session I felt affirmed that I did have positive interactions with children and we could identify the ways in which these were created e.g. eye contact, timely nods or acknowledgements, using the child’s own language and repeating their own phrases back to them, amongst many other small positive communications both verbal and non-verbal.

Initially when watching the clips my attention was on myself, partly because it’s strange to see yourself and because I wanted to see what I thought about how I was working on playback. But over time I became more interested in the impact of my actions on the child.

Anita: I was aware from the initial training session, and other experiences of VERP and VIG, that there can be a reticence to watch yourself back on camera. I was also aware that the focus on better than usual moments can be challenging as one of the teachers had queried it in the staff meeting. I admit to having been unsure of both of these issues myself at the beginning of my training on VIG, but gradually through my own supervision and further experience, I had become more certain of the approach.  I hoped to open up dialogue on both issues in the training, but was uncertain I had answered in a way that was helpful and not defensive. I also felt that both of these concerns can only be fully answered through experiencing VERP yourself!

Meg: I had understood from the staff meeting that the aim of VERP is to identify the positives in what you are already doing and then build on them. Certainly that was my experience. I realised I was using lots of helpful strategies to good effect. In identifying the strengths in how I interacted with children I was able to apply those strategies more intentionally and consider how to build on them to engage in deeper more reflective conversations.

However, although the focus is on strengths, whilst watching a clip I realised I wasn’t always present in the moment and this provoked me more than any other observations to think about my practise in the individual mentoring sessions and about what my intention should actually be.

While watching a clip with Anita I realised I had missed a cue from a child as they tried to volunteer a comment.  I missed the moment. Similarly Anita commented on a facial cue from a child which I hadn’t registered. On further reflection I realised I hadn’t missed these opportunities because I was looking the other way or setting up an activity but because in my mind I was busily thinking about something that had just happened and also about where I wanted to get to in that session. Looking at myself in the clip, I appear present but there was a short section of the clip I couldn’t actually recall. I realised I had been on autopilot at various points.

Watching myself there were times when I could see myself disengage momentarily from the interaction. I worked out this was when I was thinking on my feet as I assessed how to respond to what the child was saying or maybe reviewing something from before the session or planning ahead to my next task. Previously I had been unaware of this shift in my attention.

Anita: I remember this as a key point in the second shared review with Meg. I was so impressed at Meg’s ability to reflect on herself, and her honesty in her reflections. I was genuinely curious to hear what she thought!  It made me also stop and reflect on what engagement or presence is. It also made me stop and consider my own presence in work more generally, and specifically within VIG and VERP, and the points at which I was most present. I reflected that I find it easier to be present and fully engaged in the discussion as I have become more confident with VIG and VERP. However in VERP, I find I have to be more present as I don’t know what is coming. As an Educational Psychologist, I sometimes would over-prepare for meetings, and would have defined thoughts on where I felt the discussion should go and the outcomes of a successful meeting.

This led to a deep discussion on presence and how difficult this can be in the face of the pressure of measurable outcomes. I have been a teacher, and now spend time observing in nurseries and schools. Meg too is a teacher, and we are both highly aware of the pressure on outcomes, and moving children on in their learning.

Meg: Yes, as measuring outcomes has become so important in education, I have become more focussed on an outcome than what is currently happening in the room. I plan activities to achieve an objective, so I can show that I have addressed a particular issue. Or perhaps I perceive a number of steps I feel it would be helpful to progress the child or group through, but my attention is more on completing the current step in order to move onto the next one, rather than the children.

Anita: I was curious to consider how we can be both available and attentive, but yet hold in mind other key ideas.

Meg: I know it’s important to be planned and have an aim in mind but it’s equally important to be conscious of how that can steal my attention away from the current situation. It’s natural to have moments where you have to think on your feet. Watching my VERP clips I can spot my ‘thinking on my feet’ face.  Seeing this in the clips I am more conscious that I may need to re-engage or still be watching for communication cues from the child, even as I try to strategize on the go.

I’ve also realised that it helps me to take a moment or two to collect myself before I start a session. I am then more able to leave aside what has just happened or will be happening later so I can focus on the present moment. Also meeting up with other mentors at school to talk and support each other as a sort of debrief has helped me stay present when working with a child.

Anita: Yes, we discussed practical ways of managing being fully present as this is when time can race past, but can also be emotionally quite draining. In some ways, I reflected that having a focus on an outcome can feel safer and easier!

Meg: The VERP process has also made me think about how the activities I plan can facilitate interactions and gently provoke more reflective and deeper conversation. Previously the exercise was often more about completion within a time frame. I’ve realised that it is hard work to enable easy conversation and that there’s real value in giving a child room to chat and respond in their own time. This can then naturally lead to a child volunteering more reflective responses. I’m learning to provide more opportunities to chat whilst engaged in an activity, as this seems to encourage or allow the child to lead the conversation but doesn’t have to have a strict focus or outcome.

Anita: This particular use of VERP has helped me reflect on how I further support staff working in schools to take a different perspective on outcomes. As Vermeulen, Bristow and Landor (2011) highlight ‘…an essential part of VIG guiding is being present in the here and now’ (p. 267) and is modelled for the parent. When using VIG with professionals or VERP, this same presence here and now is vital, but may contrast with approaches traditionally taken within my own field of education. I have come to see this mindful presence as not only central to VIG and VERP, but also highly applicable to other aspects of my work as an EP. However, alongside this, I have to recognise that it contradicts dominant models within education policy and practice, where the focus is on progress towards outcomes identified by teachers from within the curriculum. This in turn means this may be a very new way of thinking for professionals within education, although could be said to be aligned to person-centred planning. For me, I have come to realise that the discussion itself is the outcome, and if I (and indeed the Learning Mentor I am guiding) focus on being fully present then the outcomes will emerge.

