*3.7. The Arts Therapists' Assessment of the Progress of Therapy* 3.7.1. Progress in the Child's Expressive Ability

Three arts therapists noted specific improvement in language abilities as a result of the therapeutic process: "It is really a long process . . . Suddenly there were words in the room." Five arts therapists described an improvement in the verbal expression of emotions: " . . . There are still outbursts sometimes but little by little they subsided, little by little he would say I need a moment in the corner to calm down. He was able to verbalize it." The same was true for expressing a desire: "This is something new that I didn't see before . . . This ability to express wanting to play with only one person."

#### 3.7.2. Progress in Terms of the Parents' Acceptance of and Adaptation to the Child

Five arts therapists highlighted the importance of the changes experienced by the parents: "The ability of the parent to change, the willingness to attend and to deal with all this complex content, I think that is the most significant part." They also mentioned its influence on the child's acceptance and progress: "A very big change when he could make space for the violence and participate in the game . . . the child experiences that the father accepts him and wants to be with him . . . The child felt that he had legitimacy and that he is much more accepted."

#### 3.7.3. Progress in the Ability to Be in a Relationship

All the arts therapists related to the change and progress in the relationship among the members of the dyad as observed through the changes in the children's behavior: "It's a process of a full year . . . to show this initiative, to spread the fabric and create some space for himself . . . and then little by little he invited the father and, in the end, invited me too," and in the parents: "A very significant component was that the father simply joined in the game and allowed himself to let go of something that was very suppressed or to experience something new for himself." Most arts therapists related to changes in the structure of play that develops into broadening the communication circles until finally the desire to play with other children develops: "Now when I see him during recess, he says: 'Would you like to play with me? Would you like to ride with me in the car? Let's drive, I can push you in the car.'"

#### **4. Discussion**

The present study described parent-child arts therapy from the point of view of experienced arts therapists who work according to this model at the Milman Center. The discussion focuses on the four central components present in the parent-child arts therapy room: the child in therapy, the parent, the arts therapist, and the creative arts.

The arts therapists described the child with ASD as the focus of parent-child arts therapy. The goal of therapy was determined by the therapists by assessing these children's levels of functioning and their ability to be in a relationship. The arts therapists described the primary goals that first and foremost included working on the relationship between the child and the parent, in addition to other facets aimed at improving the quality of life of the child, such as expanding play and its development, working on separateness between parent and child, sensory regulation and emotional expression. Contact and communication emerged as the core of this parent-child arts therapy model. In other studies, as well and with other populations [4], arts therapists who used this model reported that they focused on the relationship between the child and the parent as a source and a starting point for creating change. This approach is even more pertinent with children with ASD whose major difficulty is related to relationships and communication [30]. Similar to articles that have described clinical work in the field of arts therapy with children with ASD [22,31], here too the arts therapists described how the children learn to express themselves and learn more ways to relate to the outside world. The presence of the parent allows for a broader understanding of the child and working together expands the child's circles of communication for dyadic work and occasionally for triadic therapeutic work.

Most arts therapists related to the parents' difficulties in coping with the child's disability and vulnerability. These difficulties can manifest in different ways when the parents feel guilty and criticized or overwhelmed with emotional issues including depression. Some parents find it hard to cooperate and some find it difficult to establish contact with the child. Note that many parents contact the Milman Center shortly after the primary diagnosis when they are still processing it [21,32]. Regev and Snir [3] indicated that when a child is in distress, parents may feel that their parental competency is being tested. On the one hand, the parents are worried about the child, and on the other, the parents may feel overwhelmed with feelings of guilt and failure. In addition, most interviewees noted the parents' difficulty, as they saw it, in taking an active part in therapy and sometimes in understanding its meaning. These findings correspond to results from other studies where parents described their initial difficulties in dealing with the artistic medium, which is less familiar and accessible to them. This caused them to feel awkward when using the art materials and engage in self-criticism, which required a change in thinking patterns on the part of the parent [9,33]. Nevertheless, some arts therapists related to the parents' needs for intensive professional guidance and reported a shift that occurred in terms of parental participation as therapy progressed. This change relates to different aspects of parenting, but also to opportunities to become more playful and involved. Studies with a longitudinal design on parent-child psychotherapy with mothers and their children with ASD clearly point to the development of positive mutual emotions between the mother and the child that lead to improvement in self-regulation [34] and reduced disruptive behavior, while enhancing communication skills over the course of several sessions. Researchers have noted that the progress persisted even after a longer period of time [35,36].

All the arts therapists related to their need to find the best position for them within the dyad. This can be determined by understanding the needs of the dyad. The arts therapists discussed the changes they needed to make as a function of the interactions in the arts therapy room and their efforts to find the best way to involve parents in therapy. Kaplan and colleagues [37] emphasized the importance of finding the most beneficial position for the therapist in relationship to the dyad at all points in time. This underscores the need for therapists to understand the parental experience and adapt their position and interventions to the members of the dyad at all times [6,33,38]. The arts therapists noted that their relationships with the parents help them gain a fuller understanding of the child in therapy. Together with the parents, they can try to understand the cause and meaning of a particular behavior. In addition, all the interviewees noted that their role also involves mirroring and conceptualizing the emotions that emerge during therapy. Most arts therapists noted that they engage in the process of modeling they think is the most suitable for each child. This, according to them, can help the child be more completely understood, contained, and secure. The findings showed that most arts therapists believe that providing support to the parents and recognizing their authority is part of their role, as well as including the parents in the process, and encouraging them to find solutions. Similarly, several authors in the field of parent-child arts therapy have stated that the therapist should suspend judgmental attitudes and make an effort to understand the difficulties the parents face [3,21] by serving as a "good grandmother" [39]. The arts therapists noted their own complex feelings of failure, boredom, emptiness, and anger that arise during therapy along with feelings of

self-criticism, which are often engendered by the presence of another adult in the arts therapy room.

