Dyadic art psychotherapy: Key principles, practices and competences

The Arts in Psychotherapy 41 (2014) 163–173

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The Arts in Psychotherapy

Dyadic art psychotherapy: Key principles, practices and competences Elizabeth Taylor Buck, MA (Oxon),PG Dip Art Therapy, MBPsS a,∗ , Kim Dent-Brown, DipCOT, BSc(Hons), PGDip Dramatherapy, PhD c,1 , Glenys Parry, BA, Dip.Clin.Psych., PhD, C.Psychol., FBPsS a,1 , Jonathan Boote, MA (Cantab), MSc, PhD, FRSA b,2 a

School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom NIHR Research Design Service for Yorkshire and the Humber, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom c The Department of Psychology, University of Hull, HU6 7RX United Kingdom b

a r t i c l e

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Article history: Available online 21 January 2014 Keywords: Art therapy Competences Dyadic Delphi Consensus Parent–child

a b s t r a c t A recent survey indicates that a dyadic parent–child approach to art psychotherapy is being used by 60% of British art psychotherapists working with children and young people with some degree of frequency (Taylor Buck, Dent-Brown, & Parry, 2012). However, currently there is insufficiently robust evidence to support the efficacy of this approach. Outcome-based studies are needed to demonstrate efficacy, and an important first step in designing such research is to establish an accepted definition of the process and practices of dyadic art psychotherapy. A two-round Delphi process was used to seek consensus on the core therapeutic principles, practices, and competences required for the delivery of dyadic art psychotherapy. Consensus was reached on ten principles, six practices and fifteen competences required for the delivery of art psychotherapy which could be used in practice, evaluation, and future outcome-based research. © 2014 Elsevier Ltd. All rights reserved.

Introduction High quality research is needed to evaluate the effectiveness of art psychotherapy3 ; however studies such as randomised controlled trials depend a clear description of the process and content of the intervention being trialled. A clear consensus on the practice and process of art psychotherapy has yet to be established (Patterson, Crawford, Ainsworth, & Waller, 2011, p. 73). Obstacles to defining the process of art psychotherapy may include heterogeneous settings and diverse client groups. However, special interest groups within the British Association of Art Therapists have begun the process of developing clinical guidelines for specific

∗ Corresponding author. Tel.: +44 0114 22 20753. E-mail addresses: e.taylor-buck@sheffield.ac.uk (E. Taylor Buck), [email protected] (K. Dent-Brown), G.D.Parry@sheffield.ac.uk (G. Parry), j.boote@sheffield.ac.uk (J. Boote). 1 Tel.: +44 0114 22 20753. 2 Tel.: +44 0114 222 0892. 3 The British Association of Art Therapists has shed light on the dual use of the term art therapist and art psychotherapist: ‘All the Arts Therapies professional bodies are currently seeking to include “psychotherapy” in their professional titles in order to clarify the level at which they practice and in recognition of their qualifying standards. . . Art Therapist and Art Psychotherapist are both used although they refer to the same level of professional competency”(BAAT & AMICUS, 2005). In line with this, the terms art therapy and art psychotherapy, and art therapist and art psychotherapist are used interchangeably throughout this article. 0197-4556/$ – see front matter © 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.aip.2014.01.004

client groups (Springham, Dunne, Noyse, & Swearingen, 2012). This constitutes a promising first step towards clarity and specificity for the profession. The drive to describe and define psychotherapeutic interventions and modalities is also gaining momentum in many other related fields. Practitioners and researchers in the field of systemic family therapy have recognised and engaged with the need for specificity and clarity (Pote, Stratton, Cottrell, Shapiro, & Boston, 2003). Similarly narrative therapists have reported on their enquiry into the narrative therapy process with a study aiming ‘to explore and distil out the “common themes”’, highlighting the importance for any therapeutic model hoping to demonstrate efficacy of establishing ‘an accepted definition of its components and practice’ (Wallis, Burns, & Capdevila, 2011). The aim of this study was to reach consensus on core principles, practices and competences (PPCs) relating to one particular art psychotherapy intervention for an equally specific client group. A survey of British art psychotherapists working with children and young people (Taylor Buck, Dent-Brown, & Parry, 2012) has shown that over half of the therapists surveyed (60%) involve parents and carers4 in dyadic sessions with some degree of frequency. This practice of dyadic parent–child art psychotherapy is the subject of this Delphi study, with a specific emphasis on the treatment of

4

The term carer is used in this paper to mean a child’s primary caregiver.