Kennedy, H., Landor, M. and L. Todd (2015) Video Enhanced Reflective Practice: Professional Development through Attuned Interactions, London: Jessica Kingsley Publishers

Vermeulen, H., Bristow, J. and M. Landor (2011) ‘Mindulness, attunement and VIG’ in Kennedy, H., Landor, M. and L. Todd (eds) Video Interactive Guidance: A Relationship Based Intervention to promote Attunement, Empathy and Well-Being, London: Jessica Kingsley Publishers

 

Review of Conference Workshop: VIG with Mothers and Babies (Natasha Gray). By Pardoe, R.

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.”

References

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).

The benefits of a Video Interaction Guidance workforce that reflects the ethnic, cultural and linguistic mix of the community: Larvin, M

The benefits of a Video Interaction Guidance workforce that reflects the ethnic, cultural and linguistic mix of the community

Video Interaction Guidance (VIG) is a strength based intervention to help improve communication and interaction between at least two people. Video is taken of the interaction and then this is edited to show particular moments of attunement which are then shared with the person seeking help. This ‘shared review’ of the film is a skilled conversation where micro-moments of interaction are analysed to see what is working well and this can be a catalyst for change.

In Tower Hamlets, VIG has been used in many settings, for example, to help improve the quality of contact between parents and children who have been placed in Local Authority care and to support assessments pre or during care proceedings; within the Education Psychology service including working with teachers and teaching assistants and their pupils; and within Child and Adolescent Mental Health Service, Disabled Children’s Outreach Service, Parental Engagement Team and Children’s Centres to support parent/child relationships.

Tower Hamlets is a diverse borough in East London, where 32% of the population at the 2011 census identified themselves as Bangladeshi and 31% White British; the other 37% being a combination of all different ethnicities with ‘White Other’ being the next biggest category (London Borough of Tower Hamlets 2013). Encouragingly, the workforce within the Local Authority reflects this ethnic mix with a lot of staff both living and working in the borough; approximately 55% of the Council employees are from a Black or Minority Ethnic background (Cooke 2016). Up until 2015 however, the staff training in VIG within the borough did not reflect this ethnic, cultural and linguistic mix.

That changed when a decision was made to train 12 staff from the Children’s Centres along with two in the Parental Engagement Team and two additional staff in the Disabled Children’s Outreach Service. Of this cohort, nine were of Bangladeshi heritage, three were White British, two were Black British or dual heritage, one was White South African and one White Australian. This was not by design – no conscious decision was made to recognise a previous gap and pro-actively train Bangladeshi workers, it just happened this way. A sociological or social policy perspective on this may highlight the multiple disadvantages that are often faced by people, especially women, from Black and Minority Ethnic backgrounds which may explain why more Bangladeshi staff were found in the lower paid Children’s Centre cohort – but that’s for another paper!

My experience of seeing how VIG is offered in the UK when English is not spoken by the family or person seeking help, is that an interpreter is used – that is certainly how I have undertaken my VIG work. With an intervention based so much on film, it may be easy to think that this would be fine, and indeed I am aware of lots of high quality VIG work that has taken place using interpreters. However, the purpose of this paper is to hear some different perspectives on the value that gets added when VIG is offered by people who share the same language, cultural or religious understanding as those they are offering VIG to; as well as share some learning that has happened along the journey!

Reflections from Ruhul Tapader, Early Intervention Worker (Family Support) in the Children’s Centre:

“I am an Asian British male of Bangladeshi heritage, and speak Bengali and Sylheti as well as English. I am so pleased to be able to offer VIG in Bengali and Sylheti because so many parenting programmes or parenting information is in English which means that some families miss out. However, I have found it isn’t just the ability to undertake VIG in a family’s first language that I can bring to my VIG work, but my shared cultural and religious background too. For example, in my experience a lot of the Bangladeshi families in Tower Hamlets have a different understanding of play than childcare professionals. It would not be uncommon within Bangladeshi families to think children play by themselves or with each other, but that there is no role for the parent to support a child’s development. I have been able to challenge that idea and help parents to see on film how beneficial it is for children when parents get involved in their child’s play.

Additionally, within Bangladeshi culture there can be different understandings of what causes difficulties for children, for example a belief in the “evil eye” or “jinns”, and this can lead to a belief that nothing can be done. Being a trained Family Support Worker and (trainee) VIG Guider gives me the confidence to challenge some of these ideas, but from a starting point of understanding where the beliefs are coming from.

Being a male Bangladeshi VIG Guider has been particularly helpful, because (like in a lot of cultures), there is often a tendency to view caring responsibilities as the mother’s role. I can encourage men to get involved with their children, and can speak with authority because I am from the same background. I understand that mothers may not want to be filmed or may feel they need permission from their husband. As a male, it is easier for me to talk with the husbands/fathers and when I work with them, they will usually encourage their wives to get involved. It would have been much harder for a female to engage some of the families I have undertaken VIG with.

I also bring an understanding from a religious perspective around filming, because I understand the teachings around modesty. However, I also understand that within Islam, there can be permission to film when it is necessary and beneficial, in the same way that seeing a Doctor would equally be permissible. I recognise the importance of offering reassurances that film will be deleted afterwards and will not be shared beyond the work being offered.

