Video Intervention Therapy

You may have heard the saying that the therapy room is a microcosm of the outside world, that the patterns and behaviors that play out in our offices mimic those in our clients’ day-to-day interactions. But can we really get a true sense of our clients’ families when, consciously or unconsciously, their behaviors shift in a therapist’s presence? On top of that, do the stories you hear about their home lives really provide an accurate narrative? Sure, you could do a home visit, but that’s impractical for many therapists, and once again, our physical presence can alter the dynamic. The truth is, we’re often working with an incomplete picture.

Over the last several years, I’ve been using an approach that has all the benefits of a home visit but is more effective in many ways. In video intervention therapy, or VIT, clients film their interactions at home and bring the video into therapy, where they process and address these interactions with the therapist. Suddenly, missing puzzle pieces fall into place, the therapist and client catch things that have been overlooked, and insights and breakthroughs follow.

No matter what clinical orientation you follow, VIT can be a valuable addition to your therapy toolbox. You can use it in conjunction with any clinical approach and with any client population—including couples and peer groups—willing to be recorded outside the therapy room. My work with families has benefited immensely from it.

Dan and Susan had called me about their daughter Libby. “Libby’s 12 and Libby rages,” Susan said. “She’ll punch the walls; she’ll break anything she can get her hands on.” During a recent episode, Libby had threatened to jump out of her second-story bedroom window. “I’m worried,” Susan said with a sigh. “I think this is how she tries to get her way.”

I invited Dan and Susan to see me for an initial session so I could get more background information and discuss any perceptions, fears, and feelings that might not be appropriate to bring up in front of Libby when the time came to include her in our work. It gave me a chance to emphasize that I expect parents to be fully involved in the therapy process.

Dan and Susan said they’d chosen to work with me because they knew I’d spent nearly 30 years specializing in foster care, adoption, and residential treatment issues, and they’d adopted Libby from China when she was two. They handed me a photograph of her taken at the orphanage when she was a baby. She wore a sad, blank stare in the photo; the orphanage was clearly an overcrowded place, with more children than caregivers. I’d seen many photos of children who’d been adopted from overseas and had learned that crying, needing a cuddle, and hunger didn’t matter unless the clock said it did. Since I work from a developmental perspective, I find details about early childhood essential to understanding the why beneath confounding and extreme behaviors. It was likely that Libby had been deprived of a sense of agency at a young age, and was now burying her needs and feelings until they’d erupt in an outburst of emotion.

I also learned that both Dan and Susan came from households where little emotion was expressed. “We weren’t allowed to be angry in my home,” Dan told me.

“I was a very compliant and eager-to-please child,” Susan added. “I’d never have dreamed of behaving the way Libby does.”

It was clear that they were out of their depth trying to manage Libby’s behavior, so as our session neared its end, I decided to propose an assignment.

“The next time the three of you sit down to dinner,” I told them, “Film yourselves for five to ten minutes. Just set your phone off to the side, hit record, and show me the video next week.”

Intrigued, they readily agreed.

Why this assignment? In 2009, attachment researcher Miriam Steele invited me to a workshop led by George Downing, the developer of VIT. I was excited and curious about what I’d learn, particularly when attendees were asked to bring in videos of their clients. Since I often taped my clients during parent–child assessments and sessions, I was sure I’d have plenty to choose from. But I soon realized that VIT videos were different.

“I have a feeding video,” said one attendee who was already familiar with VIT. “I have a breakfast video,” said another. Rather than taking place in a session, these videos took place in clients’ homes. They revealed ordinary, everyday interactions. And they were fascinating! An inside look at what really happens in a client’s life? I was awestruck. Perhaps the most incredible aspect of creating these videos was that they gave clients the opportunity to step back from their relationships, slow them down, and view them more objectively. After the workshop, my brain was exploding with possibilities, and I returned to my practice eager to have clients make their own videos.

Having done in-home work with families for years, I’ve long known that the real family stories unfold around the dinner table, rather than in therapists’ offices. Although parents often say their child’s behavior comes “out of nowhere,” this is rarely the case. Usually, subtle cues lead up to a child’s big feelings, and early distress signals are missed. I knew having a video of Dan and Susan’s interactions with Libby would give all of us the opportunity to spot hidden distress signals. Together, we could watch an interaction not once, but multiple times, perhaps catching important things we didn’t see the first time.

Dinner with Libby

Dan and Susan returned to my office the following week with the video, and we watched it together on my laptop. What I noticed was striking. Instead of looking self-conscious, as clients sometimes do when being filmed, Dan, Susan, and Libby were stiff around the dinner table. Their faces looked flat, and there was a palpable lack of emotion in their interactions as they passed serving dishes back and forth. Libby’s expression was oddly reminiscent of the one I’d seen in her old baby photo. I wondered if this stiffness was Libby’s way of coping with an old attachment injury.

