From Action to Interaction. Marte Meo Video Counselling in an African Context


Background: Sensitive and supportive interactions are keys to healthy development in the early years of life. Parents and other caregivers can promote social and emotional functioning through Marte Meo Counselling. Objectives: The present study aimed to investigate whether Marte Meo Counselling was applicable in an African institutional context. Method: We chose a qualitative research design, using participant observation and focus group interviews with caregivers before, right after and one year after Marte Meo Counselling. Findings: The main finding is that the caregivers are more aware of the various infants’ cues. They describe new practices in their daily work as well as a change in their attitudes and behaviours towards the infants. Conclusion: We found that Marte Meo Counselling facilitated social and emotional development for the institutionalised infants, and thus it is applicable in this African context. Implications for Practice: Caregivers of vulnerable infants should be offered Marte Meo Counselling or similar methods focusing on enhancing emotional and social development.

Share and Cite:

Rohde, R. , Daudi, V. , Saibulu, J. and Vik, K. (2020) From Action to Interaction. Marte Meo Video Counselling in an African Context. Psychology, 11, 1925-1940. doi: 10.4236/psych.2020.1112122.

1. Introduction

In this paper, we will describe the findings of a qualitative intervention study with Marte Meo Counselling (MMC) conducted at a small unit for motherless infants at Haydom Lutheran Hospital (HLH) in Northern Tanzania.

Infants who spend their first time of life in an institution show risk of physical as well as mental developmental stress and disorders. Psychological disturbances, emotional and social problems, learning difficulties, cognitive problems, and attachment disorders, are reported (Lionetti, Pastore, & Barone, 2015; Carlson, Hostinar, Mliner, & Gunnar, 2014; Lecannelier, Silva, Hoffmann, Melo, & Morales, 2014; Crockenberg, Rutter, Bakermans-Kranenburg, van Ijzendoorn, & Juffer, 2008; Sigal, Perry, Rossignol, & Ouimet, 2003). A study of orphans in Dar es Salaam showed that they had increased internalizing problems compared to non-orphans (Makame, Ani, & Grantham-McGregor, 2002).

Varieties of Video Interaction Guidance methods have been developed to assist parents or caregivers in daily interactions with their children (Kennedy, Landor, & Todd, 2010; Brooks, 2008; Juffer, Bakermans-Kranenburg, & van IJzendoorn, 2008; Van Doesum, Hosman, & Riksen-Walraven, 2005; Hynd, Kahn, Tilley, & Chambers, 2004; Beebe, 2003; Sluckin, 1998; Van den Bergh, Klomp, & Harinck, 1997; McDonough, 1995, 2000). Marte Meo is one of them, shown to increase healthy development in several studies (Gill, Thorød, & Vik, 2019; Kristensen, 2016; Høivik et al., 2015; Vik & Rohde, 2014; Vik, 2010). Marte Meo is a strengths-based, solution-focused program that can help parents and other caregivers to take part in supportive developmental interaction (Aarts, 2008).

Marte Meo Counselling is not previously studied in Africa. With great humility, we set out to introduce and practice MMC at this small unit for motherless infants at HLH. Through MMC we intended to show the caregivers concrete, in video clips, the needs of each individual infant. By supportive comments, related to the video-clips, we assumed that practical issues in caring could be combined with social interaction. We aimed to generate detailed and in-depth descriptions from the caregivers’ experiences with MMC. Our research question was: how do caregivers perceive MMC in their everyday practice in an institution for motherless infants in Tanzania?

1.1. Marte Meo Counselling

1.1.1. MMC—Procedures

The procedures in MMC are as follows: After giving general information about the method, the counsellor emphasizes that the focus will be on the infant. The goal is to learn the special expressions and the needs of every individual infant. MMC is video based. Short, close up recordings of daily interaction moments, like feeding, nursing or playing, are recorded. The motivation for close-up filming is the opportunity to study interactional incidents as well as tiny expressions on the infant’s face. In addition, the close-up pictures seem to give the impression of being close and present emotionally (Vik & Rohde, 2014). Subsequently, the clips are analysed according to guidelines for supportive developmental interaction related to verbal and nonverbal communication (Aarts, 2008). The guidelines consist of seven dialogical elements. 1) The caregiver seeks to locate the child’s focus of attention. 2) The caregiver confirms the child’s focus of attention. 3) The caregiver actively awaits the child’s reaction. 4) The caregiver names the ongoing and forthcoming actions, events, experiences, feelings and anticipated experience. 5) The caregiver confirms desired behaviour approvingly. 6) The caregiver triangulates the child with “the world” by introducing persons, objects and phenomena to the child. 7) The caregiver takes responsibility for an adjusted and reciprocal start and ending of interactional sequences (Axberg, Hansson, Broberg, & Wirtberg, 2006).

