The era of using video for observation and intervention in infant mental health

The use of photography and cinema then video in developmental studies and in interventions began long ago, with the seminal work of Rene Spitz, then with John Bowlby’s and James and Joyce Robertson’s famous films, e.g. John and with several others. These have had an enormous influence on our understanding of infant mental health and in its recognition as a field. This paper presents a short history of the work of the early “cinema” pioneers, then briefly reviews how video has provided a focus on the importance of infant development and early interactions and concludes with how preventive work with infants and families has greatly benefited from the use of home videos.

A bit of history:

Arguably, the beginning of using movies in infant development studies can be traced with Rene Spitz’s films in 1943. Spitz showed the full extent of the distress of infants who were separated from their mothers in his famous film, Grief, a Peril in Infancy. Young mothers had their babies when in jail and were separated from them daily when the infants, 6 to 8 months old, were moved to the prison day care facility. Some of the infants showed high distress, named ‘Anaclitic Depression’ by Spitz as the developing attachment relationship was observed to be at risk, even though he stated this was not depression in the full sense of the term (Spitz, 1945, 1946, 1947). The infants who experienced more extended separation from their mothers, showed a more troublesome and less reversible picture, labelled by Spitz as ‘Hospitalism’. At this point in time, most of the work on early development by psychoanalysts was retrospective and hypothetical. Spitz brought to the community the grim picture of what brisk and unprepared separation could do to the parent infant relationship. As Robert Karen points out (Karen, 1994), this was not well accepted or easily acknowledged when Spitz showed the film to the psychoanalytic community in New York. A colleague reportedly asked him, ’”Why did you do that to us?”

Another major step in the use of film for the purpose of observation was taken when James and Joyce Robertson followed an 18 month old boy during an 8 day separation from his parents for which the child was unprepared. In looking at the images of John at the nursery, day after day, the Robertson’s and colleague, John Bowlby, were struck by the amount of distress displayed by this 18 months old boy. His distress could have been easily overlooked if he had not been filmed, day after day, at the same time. This, of course, led to a great deal of controversy. Today, this film is still hard to look at, and represents a formidable teaching tool. Other films, taken by the Robertson’s for the purpose of infant observation and study, added to the evidence regarding the impact of extended separation and coping capacities of infants and young children . These films included Lucy, Thomas, Kate, and Lucy, in A Two Year Old Goes to Hospital (Robertson & Bowlby, 1952; Robertson & Robertson, 1969). In the fifties, some others clinicians used films as a demonstration of the existence of specific syndromes linked with relationship disorders. The pictures and movies from Monica, Engel & Reischman (1979) vividly illustrated the case of an 18 month old girl born with an oesophageal fistula and showing clear signs of depression/ withdrawal. Of course many other contributions existed as well during this pioneer period, but let us quote only the films made by Myriam David and Genevieve Appell in orphanages and institutions in Post War France, as they had a great impact on the changes in these institutions (David & Appell, 1964; Dugravier & Guedeney, 2006 for a review). In the same vein, films in the Loczy Pikler Budapest institute in Loczy, Hungary have been very influential in designing better care for orphans (Tardos & David, 1961).

The era of discoveries of competencies and vulnerabilities of the infant: lessons from the Great Baby Watchers (T. Berry Brazelton, Beatrice Beebe, Tiffany Field, Daniel Stern and Ed Tronick)

This period starts with the seminal work of T. Berry Brazelton, describing the ‘Four stages of interaction’ seen at a micro-analytic level (Brazelton, Koslovski & Main, 1974). The baby takes the lead, rather than the caregiver. This becomes obvious from the frame-to-frame analysis of the video. Then the ‘Still Face paradigm’ (Cohn &Tronick, 1983; Field, 1984) shows how 2 month olds are trapped into the face-to-face interaction and shows their high sensitivity to violations of rhythm within the dyad. Murray & Trevarthen (1985) confirm this sensitivity, using the de synchronization procedure, in which baby and mother interact through a video channel, in which sound and image are subtly de synchronized. This demonstrates how sensitive the 2-month-old infant is to violations of expectations within the interaction: a single de- synchronisation of a tenth of a second has exactly the same effect as a still face procedure (See Rochat, The Infant’s World, 2001 for a review).