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disruptions and difficulties within the primary attachment relationship. Dyadic parent–child approaches Beyond the profession of art therapy the practice of working directly with the child–caregiver dyad is championed by researchers and therapists from attachment-based backgrounds (Amos, Beal, & Furber, 2007; Hughes, 2004; Moss et al., 2011) and psychodynamic backgrounds (Cohen et al., 1999; Cummings & Wittenberg, 2008). Focusing on the parent–infant dyad is a core component in some interventions and the effectiveness of this approach looks promising (Howe, 2005, p. 221). Attachment-based interventions with school-age children are also likely to involve both carer and child (Howe, 2005, p. 234). Dyadic art therapy Similarly, within the field of art therapy, the joint involvement of caregiver and child within the art therapy sessions is seen as helpful in some instances (Taylor Buck et al., 2012). This practice may be linked to the ‘Family Systems’ orientation identified in the Elkins and Stovall (2000) survey, or it may come from other theoretical origins such as attachment theory. Waller (2006) suggests that: ‘Increasingly art therapists are turning to attachment theory to explore early childhood relationships and their impact on subsequent behaviour’ (p. 281). This burgeoning interest in attachment relationships and the trauma which can ensue from damage and disruption within these relationships is evident in the writing of art psychotherapists working with children and young people (e.g. Boronska, 2000, 2008; Case, 2005, 2010; O’Brien, 2004, 2008). A review of literature discussing dyadic parent–child art therapy was undertaken. An initial search of relevant databases (PsychINFO and Web of Knowledge) retrieved an original article by Plante and Berneche (2008) and two book reviews of Strengthening Emotional Ties Through Parent–Child-Dyad Art Therapy by Lucille Proulx (2003). A search of Google Scholar produced more results, some of which indicated that dyadic art therapy is used on occasion to refer to couple or marital art therapy (Ricco, 2007), and also two person group art therapy (Brooke, 2006). Other references to dyadic art therapy included book chapters by Maggie Ambridge (2001) and Yonathan Schur (2001) and an article by Hilary Hosea (2006) about parent–infant art therapy groups. Following up references within these results also pointed to chapters in Judy Rubin’s (2005) Child Art Therapy and a paper by Helen Landgarten (1975) describing an art therapy group for mothers and daughters. The references that were found highlighted the significant contribution from Canadian Art Therapist Lucille Proulx (2003). Her rich and informative book Strengthening Emotional Ties through Parent–Child-Dyad Art Therapy is a theoretical and practical guide to dyadic art therapy interventions primarily with infants and preschoolers. Proulx describes her work as ‘a therapeutic modality based on certain principles from the fields of child psychiatry, psychology, and art therapy’ (p. 16). Proulx’s book (2003) primarily describes a group intervention with parents and infants or children under the age of three. She also discusses some groups involving older children and also some ‘individual dyad therapy’. Although Proulx describes how dyad art therapy has been successful with children of all ages from 10 months through to adolescents (p. 51), she states that the main objective of the book is ‘to record and teach dyad art therapy to art therapists interested in working in the prevention filed with the early childhood population’ (p. 19). Proulx has also contributed to a CD accompanying Judy Rubin’s (2005) Child Therapy, which itself contains a number of references to joint parent–child art therapy. Rubin writes that she