When the film is analysed and moments of significant importance are identified, the film is edited and supportive developmental moments are retained, the rest is deleted. The third step in the Marte Meo procedure is the feedback to the caregiver. After showing the film, the remote control is used to rewind, and the pause button allows us to freeze images suitable for detailed descriptions and reflections. By replaying, the opportunity to look closely at sequences or incidents on the screen occurs. Observing oneself “on a distance” seems to allow the caregiver to perceive both the infant, herself and the interaction in a new way (Kristensen, 2016; Vik, 2010).

1.1.2. MMC—Theoretical Perspectives

MMC is a practical approach, which builds on various theoretical perspectives. Attachment and social and emotional functioning depend upon supportive developmental contact early in life (Main & Solomon, 1986; Bowlby, 1980; Ainsworth & Bell, 1970; Ainsworth, 1967). According to Stern (2004), attachment theorists often emphasize the importance of somatic state regulation. The caregiver’s role is traditionally described as a one-way influence, often related to the regulation of hunger and the shift from wakeful fatigue to sleep. However, the “Self with Other as a Subjective Experience” include both the infant’s and the caregiver’s active regulation of attention, curiosity and cognitive engagement with the world (Stern, 2004).

Daily interaction moments are the basis from which infants learn their first steps in communication and social functioning. Physical and psychological state regulations are relationally based learning processes, named by Stern (2004) as building patterns of being together. The micro-events taking place repeatedly in daily interaction moments are considered as real events, they are ordinary and concrete (Vik & Rohde, 2014; Stern, 2004).

The interaction patterns influence the quality of attachment between the caregiver and the infant as well as the child’s future social and emotional functioning in other relationships. This self-experience is dependent on both the presence and action of, as well as interaction with, the other. Consequently, the early development of attachment and social and emotional functioning could profoundly influence the future. Stern (2004) suggests three crucial preverbal intersubjective relational states; Sharing of joint attention, sharing of intention and sharing affective states. The prerequisite is that the caregiver discovers the tiny cues from the infant. Furthermore, to release interaction, the adult has to answer, either by a sound, verbally or by facial or physical recognition.

Mentalisation refers to the meta-cognitive abilities to reflect upon own and others’ thoughts, feelings, intentions and actions (Lund & Rohde, 2015). Alternatively, as Shai & Fonagy (2011) put forward, the caregiver’s capacity of mentalising is to consider and treat the child as a psychological agent motivated by mental states.

The significance of social and emotional functioning is considered the foundation from where the attachment between the caregiver and the infant is built (Ainsworth, Blehar, Waters, & Wall, 1978). A frequent change of caregivers and change of caring style is a possible risk factor. Intersubjective relatedness, as described by Stern, is in institutional settings, not necessarily lacking, but the infants have to adjust their style of “being with someone” several times a day, in many different ways. Whether the caregivers are stable or not has a significant influence on this pattern building process (Stern, 2004).

When it comes to the predictability of social functioning and a good life with others, certain skills have to be developed, and certain emotional experiences have to be lived through. We set out to get the CCU-caregivers descriptions of their experiences with MMC and how it would work in this African context. We hoped it would contribute to giving infants at the CCU a better start in life.

2. Materials and Methods

2.1. A Prospective Qualitative Intervention Study

This study, based on qualitative research design, is consisting of participant observations and focus group interviews (FGI) before, immediately after and one year after the MMC. In the present paper, we used the data material from the participant observations and the FGIs conducted after the MMC.

2.2. Study Site and Research Participants

The Child Care Unit (CCU), established in 2009, is a part of Haydom Lutheran Hospital in Manyara Region, Tanzania. The CCU aims to care for infants who have lost their mother in childbirth until their families can provide for them, usually when infants are between six and nine months of age. Cultural sensitivity should be practised when we introduce an European based video interaction counselling method in an African context. Therefore, we carefully took into consideration aspects of how infant rearing and caring modes are embedded in different cultural contexts. In European culture, we encourage parents to have face-to-face contact and “baby talk” with their infants to promote interaction and attachment. In many African societies, especially in rural sites, infants development are supported mainly through body contact, carried by their mothers and by being breastfed on demand (Vik et al., 2018; Valizadeh, Ajoodaniyan, Namnabati, Zamanzadeh, & Layegh, 2013; Levine et al., 1994). At CCU, neither face-to-face contact nor close body contact practices are common. Hence, the infants’ psychosocial development may be at risk and was calling upon an intervention to promote developmental support (Vik et al., 2018).

