Participant semi-structured interviews.
Ten of the 17 participants who completed the intervention agreed to be interviewed. They were six mothers, two stepmothers and two grandmothers. There was no financial compensation for participating in this interview. Interviews were arranged when the child had an appointment at the hospital, so caregivers who did not continue treatment in the outpatient clinic reported more difficulties in agreeing to the interview.
Two main categories emerge from the analysis: ‘Workshop Perception’ and ‘Perceived
Benefits’. These categories had several subcategories as seen from the caregivers narrative. The foundations of these categories are described alongside verbatim quotes illustrating them. Participants are identified in each quote using codes for interview number, relationship and age.
Workshop perceptions: What they thought about their participation
a) Motivation to attend: The caregivers report that they accept participation in the trial because they felt it as an opportunity to received help and because it was a space for dialogue. Some of them also believed the intervention was part of the inpatient treatment.
“Because I thought: ‘this is the opportunity to help my son’. He had been going to the psychiatrist for a long time, but he did not have a therapist or anything. Then I thought this could be the opportunity; thanks to God it was like that!”. Interview number 2, mother, 36 years old.
b) Difficulties seen in workshop participation: several caregivers mention various problems in participating, in both interventions (play therapy and VIT). Mentioning aspects such as commuting distances, plus time and money constraints. Two of them failed to understand workshop purpose. Regarding workshop ambience, they mentioned that during Play Therapy, if there were any kind of interruptions or when other children were around, the noise became upsetting and it was difficult to focus in playing with their child or also they mention being uncomfortable with being filmed. They also mention that when their child was upset or restless, it became difficult to engage the child in play therapy.
“Then this other mother was there and I was there with Camilo, then the mother was like, very loud and played with her child, then I did not like that, because I could not concentrate, I was with Camilo and I tried to get into the head of Camilo, but having to work over this mother, I couldn't do it, but it was the only time I got complicated”. Interview nº1, mother, 30 years old.
c) Positive workshop references: All those interviewed mentioned positive aspects of the workshop: they liked the number of sessions, the group setting and the video-feedback. The latter because they had the opportunity to see themselves interacting with their child, to observe behaviors that are not normally noticed in daily life, particularly regarding positive aspects on mother and child behavior. Video observation also allowed them to become aware of any improvements seen during the process.
d) Concerning therapists, cares said that they felt listened to, and that they were warm and flexible, providing sound advice.
“Obviously we don’t see oneself, I mean, one doesn’t see the way one acts and cannot know that one is behaving incorrectly. But if one sees oneself in the film, then we do realise it, and it is amazing! One goes through life, strong and straight… and without the video saying, “look, this is you” one cannot reflect, one cannot realise that one is doing something badly. The film made me realise that something was wrong.”. Interview nº3, stepmother, 58 years old.
e) Suggestions for change: Some of them said they would prefer more VIT sessions, include it in the outpatient setting and incorporating the child and/or other family members, such as either the father or mother, or both (many caregivers were grandmothers). Regarding Play Therapy carers prefer interacting with their child in a quiet and private space and to involve more child unit staff members. In relation to the trial, they request greater depth when explaining the rationale behind the instruments, specifically FMSS, because they found it difficult to understand why it was necessary to answer the same questions every week.
2. Perceived benefits
a. In general, carers reported that VIT was an effective help, which supported them during their child’s hospitalisation. Support came both from therapists as well as from other parents during group sessions, as they felt understood by them. These participants helped them to see aspects in the videos that they could not see by themselves, including positive interactions between them and the child, and this proved to be, in a crisis setting, was both comforting and encouraging.
They help me to find the right words to say in certain situations, I don’t know…, for example how to react to Esteban’s anger, because when he is angry the situation is not exactly rosy. When he was enraged, he could kick anybody passing in front of him, he could hit the wall with his fists. In this, they help me a lot, how to contain him, how to handle him
Inerview 7, mother, 29 yearls old.
b. Identify parenting problems: Caregivers mention that, through looking at their interactions with their child in the video, they identified certain situations at home where they could act or feel different about their children. All situations mentioned by them were organised in two main themes, difficulties in expressing emotions and difficulties in setting rules and boundaries.
i. Emotional expression: They reported that sometimes they could over react vis-à-vis the child’s behaviour, and get angry very easily, not paying attention to the child’s feelings, not expressing love to the child, describing the child in light of their negative aspects, and not sharing with them any play spaces in the home.
“In the past, I couldn’t control myself… For example, I used to shout, I could yell at him and on occasions I could hit him. Then I would turn around, my husband would go to calm Juan and I would go to cry in my room, full of remorse… because I know I should not hit him. But not now, …and I say to myself, “My Goodness, I have changed!””. I2, mother, 36yo.
ii. Setting rules and boundaries: Being authoritarian, or to give them anything they want, not being clear in rules (or contradicting the norms), to allow the extended family taking decisions that should be taken by her, not intervening when another adult in the home ill treats the child and failing to set boundaries due to fears of how the child might react.
“Because, for example, if he wanted an ice cream, I would give him the ice cream. If he wanted me to stand on my head, I would stand on my head, if he wanted to go goodness knows where, I would take him there. The whole family behaved like that, his daddy, the older sisters; whatever he fancied, it was given to him, to avoid him throwing a tantrum, to avoid him breaking things” I5, mother, 50 years old.
c. New strategies: Together with becoming aware of their parenting difficulties, they start to practice new driving behaviors
i. Communication: Acknowledge the problem and talk about it, without disqualifications. Providing positive reward, taking into account the child’s opinions, identifying any preferences, finding out common interests, giving explanations about what the child does not understand, and sharing with him what the adult thinks and feels.