Sina Akter, Parent and Family Support Practitioner in the Parental Engagement Team has a similar story of success to tell. She writes:

“As we know, Video Interaction Guidance works for everyone. However, I have found that the intervention is great for non-English speaking immigrants because of the universal power of images. Although we have the option to deliver programmes in community languages, I still see that many parents find it hard to understand some systems and cultural aspects of this country. In such cases VIG is much more helpful.

One of my cases was a mother who was struggling with multiple problems with her teenagers who are subject to a Child Protection plan; one had been taken in to care. In particular, the mum was having a difficult time as she was anxious about the possibility of her youngest boy being taken to care. This 6 ½ year old needed more attention to his wellbeing within this household. Mum looks after the children full time and has lived in this country for a long time but has no UK education and only has primary level Bangladeshi education; she speaks Bengali.

In my introductory visit, mum looked unsure about what was going on but she was cooperative throughout the programme. The parent’s first thoughts around a helping question were, ‘how do I make my child listen to me?’ which needed some re-framing, and ‘how do I spend quality time with my child?’ So far I have done three complete cycles of filming. Through micro-analysing the clips during the shared reviews, the mum was able to realise the benefits of child led interaction and she was enabled to see where she was attuned to her child.

I have noticed an increased positive outlook in mum’s interactions with her son that helped build her confidence. She has spoken positively about the effectiveness of the VIG intervention. Now she values spending quality time with her son as she recognises the impact this has on their relationship, which ultimately has led to him being more responsive. By the end, I saw a happy parent-child relationship where mum often praises the child, allows him to take initiatives, listens to and helps him. It seems this interaction has helped to improve his self-esteem and happiness.

The mum underwent a parenting assessment by the Local Authority where she was able to adequately evidence good enough parenting capacity, including to the Court. She was successful and now her son lives with her. It is my view that it is the VIG intervention alongside other interventions that has helped her to achieve this success”.

Through supervising Bengali speaking staff in their VIG work, we have also had to reflect on some of the challenges of working in another language, as Rozina Aktar, an Early Intervention Worker (Family Support) in the Children’s Centres writes:

“Undertaking VIG with Bangladeshi families whether in Bengali or English has been an interesting but challenging experience at times. It has been an advantage to speak both languages, because there have been times when I am talking with Bangladeshi families in English and the words they use do not directly reflect what they mean. Because I speak both languages, I understand what the parent is communicating because I can see how the “mistranslation” has happened. If I only spoke English, then I may have taken what they said literally which could have led to misunderstandings.

However, some difficulties have emerged because there are lots of words in English that don’t translate easily into Bengali and vice versa. Although with my Bengali speaking clients I have managed to show families progress, it has sometimes been a difficult journey for clients to articulate themselves deeply. For example, the most common word to describe feelings in Bengali is the word ‘kushi’ which would be translated into English as happy, but is used more generally than that. I started to put a lot of thought into other possible words in Bengali to describe emotions and would try to offer these words to parents, as a possible way to explain how they or their child may be feeling; but more often than not, the parents would look very blank. At first I thought they were not taking much of an interest, but realised as I was doing VIG with more Bengali speaking families that there may be another explanation.

Although I was trying to find alternative words to describe feelings, these are not commonly used, and I began to realise that the families were not actually understanding these words in Bengali. I became aware that even when speaking in the same Bengali language that I need to be mindful about the parent’s level of understanding. This is especially the case for the families living in Tower Hamlets who have sometimes come from Bangladesh with only a primary level of education and so use quite basic language; using an interpreter would not have been helpful as it wasn’t the translation that was the issue! This has made it really difficult at times to tease out more subtle feelings and thoughts that the parent may have. However, I have learnt that by asking the parents in Bengali about their thoughts rather than feelings, this has led to much richer conversations. This is an area I am keen to explore and put more thought into as I continue to offer VIG to Bengali families”.

As the VIG supervisor of Ruhul and Rozina,it has been a really rewarding learning experience for me to be supervising Bangladeshi staff who are often undertaking their work in Bengali without the need for an interpreter. It has been particularly interesting to reflect with Rozina as she worked through the frustration of how to move beyond “kushi” as a way to describe feelings; and this has been really helpful learning that I have been able to share with non-Bengali speaking VIG Trainees in their work with Bangladeshi families.

I was interested to learn more about how Rozina’s reflections about language is supported by the work of linguistic anthropologists. In an interesting article by Benoid (2014) he shares how Hawaiians have 65 words for fishing nets and 108 for sweet potato! Hawaiians may therefore struggle to communicate which type of sweet potato they are referring to if trying to translate this into English! Other cultures have developed language to describe concepts that do not really exist in British culture – the word “mmbwe”, from the Venda language of South Africa, for example, refers to “a round pebble taken from a crocodile’s stomach and swallowed by a chief”; or “nakhur” the Persian word that describes a “camel that gives no milk until her nostrils are tickled”. People familiar with these languages may find it surprising that there is no direct translation into English! Interestingly, other concepts are more universally understood, yet do not necessarily have their own word in major languages – “wo-mba”, for example, from the Bakweri language spoken in Cameroon is a beautiful word to describe the smile on a child’s face whilst sleeping.

It is fascinating to consider how language develops contextually, and that there is a richness in all languages. Where that richness lies may be explained at least in part, by what is needed in the context it is developed. This is a good reminder that when undertaking VIG in a different language and needing to use an interpreter, there may not actually be the words to describe what we or those we’re working with want to say.

