Research design

Qualitative semi-structured interviews were conducted with parents or carers from 6 families and analysed using interpretative phenomenological analysis (IPA). IPA allows researchers to gain insight into participants’ personal lived experience and the meaning-making that occurs in relation to their experiences [35, 36]. The phenomenon investigated was the family’s personal experience of DDP from the parent perspective. In IPA, interpretation of meaning is multi-layered as the researchers make sense of participants’ meaning-making of the phenomenon, known as ‘double hermeneutic’ [37]. DDP is intrinsically a deeply personal experience given the nature of the problems it strives to explore and resolve. Additionally, each child and their adoptive parents will have had unique and individual experiences that has brought them to the attention of needing an intervention like DDP. IPA’s central focus on individual experience therefore makes it a suitable methodology to explore DDP experience. The consolidated criteria for reporting qualitative research (COREQ) was used to aid reporting of the study design [38]. Ethical approval was obtained by West of Scotland Research Ethics Committee 3. All participants gave written informed consent to be involved in the study.

Participants

Participant demographics can be found in Table 1. The names of the parents, children, and therapists have been changed to protect anonymity. Six qualitative semi-structured interviews were conducted with six parents and one long-term foster carer, from six families, who have a child that suffered maltreatment within their birth family and are now receiving DDP. The inclusion criterion for the study was that the families were currently receiving and had received at least one session of DDP with their child. The participants could be receiving DDP remotely (online), face-to-face or a hybrid of both delivery methods. Therapists involved in the RIGHT trial who deliver DDP were approached to aid in the identification of protentional participants. Email invitations to participate in the study were sent to families receiving DDP and participants recruited purposively until an adequate sample size with a variety of delivery methods and child ages was reached. The recruitment period started on 25^th January 2023 and ended on 18^th March 2023.

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Table 1. Parent and child demographics.

https://doi.org/10.1371/journal.pone.0301640.t001

Data collection

A semi-structured topic guide was created to ensure that the interview was in line with Interpretive Phenomenological Analysis (IPA) [37, 39]. IPA allows researchers to gain insight into participants’ lived experience [35]. As a result, the questions were open-ended, and did not lead the participants to elicit a specific response. A lead qualitative researcher along with two assistant researchers reviewed the topic guide and revised the questions to ensure relevant topics were included in line with the aims of the study. Questions covered family background, the child’s experience of face-to-face or remote DDP, perceived effectiveness of DDP and expectations for future sessions. Participants were asked to highlight any struggles their child faced in relation to the delivery method, and what aspects of remote or face-to-face DDP their child enjoyed. A flowing dialogue between participant and researcher was created to gain rich information in line with the aims and methodological approach of the study.

Procedure

All of the interviews were conducted via video call through Microsoft teams or Zoom. The interviews (n = 6) were between 37 minutes and 1 hour 44 minutes long (Mean = 1 hour and 20.83 minutes).

Analysis

Interviews were recorded, transcribed verbatim, anonymised and stored securely. Analysis was carried out in accordance with IPA principles by two researchers [36]. Transcripts were read multiple times to enable familiarisation of the text, followed by interesting sections being highlighted and annotated. Emerging themes were identified from the notes, and connections made between them giving rise to a group of themes. This process was repeated for each transcript. All transcripts were then cross referenced for similar groups of themes and a title given to represent a group. Finally, the themes were drawn together into a table of superordinate themes and subthemes. The transcripts were analysed independently by the two researchers and identified themes discussed to clarify interpretations and ensure agreement between researchers.

Research team and reflexivity

The research team included one post-doctoral researcher who led interviews and two undergraduate students who conducted all the analysis. All researchers and authors involved in the study are female. All researchers and authors were not involved in delivery of DDP session to the participants. It is recognised that researcher bias invariably affects analysis when using IPA. Researchers debriefed after each interview to voice and reflect on personal feelings which arose during the interviews. Recurrent group meeting were also held throughout the analysis process to discuss emerging ideas and how researcher’s subjective experience influenced their interpretative framework.

