Introduction

Sensory integration is explained as the process of detecting, registering, integrating and organizing the sensory information received from our bodies and the environment [1]. The process of interpreting information from the senses, such as sight, sound, touch, taste, smell, vestibular and proprioception, are critical to development and enables meaningful and purposeful participation in all aspects of life [2]. Impaired sensory integration impacts occupational performance including participation in activities, tasks and occupations, this, in turn, has an impact on behavior, self-esteem and emotional regulation [3–6].

Atypical sensory integration is recognized in children with Autistic Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD) and Developmental Coordination Disorder (DCD), as well as children with no formal diagnosis [7–9] and continues across the life span [10–12]. In a study from the United States of America (USA), atypical sensory patterns were found to be present in both children with typical development, and those with developmental conditions. The authors suggested this was likely to be reflective of the general population [13].

Ayres Sensory Integration® (ASI®) is an evidence-based practice for children with ASD [14–15]. Sensory integration therapy (SIT) is often the term used in the United Kingdom (UK), but this is referred to globally as Ayres Sensory Integration® (ASI®). The term ASI® will be used throughout this study. ASI® is a trademarked therapeutic practice well-established in occupational therapy (OT) [16–18]. Originally developed by Dr A. Jean Ayres in the 1950’s, this theory-based frame of reference hypothesizes that efficient integration of sensation is required for learning; that difficulty with processing and integrating sensation has an effect on function and behavior; and that sensory integration can be improved by providing sensorimotor opportunities that facilitate an adaptive response, and in turn, enhance function and behavior [19]. The last decade has seen an increase in the evidence of the effectiveness of ASI® such as improvements in performance and functional goals including play, social participation and self-care skills in children with ASD [14,20,21].

ASI® is typically carried out in a clinic-based setting using a range of suspended and floor-based equipment which provide opportunities for individually-tailored challenges with the aim of improving specific sensory systems that interfere with function and behavior [1,22]. It is child-led and draws on the intrinsic motivation to engage and experience a sense of achievement, in collaboration with the therapist. Activities are therapeutically facilitated within the context of play and exploration and are set at the just right level to promote an adaptive response. The challenge should be set just beyond the child’s capability to promote interest whilst not being so difficult that the child gives up [2]. The structuring of the therapeutic environment, to achieve the adaptive response, demands that the therapist is aware of the child’s motor capabilities, and has special understanding, ability and considerable skill [21]. Therapists’ need to be attuned to the child’s arousal state, mindful of the child’s sensory threshold and in tune with the child’s engagement level [23].

Stackhouse [24] surmised that the therapist can ‘scaffold’ activities through grading, moderating or structuring, to elicit the just right challenge and promote an adaptive response. Theory suggests that this pairing of skills promotes neuroplasticity, and is considered the basis for the art and science of ASI® treatment. When the just right challenge is achieved, the child switches on signifying that the activity is graded at the correct developmental level to allow maturation of the central nervous system [18,25]. Vygotsky in the 1920’s identified the gap between independent learning and what can be achieved with guidance and scaffolding, and named this concept the zone of proximal development. It was observed that individuals learn best when collaborating with more skilled persons, and that it is through these endeavors that they internalize new concepts, psychological tools and skills [26].

Flow is another characteristic of the therapeutic process, and is not exclusive to ASI® or OT but can be considered an aspect of human nature. Csikszentmihalyi [27] described flow as a state of complete absorption in which those experiencing it have no regard for hunger, fatigue, or discomfort, whilst Gold & Ciorciari [28] compared flow to a spiritual experience. To be in flow, the level of difficulty of the task must perfectly match a person’s skill level with just manageable challenges [29], this is intrinsic to ASI®.

Bundy and Lane [30] note that:

“Artful practitioners respond to complexity in what seems to be simple ways and without disrupting the flow. They make therapy look easy, even with the most difficult child and in the most difficult situation.”

Ayres [2] described the art of therapy as being akin to psychotherapy, especially in relation to the attitude of the therapist. In either case, if the therapist chooses, they can feel with the person and empathize so closely that the experience can become one of their own.

“Patient and therapist work together, and the togetherness is often felt quite consciously by the therapist.” Ayres (1972 P265).

OT’s are facilitators of the art of therapy as they are experts in play analysis [31], activity grading and engagement through meaningful occupation [32]. They bring with them a host of personal and therapeutic skills; this is often termed the therapeutic use of self [33]. Bundy and Lane [30] consider that the therapeutic use of self, along with the ability to read the child’s cues, to set the just right challenge and to engage in play as equals, are vital components of the art of therapy.

