Child-related factors

The impact of some of the relevant child-related characteristics may mediate as stressors in caregivers of children with ASD. Child variables, such as the child’s age [5], their cognitive or developmental level [6], may act as some of the stressors [4,7,8]. It has been noted that the presence of emotional and behavioural problems amongst children considerably predicts the caregiver’s distress [4]. However, there have been contrasting debates on the relationship between the severity of ASD symptoms and general stress in caregivers [7,9] possibly due to cross-cultural differences in parenting beliefs and value system. Irrespective of the lack of consensus around the association between child’s ASD severity and caregiver stress, Porter et al. [10] argue that all caregivers of children with ASD need support. Thus, the focus of this study is broad and inclusive of different categories of caregivers of children with ASD.

Family-related factors

Earlier studies highlight factors such as gender discrimination, difficult family dynamics, disturbed family routines, strained family relationships, marital status/single parenting may have an impact on depression and parenting stress [11,12]. Parenting stress has also found to have strong associations with marital discord, and child neglect and abuse [13]. When functioning well, family members, such as the partner/spouse, immediate or extended family members, can be a positive experience and act as a resource and support. Practical contributions towards childcare, household chores, and financial backing as well as emotional support from family can enable parents to cope with the challenges that caring for a child brings.

For teachers, it was found that salient factors especially relationship difficulties, marital status, gender, family bereavement, illness, family status and childcare issues tipped them over the edge [14]. It can be noted that Government reports [15,16] focus mainly on contextual factors: workload, the school’s circumstances, and the pupil’s behaviour in class. The Education Excellence Everywhere White Paper [16] fails to address other factors such as family commitments which can support the mental wellbeing of school staff. Ault et al. [17] identified that positive social support could play a key role in maintaining the wellbeing of caregivers. Therefore, this present study explored further ways to offer this support and the impact of creative group work.

Socio-cultural factors

Three major interlinked factors that play a vital role in the parenting experience are the socio-economic status of the parents, their education level, and their social support system [18,19]. Regardless of the revenue, parents working in more lucrative and respected occupations were found to report stress more often than parents engaged in low-income occupations. Contrastingly, even though lesser financial constraints can enhance a parent’s ability to access limited available services (e.g., therapists or good schools) or adequate housing and may shield them from some of the damaging effects of stress providing a sense of control over one’s situation [20] they reported higher amount of stress. Families caring for children with ASD often experience social isolation due to the child’s need for sameness and routine, the child’s oversensitivity to sensory stimuli, or the child’s lack of adherence to social norms. Offering respite care, inclusivity, equal opportunities, cutting down tabooing and bullying of children are societal factors that can improve the quality of life of parents [19]. However, in reality, and for most parents, the environment remains difficult.

For teachers, several factors can contribute to a positive or negative work experience. For example, early stages of work experience, special educational background, role conflict, role ambiguity, and lack of administrative support can lead to burnout. It is not surprising that teachers may experience higher levels of burnout when they are entrusted with caring for children with ASD in addition to instructional and curriculum designing duties [21]. Research on stress in teachers (in general not specific to ASD) from Brown and Lan [22] as well as Glazzard and Rose [23] has identified some trigger points to these salient factors from the work environment and busy circumstances such as pressure of assessment and catering the academic expectations; the pressure of extracurricular activities; the unforeseen tasks; keeping up with the pace of change; and changes in school management staff. Positive relationships of teachers with children, co-workers, administrators, parents, other professionals, and experts can perform as buffers to counteract the risk of burnout [24]. Research also indicates a positive association between the long-term wellbeing of caregivers and their work environment in terms of happiness at school and job satisfaction as important shielding factors for burnout risk [25]. Thus, support from the school environment and resources provided by the administration may motivate the teachers to give their best in the classroom.