Environment and child engagement

The physical environment where therapy sessions took place was an important factor influencing families’ experience of DDP. Families were divided in their experience however, with some citing the home environment as advantageous and others expressing preference for being in a therapy room. Furthermore, the experience of these families illuminated a clear link between the environment and the child’s engagement with DDP. This link was often very individual and unique to the child’s circumstances and characteristics.

Travel

Every family mentioned the impact of travelling to a therapy centre in their interviews. There was a divide in opinion, with some families seeing travelling as a means of releasing emotions after a session. Other families found long travel times to be unfeasible, and not having to travel to sessions took pressure away from the experience. Despite their long travel time to the sessions, some families believed that DDP was worth any inconvenience.

Non-verbal communication

Families highlighted the importance and usefulness of being able to observe and react to body language during DDP sessions. For that reason, loss or limited non-verbal communication perceived by many families was identified as a major drawback in online sessions. Some participants reflected on their own experience of communicating in online sessions, and others acknowledge the therapist’s perspective during this time. The were contrasting experiences with some families pointing to the skills and experience of the therapist as factors contributing to their positive experience of non-verbal communication online. Even where there was a loss of connection felt, these skills allowed the screen to not be a barrier to non-verbal communication. Some families also found that non-verbal communication could still be captured with the right set-up of screens.

Familiarity with remote interactions

A clear relationship between previous experience of remote interactions and acceptability of remote DDP was interpreted from the data. This was particularly evident in parent’s reports of older children who are said to be confident using technology and more accepting of online DDP.

Environment and child engagement

Parents discussed the role the environment played in their experience of DDP. For remote DDP families, being in the home environment was advantageous as it nurtured safety and comfort for the child. This is consistent with findings from other studies investigating online therapy experiences which highlight reduced feelings of threat and increased sense of safety for clients [40–42]. Safety in the therapeutic environment aids individuals to be less resistant and more open [43]. This is beneficial in promoting therapeutic processes in DDP, as feeling safe will allow the child to address traumatic events and moreover is an important feature within a securely attached relationship [44]. Whilst this is seen as an advantage of remote DDP, some families were concerned about boundaries as separating home life and therapy time was difficult for some families conducting DDP online. This concern is shared by therapists who also identified a blurring of boundaries when working online which importantly may impact on the perceived quality of the therapeutic relationship and further contribute to negative attitudes towards remote therapy [45]. Therapists with experience of online family therapy recommend families collaborate with their therapist to build new routines and rituals around remote therapy as this may assist in setting new boundaries and ensure easy transitioning between home life and DDP sessions [46, 47].

Many families linked the environment to their child’s engagement with DDP, however parent’s expressed mixed experiences. For the older children (aged 12 and 13 years), remote therapy overcame a major barrier to receiving support and enhanced their engagement. In adolescent populations, perceived stigma is recognised as an important barrier preventing engagement with services [48]. Online therapy removes stigma-related concerns surrounding going to a clinic, exemplifying how remote therapy can be leveraged to improve accessibility to DDP for these children [6]. Parents also described the screen as a positive barrier which aided their child to be open and have sensitive conversations. This experience is linked to the social disinhibition effect; where individuals feel greater freedom to be honest with the therapist online without fear of judgement [49]. For example, one study discovered that many gay and bisexual young men would opt for an online intervention method as opposed to face-to-face if given the choice as they felt unable to talk to a therapist in person about sensitive health issues [50]. This is useful in the context of DDP as children with attachment issues may struggle to trust the therapist which will impact on the effectiveness of therapy [44]. Conversely, for families with younger children, the screen was viewed as a major hindrance to engaging the child within the session. Parents’ concerns over their child’s engagement in online DDP is echoed by therapists who also expressed concern regarding maintaining a child’s focus when translating practice to online [51, 52].

