Antoine Guedeney, MD Akko WAIMH Regional

Conference

The era of video in infant mental health

Hard to tell everything, but a bit on:

1. History: Spitz, Bowlby2. 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 historyArguably, 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, TronickConfirmed by desynchonisation face/voice Threvarten, Murray Nadel

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

The attachmentalists and the Strange SituationVideo allows the scoring and training of the Strange

situation with infants and tolldlersWith different systems (Ainsworth, Marvin,

Crittenden,Cassidy) and different agesUse of related projective assessment techniques as

the Mc Arthur Story Stem Battery & BrethertonUse 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 interventionsFocalization 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 interactions3.Focalization on maternal representations: Mind

the baby (STB), Slade: keep the baby in mind , increase self reflective function

Video Intervention Therapy: the main contributors

Papousek, 2003Beatrice Beebe, 2003,2005Maria Arts: Marte MeoSchechter, 2006 , Brisch 1999Tronick, 2007: match, mismatch, repair and

the Still face paradigmMc Donough 2004: interactive guidanceMarvin, Cooper, Hoffman & Powell (2002):

Circle of SecurityInsightfulness Assessment : Oppenheim &

Koren Karie ( 2002): mentalizationGeorge Downing: the frame of analysis

George Downing’s frame of video analysis with parents, 2009Connection: contact, affect attunement,

contingencyCollaboration: how is shared activity organized?Boundaries: limit - settingNegotiation: mostly verbalAutonomy: how are separation autonomy and

problem solving played,Organization of time: Rhythm and temporality,

frame continuityOrganization of time: Tempo, fast or slowDiscourse; what is said and how

George Downing ‘s frame for working with videos (2009, in press)

Making the video Scanning the video and analysisShow 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

Early diagnosis of Autism using Family videos

USA: Massie 1975, Massie & Rosenthal,1984; Osterling & Dawson, 1994France: Malvy, Adrien, Brauner, WendlandItaly: Bernabei, Camaioni, 1998; Maestro 1998Goals: 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 AssessingThe 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 SituationInsightfullness Assessment of mother using clips

of Ss and play : Oppenheim & Koren KarieAmbiance: Lyons Ruth & al: caregiver disorganizing

behaviors in the strange situationMarvin’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 interactionLook at the frame by frame, micro analytic interactionIn secure dyads, even when things are ‘As Good as In secure dyads, even when things are ‘As Good as

they Get’ rate of mis attunement may reach 50% they Get’ rate of mis attunement may reach 50% (Tronick)(Tronick)

Being securely attached is working through Being securely attached is working through mismatches, not avoiding mismatches (Tronick)mismatches, not avoiding mismatches (Tronick)

For pairs with too frequent or intense mismatches, For pairs with too frequent or intense mismatches, frustration or fear of loss may lead to give up search frustration or fear of loss may lead to give up search for attunementfor attunement

Video helps focusing on the baby and on the Video helps focusing on the baby and on the relationship, it helps the parent take the baby’s relationship, it helps the parent take the baby’s perspectiveperspective

Show the big difference between what we as parents Show the big difference between what we as parents believe we do and what we effectively do, particularly believe we do and what we effectively do, particularly when stressedwhen stressed

Lessons from the Baby Watchers 2

Rhythmic coupling at 4 mo (turn taking, Rhythmic coupling at 4 mo (turn taking, joining, yielding and tracking) predicts joining, yielding and tracking) predicts attachment classification at 12 (Beebe & attachment classification at 12 (Beebe & &al, 2006)&al, 2006)

In mild to major disturbances of relationship, In mild to major disturbances of relationship, defensive maneuvers in the child get built defensive maneuvers in the child get built up quickly (i.e. by 9 months of age)up quickly (i.e. by 9 months of age)

Attachment behavior is resistant to change, Attachment behavior is resistant to change, but there is always room for changebut there is always room for change

So need for focused preventive action on So need for focused preventive action on high risk dyadshigh risk dyads

Attachment-based effective interventions

The ‘Circle of security’: MarvinSlade and Karlen Lyons-Ruth: Nurse/IMH joint programs for

high risk mothersJuffer & Bakermans: preventive use of autovideo with

adopted infantsBakermans: prevention of CD disorders using the VIPPSTEEP: 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 DisorganizationSusan 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 therapyPrevention/ intervention: Marvin and the Circle of Security,

Erickson and the STEEP, Lyon Ruth and AmbianceSteele & al, New York, Juffer in the Netherlands: adoption

projectsJuffer, 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-CapdepAncillary study within Capdep (N=440, started

2006)60 X 2, started Jan 2008High to very high risk sampleCloser 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