It has also been really helpful to hear Bangladeshi staff add more meaning to what they are seeing, perhaps recognising some additional significance in the interaction than I would. An obvious example is seen in the area of feeding. Bangladeshi families often like to feed their children using their hands, even when the child may be of school age. This would look strange and usually be frowned upon in the White British culture that I am from, but Bangladeshi staff can see this through a helpful contextual lens that starts with understanding that feeding in this way is viewed as a very nurturing part of care. They also recognise that making sure children are well fed is particularly key to families who have grown up in a country with significant poverty. Thus clips are looked at with more respect for what may be ‘better than usual’ moments than may happen without this level of understanding.

One other area of learning for me as a supervisor is more practical. When I undertake VIG with families using an interpreter, I am aware that the shared review may take longer. However, I realised I had not factored in that VIG supervisions often need to be a bit longer, if a VIG trainee is needing to translate what is being said in the film in order to help understanding. I realised that what was often happening initially was that we were spending most of the session just understanding what was going on verbally in the clip, and that there was less time and space left to reflect on what the VIG trainee and parent were doing, thinking and feeling in what we were seeing. I have had to allow longer for supervision sessions where the film is not in English, but I have also had to be a bit more intentional in not getting too bogged down in what was said before moving on to thoughts, feelings and new meanings. This may be something for other supervisors to factor in when setting up contracts and expectations about VIG supervision if shared reviews are not taking place in English.

In summary, I hope this article has provided food for thought in relation to what can be gained when VIG is offered by people that share certain aspects of identity with the community they are working with. Whilst the power of the visual image is undisputable, we know that it is the skilled conversation around this that can help to develop the new meanings that are being created. When this is facilitated by a VIG guider who understands both the first language and how this may look when translated in to English, the risk of misunderstandings are reduced and subtleties more easily received. When there is understanding of the religious and cultural context of a family, there is an even greater likelihood of VIG being offered in a way that the family feels respects and honours their beliefs which increases the potential to explore new meaning. There is also an opportunity to notice interaction that takes on a new significance when seen through a particular cultural lens, that could otherwise go unnoticed. These are all important components that can help with embodying the AVIGuk values and beliefs.

The expertise of the VIG workers sharing in this article have also helped recognise the subtlety of language that sometimes, quite literally, gets lost in translation; and that sometimes there are no words, or the words there are, are not fully understood. It is good to be reminded of the need to adapt our communication style accordingly, rather than assuming the difficulty is solely about poor translation.

I believe there is still lots to learn for those of us who are supervising VIG work that is undertaken in a different language to our own – how we find ways of allowing enough time to ensure there is both an accurate understanding of what has been said verbally, but also enough space to explore thoughts, feelings and new meanings. And for those who are involved in making decisions about who should be trained in VIG within an organisation, I believe this article is an encouragement to look at the demographics of those who we are working with and recognise the added value that can be gained from ensuring the workforce reflects this.

References:

Boinod (2014): https://www.theguardian.com/education/2014/apr/29/what-vocabularies-tell-us-about-culture

Cooke, Z. (2016) Non executive report of the General Purposes Committee: Workforce Diversity.

https://democracy.towerhamlets.gov.uk/documents/s91412/Workforce%20Diversity.pdf

London Borough of Tower Hamlets (2013) Ethnicity in Tower Hamlets: Analysis of the 2011 Census. https://www.towerhamlets.gov.uk/Documents/Borough_statistics/Ward_profiles/Census-2011/RB-Census2011-Ethnicity-2013-01.pdf

Evaluation of the use of Video Interaction Guidance in CAMHS

By Rachel Pardoe, child and adolescent psychotherapist

Acknowledgments

With thanks to VIG trainees Nancy Shelton, Amanda Stirling and Jenny Griffiths for their commitment to VIG and for contributing data to this evaluation.

  1. 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.

  1. 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.
  2. VIG practitioner takes a short film recording (5-7 minutes) of parent and child interacting/playing together in their ‘normal’ way.
  3. 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.
  4. 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.
  5. 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.

  1. At the start of the VIG cycle: where they think they are now in relation to this goal
  2. Where they would like to be after this VIG cycle
  3. 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 Results

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
Cycle 139
Cycle 214
Cycle 35
Male23
Female16
Average age2.4 years*
Under 2 years8
Total no. of Mothers35
Total no. of Fathers3
Nursery staff1

*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 changeAverage overall change across all cyclesAverage change for clients who completed 3 cycles
Cycle 13.1
Cycle 22.5
Cycle 32.6
3.45

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.

Case C

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”

Case L

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.

Case P

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.

Before VIG:

“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.

Case A

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.”

Case E

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” 

Case F

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.”

Case K

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.”

Case N

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.

Case J

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.

2.6 Discussion

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.

Methodological Issues

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.

  1. 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.

4. References

Ainsworth, M. (1978) Patterns of Attachment: A Psychological Study of the Strange Situation. New Jersey: Lawrence Erlbaum.

Barrows, P. ‘The importance of the parental couple in parent-infant psychotherapy’. In Barlow, J. & Svanberg, P. Eds. (2009) Keeping the Baby in Mind: Infant Mental Health in Practice. Routledge. pp 77-86.

Beebe, B. (2003) ‘Brief mother-infant treatment: psychoanalytically informed video feedback’. Infant Mental Health Journal, 24 (1): 24–52.

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.

Clulow, C. (1982). To Have and to Hold: Marriage, the First Baby and Preparing Couples for Parenthood. Aberdeen: Aberdeen University Press.