has experience of running weekly parent–child groups which typically involve some time with the dyads together ‘followed by separate activities – usually a 45 minute discussion time for parents and snack and activity for children’ (p. 214). Rubin also describes dyadic art therapy as a useful component of family work: ‘Although family art therapy can and usually does involve the entire nuclear family. . . it is also helpful to work with smaller components of the larger unit’ (p. 188). Rubin states that in her experience the ‘most important and influential person in a child’s life is usually the mother’ and as such ‘[i]t is often useful to have occasional mother-child session both early and late in treatment, for a variety of purposes’ (p. 188). However, she also describes some father–child sessions, and explains how dyadic sessions can have value for both ‘diagnostic and treatment purposes’, serving to complement a range of art therapy interventions such as family and group art therapy. David Henley (2005) has also written about involving parents and carers in the child’s art therapy sessions when working with post-institutionalised adopted children with attachment disorders. Henley provides three case studies which provide insight into how he structures these art therapy sessions which include some time alone with the child, and some time with the child–carer dyad. In his paper, and in a subsequent chapter written about art therapy supervision, Henley (2007, p. 92) discusses the complexities of negotiating the tricky three-way relationship between child, carer and therapist. The literature search also retrieved significant contributions from two British art therapists (Hall, 2008; Hosea, 2006) in relation to joint parent–infant interventions. Hosea (2006) describes a community art therapy group for mothers and infants. She compares this group to Proulx’s groups saying: ‘Although Proulx and I share many theoretical ideas, my approach in the community group is different, more open to individual creativity and far less structured. The health visitors, nursery nurse and I are intent on releasing the mother’s own initiative and creativity which she may have lost touch with or need to make contact with.’ (Hosea, 2006). Hosea hypothesises that the use of art materials in her groups allows mothers and children to engage in more constructive ways, with increased emotional contact. She also refers to the work of Hall (2008) who recounts her use of art therapy groups for mothers and young children over two decades: ‘I began to use art therapy in family work with the under 5s in company with a clinical psychologist colleague . . . Systemic family therapy had a strong presence in the clinic and my colleague received supervision in using a video interaction guidance technique . . . we evolved a way of working with art materials in our clients’ homes, using brief video recordings of the parents’ and children’s interaction. The art images produced became instruments for change’ (p. 23). Hall links the evolution of her dyadic work to systemic family therapy, an approach also underpinning the illustrated story books used as part of family therapy by Hanney and Kozlowska (2002). There is clearly a significant overlap between dyadic parent–child art therapy and systemic family art therapy, and in some instances (for example a single parent with only one child) it could be argued to be one and the same thing. Possibly it would be too difficult and somewhat artificial to definitively separate the two approaches which may be intertwined and mutually enriching. However, in practice a helpful distinction may be that which was given earlier by Rubin (2005), namely that family art therapy ‘can and usually does involve the entire nuclear family’ where as dyadic art therapy is ‘work with smaller components of the larger unit’ (p. 188). Although this could be seen as a technicality, there may be implications in terms of therapeutic alliance and emphasis.

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The review of literature shows that whilst some rich and detailed descriptions have been given of dyadic art psychotherapy with parents and infants (Hall, 2008; Hosea, 2006; Proulx, 2003) and also with pre-schoolers and parents (Proulx, 2003), there are, as yet, no specific guidelines, or established consensus, on the practice or process of a dyadic approach to art psychotherapy with children in the middle years of childhood (ages 5–12), nor clarity on which additional competences art psychotherapists might need to deliver such an intervention. To address this issue, a Delphi process was used to establish consensus amongst a group of experts in the field on the key PPCs required for effective implementation of dyadic art psychotherapy with parent–child dyads, involving children in middle childhood with relational or attachment-related difficulties. Although at times during this paper principles, practices and competences are discussed separately, when the term PPC is used, it refers to the collective group of PPCs. In this context, a principle is taken to mean a tenet or overarching aim of dyadic art therapy. A practice is taken to mean actions or steps taken by the therapist with the aim of increasing the therapeutic potential of the encounter, and may also include actions that the therapist encourages the carer or child to take. Competences are defined as the skill-set and knowledge-base required by the therapist for the delivery of dyadic art psychotherapy. The significance of therapist skill is increasingly recognised in psychotherapy research and measures of psychotherapist competence have been developed and tested (Bennett & Parry, 2004). The British Psychological Society’s Centre for Outcomes Research and Effectiveness (CORE) have developed nine competence frameworks focussing on major therapeutic modalities, including Cognitive Behavioural, Psychoanalytic/Psychodynamic, Systemic and Humanistic Therapies (Roth, Hill, & Pilling, 2012). Consensus methods such as the Delphi process are regularly used in medical and health services research, and reviews of these methods have been published (Jones & Hunter, 1995). Murphy et al. (1998) report that consensus methods are increasingly being used to determine clinical guidelines and argue the case for the use of formal consensus methods such as the Delphi. They clarify that in an ideal world, ‘clinical guidelines would be based on evidence derived from rigorously conducted empirical studies’ yet ‘[i]n practice there are few areas of health research where sufficient research-based evidence exists’ (Murphy et al., 1998, p. 1). The Delphi method has been used in health care settings when there is a limited evidence base (Boote, Barber, & Cooper, 2006). The Delphi process aims to synthesise information and reach consensus amongst a panel of individuals deemed to have expertise in the given field of enquiry, and who do not meet face-to-face. Researchers develop relevant statements relating to the subject of enquiry and select panellists who are asked to rate the statements in series of postal (or electronic) questionnaires. The researchers feed back results between rounds to the panel of experts who then have the opportunity to revise their opinions in light of the feedback. The size of a Delphi panel varies between published studies, with reported samples sizes varying from four to 3000 (Mullen, 2003). The level of consensus within the Delphi panel that is considered acceptable by the research team also differs, with some studies reporting an agreement level set at 90% (Pfleger, McHattie, Diack, McCaig, & Stewart, 2008) and others setting the agreement level at 70% (Persoon, Banningh, van de Vrie, Rikkert, & van Achterberg, 2011). Method A two-round electronic Delphi process was conducted between June and December 2011, with the aim of establishing a consensus on the core therapeutic principles, practices and competences required for the delivery of dyadic art psychotherapy. Ethical