There has been significant research in the field of ASI® [21], yet very little has been studied regarding the interaction between the child and therapist. Some early studies analyzed treatment sessions of OTs using an ASI® approach [34–35]. More recent, qualitative studies have explored both the perspectives on sensory-based interventions of parents of children with ASD [36] and the sensory experiences of autistic mothers [37]. Other qualitative studies have sought to gain insight from therapists in other fields, [38–39], however, no studies were found that focused on the experiences of OTs using an ASI® approach.

As the therapist’s use of self contributes to the success of an intervention, it is crucial to understand how that is internalized, particularly considering the level of effort and clinical reasoning involved in the process. In recent years, especially since the COVID 19 pandemic, ASI® education taught remotely, with synchronous videos, has become more evident, with the completion of clinical practice hours and senior mentorship being essential requirements for qualification. In this respect experiences can vary considerably, and although considered best practice, there is no current requirement for ongoing mentorship post certification. In these circumstances, the understanding of the art of practice can be lost.

The overarching aim of this study was to explore the experience of the art of therapy, from the therapist’s perspective, within which the therapeutic relationship, the just right challenge and flow seem to exist. Within that aim, we explored how flow feels in practice, and the variables perceived to either impede or facilitate success for the child. The characteristics of the art of therapy were explored through the lived experiences of the participating occupational therapists.

Method

Data collection

Participants were requested to complete a reflective journal for one month, prior to the interview taking place, to document their experiences, thoughts, and feelings, during ASI® sessions. Both Rebar [46] and Morrell-Scott [47] recognized that a diary provides unadulterated insight into phenomenological perspective as, being completed closer to the event, the information is likely to be more accurate and captures information that cannot be collected by interviews alone. This method is used successfully by researchers, albeit usually over a longer period of time [48–50]. A reflective journal protocol was provided to guide participants in their reflections (Table 1). This could be considered restrictive, however, Plummer [51] reported that solicited diaries ensure that relevant data is collected and that the writer remains focused on the research question.

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Table 1. Reflective journal guide. The guidance given to participants to complete the reflective journals.

https://doi.org/10.1371/journal.pone.0322433.t001

All participants returned their journals electronically to the researcher prior to their interviews taking place. Semi-structured 1:1 interviews between the first author and the individual therapists’, and lasting between 30 and 60 minutes, were completed virtually. Semi-structured interviews have been successful in previous research seeking to understand a therapist’s perspective [52–53]. The reflective journals were utilized to supplement the conversation during the interview [54] and to form a picture of what the researcher was not able to observe directly. According to Duke [55], journals are more effective when used in conjunction with other research tools.

Interviews were video-recorded and transcribed using the Microsoft Teams transcription facility. Interviews were guided by the topic guide provided (Table 2) and by referring to the individual’s reflective journal. Video interviewing is a visual resource in addition to auditory information, as Ganguly [56] discusses, it allows the researcher to document important nonverbal cues, which would otherwise be missed.

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Table 2. Interview guide The topic guide used in the semi-structured interviews.

https://doi.org/10.1371/journal.pone.0322433.t002

Transcriptions were manually reviewed for anomalies following each interview and confidentiality of the participants was protected throughout the process by removing all identifiable information. To provide anonymity for data analysis, each participant was given a pseudonym at this stage. Throughout the data collection process, the researcher maintained a reflective journal.

Findings

Three main themes were developed during the thematic analysis process and are illustrated below (Table 3). For this study, the participants were not required to provide information on their client group. For ease of reading, the client is referred to as the child throughout the text. All quotes provided relate to participant pseudonyms and refer to data from interviews, unless otherwise stated.

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Table 3. Themes. The themes and sub-themes that were developed through reflective thematic analysis.

https://doi.org/10.1371/journal.pone.0322433.t003

Discussion

This study explores the art of therapy and the main elements that are embedded within it, including the therapeutic relationship, the just right challenge and flow from the therapist’s perspective. Data shows that this process, tapping into unique qualities that shape capable therapists, is indeed an art. Being an insider researcher, the first author understands that her own values, assumptions and philosophy will have impacted the recording and interpretation of data in some way whilst also allowing exploration of this complex subject from an internal perspective.