Sampling procedure of this study intended to recruit as many of the caregivers at CCU as possible. The entire group of twelve female caregivers wanted to take part. They have no formal education in nursing or teaching, and only two of them have secondary school education. Ten of them were, at the time of intervention, mothers themselves. The staff was stable during the research period. The caregivers do their daily work on three shifts. Film-recordings were done early in the morning, during the day and even at evening shifts. The most suitable time for studying the films together, the feedback, was in the middle of the day when morning and afternoon staff had two hours overlap. 44 films of interaction between the caregivers and various children (range at first filming, 1 1/2 to 22 months) were conducted.

2.3. Data Collection

The first and the last author visited the site nine times from 2012 to 2016; each visit lasted from two to three weeks. During these visits, we conducted participant observations at CCU, and after a while, focus group interviews (FGIs). The interview guide for the FGIs was developed to be suitable for the cultural context of the study, together with internal investigators, authors three and four. The FGIs took place right before Marte Meo intervention (FGI 1), right after the end of the intervention (FGI 2) and the final interview (FGI 3), one year after FGI 2. The third author conducted all of them.

2.4. MMC at CCU

During participant observation, we had informal conversations with the caregivers. Among others, we discussed what the needs of every human being are. Together with the caregivers, we concluded that through life, we need “a spoonful of food and a spoonful of love”. This saying became our slogan and a guideline for the project. The “spoonful of food” seemed to be clear. It was the physical care related to food, clothing and somatic health (Vik et al., 2018). By exploring the content of the “spoonful of love”, we approached the elements of social and emotional development. As contextual involvement and collaboration, this upstart process was of great importance. The caregivers took part in preparing to be research participants.

Practically the feedback sessions in MMC took place at CCU in a separate room with translation from Swahili to English and vice versa. The results reported in this paper were presented at the site to the caregivers before submission in February 2017. A revised version of this paper was worked on with co-writers in November 2019.

Forty-two films of interaction between infant and caregiver were recorded, and the corresponding feedback sessions were taped. The three periods with MMC took place in May and September 2014 and in February 2015. Author one and a colleague, both Marte Meo Licenced Supervisors, conducted the MMC to the staff at CCU. The films are not analysed scientifically, but serve as a source of information that enriches and validates the caregivers descriptions.

We adjusted cultural and contextual elements of the seven dialogical principles from the Marte Meo methodology after some time of participant observations. We became aware of some conveyor-like, routine situations. By making caregivers aware of and dwelling on small incidents, e.g. when the infant was searching for a contact, the caregivers themselves suggested what to do. This situation provided the opportunity to introduce the distinction between what in this article is called “action moments” and “contact moments”.

We investigated which words the caregivers used when they described interactional sequences with the infants. This knowledge helped us develop a contextual adapted list of dialogical Marte Meo elements, which identified supportive developmental interaction. This list was translated into Swahili and distributed among the staff. The specific and practical guidelines encouraged the caregivers to make a clear start signal, to look for, wait and follow the baby’s signals. To say in words what the baby is looking at or doing. To say in words what you are doing, to imitate the baby’s sounds and give the baby time to respond. We also wanted them to notice what makes the baby smile, is the baby enjoying it or has he had enough? Finally, we encouraged them to make a clear ending signal. We argue that this cultural sensitivity is crucial for the outcome of the MMC. At the same time, it gives us some guidelines when looking for the movement and change from before to after MMC.

2.5. Analysis

The qualitative approach is, in this study, characterized by proximity to the research subjects. In order to increase the distance to the source of information, the focus group interviews were transcribed and analysed by emphasizing getting into a position of reflective detachment.

A reflexive and interpretative methodology characterizes the phenomenological analysis (Malterud, 2001). The selection and interpretations of the caregiver’s answers influenced the philosophical, historical and cultural circumstances we use to understand the social life-world. The dynamic of understanding human interaction is, in qualitative research, called the interpretative paradigm (Malterud, 2015). The caregivers’ experience-near reporting of data gave us as researchers challenges in sorting out into meaningful, research relevant divisions. Nevertheless, our team-based approach gave the possibility to perform fruitful professional and semantic discussions. We claim to have reached a balance between relevant theoretical frameworks, proximity to the participants’ experiences and our own role as researchers.

Approaching the transcripts from FGI 2 and 3, we read through it all to get an overview and a general opinion. Then we read the material one more time to look for meaningful sentences related to our research question; how do caregivers perceive MMC in their everyday practice in an institution for motherless infants in Tanzania? The third time we used different coloured marker pens to highlight important quotes and search for categorization. By four occasions, we met to discuss and condense into meaningful categories. Descriptions of changes, of practical issues, of certain discoveries or emotional expressions are examples of categories. The collaboration in this process included interesting discussions, both regarding psycho-social and cultural issues, which became normative for the writing of this paper.

