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Antoine Guedeney, MD Akko WAIMH Regional Conference The era of video in infant mental health.

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Presentation on theme: "Antoine Guedeney, MD Akko WAIMH Regional Conference The era of video in infant mental health."— Presentation transcript:

1 Antoine Guedeney, MD Akko WAIMH Regional Conference The era of video in infant mental health

2 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

3 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

4 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

5 Spitz, 1943: the use of video to help colleagues see a grim reality

6 History: Monica and withdrawal behavior, 1956

7 The Still Face Paradigm: Brazelton, Field, Tronick Confirmed by desynchonisation face/voice Threvarten, Murray Nadel

8 Why look at oneself- professional or parent- interacting with one’s infant? Learn how interaction truly develops: Brazelton, Tronick, Beebe, 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

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10 The attachmentalists and the Strange Situation Video allows the scoring and training of the Strange situation with 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)

11 Video : a key tool to assess and follow the ‘Time line of synchrony: Ruth Feldmann, JCPP, 2007’

12 Transcultural validity of the use of video in infants: circle of security and attachment behaviors, withdrawal behaviors, still face reaction, are not culturally dependent

13 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

14 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

15 Video Intervention Therapy: the main contributors 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

16 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

17 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 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

18 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

19 The Use of Video in Screening and Assessing The Crowell situation: use of several clips from strange 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©

20 Lessons from the ’Baby Watcher’: Beebe, Field, Stern, Tronick,Trevarthen, Tronick Look at the frame by frame, micro analytic interaction Look at the frame by frame, micro analytic interaction In secure dyads, even when things are ‘As Good as they Get’ rate of mis attunement may reach 50% (Tronick) In secure dyads, even when things are ‘As Good as they Get’ rate of mis attunement may reach 50% (Tronick) Being securely attached is working through mismatches, not avoiding mismatches (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 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 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 Show the big difference between what we as parents believe we do and what we effectively do, particularly when stressed

21 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) 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) 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 Attachment behavior is resistant to change, but there is always room for change So need for focused preventive action on high risk dyads So need for focused preventive action on high risk dyads

22 Attachment-based effective interventions The ‘Circle of security’: Marvin Slade and Karlen Lyons-Ruth: Nurse/IMH joint programs for high risk 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)

23 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

24 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

25 Video: a major tool for prevention of Disorganization Susan Mc Donough: pioneer work with hard to reach families: stick 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

26 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


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