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Marte Meo as a video interaction guidance method to support interpersonal

relationships in families: a systematic review protocol with a descriptive
meta-analysis

Research Proposal · January 2020

DOI: 10.13140/RG.2.2.27754.88005

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Marte Meo as a video interaction guidance method to support interpersonal relationships in
families: a systematic review protocol with a descriptive meta-analysis
Kuhn, Olivia; Wudernitz, Mirna; Monshi, Asita; Aarts, Maria; Ritschl, Valentin

Introduction/ Background

Knowing that relationship is fundamental to health, development and quality of life of people, a
number of interventions have emerged in literature and clinical practice. The aim is to train families,
caregivers and professionals to use strategies and techniques to build, maintain and use relationships
to support the people they care for. This is especially relevant for children [1-4], but also for other
groups of people, such as people with dementia [5-7].

The Marte Meo Method is one of the methods that support people in their social and emotional
development using relationship. It is a video based intervention developed in the Netherlands in the
80’s by Maria Aarts [1, 8]. Marte Meo is derived from the Latin ‘mars martis’ and means ‘On One’s own
strength’. It is used by more than 10,000 therapists worldwide [9]. Once developed to support parents
of children with autism, Marte Meo is now used by physicians, other health professionals as well as
non-medical professions in a wide variety of disciplines: paediatrics (e.g. children with autism or
attention deficits and hyperactivity disorders), psychiatry, geriatrics (e.g. people with dementia) and
other [10, 11].

The central Marte Meo focus is to encourage people to use their own strength to advance and
stimulate developmental processes. The Marte Meo basic information is a copy of natural
developmental models and how to use them to restart the dysfunctional developmental processes.
Marte Meo sees problems as opportunities for development. As Video-based Intervention Marte Meo
Information can be used to change the patterns at action moments in everyday interaction. Using the
technique of interaction analysis, video is used to gather detailed information about natural supportive
behaviour from actual daily situation and it gives an opportunity to provide clients with concrete
information step by step. Video provides insight into the kind of help a child or a client needs. It is not
only “solution-oriented”, but it also provides concrete steps about supportive behaviour needed [8,
12].

A fundamental idea of Marte Meo is to reveal new schemas of being together [1], to advance the
developmental process of children or other persons to care for and to support the caregivers (parents
or other relatives, professionals) [13]. The method is resource and solution orientated and leads to
empowerment of the person to be cared as well as and the caregiver [1]. Therefore, the operators
should use their own strength and capacities. Respectively Marte Meo assists people to discover their
strengths anew and to recognise their own existing potential [13].

Marte Meo uses video feedback of everyday life situations to point out and analyse communication
and interaction in detail [13]. The advantage of video sequences is, that they can be used as a
‘behavioural microscope’ [10], meaning that elected sequences can be watched moment by moment,
if required in still pictures. These sequences are watched and feedback using three analytical
questions: (1) What is the person to care for already able to do? (2) What would the next development
phase/step be? (3) Which support could the caregivers offer their child? In this way the caregivers get
a chance to look at themselves and their person to care for from a new and different perspective. The
whole process is a form of a dialog between caregivers and the therapist [1]. The conversation takes
place in a pleasant and relaxed atmosphere, often named as ‘coffee, cookies and the dog’ [8]. Together
with the therapist they search for resources and support in the area of developmental process [13].

Approximately 30 to 60 articles, bachelor and master theses have been written until today. However,
no systematic review has been conducted to gain an overview and assess the strength and impact of
Marte Meo.

Objectives/ Aim

The purpose of this systematic review is to gather, elaborate and appraise the content and the
outcome of existent Marte Meo studies (articles, reports, bachelor, master and doctoral theses).

Research Question

This review will focus on the following research questions:

1. What are the main outcomes of studies which use Marte Meo as an intervention?
2. What is the main population of studies which use Marte Meo as an intervention?
3. Which professionals use Marte Meo as an intervention?
4. What is the impact of Marte Meo on health and well-being?