Political factors

Political and the economic factors reflect on available funding, resources, research, and policies that have an impact on the health of children and caregivers of ASD. Having a child with ASD sometimes demands that one of the parents become a full-time caregiver [12]. If this happens, the family loses one source of income while at the same time paying expensive fees for specialised ASD interventions. Policies and associated funding packages are needed to reduce the impact of the financial hardships by making resources accessible along with adequate childcare services, child-minders, and psychotherapeutic support for caregivers. These all become crucial factors reducing exhaustion and influencing positively families’ wellbeing [26,27].

Similarly, Special Educational Needs (SEN) teachers require exceptional patience, dedication and skill, as well as internal and external resources, to meet the diverse abilities and increasingly varied behavioural, emotional and educational needs of children with ASD [28]. However, there is very little training available for them to address their own and the children’s emotional needs. Inadequate materialistic and non-materialistic rewards or career prospects (salary is linked to seniority) mean that professionals are not attracted to these roles unless they are driven by internal motivators. This leads to limited staff and few available resources to help cope with the high demands and requirements of such a SEN role [14]. This contrasts with the Teacher Education Theory that advocates that for teachers to be supported schools need to pay attention to both individual and contextual factors that contribute to staff wellbeing [29,30].

Overall, as a result of an interlay of the factors described above, the caregivers of children with ASD face more challenges than caregivers of children with other disabilities [9]. Parenting stress is also identified to mediate the relationship between child’s behavioural problems and decrease parenting self-efficacy [31]. Henceforth, the present study intends to explore creative ways of supporting caregivers of children with ASD.

Interventions for caregivers

Most available interventions to support caregivers are mainly psychoeducational and focus on developing caregiving skills or raising awareness. A systematic review on interventions related to improving the quality of life of caregivers of children with ASD, synthesised the data from 21 studies between the years 2005–2016 [32]. Three different themes emerged from the types of interventions that were offered to the caregivers. The first theme was learning about ASD: interventions supported the caregiver to understand the diagnosis and ASD related information. In the next theme, interventions supported the caregivers on how to help and care for their child with ASD. The last theme focused on providing psychological care, networking opportunities, coaching, provision of resources for the caregivers. These approaches were commonly delivered in a group configuration and in collaboration with the family using distinct theoretical frameworks, for example the Model of Family Stress [33], the Family Partnership Model [34], and the Ecological Validity Framework [35]. Overall, the findings of this systematic review [32] show limited attention to improving the wellbeing of caregivers.

In recent years, family-centred approaches and interventions targeting school staff are increasing in arts therapies literature [36]. For instance, Pasiali [37] and Thompson [38] explored the effects of family-based music therapy on resilience, parental self-efficacy and supporting positive parenting practice. Dance Movement Psychotherapy (DMP), one of the arts therapies which uses movement or dance as form of creative expression has shown the potential to encourage clients to discover their innate strengths and resources toward achieving personal growth and recovery [39–41]. The study focusing on the parents of children with ASD was a short-term mixed-methods DMP intervention study that was conducted in India. Although the sample size was small, quantitative measures using Parenting Stress Index-SF and HAM-D showed promising results in favour of the DMP group regarding scores of stress and depression [42]. The same study [43] provided a theoretical framework to identify the process of resilience enhancement through DMP in parents of children with ASD. However, it was limited to only a small number of Indian mothers with a specific socio-cultural and economic background. Ultimately, there is a need to explore the transferability and generalisability to a larger group of caregivers, of different socio- cultural, economic, political, gender and other characteristics. Thus, the current study, which was conducted in the UK, aimed to capture multiple views and experiences (parents, teachers, therapists and co-facilitator/researcher) on the potential contribution of DMP towards the wellbeing of caregivers of children with ASD. In addition, new guidance by the Medical Research Council (MRC) [44] provides a framework for developing and evaluating complex interventions. This framework promotes the systematic development and evaluation of interventions. In line with this guidance, the present study was conducted to capture the helpful and unhelpful factors of the intervention from different perspectives with the research question:

What are experiences of caregivers, therapist, and co-facilitator/researcher on DMP process and outcomes?