Cowan, C.P., Cowan, P.A., Heming, G., Garrett, E., Coysh, W.W., Curtis-Boles, H. and Boles, A. (1985). ‘Transitions to parenthood: his, hers and theirs.’ Journal of Family Issues 6, 451-481.

Fonagy, P. et al (1995) ‘Attachment, the reflective self, and borderline states: the predictive specificity of the Adult Attachment Interview and pathological emotional development’ in S. Goldberg et al (eds) Attachment Theory: Social, Developmental. And Clinical Perspectives. Hillsdale, NJ: Analytic Press. pp 233-278.

Fonagy, P. & Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues, 8(1), 87-114.

Fonagy, P., Gergely, G., Jurist, E.L. and Target, M. (2002) Affect regulation, Mentalization, and the Development of the Self. New York: Other Press.

Jarvis, J. (2011) ‘VIG and Attachment: Theory, Practice and Research’, in Kennedy, H. et al Video Interaction Guidance: A relationship-based intervention to promote attunement, empathy and well-being. Jessica Kingsley.

Jones, A. (2006) ‘Levels of change in parent-infant psychotherapy.’ Journal of Child Psychotherapy Vol. 32 No. 3, 295–311

Kennedy, H. (2011). What is Video Interaction Guidance? In Kennedy, H., Landor, M & Todd, L. Video Interaction Guidance: A relationship-based intervention to promote attunement, empathy and well-being. Jessica Kingsley.

Kennedy, H., Ball, K. and Barlow, J. (2017).  How does video interaction guidance contribute to infant and parental mental health and well-being? Clinical Child Psychology and Psychiatry 1-18.

Meins, E., Fernyhough, C., de Rosnay, M., Arnott, B., Leekam, S. R. & Turner, M (2012). Mind-mindedness as a multidimensional construct. Infancy 17(4): 393-415.

Pardoe, R.  ‘Integrating Video Interaction Guidance (VIG) and Psychoanalytic Psychotherapy in Work with Parents and Infants’. Bulletin of the Association of Child Psychotherapists (ACP), May 2016 (also in Attuned Interactions, September 2016)

Parr, M. (1996). Support for couples in the transition to parenthood. Unpublished PhD thesis. University of East London.

Stern, D. (1977). The First Relationship: Infant and Mother. Developing Child Series, Eds Bruner, J., Cole, M., Lloyd, B. Harvard University Press.

Trevarthen, C. ‘The Foundations of Intersubjectivity: Development of Interpersonal and Cooperative Understanding of Infants.’ In Olson, D. (ed) The Social Foundations of Language and Thought: Essays in Honour of J.S.Bruner. New York, 1980.

Tucker, J. (2016). ‘Seeing is Believing: using video-feedback in parent-infant psychotherapy to help change parents’ and babies’ negative representations of themselves’. Unpublished paper.

Conference Key note Review: Professor Colwyn Trevarthen: The Lively Human Nature of Relationships in Family and Community

Professor Colwyn Trevarthen: The Lively Human Nature of Relationships in Family and Community

Review by Rachel Pardoe, Child & Adolescent Psychotherapist

Introduction

Professor Trevarthen delivered a fascinating presentation to the Video Interaction Guidance conference, full of natural vitality, humour, and wisdom gained from his passionate and dedicated research over decades into the capacities of infants for social communication. Trevarthen really does enable us to hear the ‘voice of the infant’. Listening to him, you feel the wonderment of what it is to be human, and the tremendous potential that we are born with for human, emotional connection with others. For anyone working with children and families, his work is deeply moving and inspiring. He makes you want to bring this joy and liveliness to all parent-infant relationships.

Working, as I am, in perinatal mental health with mothers whose life experiences and mental health problems have frequently resulted in them feeling cut off from their baby, unable to tap any pleasure or liveliness in themselves in relation to their infant, I felt a longing to enliven these relationships. I think that is why I am passionate about VIG: because through VIG, parents can become in touch with the ‘lively human nature of relationships’ Trevarthen describes.

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. 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).

Trevarthen’s Background in Child Development Research

Professor Trevarthen, now in his 80s, has been in the field of child development since the early 1960s. In 1965, he worked with Jerome Bruner (Professor of Psychology at Harvard University, and later Oxford University), one of the pioneers of the study of children’s cognitive development and learning. Bruner coined the term ‘scaffolding’ (Bruner, 1975), describing how the attentive presence of an adult, available to help the child when needed, is key to learning. Scaffolding is the core of the VIG principle of attunement, ‘Guiding’.

As early as 1966, Trevarthen was studying mothers and babies ‘chatting’, looking in detail at what was involved. Using high speed film which provided an accurate picture of body movements, it became clear that the baby was using the same rhythms as the adult, for example in ‘reach and grasp’ movements.

Trevarthen’s key contribution to child development is in the area of human intersubjectivity (Trevarthen, 1980). He referred at the conference to ‘stages in the development of companionship in knowing’, thus emphasising the intersubjective nature of learning and development.

  • Newborns   from the first day are able to engage in dialogues
  • 6wks-3mths ‘proto-conversations’ emerge which do not involve words but have many of the features of verbal conversations, such as turn-taking, and rhythmical pattern of looking and withdrawal
  • 5-6 mths appearance of games and ‘showing off’
  • 1 year sharing tasks, tools and knowledge

He mentioned Berry Brazleton (American paediatrician, and the developer of the Neonatal Behavioral Assessment Scale) who, Trevarthen said, demonstrated that newborn babies are persons. He added: the newborn “waits for bright company” – which I think is a lovely phrase.