Keywords
Marte Meo; video feedback; video counselling; video interaction guidance method

Inclusion Criteria

Participants

Studies will not be excluded based of participant’s diagnosis. If Marte Meo was the main intervention,
the study will be included.

Intervention

This review includes all studies, articles, reports or theses which focus on the Marte Meo intervention.

Comparison

Not applicable. All studies will be included, which use Marte Meo as an intervention.

Outcome

We will not focus on a specific outcome, but studies included should describe the outcome of the
Marte Meo intervention.

Types of studies

This review will include all types of quantitative and qualitative research, including articles, bachelor,
master and doctoral theses.

- Included types of quantitative studies are experimental study designs (like randomized
controlled trials, non-randomized controlled trials, other quasi-experimental studies) and
observational designs (descriptive studies, cohort studies, case studies).
- Systematic review and meta-analysis will be screened to identify relevant original studies.
- All types of qualitative studies will be included, e.g. phenomenology, grounded theory,
ethnography, content-analysis, case-study and others.

Exclusion criteria

There will be no exclusion because of publication date.

If the language is not in German or English, the task force members will be asked to translate the report
findings to be also included in this review.

Methods

This following task will be performed within this project[14]:

 1. Establishing an international expert task force including representatives from European
countries (at least Austria, The Netherlands, Germany) who are experts in the Marte Meo
Method.
2. Having a first (virtual) task force meeting to discuss and defined search questions, keywords,
MeSH-Terms, search strategy for the Systematic Literature Review (SLR), key-publications and
grey literature.
3. Conducting the SLR supervised by the methodologist.
4. Reviewing and discussing the findings of the SLR in a second (face-to-face or virtual) task force
meeting.

International expert task force

The total task force will consist of representatives from European countries (at least Austria, The
Netherlands, Germany) who are experts in the Marte Meo Method, identified through a snowball
process. The core team includes OK, MW, VR as well as a methodologist, a research fellow and a
patient/ citizen representative.

First (virtual) task force meeting to discuss and define research question, keywords, MeSH-Terms
and search strategy for the SLR

The core team will draft the search question(s), identify relevant keywords, MeSH-Terms and build the
search strategy for the SLR on different databases together with the methodologist and the research
fellow and refine these based in the feedback from the task force. These search question(s) will then
be converted into the PICO (Patient, Intervention, Comparison, Outcome) scheme by the core team.

Performing the SLR to collect the evidence

A SLR based on the identified PICO questions will be undertaken by the research fellow supervised by
the methodologist. Relevant records will be identified using the databases: Medline [PubMed], CINHAL
[Ebsco], web of science, science direct, and the Cochrane Database of Systematic Reviews. The
following study designs will be included: randomized controlled trials (RCT)/ controlled trials (CT),
quasi-experimental studies, observational studies, cohort studies and case-control studies. Systematic
review and meta-analysis will be screened to identify relevant original studies. There will be no
exclusions based on publication date. All results obtained by the research fellows will be discussed
with the core team.
In order to identify grey literature which hasn’t been found through the database query mentioned
above the task force members will be consulted via email. In addition, to disclose unreleased literature
the search will include OpenGrey-System for Information on Grey Literature in Europe. Subsequently
the reference lists of all obtained results/ identified papers and reviews will be screened for relevant
articles which will be subjected the same searched and selection process.

The search will be based on keywords/ MeSH-Terms regarding Marte Meo and video feedback/
counselling. The search strategy exemplified on PubMed is displayed in table 1.