Participants

Ethical approval for the study was granted by the Faculty of Arts and Sciences Research Ethics Committee of Edge Hill University. Purposive sampling was initiated by sending letters of invitation and project information sheets out to the headteachers of 18 different SEN settings in the North-West of England. Four schools expressed interest and permitted the researcher to mail invitation letters, participant information sheets and reply slips to the caregivers. Once approximately 15 eligible participants expressed interest from one location, participants were invited for providing detailed information about the intervention, research process and finally obtain their written informed consent if they wanted to take part in the study. A total of thirty-seven caregivers (including teachers, teaching assistants and parents) were recruited from two Special Educational Needs (SEN) school settings. Inclusion criteria were that they were caring for children aged 16 years or under with a diagnosed ASD. Data collection took place within a spacious room, confidential space with minimal disturbance, within the respective school premises between September 2018 to April 2019. Out of 37 participants, 20 belonged to the DMP intervention groups (N = 20), and it is this data which is presented in this qualitative report.

Intervention

Caregivers were offered five DMP sessions lasting for 90 minutes each across a five–week period. Teachers and parents were grouped into four separate clusters with 5 participants in each for practical reasons and for maintaining professional boundaries. Attendance in each group varied each week. At first, following the template for intervention description and replication (TIDieR) guidelines [46], a DMP intervention protocol was developed, which is described in detail separately [47]. The protocol was designed to be integrative and eclectic in nature, and to be delivered flexibly based on the needs of the participants. Briefly the theoretical principles; overall process consisting of tools, techniques, and materials; and finally the session structure, which informed the DMP intervention were extracted from three projects [41–43,48] and incorporated into the protocol.

All sessions were delivered by an ADMP UK registered female dance movement psychotherapist and co-facilitated by the first author/female researcher; the latter of which was also responsible for the data collection and analysis. Sessions had a flexible structure with a new theme to explore each week. Each session started with a gentle opening ritual for a quick check-in followed by a warm-up involving mindful use of different body parts, improvised movement patterns, creating body rhythms, passing the leadership of the movements to different members of the group while the rest of the group echoed and mirrored the movements. The main themes that formed the core of each session included: knowing each other; identifying personal strengths and challenges; enjoyable moments with children; setting new vision and exploring new ways of being. The participants explored these themes creatively using creative movements and props such as fabrics, hoops, balloons, canopy scarves, large parachute, personal objects and sometimes music. Sessions ended with a closing ritual and reflections through words and creative medium. These verbal and creative reflections formed the source for the data presented in this study.

Data collection

Data were collected in multiple forms and perspectives to answer the research question and enhance the trustworthiness of the data.

1. Caregivers: Towards the end of every session, participants were invited to share their experiences through verbal and creative reflective focus groups. Open ended questions were asked on their experiences of the sessions and any changes they may have noticed in themselves and make a mark using visual artwork or creative movements. For example, what was this session all about for you? How do some of movement expressions/visual artwork relate to your life? What was the most enjoyable or challenging part of the session? Are there any movements or gestures of how you are feeling now? Artwork and movement experiences were considered as reference points to generate follow-up questions. The questions were piloted with co-researchers before the data collection.
2. Therapist: The therapist was invited to offer verbal and movement reflections on the significant moments of the session after finishing every session and this was video recorded. The therapist also maintained written session notes.
3. Researcher/co-facilitator: The first author actively took part in all the sessions as a participant researcher to gather data, offer technical support and to co-facilitate the sessions when necessary. Being observer-as-participant [49] created a platform for embodied recall of the experience during retrospective analysis of the video content [50]. Retrospective analysis of session video recordings were conducted to document the groups journey and participants movement qualities. Retrospective video observation allowed the researcher/co-facilitator to view the data from a distance.