Why look at oneself interacting with an infant?

This situation may help us learn how interaction truly develops: Brazelton, Tronick, Beebe and Stern, looking at who does what and when, have helped us understand how the interaction truly develops, as opposed to reconstructive speculation. Looking at oneself interacting with an infant will help see the ‘objective self’ of the observer, seen from the outside and integrate it within the ‘subjective self’, seen from within (Rochat, 2001). Several manualized programs are available now, which show us how autovideo has a huge impact on helping the parents realize to which extent the infant is sensitive to relationships. It helps moving from an expert’s point of view to a ‘let’s see together what we have here’ perspective, increasing the working alliance when noticing the parents’ own expertise.

The ‘Attachmentists’ and the video: the Strange Situation, the disorganization of attachment

Video allows the scoring and training of the Strange Situation with infants and toddlers with different attachment systems (Ainsworth, Marvin, Crittenden, Cassidy, see the Handbook of Attachment, 2008, for a review and references) and at different ages. Separation contextualizes the situation with a middle level of stress. Video helps identify the often subtle and briefs signs of infant disorganization, as well as disorganizing behaviours in parents (Lyons-Ruth, 2005). Frightening/ frightened behaviors or abdicating behaviors are some of the variations leading to an infant’s disorganization of attachment. These behaviors may be subtle, occurring very quickly. One has to be particularly attentive to what happens or not when attachment is activated. The key point is that video is most interesting when the attachment system of the infant is stimulated, through fear, separation, anxiety, and distress of any kind, hunger, sleepiness or pain. Video can capture what takes place – secure base behaviour or its absence or brief events described as disorganized behaviours. The main idea here is the use of contextualized specific situations during which attachment orexploration behaviors are activated, be it free, cooperative play, face to face or still face, separation/reunion, nappy changes, feeding. Related projective assessment techniques such as the Mc Arthur Story Stem Battery (Bretherton & al, 1990) do use video, for the procedure as well as for training and reliability.

Some Attachment based interventions use video and the strange situation as a core tool:

The ‘Circle of Security’ COS: Marvin (Marvin &al, 2002) has established a system of assessment of secure base behavior that can be used in group or in individual settings, with parents’ reactions to the strange situation of their child.

Slade (Slade, 2008) and Karlen Lyons-Ruth (2005): Nurse/IMH joint programs for high risk mothers, use auto video in interactional guidance, to increase self reflective function in mothers.

Juffer & Bakermans preventive use of auto video with adopted infants shows great effect size, compared to usual guidance. Juffer, Bakermans & van IJzendoorn: the Video Feedback Intervention for Promoting Positive Parenting (VIPP, 2005, 2007)

STEEP: Martha Erickson’s and Egeland’s program, ‘Seeing is Believing,’ is one of the most effective programs for prevention and intervention, using video with families. (Egeland & Erickson, 2004).

CAPDP, the first French prevention study for high-risk mothers, uses video extensively for increasing a mother’s sensitivity and mentalization and reducing parental disorganizing behaviors.

All these models use auto video guidance, a major tool for intervention & prevention, since video is such a strong incentive for maternal/parental mentalization: ‘What do you think the baby is feeling now? Why? What are you feeling when you are doing this?’

A major advantage of video is to help look at organizing and disorganizing behaviors in parents: AMBIANCE: is a scale for assessing parental disorganizing behaviours, through the assessment of emotional communication (Lyons-Ruth et al, 2005), through clips of strange situation and play.

Names and models in interventions using video

Some of the pioneers:
Selma Fraiberg (1980) used film to carefully assess the capacities and risks of infants and parents referred for infant mental health home visiting services, during consultation with parents and to study interactions and early relationship development during supervision and consultation to understand the risks and enhance the capacities of parents and very young children.

