INTRODUCTION

Video Interaction GuidanceTM is an intervention through which a practitioner aims to enhance communication within relationships . It works by engaging clients actively in a process of change towards realizing their own hopes for a better future in their relationships with others who are important to them. Guiders are themselves guided by the values and beliefs around respect and empowerment.   These include a belief that people in troubled situations do want to change, a respect for what clients are managing to achieve in their current difficulties, and a conviction that the power and responsibility for change resides within clients and their situations. It is most typically used for interactions between children of any age and adults, either parents or professionals, although it can also be used within pairs (or even groups) of adults.  When it is used by professionals to reflect on their own communication with service users it is usually referred to as Video Enhanced Reflective Practice (VERP).  In both versions, its aim is to give individuals a chance to reflect on their interactions, drawing attention to elements that are successful, and supporting clients to make changes where desired.

Video interaction guidance is used in more than 15 countries and by at least 4000 practitioners  in helping professions (social work, education and health) and in business management. There are many links between projects across Europe and North and Central America.  It was brought to the UK by a small group of Educational Psychologists working in Tayside, Scotland in the 1990's.  You can listen to one of these pioneers, Hilary Kennedy, on Soundcloud, reflecting on the origins and success of Video Interaction Guidance in developing positive  relational patterns.





HOW VIG IS DELIVERED

Video interaction guidance is an intervention where the client is guided to reflect on video clips of their own successful interactions . The process begins by helping the family or professional to negotiate their own goals. Asking them what it is they want to change helps to ensure that they are engaged in the process. Adult-child interactions are then filmed and edited, to produce a short film that focuses on the positive.
 
In the video review sessions that follow, the family and professional reviews the micro-analysis of successful moments, particularly those when the adult has responded in an attuned way to the child’s action or initiative using a combination of non-verbal and verbal responses. They reflect collaboratively on what they are doing that is contributing towards the achievement of their goals, celebrate success and then make further goals for change. These reflections move very quickly from analysis of the behaviour to the exploration of feelings, thoughts, wishes and intentions.

Guiders are supervised in their own practice through the analysis of themselves in filmed interaction. Film is gathered of shared review with clients and these are used in supervision, focusing and building on micro-moments of attuned interaction, particularly those where they activate the client to make initiatives, then receive the client fully and respond with ideas that can be understood and used to promote positive change.

The approach takes the view that change can be achieved more effectively in the context of a ‘coaching’ relationship than a didactic ‘teaching’ relationship, because it is collaborative rather than prescriptive, empowering rather than de-skilling.  It conveys respect for strengths and potential, rather than drawing attention to problems or weaknesses.  Throughout filming and review sessions, clients are supported to become more sensitive to children’s communicative attempts and to develop greater awareness of how they can respond in an attuned way.  In the process of standing back and looking at themselves on screen, parents are able to analyse what they were doing when things were going ’better than usual’.  In this way they are empowered to make an informed decision about how they would like to improve situations that are more problematic.

The use of the video is also of central importance both as a focus for client and guider to construct new possibilities and as a trigger for revealing intuitive feelings which can be the key to lasting change.  It seems that the video helps troubled families uncover the possibility of an alternative story about themselves. In this way they can grow in an organic way into their new way of being without having to consciously remember and put in place new skills. There is a deeper level of healing that can take place when relationships are restored, allowing further positive changes to occur naturally .

Learning to practise video interaction guidance is not a simple skills-based training that can be achieved by simply following a manual. The training process for professionals provides an in-depth focus on the developing relationship between a practitioner and a client. The supervision sessions using film of the shared reviews gives space for self-reflection, reflection with a supervisor, plans for improvement and identifying evidence of change on video. This cyclical process has all the elements of effective adult learning. Supervisors see their trainees becoming more animated and effective with their clients as they progress through the training.

Many practitioners will say that working with video interaction guidance has fundamentally changed their interactions with clients, colleagues and with their friends and loved ones. This may explain the very high level of enthusiasm and dedication to this way of working by those involved and the very positive feedback from parents’ experiences of the review of the video. Turning points for parents and professionals seem to be around moments of joy which can be observed on the video and celebrated by both the professionals and the families and then again with the supervisor.


RESEARCH BACKGROUND

The method is based on a model developed in the Netherlands by Harrie Biemans and colleagues in the 1980’s. The concept is to use principles which promote successful interactions between mothers and infants in the earliest months as a framework for identifying positive moments in communicative exchanges.  These moments are selected by focusing on the way in which children’s communicative initiatives are responded to by adults.  These principles are fundamental to video interaction guidance and are known as the  ‘principles for attuned interactions and guidance’.

Professor Colwyn Trevarthen at Edinburgh University has provided the central theoretical core (Primary and Secondary Intersubjectivity and Mediated learning) of this method and has been personally involved in its development from the start. The idea is to use principles which promote successful early mother-infant dialogue as the framework for picking out positive moments in any communication.

Professor Trevarthen has been a supporter of VIG from its beginnings and you can listen to him talking about it on Soundcloud.