“How was school today, Libby?” Susan asked a few minutes into the video.

“Oh, fine,” Libby replied with a strained smile and feigned cheerfulness.

I paused the video. I find that keeping a still shot of the family on the screen while I ask questions helps family members dive deeper.

“What do you notice here, Susan? What stands out to you while watching this?”

“Well, for starters, I never smile,” she replied. “I didn’t realize that. I mean, I knew things had gotten pretty bad, but wow. This is sad.”

I paused so we could take in Susan’s realization, and saw tears well up in her eyes. For a moment, my thoughts shifted to Libby. Children who spend their early years in an orphanage often miss out on the smiles and delight in a familiar caregiver’s face, and I wondered what it must be like for Libby to live with a mother who never smiles.

Turning back to Susan, I remembered the words of child psychoanalyst Selma Fraiberg: “We must first hear the cries of the mother. She will then begin to hear the cries of her baby.”

“It’s been really, really tough,” I affirmed for Susan. “How about you, Dad? What stands out for you?”

“I guess how helpless I feel as I watch this,” he said softly.

I nodded, trying to communicate that I understood his pain, too.

After seeing what stands out for clients watching their video, the next step in VIT is to point out something positive the client notices. It’s what narrative therapist Michael White famously called “looking for the sparkling moment”—the moment where a problematic pattern stops when someone does something different, keeping alive the hope that things can change. Since many VIT clients already feel vulnerable watching a video of themselves and often expect they’ll be corrected and told what they’re doing wrong, nurturing hope is essential.

“Well, you did manage to have a meal together!” I said. It was indeed a positive sign. In some families, the tension is so great that they can’t even sit down for dinner.

Dan and Susan chuckled. I could see on their faces that they felt some small sense of accomplishment.

“I also noticed a few moments at the beginning of the video, Susan, where Libby smiled when you did. Did you happen to notice that?”

Susan shook her head, so I rewound the video to show her. Sure enough, when Susan smiled, Libby did too. I could see her mirroring her mother’s posture: when Susan’s shoulders dropped, hers did too. For a moment, both of them had relaxed.

“See that?” I pointed at the screen. “This is Libby’s bid for connection. For a moment, you two found each other.”

I looked over at Susan, who’d begun to cry again.

“Yes,” she said, reaching for a tissue. “I guess we did.”

Next, I decided to use a VIT technique known as the Inner and Outer Movie. The outer movie refers to the objective behavior we see in the video, while the inner movie refers to the thoughts, feelings, and body experiences going on inside clients as they engage in that behavior.

“You mentioned you’re not smiling,” I said, referring to Susan’s outer movie. “I want to play a little bit more of this video again to better see what you’re talking about.” I pressed play right when Susan began asking Libby about her day at school. Cold and frowning, her sadness seemed to leap out of the screen.

“Susan, I’d like you to put yourself back in that moment,” I said. I wanted to help her access her inner movie. “What are you thinking and feeling here?”

“I feel sad and disconnected that she gives one-word answers to my questions,” she replied. After a moment, she asked, “Do you think Libby can tell that I feel that way?”

Now we were getting somewhere! This is exactly what I love about VIT: sometimes, the video seems to do the work for me! Without it, helping Susan reach this level of understanding might have taken weeks or months. Or worse, I might’ve mistimed a suggestion that Libby was picking up on her mother’s negative feelings and reacting angrily, which Susan might’ve vehemently denied or reacted to with even more despair or shame. Susan might not have been ready to hear this insight from me, but now she was inching toward it on her own.

“It’s a good question,” I replied, containing my enthusiasm and meeting Susan where she was. “Let’s keep watching and see what we notice from Libby.”

We rewatched Libby answering her mother’s question about school, and I paused the video when Libby flashed a superficial smile, allowing Dan and Susan to absorb it. For a minute or two, they were silent.

“I never thought about it this way,” Susan said. “But I think maybe, in some ways, Libby and I feel the same. We both feel sad, rejected, and afraid.”

I nodded, again proud of Susan’s insight. “From what you’ve shared with me about your own upbringing, it sounds as if you never felt you could express negative emotions—or that you’d be supported if you did. You’re navigating completely new territory here.”

We had more work to do, but Susan had begun to understand how her own feelings and behaviors were affecting Libby; she was beginning to see how they were similar. Now, she was no longer lost in her own frustration, convinced that Libby was being manipulative. Instead, she could join with her feelings. We can build on this, I thought to myself.

I decided to incorporate another VIT technique, called Giving a Voice. It entailed stopping the video when Libby was quietly looking down at her plate, and speaking as though I were Libby.