Analysis

The data obtained from four clusters of caregivers with five sessions for each cluster, gave the total data from twenty sessions with the total video footage of around 1800 minutes. The focus of the analysis revolved around exploring the views of the therapist, researcher and caregivers on the contribution of DMP towards their wellbeing. The contents were anonymised, transcribed and extracted to a spreadsheet to meet the research question to subject the content of these sessions to thematic analysis manually by the first author [49]. Contents of all the sessions were considered. However, priority was given to the key moments in the video sample which the therapist noted for every session. The process of ‘dialoguing’ was considered for the analysis of art-based data instead of interpreting the images from the researcher’s frame of reference [51]. Dialoguing was encouraged between the artists and images. After silently viewing the images or noticing their movements an aesthetic response between the art work and themselves was invited. For instance, the artists spoke what the use of space, colours, direction, intensity of lines, shapes etc meant to them with reference to their art work or movement. In the next phase the transcripts and annotated arts-based responses were collectively subjected to inductive thematic analysis for identifying, analysing and reporting patterns (themes) within data [52–54]. This process was intended to organize information, examine relationships, and identify trends in non-numerical and unstructured data [55].

Several measures that speak to qualitative and arts-based approaches have been used to establish the trustworthiness of this study. For qualitative and arts-based components of the study, credibility, transferability, dependability, and confirmability were considered [56]. The credibility aspects were monitored by implementing prolonged engagement and persistent observation with the participants and also with the data by the first author. Peer debriefing and discussion with supervisors also supported to enhance the credibility of the qualitative and arts-based analysis. The next aspect on transferability was addressed by paying attention to detailed description of the study’s settings, participants, procedures used to collect data and data analysis so that it helps other researchers assess whether the findings make sense in other similar contexts. In order to improve the dependability of the study, emphasis was given to the referential adequacy of the stored raw data and clarity in the description analysis, and interpretation to support step wise replication. Confirmability was achieved by taking measures such as paraphrasing and reflecting movements back to the participants to check if the researcher’s understanding of the materials shared by the participants reflected what they actually intended.

Overview of the participants

As shown in Table 1, most of participants who took part in the intervention group were females (18/20) and their overall age range was between 28–56 years with a mean of 39.25 years. All the participants were British and the majority were from white ethnicity. Demographics on the marital status of the participants indicated that many of them were single parents raising more than one child. Their attendance to the sessions was poor, with only 50% of participants in the DMP intervention group attended at least 70% of the sessions until its end due to several personal and logistical challenges.

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Table 1. Descriptive statistics of the participants background characteristics in the DMP intervention and standard care groups, separated by teacher/parent status.

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Verbal and non-verbal data from the participants, the observations from the therapist and the researcher who participated in the sessions were grouped together and it led to the emergence of six themes. These themes are:

1. Beholding within and around
2. Reinforcing and reflecting on strengths
3. Exchanging views
4. Looking back and carrying forward
5. Core benefits
6. Challenges to engage in DMP.

Most of the themes comprised of further subcategories. Table 1 offers an outline of the full codebook with all formulated themes and subthemes. Furthermore, the illustration depicts closely knitted links between the coded excerpts in each main and subcategory. Personal experiences shared by the caregivers are quoted with abbreviations such as P (number) for parents, T (number) for teachers, R (session number) for researcher and D (session number) for dance movement psychotherapist. Although, this is a qualitative analysis the excerpts were number coded, the frequency of occurrences of the themes and in which sessions were documented to enhance the specificity and trustworthiness of the data representation in this report. It is also believed that the information provided in Table 2 will be valuable to reveal and infer from the context in which such statements were made or when such observations were made.

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Table 2. Qualitative themes codebook for caregivers.

https://doi.org/10.1371/journal.pone.0288626.t002

The above six main themes and 20 sub-themes are illustrated as a three-layered process (Fig 1). The central part of the figure represents the core benefits from DMP as perceived by the group participants. The boxes surrounding the core benefits are helpful factors relating to the experience of the DMP process. Finally, the four arrow marks pointing outwards are the unhelpful factors that obstructed to engage in the therapeutic process.

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Fig 1. Summary of the qualitative results of caregivers.