This section of this website describing evaluation studies that demonstrate the impact of VIG only cites studies where the guiders have been trained using the 18 month training programme initially developed in The Netherlands and subsequently adapted to the UK context by members of AVIGuk over the past two decades.  Other approaches may appear to be similar to VIG but only an AVIGuk accredited guider can reasonably claim to have practice similar to that used in the published research.

The evidence–base for the effectiveness of video interaction guidance has been developing in various ways over the past 20 years and in this article we will outline some of these.  One of the difficulties in the evaluation of any intervention is that the method may vary from one practitioner to another and between contexts.  Furthermore, interventions which have different names may be almost identical in reality.  Therefore, in determining the effectiveness of video interaction guidance as developed in the UK since 1995 we can examine not only the relatively small-scale studies carried out in the UK  but also findings using randomised controlled trials from other approaches that have features in common or are closely related.

Firstly, we draw attention to evidence that the features that are central to video interaction guidance are features of effective intervention.  Meta-analyses of the effectiveness of attachment-based interventions carried out in the Netherlands (Bakermans-Kranenburg et al. 2003) found that relatively short interventions using video-feedback were more effective than those without and that interventions that focused on adult sensitivity alone were the most effective.  In the UK, key findings from a review of studies conducted by the Department for Children, Schools and Families (Barlow & Schrader-MacMillan 2010) indicate that targeted early interventions that are aimed at increasing parental sensitivity and promoting attachment are effective in preventing emotional maltreatment.  They cite evidence of the effectiveness of video interaction guidance in improving parental sensitivity.  Video interaction guidance has now been selected to be included as one of the European evidence–based interventions in the follow-up to the above review (Dataprev 2011).  Video interaction guidance was one of two recommended programmes in the NSPCC’s evidence to England’s review of the delivery of early interventions (NSPCC 2010).

A further meta-analysis of studies using video feedback concluded that parents become more skilled in their interactions with their children, and have a more positive perception of parenting which helps the overall development of their children (Fukkink 2008).  The paper claims that in addition, interventions using video feedback are not only influential in increasing parental sensitivity, but that this results in behavioural and attitudinal changes towards their children.  The specific gains are in reducing parental stress and increasing self-confidence in parenting.

We turn now to the effects of video interaction guidance as it has been implemented and evaluated in The Netherlands.  Depending on the employment setting of the practitioners, the interventions have various names but all have a close resemblance to video interaction guidance as practiced in the UK.  The meta-analysis of 29 video-feedback studies (Fukkink 2008) contained a subset in which video interaction guidance (mostly Video Home Training) was utilised.  Various family contexts featured, as well as a range of difficulties (hyperactivity, crying babies, family difficulties etc), and the ages of the children in the interventions ranged from 0.2 years to 8 years. These studies suggest positive effects for video interaction guidance (VIG) over and above the effect of video feedback (VF) alone (figure 1). The aggregated effect sizes in the meta-analysis for these studies were, 0.76 (i.e. medium to large effect) for the behavioural domain (the effect on parent skills) and 0.56 (i.e. medium effect) for the attitude domain (the effects on parent attitudes). The effect size was 0.42 (i.e. small to medium effect) for the development of children in this study. This meta-analysis provides empirical evidence that video interaction guidance enhances positive parenting skills, decreases/alleviates parental stress and, finally, are related to a more positive development of the children.

Figure 1
Effect sizes for experimental outcomes of VF and VIG studies




A criticism that could be made of a number of the studies is that their sampling methods were insufficiently stringent.  However, Fukkink (2008) identified two studies that used randomised control research designs and both of which reported positive results.  One of these is an evaluation of Video-feedback Intervention to Promote Positive Parenting (VIPP).  This method, very similar to video interaction guidance, is the result of research carried out by Femmie Juffer and her team in Leiden.  They have produced an important book called Promoting Positive Parenting (Juffer et al. 2007a) summarizing research carried out over the last 20 years. It contains results of high quality randomised controlled studies, summarised in figure 2, demonstrating that interventions that promote sensitivity and use video are effective and that VIPP in particular is effective in promoting sensitivity between parents and young children with attachment and feeding difficulties.


Fig 2
Effect size for randomised control trials of VIPP compared to a meta-analysis of attachment-based interventions



Evidence of the enduring impact of parent sensitivity on child behaviour was shown by Klein Velderman (2005, see also Juffer et al 2007b) comparing VIPP on its own with a condition in which a “representational” component was added (i.e. VIPP-R, intervening in how the mother saw her understanding of her own attachment).  A group of 81 first time mothers, selected on the basis of insecure attachment representation, were randomly assigned to VIPP, VIPP-R or a control group. In the short-term (T1 = 6 months, T2 = 11-13 months) the mothers in both intervention groups were significantly higher in maternal sensitivity than in the control group. The rate of disorganized attachment was significantly reduced.  At 3 years the children in both intervention groups exhibited fewer externalizing behaviour difficulties. Interestingly the group who received VIPP plus discussions of past attachments showed significantly fewer gains than those receiving VIPP alone.