Table 1. Search strategy exemplified on PubMed

MeSH Terms (exploding all trees) for Counselling
"Counselling"[Mesh]
Free Text for Counselling
"Counselling"[All Fields] OR "advice"[All Fields] OR "assistance"[All Fields] OR "feedback"[All Fields]
MeSH Terms (exploding all trees) for Marte Meo, video feedback, video counselling
n.a.
Free Text for Marte Meo, video feedback, video counselling
"Marte Meo"[All Fields] OR "video feedback"[All Fields] OR "video counselling"[All Fields] OR
"video guidance"[All Fields] OR "video"[All Fields] OR "recording"[All Fields]

Study selection

Firstly, all identified literature (studies, articles, reports, theses) through the queries will be uploaded
into EndNote and duplicates removed. The selection process will then have two phases. Firstly, two
researchers will independently screen the titles whether they met inclusion/ exclusion criteria or not,
followed by screening abstracts. A third researcher will assess possibly disparities in the selection of
these titles and/ or abstracts. Secondly, the full texts for studies/ articles/ reports/ theses will be
retrieved and analysed. When in doubt whether a paper met the inclusion/ exclusion criteria, three
experts will be asked to assess the paper and the decision will be made by consensus. According to the
“A MeaSurement Tool to Assess Systematic Reviews” (AMSTAR) reasons for exclusion of full text
studies will be provided. The results of the search will be reported in the final report and a PRISMA
flow diagram will be presented.

Data extraction and data mapping

Data will be extracted using a data extraction form. The following information/content will be
extracted out of the studies: authors, country, year of publication, sample characteristics, study design,
assessments/ evaluation tools, outcome parameters, and conclusion. This may be further modified
and revised as necessary during the review process. Two reviewers will extract data independently. A
third person will check independently the data extraction of 20% of selected papers. Any
disagreements that arise between the reviewers will be resolved through discussion and consensus
with experts.

Assessment of included studies, risk of bias assessment and synthesis of evidence

The quality of all retrieved papers will be assessed by validated assessment tools. Quantitative studies
will be assessed with the Cochrane Risk of Bias tool. As only RCT studies can be assessed by the
Cochrane Risk of Bias tool, we will use other tools to assess risk of bias in studies with other designs,
e.g. The Risk of Bias In Non-randomized Studies-of Interventions (ROBINS-I) assessment tool, or the
Newcastle-Ottawa Scala for assessing the quality of nonrandomised studies
(http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp).

If enough (R)CTs are identified, we will perform a meta-analysis (from which the studies with other
design are excluded). However, we will include the knowledge from observational studies, cohort
studies and case-control studies in the narrative synthesis. Meta-analysis will be conducted if a
minimum of three (R)CTs are identified which use the same outcome measures. As a first step, for each
reported outcome, we will calculate a standardized mean difference effect size[15-18]. Secondly,
heterogeneity will be tested using Cochran’s test. Q statistic (Chi-square) tests whether effect size is
similar or significantly different from each other. If the Q value is 0.05 or smaller, a heterogeneity is
present. In this case, the amount of the heterogeneity will be calculated using Cochrane I2. A Cochrane
12 value of 50% or higher indicates a considerable heterogeneity, and we will us a random-effect
model (otherwise, a fixed effect model will be used). Although a random-effect model takes the
variance within studies into account, an outliner analysis will be performed and studies which were
identified as an outliner (according to the results of the previous analysis), will be excluded and the
meta-analysis recalculated. If the heterogeneity persists, this procedure will be repeated. If a study
proves to be responsible for significant heterogeneity, it will be excluded from the meta-analysis[19-
21]. To detect publication bias (= results of experiments may influence probability to be published)
funnel-shaped plots will be used. Studies with a small sample scatter more broadly around the mean
effect size than larger studies. An asymmetric distribution may suggest publication bias[22, 23]. In
order to deal with publication bias, we will exclude observational studies and low quality RCTs from
the meta-analysis. Additionally, we reduce publication bias, by including as many studies as possible.
There will be no exclusions based on publication language. Further, we will avoid multiple inclusion of
datasets from which more than one publication has arisen [24]. Subgroup analyses will be performed
between different diseases and PROMs if two or three comparable studies are identified. Forest plots
will be used to display the results of the meta-analysis. R (https://www.r-project.org/)[25] will be used
for all statistical analyses.

Reviewing and discussing the findings of SLR in a second (face-to-face) task force meeting

The results from the literature reviews will be categorised according to the Oxford system, presented
and discussed at the taskforce meeting.

Conflicts of interest

The authors declare no conflict of interest.

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