“Now I sit with her, or we go for a walk. ‘D, what is the matter? I feel there is something wrong, I know you’ … ‘I don’t think it is nothing …” “I feel something is happening, …tell me, perhaps I could help you, let’s talk” I3, stepmother, 58yo.
ii. Related to affections and emotions: Keeping calm before reacting. Imagine what the child might be feeling, finding ways to calm the child (first, by calming herself, then distracting them and connecting with their emotions), avoiding escalating aggressions, pondering and repairing negative reactions against the child.
“I say to him, ‘. Jorge, I am fed up with you. Why don’t you go to hospital, I am tired with you, obey me…’ and then, I reminded myself! And I thought ‘No, something might be happening to him’. So, I said to him, ‘forgive me that I shouted at you, sit down, and tell me, what is the matter?’ He said, Mum, I wanted to do this or that, and I said, ‘We’ll do it later, on our return; I have to go out and I cannot leave you alone, we will go out, we will come back and then you will do it’. He replied, ‘Okay’. I realized then that, before, he would have shouted, ‘I’ll do nothing at all!’ and he would have been distressed.”. I2, mother, 36yo.
iii. Related to rules and boundaries: Defining the rules and respecting them, being flexible vis-à-vis child’s needs, setting boundaries though dialogue, keeping the child apart from conflictive situations, avoiding children’s involvement in adults’ problems, intervening in case of verbal aggression to the child by other adults.
“I am not any longer the way I used to be. I was permissive, I used to accept anything, I kept quiet - Not any longer; I say whatever I need to say, I do whatever I need to do.” I8, grandmother, 59 years old.
d. Changes in the way the child is perceived: They feel that they understand better the child’s problem, they are able to acknowledge positive changes, they can put themselves in the child’s place when the child is feeling poorly, when the child is insistent in certain demands or behaves inadequately. They manage to read better the child’s body language, thus being able to identify better their different emotional states.
“It happened that I did not know how to contain her, I didn’t realize that she did all that so as to be taken into account … now it’s better because I have a psychologist, the lady doctors, the play time. Thus, I spend more time with her, I ask her questions about her, …if she feels good or poorly…” I9, stepmother, 61 yo.
e. Family repercussions: Carers reported that they could transmit to the rest of the family what they had learned in the workshop, they could observe the positive changes occurring in the family, such us showing more respect for each other, expressing better their loving feelings and finding more spaces to share. Some mothers reported that they recovered their authority within the family.
“My husband also learned how to control himself, because before he would shout in anger. Now with just one look, ‘go talk to him’, goes upstairs and then he comes down already calmed” I2, mom, 36yo.
f. Persistence of the changes: Carers gave concrete examples about their ability to transfer what they had learned in the workshop, whilst the child was hospitalized, to their daily life at home after being discharged.
“Last night for example, during Nina’s homework time, I realized that something was wrong with her […] because of her facial expression, her gaze… I understood and then I talked with her.” I8, grandmother, 59yo.
- Therapists’ interviews
Four therapists were interviewed, two of them were classified as senior, because they had greater clinical experience and were qualified VIT teachers. The other two were junior therapists as they were under training and with supervised VIT by senior therapists. The open code used in these interviews allowed for the emergence of these two categories.
Motivation and perceived benefits: For therapists, participating in these interventions gave them the opportunity to learn a new technique; by learning about VIT they realized it was a useful tool for going beyond diagnosis and to have a more sensitive understanding of the child, and build a better knowledge of the carer’s upbringing and the way their life history may have affected their relationship with their son. There was also a favorable impact at work with the extended team as every week the processes of each dyad were reported in the team meeting. Besides, paramedics also participated in the games workshop. The two junior therapists valued the opportunity of gaining clinical experience and senior ones felt challenged for bringing into practice their creativity and flexibility.
“Compared with what I have done before, this was a completely different experience. In general, one approaches parents with certain ideas about how they should change or deal with children. There are only a few opportunities to work together with parents, examining our own thoughts and, progressively, understand parents’ anxieties, expectations… which they might transfer to their children. At the same time, understanding what obstacles there might be to visualize the child’s need. Previously, with my university background, I used to think, ‘blimey! why this dad is not doing this or that’. And one also understands the child’s vulnerabilities from the point of view of certain interactions and not necessarily as something that is intrinsic to them.” Young therapist.
2. Conditions necessary to practice VIT: The therapists reported;
3. (a) the need to program the necessary time (extra time is required to analyze videos and prepare the workshop; they concluded that this required 30 to 60 minutes of work per week, according to the number of carers). (b) Technical supervision, which can be scheduled for according to the professionals’ prior training and knowledge about VIT(, young therapists also had the requirement of accepting weekly supervised sessions, during which the videos were analyzed by the whole team. This resulted in an extra hour per week to prepare the workshop.
4. (c) Technical requirements such as internet access, cameras or cell phones and play materials.
5. (d) Collaboration from t team members in preparing the workshop room, to avoid interruptions to the play process (with tasks such as blood pressure checking, administering medicines, amongst others), and, most importantly, be available in case the primary care giver is not present for the play workshop or any other contingency (for example in case of child agitation or aggression between peers).
“These were some situations that occurred during the workshop. The children were playing, as part of the therapy process, and suddenly it was mealtime and the assistant workers would arrive with the food. From the point of view of the workers, ancillary, nursing or paramedic staff, this was never an interruption, but from the therapeutic point of view, there was a clear interruption of a process.” Senior therapist