2.6. Ethical Considerations

The Marte Meo approach was presented and approved by the staff at CCU, the head of the research unit and the administration at Haydom Lutheran Hospital. The caregivers and the infant’s next of kin taking part in this project signed a formula of consent. The caregivers are given pseudonyms in the quotes in the results section to secure anonymity.

The study is ethically approved by the National Institute for Medical Research (NIMR/HQ/R.8a/vol. IX/1629) in Tanzania and the Regional Committee for Medical Research, Southern Norway (2012/1159 REK sør-øst B). The Commission for Science and Technology (Research permits No. 2014-19-NA-2013-196 and No. 2014-18-NA-2013-196) granted the non-Tanzanian researchers involved in the study approval.

3. Findings

The main finding is that the caregivers are more aware of the various infants’ cues. They describe new practices in their daily work as well as in their amendment in attitude and behaviour towards the infants. In addition, their thinking about themselves as caregivers seems to have changed. The recordings challenged the caregivers to take the perspective of the infant. These changes were reflected in the detailed descriptions and statements from the caregivers, which refer to their interactions with the infants before and after MMC. The result of our analysis suggests four primary categories, all describing movement from one position to another. The categories are: 1) from object to subject; 2) from action to interaction; 3) from seldom to often, and 4) from incomplete to complete.

3.1. From Object to Subject

The first movement described the position from where the caregiver perceives the infant. From considering the infant as an object for her ideas of what were the working tasks, the caregivers, increasingly described the infant as an active subject influencing the interaction. We found several statements illustrating this development, from considering and treating the infants as objects to the status of interaction between subjects. Faraja said:

Not like in the past, when I wanted to change nappies. I just picked it up and changed militarily… but now, after learning knowing this approach when I pick up a child, I have to speak or talk to the child.

The caregivers described the importance of talking to the infants several times. Raheli elaborated:

The difference I have noticed is that previously I did not know that when I was with a child, while I am bathing it or clothing it, I was supposed to speak to it. I did not know this. But now I know that I have to talk to it and we can talk. The child happily turns and smiles. We are both happy.

The supportive behaviour of talking is both psychologically and socially significant. The caregiver confirms that they have heard the infant by answering or repeating the word or the sound. In this way, language development is in a socially interactive, turn-taking mode. Likewise, when the infant receives the message that she is heard and responded to, she is involved as a subject, and her experience supports the development of trust and confidence. When describing the significance of “being with”, in an interactional style, the caregivers often referred to their own emotions and described relational experiences.

…we know how to stay with children, the child knows that we have more close relationship… And I have to give a room to a child to respond. (Neema)

The caregivers described being more aware of the cues from the infants in different ways. Some caregivers also told how they became more involved as subjects in the interaction. Like Ombi:

The infant is a human being who can’t do anything to support itself, isn’t it? And the best way to attend it or what particular environment is needed to care for it. But what comes is sympathy within my heart.

Positive emotions are expressed, and the infant is supported in social development and differentiations of feelings. By doing practical work, and at the same time communicating actively in daily interaction moments, the caregivers became aware of the infant as a person. The opportunity and ability to give developmental support to the infants became more visible.

3.2. From Action to Interaction

The second movement was often referred to as division between action moments and contact moments. In counselling, we focused on how action could include interaction when followed by words and gentle touching. The caregivers reported that naming of things, phenomena and feelings became a part of the daily communication style. The importance of giving words to actions and states was a new discovery to Maua:

At the beginning, I did not know that we need to talk to a child. What I knew was to pick it up, undress, put in water and wash it, I had never thought of talking to it.

A quotation from Upendo is describing the importance of the nine Marte Meo points. She told how she is practising interaction in everyday life situations.

We were given pamphlets and have been guided on what to do from start to the end. What you do to the child is first to inform on what you are going to do.

When Furaha told about the relationship to a baby boy, lying on the bench, being dressed, she said:

Personally, I’m very grateful because I have learnt much. For example, in the film. I was dressing a boy, cuddling him, and I said: “me and you, you and me”. It was very good and made both of us very happy.

The quotations are illustrating how daily activities include communication and sharing of emotions. The mutual influence between caregiver and infant develop social interaction and stimulates naming of feelings. This interaction might assist the infant to give words to her own feelings and regulate the emotion without getting upset. Furthermore, it might, in the long run, predict positive mental health development.

3.3. From Seldom to Often

The caregivers reported in different ways that their social interactions have developed from occurring from time to time into a more systematic and more frequent appearance in everyday situations.