Trevarthen and VIG

Trevarthen’s work is at the core of VIG. Inspired by Trevarthen’s work, Harry Biemans in Holland developed the ‘principles for attuned interactions and guidance’ (Biemans, 1990), which he used in his video home training approach. Trevarthen stated clearly at the conference his support for VIG. He referred to Catherine Bateson’s term ‘exquisite ritual courtesy’ to describe the mother’s proto-conversation with a two-month old (Bateson, 1979). Trevarthen suggested that this could be a motto for VIG, referring as it does to respect for others.

Trevarthen showed us the video clip (shown in the VIG ITC) of the Moroccan father providing ‘kangaroo care’ for his 3 month premature baby in NICU. Interestingly, this footage was filmed by a colleague of Harry Biemans. Trevarthen commented on the couple ‘sharing a conversation’. Measurement showed that the father is imitating her sounds accurately; the father and infant are sharing a rhythm of andante (0.7 secs), and sharing time with vocal expression – making up a story together. The spoken phrase in any language has a tendency for the last syllable to be longer; the speech of both father and baby corresponded to this norm. In addition the arm movements of the infant synchronise with the timing of human speech. Trevarthen also reported a study where the baby’s arm movements mirrored the rhythms of a Scottish lullaby.

Trevarthen mentioned Emese Nagy’s research showing that when the newborn baby imitates (eg tongue protrusion, or holding up fingers) the infant’s  heart rate increases. The baby repeats a gesture (‘provocation’) if there is no response from the adult, and the infant’s heart rate slows down while the baby is paying attention to the adult and waiting for a response. In commenting on this synchrony and mirroring, Trevarthen said that “acting out stories with emotion, listening to thoughts and imitating actions is how humans learn, in shared vitality and awareness.”

Musical Analysis of Parent-infant Vocal Interaction

Trevarthen’s research has included musical analysis of parent-infant vocal interaction, identifying the typical musical phases of introduction, development, climax and resolution. His 2008 paper with Gratier states:

Babies are born to find meaning in intent participation with the imaginings and ambitions of older minds. They have a musical sense of time, and a language of emotions that matches that of the wisest adult, including sensitive feelings about the contingent appropriateness of other persons’ behaviours. And they soon build a ‘personal narrative history’ that connects moments of the present to an imagined future as well as a remembered past.

Gratier, M. & Trevarthen C. (2008) ‘Musical Narrative and Motives for Culture in Mother-Infant Vocal Interaction. Journal of Consciousness Studies 15(10-11): p 150.

Trevarthen cited the example of a 5 month old blind baby conducting her mother’s songs with her left hand. The infant’s hand moves 1/3 second before the melody, ie she is telling a story she knows well, anticipating the movements of her mother’s voice. Trevarthen referred to this as an example of ‘inter-modal transfer of consciousness’, which I believe indicates that information from different modalities (here, sensory processing of sound, and body movement), is being communicated from one conscious being to another. Trevarthen commented that this parent-infant interaction follows  the same pattern as is seen in an improvised jazz duet, where one person leads the other and vice versa, and then at precise moments the two people synchronize.

Trevarthen linked this with what we do in VIG: we are trying to identify moments of good interaction and trying to focus on synchronised interaction where there is “happy communication, amazingly coordinated, and which leads to feelings of enormous pride in both parents and babies”.

Infant Expression of Emotion in Parent-Infant Interactions

Trevarthen referred to the research of his colleague, Vasudevi Reddy, who has studied the development of self-consciousness in infants during the first year. She has identified that as early as 2-3 months, a baby with a mirror shows coyness, consisting of smiling with simultaneous gaze and head aversion, curving arm movements, and hiding her face. Reddy’s 2001 paper states: ‘These smiles were elicited in contexts of social attention, and were more likely following the renewed onset of attention. They occurred in interaction with familiar adults, with strangers and with the self in a mirror. Such expressions have previously only been reported in adults and in toddlers in the second year’ (Reddy 2001, p186).

Trevarthen also mentioned the impact on the infant of troubled interactions. As early as 6 months old, the infant feels shame: feelings of worthlessness, of not being understood, of anger and upset, and may attempt to escape this misunderstanding by the adult by looking down, covering their face etc. Although shame is recognised as an essential affective mediator of the socialization process – a parent’s stern facial response can evoke a feeling of shame in the infant which then inhibits the socially ‘unacceptable’ behaviour – too much shame (‘pathological shaming’ by the adult) can be toxic, resulting in patterns of major dysregulation in the infant, with damaging consequences for the infant’s developing sense of self (Schore, 1994).

In the last few weeks I have observed a worrying shame response in a 1 year old infant I am working with, who is suddenly exhibiting a behaviour new to him, usually in response to an adult focusing attention on him (even a familiar adult showing gentle curiosity). His response is to go very still, look down, and cover his face with one hand. He remains like this for several moments, emerging with a blank facial expression which evokes in me intense sadness. This behaviour is, I believe, in response to feeling not understood by his mother, not being able to repair mis-attunements in their interaction, or evoke in her any joy or pleasure; his response to other enlivening adults can be delightful and joyful. I hope that VIG may help to bring some pleasure to this mother-infant relationship.

Trevarthen made an interesting comment on the infant’s fear of strangers: the fear is to do with  embarrassment and worry that the stranger won’t understand what the baby knows (through repeated interactions with familiar adults). The baby feels threatened if a stranger pretends they know the baby, eg coming up confidently and taking the lead in interacting. The baby feels the lack of attunement and feels fear.

