Transcript The era of video in infant mental health

The era of video in infant mental health
Antoine Guedeney, MD
Akko WAIMH Regional Conference
Hard to tell everything, but a bit on:
 1. History: Spitz, Bowlby
 2. What research on infant development got from
video: Brazelton, Still face
 3. Pionners in the clinical use of video within and
without an attachment frame, and recent developments:
(almost) everyone uses video now !
 4. Prevention programs and video: STEEP, VIPP,
Capdep
1.A bit of history
 Arguably, the beginning of using movie in infant mental
health can be traced with Spitz’s films, 1943
 Then with Bowlby’s and Robertson’s use of systematic
filming in a research protocol: ‘John goes to Nursery’ show
the extend of distress of a 18 months old during a 8 days
separation from mother
 Monica , a famous case of withdrawal behavior, Engel
&Reischmann,1956
 And several uses of pictures /movies to realize what the
infants can show us about themselves
Then the era of video in discovering both the
competences and vulnerabilities of the infant
 Starts with the seminal work of Brazelton, describing the ‘4 stages
of interaction’ seen at a micro-analitic level: the baby takes the
lead, not the caregiver
 Then the ‘Still Face paradigm (Brazelton, Tronick, Field) shows
how the 2 months olds are trapped into the face to face
interaction, and shows their high sensitivity to violations of rythm
within the’ dyad
 Trevarthen, Murray & al confirm this sensitivity, using the
desynchronization procedure
Spitz, 1943: the use of video to help
colleagues see a grim reality
History: Monica and withdrawal behavior,
1956
The Still Face Paradigm: Brazelton, Field, Tronick
Confirmed by desynchonisation face/voice
Threvarten, Murray Nadel
Why look at oneself- professional or parentinteracting with one’s infant?
 Learn how interaction truly develops: Brazelton, Tronick, Beebe,
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Stern, looking at who does what and when as opposed to
reconstructive speculation
See the ‘objective self’ of the observer seen from the outside and
integrate it within the ‘subjective self’, seen from within (Rochat,
2008)
Seeing is believing (STEEP, Engeland & Erickson, 1999): auto
video has a huge impact on having the parents realize to which
extend the infant is sensitive to relationships
Moving from an expert’s point of view to a let’s see together what
we have, thus increasing the working alliance in showing parental
expertise
Professionals in infant mental health may learn to make a video, to
propose it to the parents, to analyze it and to discuss it
The attachmentalists and the Strange Situation
 Video allows the scoring and training of the Strange situation with
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infants and tolldlers
With different systems (Ainsworth, Marvin, Crittenden,Cassidy) and
different ages
Use of related projective assessment techniques as the Mc Arthur Story
Stem Battery & Bretherton
Use of clips of the strange situation and of several situations (change ,
free play or tasks, feeding) to contextualize assessment (Cromwell)
These situation may then be edited and reviewed with the parents
(Marvin’s Circle of Security, Oppenheim’s Insightfulness assessment)
Video : a key tool to assess and follow the ‘Time line of
synchrony: Ruth Feldmann, JCPP, 2007’
Transcultural validity of the use of video in infants: circle of
security and attachment behaviors, withdrawal behaviors,
still face reaction, are not culturally dependent
Pioneer in the Therapeutic use of video
 Pionners: Susan Mc Donough with hard to reach families
 Beebe, in parent infant therapy
 Stern: how to read a video of an interaction
 Video has become a major tool for training/ supervision and for seeing
what is going on in such a setting, with the miniaturisation of cameras and the
diminution of costs
 ‘Therapeutic consultation’ in video: the Stern /Cramer research 1980’s:
the comparison of psychodynamic vs CBT; what makes the client happy with
the session
 Serge’s Lebovici’s use of empathy and enaction within parent infant
work
 Fivaz-Depursinge, Corboz-Varnery ,2004: Triadic interaction
 Lyons Ruth, 2004: AMBIANCE and parental disorganizing behavior
Three major models of attachment based
video interventions
 Focalization on behaviors or representations:
 1.VIPP: Juffer, Bakermans Kranenburg
& van IJzendoorn:
Video feedback Intervention to promote Positive
Parenting (VIPP)
 2.STEEP:Steps for Enjoyable Effective Parenting:
Engeland & Erickson, 1999 (STEEP)
 Slade , 2005: Mind the Baby (MTB)
 The goal is to develop and reinforce parental sensitivity and
positive parent infant interactions
 3.Focalization on maternal representations: Mind the baby
(STB), Slade: keep the baby in mind , increase self reflective
function
Video Intervention Therapy: the main
contributors
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Papousek, 2003
Beatrice Beebe, 2003,2005
Maria Arts: Marte Meo
Schechter, 2006 , Brisch 1999
Tronick, 2007: match, mismatch, repair and the Still face
paradigm
Mc Donough 2004: interactive guidance
Marvin, Cooper, Hoffman & Powell (2002): Circle of Security
Insightfulness Assessment : Oppenheim & Koren Karie ( 2002):
mentalization
George Downing: the frame of analysis
George Downing’s frame of video
analysis with parents, 2009
 Connection: contact, affect attunement, contingency
 Collaboration: how is shared activity organized?
 Boundaries: limit - setting
 Negotiation: mostly verbal
 Autonomy: how are separation autonomy and problem solving
played,
 Organization of time: Rhythm and temporality, frame
continuity
 Organization of time: Tempo, fast or slow
 Discourse; what is said and how
George Downing ‘s frame for working
with videos (2009, in press)
 Making the video
 Scanning the video and analysis
 Show a preselected part of the video, usually short (3’) and
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ask: What did you find most important here?