The findings suggest that a strong bond between child and therapist emerged during the assessment process and continued throughout intervention. The theme ‘The Human Connection’, and specifically the sub-theme ‘Sensibility’, relate to the child and therapist being both physically and emotionally responsive to each other. This was the first step towards forming the relationship and is considered a two-way process. This mirroring of movements and body language is termed kinesthetic empathy and is a concept implemented in dance movement therapy (DMT). In her book on DMT, Fischman [63] explained this phenomenon as the ability to understand a person by attempting both to experience their inner life and to understand how they feel through non-verbal communication and body movements. The findings in this study are supported by Rova’s [6] practice-based interdisciplinary research project which compared a group of experienced dancers with a group of health care professionals. She found that kinesthetic responses were observed in both groups, regardless of prior experience, and that it exists in clinical practice.

Not all relationships flourish easily, and this can take time. Participants were honest in sharing that some work better than others. The sub-theme, ‘You Can Count on Me’ suggests that trust, safety and security are building blocks that strengthen the therapeutic relationship and current evidence supports this. In her book The Intentional Relationship, Taylor [6] breaks down these characteristics and conceptualizes that they make up the therapeutic use of self and are considered integral to Occupational Therapy. Crom et al [66] interviewed parents and children receiving physiotherapy intervention and found that parents valued therapeutic relationships more than skilled intervention.

The sub-theme ‘Common Ground’ highlights that providing a haven where children can be themselves, feeling valued and accepted, facilitates their willingness to engage. In a similar study by Lawton et al [6], semi-structured interviews were used to explore speech and language therapists’ perceptions and experiences of alliance. Similar qualities laid the groundwork for therapeutic relationships and were called recognizing personhood. The book Clinician’s Guide to Implementing Ayres Sensory Integration® [1] confirms that, to promote participation, the therapeutic relationship must be strong enough for the child to trust and attempt challenges where they might have previously experienced failure.

Collaboration, shared joy and playfulness were considered important factors in finding common ground which some therapists found challenging. Bundy and Lane [30] consider that, for therapy to be effective, both the therapist and child must be playing with the therapist seen as an adult playmate. The Royal College of Occupational Therapists (RCOT) [31] has since issued an occupational therapy and play practice guideline developed by Ward and Payne [68] which directs OTs to pay attention to play as an internal state of being and not just as an observable state of doing.

The theme ‘Setting The Scene’ and, importantly, the sub-theme ‘Be Prepared! Everything In Its Place’ suggests that participants endeavored to collaborate with the child and scaffold the just right challenge to facilitate success. This is consistent with the core components of ASI® and heavily supported in the literature [69–71]. The sub-theme ‘Extraneous circumstances’ describes caregivers as both barriers to and supporters of success. As to which one, this is mostly dependent on their understanding, and the level of information they received from the therapist. Previous research supports that parent/teacher education and participation is expected [72–73], yet often it is focused on goal-orientated coaching. Schaaf and Mailloux [1] developed a parent guidebook which Roan et al [74] adapted using knowledge translation strategies. This offers best practice strategies for educating parents of children with ASD who use an OT ASI® approach. If this parent guidebook is to be a common reference used in clinical practice, its content is likely to be adopted by other countries.

The theme ‘Magic Happens! The Optimal Experience’ and, in particular, the sub-theme ‘Mindfulness In Action’ suggests that the high level of in-moment clinical reasoning required during flow became an unconscious effort for some but proved challenging for others. The level of conscious thinking could relate to the ease of the therapeutic connection: when things were going well, therapists felt fully connected and completely immersed in the present moment. This is not unlike mindfulness as Germer [75] described this concept as being totally immersed in the task at hand. The findings in this study are supported by recent research by Smith et al [76] where mindfulness was found to be present in pediatric OT practices in Scandinavia. They concluded that mindfulness has the potential to support therapeutic relationships but advised that more research is needed.

The sub-theme ‘Magic! Self-Actualization’ discussed the therapist’s sense of achievement when intervention was successful. This was supported by the psychotherapist Kottler [77] in his book On Being a Therapist. The impact of client intervention on the therapist was explored and affirmed that the decision to become a therapist in whatever capacity was a commitment to self-growth and discovery.

Participants in this study described how the adaptive response occurring during moments of flow often felt like magic. Flow was studied by Csikszentmihalyi [27] who viewed it as the optimal experience. In their psychological study of flow in consciousness, Csikszentmihalyi and Csikszentmihalyi [78] discussed how flow has become a technical term used in the field of intrinsic motivation which supports its place within ASI® therapy. Yet flow is deeply rooted in psychology and relates to all human experience. The musician Slash, of Guns N Roses fame discussed his experience of flow, whilst playing guitar. He states in his autobiography [79] that with his hands occupied and his mind engaged he had truly found his inner peace. The findings in this study are supported by Solmon and Clouston [80] whose article elucidated that it is the role of the OT to use their therapeutic use of self to facilitate the optimal experience and to achieve the best outcome for their clients.