Further Reading

I have included just some of the points Trevarthen made during his talk. If you are interested to read more, he has published multiple papers and contributed to several books, including the core VIG book (Kennedy et al 2011). In the references below, I have cited just a few, which may prompt us to read further! An excellent summary of Trevarthen’s work is provided by Jenny Cross and Hilary Kennedy (Kennedy et al, 2011).

To end, a quote from a video of Trevarthen on YouTube produced by Education Scotland in 2016, entitled ‘Pre-Birth to Three’:

So babies are looking for companionship, they are looking for somebody. And I would like to make the point that the baby’s looking, or curiosity is more important than any parent’s desire to teach the baby, or anybody’s desire to teach the baby; the baby is not a pupil, it is not just an ignorant human being that needs to be taught knowledge…. I think if you are wondering what kind of companion a practitioner should be, I think the ideal companion of any kind – and it can be a practitioner or not – is a familiar person who really treats the baby with playful human respect.

This resonates well with our work: ‘playful human respect’ is a key ingredient of VIG.

References

Biemans, H. (1990) ‘Video Home Training: Theory, Method and Organisation of SPIN’. In J. Kool (ed.) International Seminar for Innovative Institutions. Ryswijk: Ministry of Welfare, Health and Culture.

Brazelton, T. Berry; Nugent, J. Kevin (2011). Neonatal behavioral assessment scale (4th ed.). London: Mac Keith Press.

Bruner, J.  (1975) ‘The Importance of Play’. In Lewin, R. ed. Child Alive. London Temple Smith.

Bateson, M.C. (1979) ‘The epigenesis of conversational interaction: a personal account of research development’. In Bullowa, C. (1979) Before Speech: The Beginning of Interpersonal Communication. Cambridge: Cambridge University Press, 63-77.

Cross, J. & Kennedy, H. ‘How and Why does VIG Work?’ In Kennedy, H., Landor, M & Todd, L. Video Interaction Guidance: A relationship-based intervention to promote attunement, empathy and well-being. Jessica Kingsley.

Gratier, M. & Trevarthen C. (2008) ‘Musical Narrative and Motives for Culture in Mother-Infant Vocal Interaction. Journal of Consciousness Studies 15(10-11):46-79.  

Kennedy, H. (2011). ‘What is Video Interaction Guidance?’ In Kennedy, H., Landor, M & Todd, L. Video Interaction Guidance: A relationship-based intervention to promote attunement, empathy and well-being. Jessica Kingsley.

Kennedy, H., Ball, K. and Barlow, J. (2017).  How does video interaction guidance contribute to infant and parental mental health and well-being? Clinical Child Psychology and Psychiatry 1-18.

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To improve young people’s health and wellbeing by developing their resilience through the use of targeted evidence based interventions, professional development opportunities and teacher coaching and mentoring (i.e. Video Enhanced Reflective Practice). Published in Educational Psychology in Scotland Vol.18 No.1 Winter 2017. Cruikshank, Findlay and Quinn

Research Questions:

  1. Does the Resilience Planning Toolkit combined with professional development opportunities in the area of resilience enable school staff to better identify barriers and supports for children with emotional and mental health needs?
  2. Does Video Enhanced Reflective Practice (VERP) help staff to implement resilience theory in practice?

Resilience

Getting it Right for Every Child (GIRFEC) is the national approach in Scotland to improving outcomes and supporting the wellbeing of our children and young people by offering a variety of supports via partnership working. The Resilience Planning Toolkit (RPT) is a planning tool, developed within North Lanarkshire to help staff, in conjunction with children and young people, to assess, plan for and support a wide range of additional support needs using a single framework based on resilience. The Resilience Toolkit has been created to help professionals make sense of the assessment information gathered through GIRFEC processes. It takes well known resilience factors identified from research and maps these onto the GIRFEC wellbeing indicators in order to link evidence based interventions, strategies and resources to GIRFEC assessment processes.

Resilience is a key feature of GIRFEC and underpins health and wellbeing. The cornerstone of addressing the emotional wellbeing and resilience of children would seem to be effective models of training and support and development for staff within establishments to allow them to plan for and support children’s mental wellbeing. The concept of resilience and how to integrate this into assessment has been highlighted as difficult for practitioners (Scottish Government, 2012).

VERP

Video Enhanced Reflective Practice (VERP) supports practitioners to reflect on and develop their communication skills within their typical daily work. The process of VERP aims to allow practitioners to discover how important they are in any interaction and their impact on the other person in their interaction (Kennedy and Landor, 2015). An aim of VERP is to develop more effective interaction and communication through which a practitioner can establish a greater sense of safety and security for pupils and build strong, nurturing relationships. There is a rapidly growing evidence base to support the benefits of video interventions in many different contexts to support children with a range of needs: social, emotional, behavioural and cognitive (Fukkink, 2008). Evidence also supports the professional benefits of an approach such as VERP for practitioners in many different roles and capacities. Video Interaction Guidance (VIG) and VERP in schools has been shown to lead to cognitive and emotional gains for pupils (Gavine and Forsyth, 2011).

What did we do?

We selected nine primary schools (5 experimental and 4 controls) that were identified to have high percentages of pupils within SIMD decile 1-3. The experimental schools were provided with two sessions of whole staff training on theories of resilience and use of the Resilience Planning Toolkit.