Susan Mc Donough (Mc Donough, 1993) has long used video with hard to reach families as a major tool for making interactive guidance effective. Susan Mc Donough was one of the first to have designed video use with hard to reach families. She gave us some major cues for this work: stick to the goals of the family, closely monitor working alliance, and keep on working on the positive aspects.

Maria Arts: Marte Meo (2008) Beatrice Beebe, in parent infant therapy (Beebe & Stern,1977) Daniel Stern: His work with Bertrand Cramer was essential to understand ways through which parent-infant therapy works. The comparison of psychodynamic vs. CBT showed no major differences, but video was key to understanding changes in therapy (Stern, 1995).

Serge’s Lebovici’s use of empathy and action within the parent infant relationship was remarkable in his recorded therapeutic consultations (Lebovici, 1983).

Elisabeth Fivaz-Depursinge and Antoinette Corboz-Varnery (The Primary Triangle, 2004): based on systemic principles, their work on Triadic interactions is a major contribution to the understanding of early mental development .It is based on closely organized video clips with both parents, leading to an assessment system of the triangulation within the family.

John Byng-Hall has designed an attachment-based family therapy with the use of video to supervise and train therapists (Byng-Hall, 1995)

George Downing has worked with Ed Tronick, Beatrice Beebe and Bob Marvin. He has gathered a very large experience with video in different settings, with infants and mothers in patient unit in Germany, and in parent infant consultation in France, as well as with adolescents; he proposes his frame of analysis for videos with parents and infants, and guidelines to make videos and to watch them with families (Downing under press ): Downing suggests to look carefully at these dimensions prior to watch the videos with parents:

Downing’s frame of analysis of videos clips: 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 and continuity Organization of time: Tempo, fast or slow Discourse; what is said and how

Finally, 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.

Lessons from the Great Baby Watchers

Video has permitted us to gain insight into the way parent infant interaction develops. Through this tool we have learned from the Great Baby Watchers: Beebe, Stern, Tronick, and Brazelton, among others. To summarize:

Look at the frame by frame, micro analytic interaction

In secure dyads, even when things are ‘As Good as they Get, ’the rate of misattunement may reach 50% Being securely attached is working through mismatches, not avoiding mismatches 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 and 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

Rhythmic coupling at 4 mo (turn taking, joining, yielding and tracking) predicts attachment classification at 12 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 traumatized dyads

Using video with early diagnosis of autism

The seminal work of Massie opened the way through analysis of family videos of autistic children. Now that video is much more easily available, we can often get family films and see them with parents. The goal is to find the early specific signs of autism, see the different modes of onset and discuss the diagnosis with parents (USA: Massie 1975, Massie & Rosenthal, 1984; Osterling & Dawson, 1994 France: Malvy, Adrien, Brauner &Wendland; Italy: Bernabei &Camaioni, 1998; Maestro 1998 (see Wendland & al for a review and references).

Using video in assessment

Video is now playing a key role in the clinical assessment of infants and parents. Several situations or assessment scales rely mainly on video clips of infants and parents in several settings: Use of several clips from strange situation, play, change, clean-up in the assessment of children in foster care The Alarm Distress Baby Scale (ADBB Guedeney & Fermanian, 2001): using a pediatric examination a ‘Set Situation’ to assess withdrawal behavior in infants Feldman’s Classification of Infant Behavior: using a feeding situation to assess parent infant interaction Feldman CIB, (Feldman, 2007). Ambiance: Lyons Ruth & al (2005): caregiver disorganizing behaviors in the strange situation Marvin’s use of the strange situation and Circle of Security© (2002).

Conclusion

Video has become a major tool for psychotherapeutic intervention and prevention, as it allows us to catch brief and meaningful events that can be reviewed with the parents. It is helps to focus on the young child’s reactions and interactions within the context of developing relationships. It is a key tool for training and supervision. Its strength is to highlight positive aspects that parents may be unaware of in the middle of difficult relationships. However, its use must be closely framed within the therapeutic relationship with the family. It should be avoided when parents are in a conflict about the care of children with legal implications.

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The era of using video for observation and intervention in infant mental health

Authors

Guédeney, Nicole, MD
Guédeney, Antoine, MD
France

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