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Beholding within and around

Many participants acknowledged during DMP sessions that the process of therapy encouraged them to observe themselves and their surroundings. They perceived that the sessions offered an opportunity to observe movement patterns of other participants in the group as well as sensations in their own bodies. These experiences were categorised under the following two themes:

Enhancing awareness and alertness.

As an opening ritual all the sessions began with checking in to notice feelings, physical sensations, aches, reactions, behaviours, and thoughts at that moment. One of the most frequent answers given by the participants when asked about body parts seeking attention were neck and shoulders. They reported ‘stiffness’, ‘heaviness’, ‘tightness’ and ‘problems’ in their neck, shoulders, and some joints (P2, P3, P4, T2, T3, T5, T6). This was not reported just once or twice but was repeated several times by both parents as well as teachers. In one of the sessions a participant reflected about the observations on her life in general based on the drawing that she created after moving “I have realised how my life is in general. Rollercoaster like, with ups and downs. Powerful up swings and powerful down swings” (P5, see Fig 2).

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Fig 2. The rollercoaster.

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The therapist observed that the movements of the participants, especially of the parents, were restricted to the movements of body extremities with limited movements of upper torso. In addition, their movements were observed to be performed within a small kinesphere and with hesitancy. The researcher/co-facilitator noted ‘fisted hands’, ‘stiff wooden log-like postures’ during initial phases of the sessions (R1). When the therapist offered the participants some of these observations, a participant spoke about how DMP enhanced her alertness about herself and surroundings “I think it makes you think a little bit more. It is helping my mind in thinking different postures mean different things. I am looking around and seeing how everybody has stood and sat. It tells us a lot by the posture regarding body image, feelings, emotions etc” (P2).

Unlocking the unfamiliar.

During these sessions, the participants shared their experiences on exploring unknown material and allowing to surprise themselves with the unfamiliar things that emerged during their movement explorations. For example, while reflecting on their movement experience, one of the participants shared the pleasure of engaging with the unfamiliar:

“I don’t know. My hands were just free flowing (with a shrug). I think we all start with something that we don’t know to do with and then we slowly start shaping it into something functional. Just feels good. I started somewhere, and from somewhere came this life you know, life with some kind of plant life” (T6).

Another participant indicated that she “had surprisingly kind of comfortable positive experience” (T1) when she was involved in a movement exploration activity.

Some of the participants suggested that dealing with uncertainty and dwelling in an unfamiliar space within were challenging: “In the beginning it is quite difficult as you don’t know what to expect. So there is a little bit of shyness and just not knowing what to do. A little bit wobbly, not too sure, one foot in, one foot out” (T5, see Fig 3).

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Fig 3. The unfamiliar space.

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However, it was further reported that by allowing themselves to experiment with different movements arose novel strategies to deal with stressful events: “I think we are adding new things to it and experimenting with actually if it is working well or not. hmm.. it will be flower or weed. It will need some pulling up at some point when it starts growing up” (T3).

Reflecting and reinforcing strengths

Participants recognised and acknowledged that the strengths-based intervention approach used in the study was supportive. Some of the participants stated that the sessions provided a platform to identify some of the strengths within them. The therapist pointed out that the usual tendency of the participants was to talk about the successes they have had, but they did not want to attribute their own strengths to it. Henceforth, the therapist highlighted her role in identifying strengths in the participants and deliberately paraphrase their narrations to showcase the strengths in what they expressed.

“And so I had to tell them this is because of your so and so quality or what you have done is with your strengths and resources. It is not a common practice to talk about strengths. People feel uncomfortable boasting about themselves. But it is helpful to have them reflected back to them. I guess it is what it felt like with the paper activity as well” (D3).

The therapist witnessed, reinforced, and validated their strengths. In one instance the therapist articulated “It sounds like you have got a wealth of experience. Through dedication and consistency you know how to actually make all those threads happen”(D4). After this, a teacher (T2) acknowledged her years of experience as a resource and also credited her “internal skills” and said “it takes a long time” to mindfully inculcate them. Patience, creativity, persistence, loving, caring, reliable and good time management skills were some of the other qualities that were recognised as their strengths.