Having recognised the potential for distraction when working online with children, therapists and families also identified and developed various solutions to engage children effectively during the pandemic. Drawing together using the zoom whiteboard, using the chat function, watching videos together via screen share, playing online games and taking the therapist on a tour of the child’s space and toys promoted children’s engagement. Furthermore, these unique approaches to online communication also functioned as a means to convey emotions and facilitate difficult conversations [47, 52, 53]. Importantly, these creative uses of technology to facilitate interactions will not only enhance the child’s attention but may further act as means to introduce the playfulness aspect of PACE into online DDP sessions. Additionally, some parents who expressed negative views of the screen, believing their child would engage less, were thinking hypothetically having not experienced online DDP first hand. This outlook illuminated some parents’ bias towards face-to-face therapy. Assessments of mental health professionals’ attitudes revealed a general perception of online therapy as less effective; however they also recognised that negative attitudes can negatively influence the therapeutic relationship when working online [54]. Importantly, the researchers concluded that effectiveness is directly related to client characteristics such as patient age, computer literacy, and home environment. One parent did demonstrate a difference between assumptions and reality as her perception that screens are detrimental for concentration changed after seeing her child engage well with and benefit from DDP online, to her surprise. This family’s experience highlights how parents and therapists cannot be certain about which children will engage with DDP in the online environment and which need an in-person approach. Much like how DDP adopts a curious stance, if parents can let go of rigid views surrounding the therapy environment and be open to trial and error, they can learn how environments impact their child’s engagement in DDP sessions fist hand, reflect on the experience and use the information gained to adapt their therapy environment going forward.

Travel

Every family interviewed in the study mentioned travel as either a positive or a negative aspect of DDP. For a number of families who were receiving face to face DDP, they relayed that travelling was a way to compartmentalise their feelings and decompress after a session. Being in a car or on public transport for 30 minutes to an hour or more allowed the children to talk about their feelings and the parents were able to guide them away from negative patterns of thinking. When clients are talking about stressors, triggering topics, or traumatic events, this can lead them to feel emotionally exhausted and can manifest as physical exhaustion. There is a positive link between childhood maltreatment and somatic symptom distress [55], therefore allowing oneself to transition from therapy to the personal realm in a controlled environment such as a car can be an effective way to maintain balance and reduce fatigue post-therapy. Sleep-related interventions could be used to complement the effects of psychotherapy in patients, and post-exposure naps have been found to reduce some indices of psychological stress in patients receiving exposure therapy for social anxiety [56, 57]. Travelling from a therapy session may give children a short window to reflect and re-consolidate their thoughts with few distractions. This is consistent with our findings and shows that travelling may help to build consistent post-session routines. Furthermore, parents reported that when they are near to their children in the car, they feel more able to help them with emotional regulation techniques. This was reportedly difficult to achieve if the child was able to go to their bedroom to be alone for example. An important facet of DDP is co-regulation [19, 31], and families have reported that the transition period between the therapy centre and the home can help foster regulation patterns for the children. Emotional regulation is a dynamic process that can be refined over time by exposure to difficult emotions and implementation of regulation strategies [58]. Families who identified the car journey as a tool to give children time and space to emotionally regulate have shown its usefulness to allow to practice of response-focused emotional regulation which overtime, during DDP sessions, can be transformed to a reappraisal process where the child can change how they think about an experience to dampen the negative emotional impact and promote positive behaviour. Families who undertake DDP remotely may benefit from leaving the house for 15–20 minutes after a session to emulate the act of travelling home which can provide an effective transition for the child and aid development of an emotional regulation framework.

Families who were receiving DDP face-to-face believed that DDP was providing such positive results that travelling a long time to the sessions was not as much of a problem as opposed to if they had to travel for another type of therapy. They believed that DDP was worth the travelling. This is consistent with previous studies on DDP and family therapy [33]. However, this alludes to the idea that DDP might work best in person, and that remote therapy might feel like a second option for many families. Previous findings have suggested that most people would not choose remote therapy over a face-to-face option but would opt for remote therapy if there was no face-to-face alternative [59, 60]. However, adolescents are less likely to drop out of therapy if they are given the choice of remote or face-to-face delivery [61]. Attrition rates for therapy are higher if the young person is randomly assigned a delivery method. One study found that in mental health interventions for children in state care, high levels of commitment to the therapy will enhance efficacy rates [62]. Therefore, by allowing the family to choose between travelling or staying at home for therapy, DDP can be tailored to individual needs and circumstances.