When Faraja said “It has built our capacities to better interact with the children.We are now much closer in communication with the children”, she summarizes what many of the caregivers said in FGI 3. Upendo underlined this statement when telling “you talk to a baby and you do it step by step by activity. This procedure now has become our routine.” The phenomenon of talking to the infants is appearing as the most obvious change in interaction and is richly described by the caregivers in FGI 3, using terms like talk, speak, telling and saying. Further, the caregivers told that they had learned to wait for the infants to respond.

In the movement from seldom to often, we find some statements pointing at the spreading of practices outside the CCU.

These guidelines [the dialogical elements] have also helped us to be trusted more by the community. For example, if there is a child in the neighbourhood with a problem, we are often called (Faraja). The training has been of paramount importance not only here (CCU), but, also, we can apply in our homesteads and community at large (Upendo). So, what I have learnt here I also take it home and do to my child as well. Generally, I have benefitted from Marte Meo training (Adili).

The repeated words telling the infant about what is happening, feelings related to events or things are building patterns of developmental support. The naming of actions, moment by moment, increase the likeliness to stay with the activity for longer. In this way, the child’s ability for focused attention might grow.

3.4. From Incomplete to Complete

Many routines were well established at CCU, and the opportunity to use the physical oriented actions to become more interactional complete is the fourth movement. Ombi called it to be more systematic:

I personally am very happy for those nine steps. I have learnt from those steps because we were used to do something which we do not even finish and we jumped to the next child. The training made us more systematic, following each step.

We observed how small incidents of sound making are given attention, highlighted and then developed into words. In this way, the incomplete becomes verbally more complete and additionally, in a supportive developmental way. Vumilia:

We have to talk to the baby even if it is not talking back to you. In the past, I just changed nappies without even saying a word. Now we can speak with the child and tell all that we do. And he also is learning from me. It is important for its growth and development.

The talking, not only speaking to the child, must go both ways to create an interpersonal dialogue. The movement from incomplete to complete include as Neema said: “I have to give the room for the child to respond”. In addition, she added: “there must be time to listen and answer”. The significance of looking for and following the infant’s signals includes waiting. In this way, as reported by the caregivers, their dialogues have become more interactively complete.

In summary, we suggest that the selection of quotes and the mediation of their meaning are a movement towards a positive change developmentally for the infants and as an improvement in the daily performance of the care for the caregivers. The change in these fourfold levels is illustrated in one single quotation from Upendo:

The approach has been very useful to us the way I assessed (…) For example when washing a baby, or when you oil it, and cloth it, from the start you should talk to the baby and throughout attendance and you do it step by step by activity. This procedure now has become our routine. And a baby also learns something, not only that but also you are building a close relationship with a child which brings the harmonious environment in care.

In this way, Upendo sums up the findings and describe the importance of the interaction that takes place in everyday caring practices. Her descriptions show the rhythm of a well-functioning combination of action moments and contact moments. Furthermore, she mentions the sustainability of the change at CCU, by referring to behaviour becoming a routine and the impact for harmony in care. She reflects upon the infant’s ability to learn something and refers to the building of close relationships. She is describing tendencies of increased capacity to involve in communicative relationships. She has established recognition of herself when reflecting upon her own and the infant’s thoughts, feelings and actions. We will now discuss the impact of our findings in light of relevant and already mentioned theoretical frameworks. At the same time, we will take into consideration some critical reflections before we conclude.

4. Discussion

Our first point,from object to subject, indicates that the caregivers are more likely to see the infants as subjects in their own right, rather than objects. Their attitude has changed to perceiving the infants as reaching out and as participatory human beings. When the caregivers are looking for and aware of the infants’ initiatives, the infants became subjects with their own needs and feelings. Stern’s theory of three preverbal intersubjective relational states is relevant to understand the relational significance of this change: Sharing of joint attention, sharing of intention and sharing affective states are crucial for a healthy emotional and social development (Stern, 2004). The experiences of being with someone are qualitatively different when developing from practical actions to the same actions, including dialogical interaction. The self-experience is dependent on the presence and action of the other (Braten, 2007). When sharing the focus of attention (Aarts, 2008), the establishment of joint attention, (Stern, 2004) is crucial for the intersubjective relatedness.

The second finding, from action to interaction, brings up the discussion on how a positive development of an infant is relying upon the caregiver’s mentalising capacity. The prerequisite is that the caregivers are capable of discovering the tiny cues from the infant. To release interaction, the adult has to answer either, by a sound, verbally or by facial or physical recognition (Aarts, 2008). Awareness of the importance of giving a reaction to actions requires a position of reflective self-functioning (Shai and Fonagy, 2011). We argue that the caregivers increased their mentalising capacity after the MMC, although we see in hindsight that the interviews could have investigated this phenomenon more thoroughgoing.