In addition, two teachers from each of the experimental schools were offered training in VERP; consisting of one full day of training and four follow up workshops. All teachers (control and experimental) were asked to identify one pupil in their class in SIMD decile 1 or 2 who required support in relation to their health and wellbeing needs. This pupil would be the focus of planning, intervention and VERP (if applicable).

Evaluation was carried out and consisted of:

  • Staff Questionnaire (investigating understanding of pupils’ needs and confidence in planning for them) across all schools, pre (39 returned from experimental schools and 35 from control schools) and post intervention (26 returned from experimental schools, 28 from control schools).
  • Resilience Planning Toolkit (RPT) evaluation for those participants within the experimental schools. VERP evaluation questionnaire (for those participating in the VERP training) Video analysis of raw footage from 1stand last VERP sessions.
  • Finally, existing planning documentation for identified children across all schools was requested, as was any further documents developed following the training and over the course of the session August 2016 – June 2017.

What have we found so far?

Research Question 1:

There was a significant increase in teachers’ confidence in their knowledge of the Resilience Toolkit post intervention. At pre-test no teachers rated themselves above 6, whereas 75% of teachers rated themselves between 7 and 10 at post-test, suggesting the training was effective.

The Staff questionnaire was completed by all teachers (in experimental and control schools) at both time points (pre- and post- intervention). Staff confidence in assessing children’s difficulties and implementing appropriate strategies across the areas of learning and health and wellbeing was recorded using a seven point rating scale ranging from 1 (not confident at all) to 7 (very confident). Staff in the experimental schools demonstrated statistically increased confidence in their ability to both assess difficulties and implement appropriate intervention strategies for children with learning difficulties. This was also the case for children with health and wellbeing difficulties. Furthermore, a statistically significant increase in staff knowledge and understanding of resilience was found following training in the use of the Resilience Planning Toolkit.

In the control schools, staff confidence in their ability to assess and implement appropriate strategies for children with learning difficulties decreased. No statistically significant difference was found in staff confidence in assessing and implementing appropriate strategies for children with health and wellbeing difficulties or in their knowledge and understanding of resilience.

Analysis of planning revealed that out of the 37 children in the experimental schools, only one had any type of pre-existing planning prior to the project. Following the intervention, 35 of the pupils had planning in place:

  • 25 pupils had a joint summary plan and/or resilience assessment developed directly from the RPT. Such plans were based on assessment of the child’s resiliency factors, and highlighted target areas with a range of evidence based interventions to support the child.
  • 9 pupils had a formal Additional Support Plan in place which included health and wellbeing targets that were assessed and identified through the RPT and included evidence-based interventions to support the pupil.

The evidence suggests that the RPT and opportunities for professional development in the area of resilience do enable school staff to better identify barriers and supports for children with emotional and mental health needs.

Research Question 2:

A total of 9 out of 10 participants from experimental schools completed the RPT plus VERP training programme. Due to technical issues, raw footage from first and last VERP sessions was gathered from three participants for analysis. Two minutes of each video was coded following the Principles of Attuned Interactions and Guidance (teacher behaviour) and taking initiative (pupil behaviour). Video analysis highlights the positive impact of VERP plus RPT training. Specifically, improvements were identified in teacher behaviour in all but one of the Principles of Attuned Interactions and Guidance. Although these findings were not statistically significant, the greatest increase was observed in the teacher’s ability to develop attuned interactions. In terms of pupil behaviour, despite results not being statistically significant, there was an increase in overall number of initiatives taken by the child during the analysed interactions.

VERP evaluations showed that 86% of staff members reported they had made changes to their practice as a result of VERP and all staff members involved reported that the training had an impact on the children with which they work.

It can therefore be argued that VERP plus RPT training has brought about positive changes for the individual child and teacher.

What do we plan to do next?

The RPT and the associated training will now be provided as a universal offer to schools in North Lanarkshire by the educational psychological service. Future improvements may include:

  • Ensuring a greater time period between pre- and post-test evaluations to increase validity of findings.
  • Commencing pre-testing at a later date as staff members did not feel that they knew the children very well at pre-test stage.
  • Ensuring all VERP videos are recorded using allocated iPads to enable a greater number of videos to be returned for analysis.

References

Fukkink, R. (2008). Video Feedback in the widescreen: A meta-analysis of family programs, Clinical Psychology Review 28 (6), 904 – 916.

Gavine, D. and Forsyth, P. (2011). “Use of VIG In schools” in H. Kennedy, M. Landor and L. Todd (Eds.) Video Interaction Guidance: A relationship based intervention to promote attunement, empathy and wellbeing (pp.134 – 143). London: Jessica Kingsley Publisher

Jarvis J. and Lyon, S. (2015). “What makes video enhanced reflective practice (VERP) successful for systemic change” in H. Kennedy, M. Landor and L. Todd (Eds.) Video Enhanced reflective practice: Professional development through attuned interaction (pp 35-46). London: Jessica Kingsley Publisher.

Joyce, B. and Showers, B. (2002). Student Achievement through Staff Development, 3rd Ed. Longman: London.

Kennedy, H. and Landor, M. (2011). “Introduction” in H. Kennedy, M. Landor and L. Todd (Eds.) Video Interaction Guidance: A relationship based intervention to promote attunement, empathy and wellbeing (pp.18-34). London: Jessica Kingsley Publisher

Scottish Government, (2012) Preparing Scotland: Scottish Guidance on Resilience. Edinburgh: Scottish Government.

Further information and materials

North Lanarkshire Council – Research and Development

Email: CruickshankC@northlan.gcsx.gov.uk Telephone: 01698 262840