“What might she say to us here if she wasn’t silent?” I asked Dan and Susan. “I feel scared and unsure,” I said, pretending to be Libby in the video. “I’m afraid to speak; I feel so alone.”

“Do you think that fits what Libby might be experiencing here?”

Dan and Susan nodded.

“Now, I’d like you to add to or change what you think Libby might’ve said.”

“Sometimes I also feel really mad,” Susan said, channeling Libby. “Does anyone here really see me?”

Dan, listening intently, reached over and took Susan’s hand. I could sense that their clashes with Libby were beginning to make sense. They were having important realizations that had previously escaped them.

After the Insight

After that session, I asked Dan and Susan to bring in more videos: helping Libby with her homework, playing together with her, and everyone cooking dinner together.

Over the following months, I employed other VIT techniques, including “linking techniques,” where the therapist invites the client to reflect on parallels between interactions seen in their videos and those in their other relationships, as well as “insertion techniques,” where the client practices new behaviors in the moment by stopping the video at a point where they could implement those new behaviors—a role-playing of sorts.

Sometimes, Dan and Susan’s opinions of what was happening in the videos were different, like when Dan thought Libby was being rude and disrespectful, but Susan thought she was just overwhelmed and trying her best to cope. This presented another opportunity: to see how Dan and Susan managed contrasting viewpoints, and whether they could make room for each other’s perspectives and get on the same page.

When I finally brought Libby into our sessions, it became clear that she’d been misreading her mother’s sad demeanor to mean she was unloved and unwanted.

“My mom hates me, and I think she wishes she could give me back,” she said.

But after showing Libby parts of these videos, too, her tone changed. “I look so mean!” she said at one point. It was a turning point. Up until now, she’d been convinced that her parents were the mean ones.

In the sessions that followed with Libby and her parents, she began to see that her mother desperately wanted to connect with her but didn’t know how. Through VIT, Libby’s parents had deepened their understanding of how Libby’s internal experiences were fueling her anger, and how their own emotions and behaviors were contributing to her difficulties. As we continued VIT, Libby and her parents started looking happier and more relaxed—in the videos they filmed and in my office—and Libby’s angry outbursts gradually subsided.

This is just one way to use VIT. It may seem “out of the box,” but once you’ve given it a try, you’ll get a sense of how much it can bring to therapy. Clients in VIT often say things like “Wow, I had no idea I was doing that!” or “I look angry so much of the time,” or “My child looks so sad; I didn’t catch that in the moment.”

VIT has given me invaluable insights into family relationships and dynamics that would’ve otherwise remained unknown. It’s helped me slow down the dance between partners, and between children and parents, to see nuanced behaviors and explore the thinking that drives negative cycles. Thanks to VIT, I’m a much more effective therapist. It’s opened a window into my clients’ real lives—which is, after all, what we’re trying to help them improve.

Case Commentary

By DAFNA LENDER

I’m grateful to Karen Buckwalter for highlighting the usefulness of video intervention therapy, no matter what method or framework you’re practicing. For 27 years, I’ve videotaped parent–child interactions in sessions as a way to help clients become more aware of what they’re transmitting through their posture, tone, gestures, movements, and facial expressions. What I find particularly interesting about this case is that the therapist asks the family to record themselves at home, allowing a better view of the subtle dynamic of their interactions.

I’m also struck by Buckwalter’s sensitive and masterful use of the resulting videos. She illustrates how watching a segment with parents and exploring what they saw and felt in that moment can result in a profound, positive shift in understanding. This understanding opens the door to exploring the parents’ own attachment histories, which I’ve found many therapists are hesitant to do for two main reasons.

One, they worry that asking parents about the way they were raised will make them feel blamed for the child’s problem. Two, they worry that the parents will balk at becoming an intimate focus of the work, since they thought their child was the focus of therapy. It’s why I appreciate Buckwalter’s approach of telling parents from the beginning that they’ll not only be involved in the work, but may be asked to examine and change themselves if they want their child’s mood and behavior to change.

I expect some therapists will retort that a video isn’t representative of “real” interactions if the participants know they’re being filmed. But in my experience, while clients may initially alter their behavior, they usually fall into their regular patterns quickly. To check, I suggest asking the client during the review session something like, “Was this interaction pretty typical of how things go? If not, why do you think it was different?”

Still, therapists should be warned that recording a child should be done only with the child’s consent. Parents should be told from the beginning that the recording isn’t meant to “catch the child being bad” or to be used as evidence that the child is in the wrong. Used in an attuned and supportive way, as Buckwalter illustrates, VIT is a valuable tool for examining the unspoken, tacit, and energetic relational interactions that contribute to the narratives and roles we take on as family members. Even though I mostly work with parents and children, I’ll consider using this tool with the couples I see as well.

ILLUSTRATION BY SALLY WERN COMPORT