Families who received DDP remotely noted that online sessions enabled them to receive DDP when they otherwise would not be able to do so. This includes families who live in remote locations, and families with children who struggle with travelling. By advancing remote therapy and adapting to different family’s needs, DDP can become accessible to more families from a range of backgrounds and locations. Remote healthcare can help attract people that would otherwise have been unable to engage in support. One study conducted in Finland showed that increased travel time was associated with fewer mental health visits [63]. Those living more than 30 minutes away from their nearest health centre had fewer visits compared to those living 15 minutes or less from the centre. This shows that long travel times can be a barrier for patients accessing care which was a concern raised by families in this study. Importantly, this study shows that remote DDP can reach families who would not be willing or would be unable to receive DDP in person as demonstrated by those families who experienced success in DDP sessions conducted at home from an area where the service is not accessible at a short distance.

Non-verbal communication

Parents unanimously identified body language as a crucial factor in DDP sessions and all but one family felt their ability to observe and react to non-verbal cues was compromised online. This view aligns with various studies into teletherapy which identify lack of non-verbal cues as a negative aspect of remote therapy [9, 11]. In DDP, great emphasis is placed on non-verbal communication as it is essential for building an affectively attuned therapeutic relationship which encourages the child to feel at ease to explore their past [64]. In addition, conveying acceptance, curiosity and empathy, all aspects of PACE, can be done through facial expression and movement which families fear may be lost or more difficult for children to understand when online. In DDP, it is important for the child to perceive empathy and behaviour that demonstrate interest as this allows the experience of such qualities oneself. An additional layer to this is the child’s ability to reflect and understand their own state of mind, described as ‘mentalisation’ by Fonagy, which is also achieved by the child observing a reflective stance through the parents’ body language [65, 66]. The capacity to mentalize is an important skill to be able to emotionally regulate, understand other’s feelings and develop a stable sense of identity which can contribute to enabling secure attachment. Non-verbal communication difficulties online may therefore negatively affect DDP to a greater extent than other family therapy services. On the other hand, parents described having a strong therapeutic relationship, therapists’ skills and correct use of the technology as factors which can overcome or mitigate against challenges with non-verbal communication. These observations are supported by research which emphasises therapists use family members names, ensure appropriate camera placement and engage in interactive ways to solicit feedback such a using toys and objects to help guide sessions [67]. Previous DDP qualitative research further echoes this by identifying that families believe the skills of the therapist is an important aspect of DDP [33]. One family’s experience characterises this as they voiced trusting their therapist to continue making progress in their DDP journey after switching to online during the pandemic. At the heart of DDP is the therapist’s use of an intersubjective stance to create trust, safety and help the child develop a new positive autobiographical narrative [44]. Therapists employ empathy and active listening to convey their intersubjective experience of the child which are skills this family points towards as enabling them to trust the therapist when moving to online DDP. Overall, this family’s experience of establishing a strong therapeutic alliance and intersubjectivity in-person highlights how this can help with continuation of therapy processes online.