Most arts therapists stated that they would like to find a way to integrate the arts into the therapy session, but about half noted that some children do not always want to engage in arts modalities. Most arts therapists indicated that in order to feel secure, children will usually turn to a familiar activity, and many prefer to play rather than do artmaking. Some arts therapists mentioned that it is important to understand the sensory profile of each child and that some children recoil from touching or handling the art materials. A few arts therapists discussed these children's difficulty regulating their emotions, and one therapist suggested that even the thought of artmaking might cause a child to feel anxious. However, a few arts therapists described the act of playing as a way for these children to become familiar with the world of arts. Malchiodi [40] and Martin [21] related to the wealth and abundance of art materials and instruments that impact all the senses, but that can also be an emotional overwhelming experience for children with ASD. Dunn [41], an occupational therapist, found that children with ASD have different patterns of sensory processing. They may absorb sensual stimuli at an extremely slow pace, perhaps not even notice the stimulus, or alternatively, they may react very intensely and be unregulated. In this situation, some children will develop a strategy of avoiding engaging with their senses to facilitate their self-regulation. This has led several authors [21,40,41] to note the importance of planning the therapeutic space and finding the right balance between the different stimuli so that the child can remain in the arts therapy room and benefit from the session.

#### *Limitations and Suggestions for Further Research*

This study has several limitations. It was based on the perception of arts therapists who work at the Milman Center using the parent-child arts therapy approach. It was therefore written from their point of view without exploring the points of view of the parents or children with respect to the content that emerged in therapy or its effects on them. In addition, due to the limited number of arts therapists working at the Milman Center, all types of modalities were examined together as a whole, which presents a problem when attempting to characterize a specific type of arts therapy. Future research could develop this topic by investigating the parents' experiences during the process or exploring each modality in more detail. Finally, a longitudinal study could examine the effectiveness of parent-child arts therapy with this population post-therapy.

#### **5. Conclusions**

The field of parent-child psychotherapy has made considerable progress in recent decades. Arts therapists have also begun to adopt this therapeutic approach, which combines work with children and their parents as illustrated at the Milman Center, where arts therapists work with children with ASD and their parents. The present study was designed to map this process. The findings suggest that according to the arts therapists, integration of the arts can contribute to the parent-child relationship but needs to take the sensory profile and individual characteristics of each client into account.

**Author Contributions:** This research was conducted as part of M.B.'s Master's thesis; supervision, D.R.; All authors collaboratively conceived and contributed to the study and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was approved by the Ethics Committee of the Faculty of Welfare and Health at the University of Haifa (107/20, 16 March 2020).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data are not publicly available due to ethical restrictions.

**Acknowledgments:** The authors would like to thank the Milman Center, Naama Tishrey Ben Moshe and Hadas Lustman, for opening their doors and allowing this collaboration to take place. In addition, we are grateful to Serene Dakak, Tal Lasry, Libby Eisner, Orit Levi, Ayelet Shamir, Mor Sadan, Yaara Porat, Hadas Kaduri, Rotem Green Raginsky, Inessa Chernikov, and all the other arts therapists who chose not to be mentioned by name. They devoted their time and shared their vast knowledge and experience with us. Special thanks to Rotem Patishi, who participated as an interviewee, and helped us immensely in answering questions, referring us to more potential interviewees, and for her clarifications, coordination, and support throughout this study.

**Conflicts of Interest:** The authors declare no conflict of interest.

## **Appendix A. Interview Guide**

Age

Gender

General experience as an art therapist

Seniority as an arts therapist at "Milman"

Modality

On average, how many children do you work with in "Milman" each year?

What is the age range of the children you work with?

1. Describe the course of one therapy session with a child and his/her parent in your modality. How does the child take part? The parent? How would you define your role?

2. What was the goal of this session? What goals do you set for parent-child arts therapy with children with ASD?

3. Is there a standard way of conducting a therapy session? What interventions typically characterize your work in parent-child arts therapy with children with ASD?

4. In your opinion, which interventions are more successful and which are less successful? What causes failures?

5. Describe how you incorporate your art during the session. Is your modality suitable for all children with ASD? Is it more suitable for some than others?

6. Give examples of a process of change or overcoming a difficulty with clients.

7. What are the challenges of working with this population in parent-child arts therapy? Give an example.

8. How does the parent's participation affect the therapeutic process?

9. What are the advantages and disadvantages of incorporating the arts in parent-child arts therapy?

10. What do you think helps the child the most in parent-child arts therapy? And what helps parents?

11. In conclusion, based on your experience, would you recommend parent-child arts therapy for children with ASD? Why?

#### **References**