Subsequently, two sub-themes related to this main idea were identified in the data and they are described below.

Exchanging views

Over the period of DMP sessions while the participants shared their experiences and exchanged their views with the group, they appeared to be learning from each other. Especially in session 3 and 4 the participants after engaging movement explorations, described different coping styles. In addition, they discussed several child management techniques that worked with their children and some of which were acknowledged by the members of the group as useful. They stated that they would consider some of them as they believed some of the strategies were worth implementing in their personal life and with their children. Sometimes the participants just acknowledged the individual differences and processed why their personal preferences differed from others or why such an approach would not be applicable to them. Different patterns that were noticed overall are categorised under the following sub-themes:

Structuring and compartmentalising.

Participants reported that some of the DMP activities facilitated them to know how they had compartmentalised resources and challenges. They realised that tidying them away at regular intervals was necessary to maintain wellbeing. Knowing the ways through which participants can have strategies to release challenges and sometimes keep them without being affected by those challenges were discussed. “Trying to do some organising and tiding up really. I was thinking about what you said about challenges before. I actually realised that there is a space in my mind for challenges, but it just has to sit in the right space and make sure that I don’t over think that it is challenging and giving it right support. It is not locked in. It is free to go if it wants to go” (T4, see Fig 4).

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Fig 4. Structuring and compartmentalising.

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Sense of control.

One of the participants after a movement improvisation activity with a balloon filled with their challenges session described how the strategy to deal with her challenge unravelled. She expressed that she realised that she must be more specific to identify challenges, have some control over them instead of just letting them overwhelm her. Pointing to the balloon she revealed “This is the challenge. But that is okay. It’s there. I still need to do all the other things. Just having a side to an eye. Just being in control of them. Once all the challenges were in here (balloon) I was able to move it in a way I wanted to and it was not moving me. That sense of control over managing the challenges is something that I would want to have” (P3, See Fig 5).

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Fig 5. Sense of control.

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Acceptance.

One of the views most expressed and agreed by all the participants was accepting the circumstances they were in. Everyone (parents and teachers) agreed that there were some aspects which were beyond control and the challenges had to be accepted as they were. One of the participants described a situation which was very common in a classroom setting “In my class there is a lot of energy. I was thinking about a specifically particularly a stressful day when one of my TA was off. I was literally, every time I sat down a student would call and then had to get up and move back and forth. Every time I took a step forward I had to back again to sort things out. Sort someone out sort someone out.. so this is kind of a lot of different colours and energy and they all need different things and I’m trying to fix it all which is not possible” (T2). She further described movement exploration of this situation in this way “At one point I was looking at the tennis ball and I was thinking you (the ball) come to me, I’m not coming over there again. But then it’s not gonna come over to me. I’ll have to get up and go and get it. When it starts moving I feel like stop, stop it!! alright I’ll come over and stop” (T2).

Another participant reiterated a similar circumstance and highlighted that acceptance of things as they are is sometimes the only option and becomes important to enjoy even when the situation is chaotic and out of control. She uttered “I’m having my fun thing here. That’s my vision. I decided go with the flow. So that’s why I just let my balloon just go off. Sometimes you will just have to let go the way it is. I was tiding up a little bit when I was doing my obstacle course for a while but later decided to let it go. Okay.. let the chaos come. It’s gonna come all the way just let it go with it anyway. Fighting it is gonna be more of a challenge” (P4). Likewise, the theme of acceptance unearthed in an artwork which was created in response to the movement exploration: “I know when I saw all the dust on, it was getting quite messy. I was trying to sort that out by sweeping it all. But still you can see those little dust particles on the paper. I guess it is always going to be there” (T6, See Fig 6).

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Fig 6. Sweeping the mess.