The third and fourth point, from seldom to often and from incomplete to complete, means that the caregivers’ attention, curiosity and cognitive engagement are occurring more often. The caregivers’ practices are complete, meaning that they answer not only physical but also social and emotional needs. The phenomenon of interrelatedness is a predictor for secure attachment, and interactional experiences give a fundament for mental health and growth (Stern, 2000). The caregivers increased the frequency of dialogical practices with the infants, and they practised their interpersonal awareness more often. However, we do not know if the frequency was the same when we were not at the site.

We have shown many examples from the caregivers’ reports showing social and emotional behaviour occurring more frequent in daily interactional moments. We do not know whether these changes are sustainable after the last FGI, and we ask ourselves whether these new practices of social interactions will continue to be a routine that is anchored in the institution. According to Stern (2004), repetition of interactional sequences is a prerequisite to making a durable change. At CCU the dyads of caregiver and infant alter, because of both working hours and changes to staff and infants over time. This fact is, of course, a challenge when building healthy patterns of being with someone. Therefore, when looking at the findings, from seldom to often and from incomplete to complete, we find weaknesses. However, the findings of this study indicate that the caregivers at CCU have established new ways of being with the infants (Stern, 2004). The indispensable role played by others in interaction is the basis for considering the infant as a subject. From this relational understanding, we argue that the caregivers are more likely to see the infants having not only physical but also psychological and social needs in regulation after MMC.

We have elaborated analysis from empirical data, presented descriptions and derived conclusions. Cultural adjustment of the intervention method has been addressed. Our fear was that experiences from the European style of Marte Meo performance could prevent us from making the best-tailored version of counselling in this actual institution. Despite this fear, we propose that MMC is promising in this African institutional context. We state that these actual infants, in this institution, and at this time, were met in a supportive developmental way. MMC facilitated the discovery of the caregivers “own strength”; in giving the infants developmental support and acknowledging the relationship between themselves and the infants.

4.1. Strengths and Limitations

Both first and last authors are Marte Meo-therapists and have positive experiences with the method. Moreover, the first author conducted the MMC together with a colleague.

This process required thorough reflections on ethics and outcome. Our prejudices, preconceptions, and own lived experience can coexist as hidden biases. We cannot escape our prejudices and pre-understanding, but we can reflect upon them. Thus, the concept reflexivity (Hammersley & Atkinsons, 1983) that is to be reflective and self-reflective during the research process was helpful for us. We aimed to make our pre-understandings and choices that we made in the research process evident to secure transparency. Our results are valid for the CCU, but other more comprehensive studies have corresponding findings (Kristensen, 2016; Vik, 2010) which indicate external validity.

The second and third authors have local knowledge from the research site, which primarily was an advantage because they were acquainted with the organisation and the culture. However, when conducting the FGIs and interpreting the answers from the caregivers, their background might also represent some challenges. Therefore, we discussed and strived to avoid that their subjective attitude should prevent them from getting into a reflexive distance. The adequate doubt and critical questions were given space in order to achieve research, distanced level on one’s own practice (Malterud, 2015).

The positive changes reported in the FGIs are also visible in the film material from the first film where the caregivers were naïve about MMC, until the last film in the process. The film material strengthens and validates the descriptions from the FGIs. Our resources were too limited to include the film material and a thorough scientific analysis thereof.

4.2. Implications

For research, we suggest larger studies, both qualitative and quantitative, of MMC or similar video based interventions in various African contexts. Further, video analysis could be performed, studying the body language of the infants and the caregivers, for example, using the measure of Parental Embodied Mentalizing (PEM; Shai & Fonagy, 2011). The nonverbal modalities of the caregivers would be of high interest. Likewise, to search for in what way they are available to the infants in interaction; including their head movements, paralinguistic speech, touch, posture and facial expressions (Stern, 2000; Trevarthen, 2003; Tronick, 2007).

This study shows that a relatively simple and very practical intervention was adequate at CCU. In preventing ill mental health, we suggest to highlight and invest in early intervention. Further scaling up and implementation of a tailored counselling method is depending both on health policy guidelines and on the professional human resources available. For practice, we suggest that caregivers of vulnerable infants should be offered Marte Meo Counselling or similar methods focusing on enhancing emotional and social development.

5. Conclusion

To conclude, we found that MMC facilitated social and emotional development for the infants at CCU. Hence, MMC is applicable in this African context. The extended awareness of sensitive interaction had an important influence on caregiver practises in daily work. Further, we suggest that mentalising processes are possible working mechanisms of the MMC. By observing themselves and the infants in supportive developmental interaction on film, the caregivers became capable of seeing the infants’ social and emotional needs. The results contribute to the discussion on what could promote a positive early childhood development in general and in institutions in particular.