Familiarity with remote interactions

Most of the families mentioned that DDP was different to any therapy that they had tried before. As a result, they were unsure of how DDP would work in a remote setting. This unfamiliarity is consistent with other studies on remote healthcare [14, 33], as for a lot of clients, online therapy is uncharted territory. With COVID-19 propelling online schooling and zoom meetings into the forefront of our daily lives [68], more people are becoming familiar with remote interactions. This ‘new normal’ is allowing parents and children to navigate remote therapy in ways they would not have previously. Previous knowledge of technology and experience in the digital world has a positive relationship with acceptance of remote therapy [69]. This is true of the families interviewed in this study, as familiarity with remote work was linked to family’s acceptability of remote DDP. Likewise, families whose children had negative, little, or no previous experience of online interactions expressed greater ambivalence towards conducting DDP online. Previous experience of remote interaction, particularly positive experience, may therefore be a potential predictor for effective remote DDP. Correlations between increased confidence and positive attitudes towards online therapy were elicited in studies assessing therapist experiences during COVID-19, aligning with the experience of remote DDP families [14, 45]. However, families who experienced face-to-face therapy perceived this as being more beneficial to them and disclosed notions that remote DDP would not be as successful. In particular, one family who were fixated on physical elements such as toys and a cake as factors which aided their child to open up during a session could not conceive how that could be replicated online. This disinclination towards DDP appeared to be rooted in fear of it not working. Indeed, for DDP families there is more at risk as there is currently no therapy with a strong evidence base for helping adopted children with complex histories of maltreatment, and traditional interventions such as CBT and play therapy are often not effective for these cohorts. Whilst therapists may be willing to transition to online therapy and embrace the challenges, families fear how this will affect their child’s care and ultimately their treatment outcome [45].

Strengths, limitations, and implications for future research

This study adds to the growing research surrounding DDP and is the first study to qualitatively analyse the strengths and barriers to remote DDP. Instead of extrapolating study results from other therapies, this study has collected and analysed first-hand accounts from parents who have experienced remote and face-to-face DDP with their child. Semi-structured interviews allowed parents to discuss their experience in detail without constraints of a questionnaire or survey and an adequate sample size was recruited as similarities and differences were elicited in analysis with IPA. Overall, this study echoes the findings of Casswell et al. and Gurney-Smith & Wingfield [33, 70], suggesting that DDP needs to continue to be flexible and accessible for clients who do not respond to traditional, behaviour focussed interventions.

The salient insight of this study is that family experience of DDP is unique and individual. From this, clinicians should consider how the different delivery methods can be used to inform the other. For example, how can the perceived decompression or psychological barrier between home and DDP via travel be translated in an alternative form into remote DDP or how can the comfort of having a safe and familiar environment be introduced into face-to-face DDP? Ultimately, by offering families both delivery methods and by families having the opportunity to experience both methods, advantages and disadvantages can be found, reflected on, and implemented into future sessions. The skills and approach of the therapist seems pivotal to all experiences, often mitigating against perceived drawbacks of either mode of delivery.

To deepen our understanding of the participant experience of DDP and to address the limitations of this study, future research should consider including perspectives from children and from more families with comprehensive experiences of both delivery methods. This will allow for fair comparison of experience and shed light on how the assumptions towards remote DDP therapy could potentially be overcome. Furthermore, understanding the child’s perspective of delivery method preference, where possible, will elicit further recommendations for therapists by families themselves. As travel was shown to be an important aspect of the DDP process, future research should explore the effects of geographical restraints and public transport on families’ experience of DDP. This would allow healthcare providers to widen accessibility for remote family therapy into middle-and low income countries. Overall, by continuing this research and expanding our understanding of DDP experience, families and therapists will be better able to work towards tailoring the delivery of DDP to the child’s characteristics and needs.

A recent longitudinal survey has shown DDP to be associated with improved child and caregiver wellbeing [71], however, an important question that remains to be answered is if, when delivered remotely, DDP stands up to the core values set out by its founder. This study aimed to assess families’ lived experience of DDP delivery methods via parent and carer views, and therefore the results from this study cannot be used to make claims about the fidelity of online DDP. Our results do show that families can have positive experiences with online DDP, and for some families, DDP works best when it is delivered online. Randomised Controlled Trials alongside further qualitative research should be undertaken to generate further evidence of remote DDP’s efficacy and alignment to the core principles of DDP. Potential results from such studies will have important implications for the equitable distribution of family therapy. If remote DDP is found to be a compromise of face-to-face therapy then families in remote, rural, or low-income countries may still experience health inequality. However, if remote DDP is demonstrated to be efficacious then families who prefer or require this delivery method can be assured that they are receiving high quality care and strategies to expand accessibility to DDP can be evaluated.