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Looking back and carrying forward

It was evident in some of the participants’ art and movement-based expressions that they were carrying unprocessed materials from their past experiences. The participants have referred to their childhood memories as well as tragedies of their recent past while creatively engaging with the arts. In addition, worries about the future of their children and eagerness to learn arts-based skills to implement with the children were noticed. These two patterns where the participants oscillated backwards and forwards in their thoughts are discussed separately in the following sections.

Unprocessed baggage.

During movement-based and verbal interactions with the participants, it was noticeable that they were carrying psychological baggage of a lifetime on their shoulders. Sometimes this extra burden they carried reflected on as physical symptoms and had an impact on their present. Although attempts were made to encourage the participants to acknowledge and process those issues, not many of them were in fact ready to face and address the issues. Sometimes they appeared to be ignorant about the unprocessed psychological baggage and at times it seemed they were not ready or equipped to process the emerging materials. For instance, P1 during movement exploration had series of movements where he walked backwards with backhand strokes and created a brown and yellow tangled pile in response to his movement experience. When inquired about what that meant to him, he replied “nothing, just some colours and lines” (P1, See Fig 7). The therapist interpreted that image as communication of his untreated inner conflicts or confusions filled with disdain and disgust. However, the participant ducked further processing and reported as something insignificant. There were several such instances across the four clusters. One of the participants recalled childhood days as the memory was evoked by a hand gesture using two hands setting the fingers apart. It was only one participant who ultimately opened up in the last session about her unhealed grief of losing her father. Since it was the final session, there was not much time to process it further.

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Fig 7. Just some colours and lines.

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Core benefits

The participants expressed different ways in which DMP had an impact on their body and mind. These were the immediate changes that they perceived within themselves by comparing their movements at the beginning and towards the end of the sessions. The caregivers noticed that they were able to experience being relaxed, express themselves, feel grounded and enjoy the moment by letting go unnecessary thoughts and stressors from their mind and body.

Relaxation.

This was one of the most frequently used words by all the participants. They perceived these DMP sessions as a platform to unwind and bring clarity in their thought processes. Some of them reported a calmer composure of mind, low tension, and anxiety. The participants also compared the DMP process to Yoga from their earlier experiences. It was also conveyed that the opportunities to stretch and loosen the body and focus on breath facilitated them to relax. One of the participants placed several layers of garment over her head and represented that they were all the worries sitting there in her head where there was no scope for anything to fully pass through it. She described her experience in DMP sessions by unwinding different layers of the garment like the layers of an onion. Another participant described that her experience was “like water from the top rolling down the shoulders and now I’m relaxed” (P4). Similarly, another participant dropped her arms and mentioned that she was able to slacken the tension around her shoulders after session 4. The participants’ movements were observed to be using light and free flowing body efforts while describing their relaxed sense of being. In addition, the relaxed state of mind reflected on their choice of colours during closing self-reflection using artwork. A caregiver stated: “I started off with purple, because it is the colour I like. It brings calmness to me” (T3, See Fig 8).

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Fig 8. Bringing calmness.

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Self-expression.

The participants noticed that DMP had given them an opportunity to be themselves by expressing their thoughts and feelings without any hindrance and fear of being judged. They mentioned that they were able to break out of their generalised and fixed patterns of living and experience some sort of change in their way of living. For instance, a parent expressed that “routine and the straightness are the most challenging kind of aspects” (P2, See Fig 9). She explored this challenge through movements and represented her experience through art work. She represented her son’s routines with straight lines and her desire to bend and take different curves around that. After movement exploration she decided to overwrite on the original drawing by adding some chaotic marks on the original straight lines. She reported that she had found alternate ways and some room for a curve or divergence in between straight lines. She specified that finding a break from routine was something that was not practically feasible. Although organised chaos within the set routine was something achievable by containing the chaos within a boundary. Another parent looking at her art work created towards the end of the session expressed that “I have been carrying a lot of stuff while managing to maintain a positive outlook in the front whilst also dealing with the stuff inside or underneath. I can see it being stormed up in my drawing”. The therapist observed that the participants had used the whole space when they had expressed them fully. Otherwise, they seemed stagnant and used very little space in the room. She described “People have extended a bit further than what they would usually do. Felt it flowed well today” (D4).