The sub-theme ‘The Artful therapist’ explored how participants learned to facilitate flow. It was evident that hands-on practice and observations of experienced mentors was crucial to their understanding of what it means to be an artful therapist. This is supported by a recent study by Rahman et al [81] that utilized questionnaires to assess how important and how confident 161 OTs in Malaysia using ASI® felt about the different components of intervention. Many of the participants were not yet certified in ASI® and learning had consisted of attending University courses only, with no mention of mentorship. They found that the majority of OTs considered the therapeutic relationship and setting of the just right challenge as very important, and they felt comfortable and confident in these areas. However, only 50% felt the same level of comfort and confidence in ensuring the child’s success, which could be an indication that the art of therapy has not been fully understood.

A recent study of mentorship for OTs in vocational rehabilitation by De Dios Pérez et al [82] supports that mentorship improves confidence and competence. Similarly, Schoen et al [69] studied the effectiveness of a specific mentorship program for OTs specializing in sensory integration and processing challenges. The results were positive which suggests that there is a need for more in-person, structured, mentored learning experiences.

Implications for practice and future research

Throughout this study, practitioners have voiced their honest opinions by disclosing their concerns and sharing highlights of their intervention. Much of the data confirms what is already known regarding the art of therapy in the context of ASI®. Findings confirm the therapeutic relationship as multilayered and dependent on the therapeutic use of self. This is supported by current research [64,65,67] and is intrinsic to OT [65]. Yet the findings demonstrated how experienced therapists described some relationships as being difficult to cultivate. It is therefore suggested that, at entry level, more emphasis should be placed on assisting students to fully understand the building blocks of the therapeutic relationship, especially in relation to complex client groups.

The importance that participants placed on collaboration, setting the just right challenge, and flow within the art of therapy, showed their level of commitment and adherence to ASI® principles. It is crucial to develop these in caregivers to ensure better outcomes for their children. As discussed, clinicians in the USA have already developed a best practice guide on educating others [1,74]. It is suggested that clinicians in the UK consider doing the same. This would be a valuable asset, not only to assist therapists in supporting caregivers during intervention, but also to promote the fundamental principles of OT.

Findings indicate that participants experience feelings akin to mindfulness which emerging evidence supports as a therapeutic tool [76]. In recent years, mindfulness has emerged as an important concept for well-being and is used by many therapists and educators as well as in other areas of work [83–85]. It is suggested that further research is needed to explore its use in all fields of OT and with different client groups across the lifespan. Educators should consider its inclusion within curricula to help OT students using ASI® to fully understand the concept of the optimal experience and to improve practice and learning.

It was mentioned that much of OT and ASI® has moved to online learning which limits hand-on experiences for many. In recent research, students themselves have voiced their dissatisfaction with this approach [86–87] and further research is required to understand the impact that online learning has on skill acquisition and learning experience. Long et al [88] concluded that humans have a fundamental need for physical interactions and suggest that this cannot be replaced by online interaction; therefore, it is safe to assume that the move to virtual education has somewhat removed the concept of personhood and this is something which can limit the optimal experience of learning for many.

Whilst a virtual approach has its benefits, educators are strongly encouraged to reinstate hands-on practical workshops or modules. This would enable students with limited access to experienced workplace mentors, to fully understand how the art of therapy feels, as opposed to how it should look, to ensure the therapeutic elements are not lost. Schreiber et al [89] affirm that experiential learning provides critical exposure and opportunities that are fundamental to student development. In the present study, therapists who had learnt the art of therapy from skilled mentors, regarded them as integral to their learning process. This finding aligns with Husband [90] who highlighted that levering the skills and experience of mentors enhances professional learning. Collectively, these studies underscore the importance of incorporating both mentorship and hands-on learning opportunities into ongoing professional development for therapists, which could be effectively facilitated in small group settings.

This study gained novel insight into the therapist’s perspective of the therapeutic elements of OTs using ASI® and it is hoped that this study triggers experienced clinicians to reflect on their current practice. OTs working with children within the context of play, must develop a deep understanding of the art of therapy to ensure meaningful outcomes for their clients. It was important to reflect on current clinicians’ lived experiences to understand how that feels in practice.

Acknowledgments

The authors wish to thank the occupational therapists who kindly gave their time to participate in this study, remained open and honest throughout and were brave enough to share their fears.