Point out something positive by the parent, the child or both
Only then move to some significant negative pattern evident
in the video, tactfully and only one, choosing the one
possibly easier to change
Summarize key points and prepare for the next video.
Discuss the findings with the parents along mentalization,
along what is stirs up in their past
Early diagnosis of Autism using Family
videos
 USA: Massie 1975, Massie & Rosenthal,1984;
 Osterling & Dawson, 1994
 France: Malvy, Adrien, Brauner, Wendland
 Italy: Bernabei, Camaioni, 1998; Maestro 1998
 Goals:
 Find the early specific signs of autism, in the different modes
of onset and within the different types
 Assessment and discussion of diagnosis with parents
The Use of Video in Screening and
Assessing
 The Crowell situation: use of several clips from strange
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situation, play, change, clean-up in the assessment of children in
foster care (Crowell, Zeanah)
Alarm Distress Baby Scale ( ADBB Guedeney & Fermanian, 2005):
using a pediatric examination a ‘Set Situation’ (Winnicot, 1943) to
assess withdrawal behavior in infants
Feldmann’s CIB : using a feeding situation to assess parent infant
interaction. Keren’s use in tele psychiatry (2006).
Fivaz Depursinge & al: the Triadic Situation
Insightfullness Assessment of mother using clips of Ss and
play : Oppenheim & Koren Karie
Ambiance: Lyons Ruth & al: caregiver disorganizing behaviors in
the strange situation
Marvin’s use of the strange situation and Circle of Security©
Lessons from the ’Baby Watcher’: Beebe,
Field, Stern, Tronick,Trevarthen, Tronick
 Look at the frame by frame, micro analytic interaction
 In secure dyads, even when things are ‘As Good as they Get’
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rate of mis attunement may reach 50% (Tronick)
Being securely attached is working through mismatches, not
avoiding mismatches (Tronick)
For pairs with too frequent or intense mismatches, frustration
or fear of loss may lead to give up search for attunement
Video helps focusing on the baby and on the relationship, it
helps the parent take the baby’s perspective
Show the big difference between what we as parents believe we
do and what we effectively do, particularly when stressed
Lessons from the Baby Watchers 2
 Rhythmic coupling at 4 mo (turn taking, joining, yielding
and tracking) predicts attachment classification at 12 (Beebe
& &al, 2006)
 In mild to major disturbances of relationship, defensive
maneuvers in the child get built up quickly (i.e. by 9 months
of age)
 Attachment behavior is resistant to change, but there is
always room for change
 So need for focused preventive action on high risk dyads
Attachment-based effective interventions
 The ‘Circle of security’: Marvin
 Slade and Karlen Lyons-Ruth: Nurse/IMH joint programs for high risk
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mothers
Juffer & Bakermans: preventive use of autovideo with adopted infants
Bakermans: prevention of CD disorders using the VIPP
STEEP: Martha Ericksson ‘Seeing is Believing’
CAPDP: the first French study, joint well baby clinic and IMH preventive
study for middle to high risk mothers
All use auto video guidance, a major tool for intervention & prevention.
Video is a strong incentive for maternal/parental mentalization: what do
you think the baby is feeeling now? Why, What are you feeling when you
are doing this?
Video is a strong help to see disorganization of attachment when
attachement is activated (Baby at the bottom of Circle of Security)
Video intervention within the attachment
theory
• Increase mother’s sensitivity to the infants signals: increase
security of attachment, decrease disorganization
• Prevent or maybe only decrease parental disorganizing
behaviors , be it frightening or frightened behaviors (Main;
Ambiance)
• The use of contextualized specific situations during
which attachment or exploration behaviors are activated
– Free cooperative play
– Face to face or still face
– Separation/reunion, nappy changes, feeding
Looking for Disorganizing Behaviors in Parents
 AMBIANCE: assessment of emotional
communication (Lyons Ruth et al, 2003)
 Frightening/frightened behaviors (Main & Hesse)
 Abdicating behaviors (George & Solomon, 1999)
 These behaviors may be subtle, occurring very quickly
 One has to be particularly attentive to what happens
or not when attachment is activated
Video: a major tool for prevention of
Disorganization
 Susan Mc Donough: pioneer work with hard to reach families: stick
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to the goals of the family, closely monitor working alliance, keep on
working on the positive aspects
George Downing: use in therapy with mentally disordered parents
or high risk families, extension to children, families and adolescents
Beatrice Beebe: use in parent infant therapy
Prevention/ intervention: Marvin and the Circle of Security,
Erickson and the STEEP, Lyon Ruth and Ambiance
Steele & al, New York, Juffer in the Netherlands: adoption projects
Juffer, Bakermans & van IJzendoorn: the Video Feedback
Intervention for Promoting Positive Parenting (VIPP), 2005, 2007.
Beebe, van IJzendoorn & al: disorganization starts early: what work
best is what is focalized and begins at 6 months or before
A-Capdep
 Ancillary study within Capdep (N=440, started 2006)
 60 X 2, started Jan 2008
 High to very high risk sample
 Closer look at disorganizing attitudes of parents
(Ambiance, Lyons Ruth), at Insightfulness abilities
(Oppenheim)
 Effect of sensitivity centered intervention using auto
video guidance (STEEP, VIPP, Downing)
 Security of infant assessed with AQS-Sort (Vaughn) and
Strange Situation at 15 months
 Video is an effective tool in reducing disorganization
within high risk dyads, if used early and frequently