Finally, we turn to data reported by Kennedy, Landor & Todd (2010) from an intervention in the UK using video interaction guidance to promote early attachments in  families who were considered hard-to-reach.  Robertson and Kennedy (2009) looked at the effect of VIG as an intervention in a residential treatment centre where parents are placed with their children for three months as a result of court orders due to child protection concerns. Results from naturally occurring data suggests that video interaction guidance is effective in families where there are severe attachment needs such that there is a danger of family breakdown and child care placement. In this study, video interaction guidance was offered to all parents and delivered to those families who wished to take up the offer. Parents in these circumstances are traditionally thought of as being very hard to engage, having often had abusive backgrounds themselves or having lost older children within the care system. Pre-and post-intervention data was collected on 15 parent-child dyads that received ‘treatment as usual’ and 8 parent-child dyads that received VIG as an intervention alongside the standard treatment. The VIG intervention took the form of 3-5 films and shared review sessions for each parent. For the ‘pre-score’ a brief film of 3-4 minutes of interaction was taken between parent and baby ‘as they would normally do’.

Data was collected using the CARE-index (Crittenden 2005) as providing a reliable score for seven aspects of behaviour for both caregiver and infant . For this research, the maternal sensitivity score was used. Scores are calibrated as follows: 8-14 indicates the interaction is ‘good enough’; 4-7 indicates ‘of concern’ and 0-3 indicates that the interaction between the infant and parent is ‘seriously compromised’. Results showed that the mean pre-intervention CARE-Index score was very similar for each group. The mean post-intervention CARE-Index score of the control group deteriorated slightly whereas it improved by 3.13 for the video interaction guidance intervention group. This result is equivalent to a medium-sized and statistically significant effect size (ES = 0.5).  Before the intervention only 25% of the video interaction guidance intervention group were scoring in the ‘good enough’ range whereas afterwards 87.5% were now considered ‘good enough‘ and all families who were ‘of concern’ had made improvements by at least 2 points. This is in stark contrast to the control group who started the intervention with 46% and ended the intervention with 27% in the ‘good enough’ category.  The tentative conclusion that can be drawn from this pilot study is that video interaction guidance has been successful in increasing parental sensitivity as measured by the CARE-Index and that a more substantial study is justified.

This brief review focuses on studies concerned with situations where attachment issues are foremost as this is where the most rigorous research effort has been made to date.  However, evidence has been accumulating that indicates the effectiveness of video interaction guidance in many other settings.  Full details can be found in the book.


Video Interaction Guidance
A Relationship-Based Intervention to Promote Attunement, Empathy and Wellbeing
Edited by Hilary Kennedy, Miriam Landor and Liz Todd
The book explains the theory behind the approach, reviews research evidence, and offers case studies that document how VIG has been successfully applied to family relationships, schools and higher education, individuals with communication and developmental disorders, and as a reflective professional development tool. The approach is then discussed from a range of theoretical perspectives and within the contexts of narrative therapy, infant and attachment interventions, positive psychology and mindfulness.








REFERENCES

Bakermans-Kranenburg, M.J., Van IJzendoorn, M.H. & Juffer, F. (2003). Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129,195–215.

Barlow, J. & Schrader-MacMillan, A. (2010) Safeguarding children from emotional maltreatment: What works? London: Jessica Kingsley.

Crittenden, P. (2005) ‘Using the CARE-Index for Screening, Intervention, and Research’,  accessed on 19 july 2011: http://www.patcrittenden.com/include/docs/care_index.pdf

DataPrev. (2011) 'Mental health prevention focusing on parenting.' DataPrev, accessed on 3st January 2011: http://www.dataprevproject.net/Parenting_and_Early_Years

Juffer, F., Bakermans – Kranenburg & van IJzendoorn, M.H. (2007a) Promoting Positive Parenting: an attachment based intervention New York: Lawrence Erlbaum.

Juffer, F., Bakermans – Kranenburg & van IJzendoorn, M.H. (2007b) Attachment-based Interventions: heading for Evidence-based ways to Support Families in W.Yule and O.Udwin (eds) Attachment: Current Focus and Future Directions ACAMH Occasional Papers No.29

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

Kennedy, H., Landor, M. & Todd. L. (2010) Video Interaction Guidance as a method to promote secure attachment Educational and Child Psychology Vol. 27 No. 3.

Klein Velderman, M., Bakermans-Kranenburg, M. J., Juffer, F., Van IJzendoorn, M. H., Mangelsdorf, S. C., and Zevalkink, J. (2006) 'Preventing Preschool Externalizing, Behavior Problems Through Video-Feedback.' Infant Mental Health Journal,  27, 5, 466–493

NSPCC (2010) 'The National Society for the Prevention of Cruelty to Children (NSPCC) Evidence to the independent review of the delivery of early interventions intended to fulfil potential and reduce dysfunction in the lives of children and young people.
November 2010.' Accessed on 29/1/2011 at http://www.nspcc.org.uk/Inform/policyandpublicaffairs/
consultations/responses2010_wda70544.html.

Robertson, M. and Kennedy, H. (2009) Relationship-Based Intervention for High Risk families and their babies : Video Interaction Guidance – an international perspective’ Seminar Association Infant Mental health, Tavistock, London, 12th December 2009




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