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Fig 9. An organised chaos.

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Challenges to engage in DMP

Alongside the positive aspects of DMP, the interviews, remarks and reflective narrations made by the therapist and observations documented by the researcher strikingly revealed several challenges. There were several factors noticed in the participants that impeded their personal growth and group development. Across all four clusters a strong group bonding was not noticed. In fact, in some instances a group never formed, especially with the parents. Several unhelpful factors that hindered the therapeutic engagement were observed and they were categorised under following themes.

Contemplation about the approach.

Preconceived attitudes, conceptual mis-associations, and expectations from DMP played a vital role in the responses and engagement of the participants. In terms of preconceived attitudes, many participants were expecting some sort of dance-based tool kit, skill set or series of steps that they could learn. Some of the participants were convinced that DMP is something for their personal wellbeing. Most of the times their focus was on how useful will it be for their children. The expectation was that it would be some type psychoeducational or behavioural training programme through which they could learn certain techniques which can be directly implemented in training or teaching children. After attending four sessions one parent mentioned “I was expecting to learn teaching skills and strategies to manage my son’s energy. What you are doing is good. But, this is just not for me. Probably, I can see my son may benefit from this” (P1). There were only two male participants who had signed up for the programme and one of them said “I was just curious and came in to see what this is all about really. I don’t think this is for lads” (P7, See Fig 10). These were some of the responses received from the participants despite providing participant information sheet and verbal description about the approach provided before commencing the intervention programme.

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Fig 10. What is DMP really about?.

https://doi.org/10.1371/journal.pone.0288626.g010

Limitations and future recommendations

The quality of the data could have been influenced by poor acoustic, video recording angles of the camera and room dimensions. Hence use of multiple cameras and cameras with motion capture functions can further the quality of movement related investigation. In addition, English not being the native language of the researcher could have impacted the data collection and analysis. Reflections from the participants were clarified with the participants by paraphrasing it to them during the sessions and later transcripts were verified by a native English speaker and researcher. However, due to time restrains and potential emotional burden it was not possible to get the participants to comment or review the transcript or conduct follow up interviews.

Although there were some similarities across four groups, data saturation was not noticed in the research process as new information was still being shared in different sessions [71]. In addition, the heterogeneity in the sample makes the topic fertile for further in-depth exploration of the nuances. Inconsistent attendance of the caregivers may have impacted their experience and the quality of the data. One of the reasons could have been because of the separate sessions for caregivers and children. The concept of child and caregiver seen separately by the same therapist is a well-accepted model in verbal child psychotherapy [72,73]. Since, it is novel to DMP, further thoughts around enhancing caregivers’ engagement are warranted. Blauth [36] who conducted parental counselling sessions while providing music therapy to children reported good attendance and positive results. The differences are verbal v/s nonverbal or creative and individual v/s group which appears to have impacted this study drastically. Parsons and Dubrow-Marshall [59] in their article, discuss about the polarities of themes stressing on the intrinsic undercurrents in delivering creative, unconventional, and embodied forms of therapies within a school environment. The authors suggested that although, there are no quick solutions to the constraints, normative inhibitions and expectations of the participants and wider school structures and community mind-set; taking cognizance of the tension between helpful and unhelpful factors might be valuable for dance movement psychotherapists in setting themselves. Regardless of being aware of the school dynamics and taking rigorous actions, it was still hard to consistently establish a therapeutically safe environment within the school settings. Future research could involve different stakeholders and lived experience consultants to discuss the practical strategies to manage the glitches pertaining to SEN settings. In addition, a collective effort the therapists’ community to sensitize and create awareness about the work of arts therapies within the school management, and amongst staff and parents could help in establishing sustainable interventions.