Our gratefulness, first, goes to the caregivers at Child Care Unit. Their devotion and their desire to contribute to good infancy for the vulnerable infants touched us deeply. Marte Meo Licensed Supervisor Anne Britt Willumsen deserves special thanks for her insightful and wise participation in MMC. We also thank the administration, both at Haydom Lutheran Hospital, Tanzania and at Department of Child and Adolescent Mental Health, Sorlandet Hospital, Norway, for encouragement. The latter funded the study.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Aarts, M. (2008). Marte Meo: Basic Manual (2nd ed.). Eindhoven: Aarts Productions.
[2] Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant Care and the Growth of Love. Oxford: Johns Hopkins Press.
[3] Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of Attachment: a Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum.
[4] Ainsworth, M. D., & Bell, S. M. (1970). Attachment, Exploration, and Separation: Illustrated by the Behavior of One-Year-Olds in a Strange Situation. Child Development, 41, 49-67.
[5] Axberg, U., Hansson, K., Broberg, A. G., & Wirtberg, I. (2006). The Development of a Systemic School-Based Intervention: Marte Meo and Coordination Meetings. Family Process, 45, 375-389.
[6] Beebe, B. (2003). Brief Mother-Infant Treatment: Psychoanalytically Informed Video Feedback. Infant Mental Health Journal, 24, 24-52.
[7] Bowlby, J. (1980). Attachment and Loss. New York: Basic Books.
[8] Braten, S. (2007). Altercentric Infants and Adults: On the Origins and Manifestations of Participant Perception of Others’ Acts and Utterances. In S. Braten (Ed.), On Being Moved: From Mirror Neurons to Empathy (pp. 111-135). Amsterdam: John Benjamins Publishing Company.
[9] Brooks, J. (2008). Video Interaction Guidance: A Practitioner’s Perspective. Community Practitioner, 81, 21-24.
[10] Carlson, E. A., Hostinar, C. E., Mliner, S. B., & Gunnar, M. R. (2014). The Emergence of Attachment Following Early Social Deprivation. Development and Psychopathology, 26, 479-489.
[11] Crockenberg, S. C., Rutter, M., Bakermans-Kranenburg, M. J., van Ijzendoorn, M. H., & Juffer, F. (2008). The Effects of Early Social-Emotional and Relationship Experience on the Development of Young Orphanage Children: Abstract. Monographs of the Society for Research in Child Development, 73, 245-262.
[12] Gill, E. H., Thorød, A. B., & Vik, K. (2019). Marte Meo as a Port of Entry to Parental Sensitivity—A Three-Case Study. BMC Psychiatry, 19, Article No. 5.
[13] Hammersley, M., & Atkinson, P. (1983). Ethnography: Principles in Practice. London: Tavistock.
[14] Høivik, M. S., Lydersen, S., Drugli, M. B., Onsøien, R., Hansen, M. B., & Berg-Nielsen, T. S. (2015). Video Feedback Compared to Treatment as Usual in Families with Parent-Child Interactions Problems: A Randomized Controlled Trial. Child and Adolescent Psychiatry and Mental Health, 9, Article No. 3.
[15] Hynd, S., Khan, S., Tilley, S., & Chambers, M. (2004). Identity and the Experience of Postnatal Depression: The Use of Video Interaction Guidance. Journal of Psychiatric and Mental Health Nursing, 11, 738-741.
[16] Juffer, F., Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (2008). Methods of the Video-Feedback Programs to Promote Positive Parenting Alone, with Sensitive Discipline, and with Representational Attachment Discussions. In F. Juffer, M. J. Bakermans-Kranenburg, & M. H. van IJzendoorn (Eds.), Promoting Positive Parenting. An Attachment-Based Intervention (pp. 11-21). New York: Psychology Press.
[17] Kennedy, H., Landor, M., & Todd, L. (2010). Video Interaction Guidance as a Method to Promote Secure Attachment. Educational and Child Psychology, 27, 59-72.
[18] Kristensen, I. H. (2016). Video Feedback Promotes Early Relations between Infants and Vulnerable First-Time Mothers. Characteristics of First-Time Mothers and the Health Visitors Supporting Them. PhD Dissertation, Aarhus: Aarhus University.
[19] Lecannelier, F., Silva, J. R., Hoffmann, M., Melo, R., & Morales, R. (2014). Effects of an Intervention to Promote Socioemotional Development in Terms of Attachment Security: A Study in Early Institutionalization in Chile. Infant Mental Health Journal, 35, 151-159.
[20] Levine, R. A., Dixon, S., LeVine, S., Richman, A., Leiderman, P. H., Keefer, C. H., & Brazelton, T. B. (1994). Child Care and Culture: Lessons from Africa. New York: Cambridge University Press.
[21] Lionetti, F., Pastore, M., & Barone, L. (2015). Attachment in Institutionalized Children: A Review and Meta-Analysis. Child Abuse and Neglect, 42, 135-145.
[22] Lund, I. & Rohde, R. (2015). Marte Meo as a Basis for Increased Capacity for Mentalization. International Professional Journal of the Marte Meo Method, Art.48E.
[23] Main, M., & Solomon, J. (1986). Discovery of an Insecure-Disorganized/Disoriented Attachment Pattern. In T. B. Brazelton, & M. W. Yogman (Eds.), Affective Development in Infancy (pp. 95-124). Westport, CT: Ablex Publishing.
[24] Makame, V., Ani, C., & Grantham-McGregor, S. (2002). Psychological Well-Being of Orphans in Dar El Salaam, Tanzania. Acta Paediatrica, 91, 459-465.
[25] Malterud, K (2015). Theory and Interpretation in Qualitative Studies from General Practice: Why and How? Scandinavian Journal of Public Health, 44, 120-129.
[26] Malterud, K. (2001). Qualitative Research: Standards, Challenges, and Guidelines. Lancet, 358, 483-488.
[27] McDonough, S. C. (1995). Promoting Positive Early Parent-Infant Relationships through Interaction Guidance. Child and Adolescent Psychiatric Clinics of North America, 4, 661-672.
[28] McDonough, S. C. (2000). Interaction Guidance: An Approach for Difficult-to-Engage Families. In C. H. Zeanah (Ed.), Handbook of Infant Mental Health (2nd ed., pp. 485-493). New York: The Guilford Press.
[29] Shai, D., & Fonagy, P. (2011) Beyond Words: Parental Embodied Mentalizing and the Parent Infant Dance. In M. Mikulincer, & P. R. Shaver (Eds.), Nature and Formation of Social Connections: From Brain to Group. Washington, DC: American Psychological Association.
[30] Sigal, J. J., Perry, J. C., Rossignol, M., & Ouimet, M. C. (2003). Unwanted Infants: Psychological and Physical Consequences of Inadequate Orphanage Care 50 Years Later. American Journal of Orthopsychiatry, 73, 3-12.
[31] Sluckin, A. (1998). Bonding Failure: “I Don’t Know This Baby, She’s Nothing to Do with Me.” Clinical Child Psychology and Psychiatry, 3, 11-24.
[32] Stern, D. N. (2000). The Interpersonal World of the Infant: A View from Psychoanalysis and Developmental Psychology: With a New Introduction Author. New York: Basic Books.
[33] Stern, D. N. (2004). The Present Moment in Psychotherapy and Everyday Life. New York, London: Norton.
[34] Trevarthen, C. (2003). Infant Psychology Is an Evolving Culture. Human Development, 46, 233-246.
[35] Tronick, E. Z. (2007). The Neurobehavioral and Social-Emotional Development of Infants and Children. New York: Norton.
[36] Valizadeh, L., Ajoodaniyan, N., Namnabati, M., Zamanzadeh, V., & Layegh, V. (2013). Nurses’ Viewpoint about the Impact of Kangaroo Mother Care on the Mother-Infant Attachment. Journal of Neonatal Nursing, 19, 38-43.
[37] Van den Bergh, P. M., Klomp, M., & Harinck, F. J. H. (1997). Video Interaction Guidance in Residential Treatment. Child and Youth Care Forum, 26, 357-368.
[38] Van Doesum, K. T. M., Hosman, C. M. H., & Riksen-Walraven, J. M. (2005). A Model-Based Intervention for Depressed Mothers and Their Infants. Infant Mental Health Journal, 26, 157-176.
[39] Vik, K. (2010). “From the Outside Looking in”: A Phenomenological Study of Postnatal Depression, Mother-Infant Interaction and Video Guidance. Ph.D. Doctoral Thesis, Oslo: University of Oslo. (Unipub.)
[40] Vik, K., & Rohde, R. (2014). Tiny Moments of Great Importance: The Marte Meo Method Applied in the Context of Early Mother-Infant Interaction and Postnatal Depression. Utilizing Daniel Stern’s Theory of “Schemas of Being with” in Understanding Empirical Findings and Developing a Stringent Marte Meo Methodology. Clinical Child Psychology and Psychiatry, 19, 77-89.
[41] Vik, K., Daudi, V. Z., Kajula, L. J., Rohde, R., Ubuguyu, O. S., & Saibulu, J. N. (2018). Infancy and Caring: Descriptions from Motherless Infants’ Caregivers in an Institution in Rural Tanzania. Psychology and Developing Societies, 30, 105-125.

Copyright © 2024 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.