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approval was granted by the East Midlands NHS Research Ethics Committee and the exercise was co-ordinated at the University of Sheffield School of Health and Related Research, as part of a clinical doctoral research project funded by the National Institute for Health Research. Delphi panel members were selected who could demonstrate expertise in one or more of the following areas: • Art psychotherapy with children and young people, evidenced by authorship or editorship of professional texts judged to be influential by the researchers. • Dyadic art psychotherapy, evidenced by specialist papers written about parent–child art therapy. • Art (or arts) based therapy and attachment, evidenced by substantial experience of working in specialist attachment treatment settings and/or clinical expertise in attachment. In the first round of the Delphi process, members of the panel were asked to rate a researcher-generated list of potential PPCs comprising seven principles, eight practices and four competences. These potential PPCs were identified from research papers describing dyadic attachment-based therapeutic interventions. The decision was taken to use PPCs from existing dyadic interventions that were not art therapy based for a number of reasons. The first was to provide a model for potential PPCs based on interventions which were already seen as sufficiently clearly and systematically described to enable involvement in robust outcomebased research. However, it was also clearly explained to panellists that this was only a list of ‘suggested’ PPCs which might, or might not, be important for the therapist to bear in mind when adopting a dyadic approach to art therapy. Panellists would then be invited to suggest further PPCs themselves which they considered appropriate. Given the degree of expertise amongst the panellists, this elicitation was seen as key to the Delphi process. As such, the sample PPCs were not intended to be an exhaustive or even a coherent list: instead they were designed to provide a model and to stimulate thoughts about panellists own experience and practice. A further reason was the intention that many of the art therapists identified by the literature review would be invited to be members of the Delphi panel. Inclusion of panel members’ own work or words in the initial PPCs could have introduced a degree of weighting or bias that would have been hard to account for. The idea of a Delphi being that each panel member has equal weight or influence. Finally, it was envisaged that seeing PPCs from other related interventions might lead to an interesting and creative cross-fertilisation of ideas, and a recognition that dyadic art therapy can be seen as part of a wider group of parent–child approaches. Databases searched to identify the research-based papers were CINAHL, PsycINFO, Web of Science, BIOSIS Previews, MEDLINE, and Journal Citation Reports. The search terms used were: therapy OR psychotherapy; approach OR treatment OR model OR intervention; dyad OR dyadic OR mother–child OR father–child OR parent–child; attachment-based. The search strategy, which combined these four searches using the AND operator, elicited 35 results. However, some of these articles did not refer to a model of treatment which directly involved both children (or young people) and parents (or carers) in at least some joint therapy sessions, and some papers were referring to the same interventions, so papers such as these were excluded from the results. The remaining nine papers all mentioned specific interventions for children and young people which included at least one component of direct parent–child contact, and these became the interventions from which the researcher-generated PPCs were elicited. In addition, two review papers were found by the search strategy, one was a review of interventions in the parent–child

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Table 1 Papers and related interventions from which researcher-generated PPCs were derived. Article title

Intervention discussed

Efficacy of a home-visiting intervention aimed at improving maternal sensitivity, child attachment, and behavioural outcomes for maltreated children: A randomized control trial (Moss et al., 2011) Identifying therapeutic action in an attachment-centered intervention with high risk families (Steele, Murphy, & Steele, 2010) The Mothers and Toddlers Program, an attachment-based parenting intervention for substance using women: Post-treatment results from a randomized clinical pilot (Suchman et al., 2010) Generating nonnegative attitudes among parents of depressed adolescents: The power of empathy, concern, and positive regard (Moran & Diamond, 2008) Effects of an attachment-based intervention on daily cortisol moderated by dopamine receptor D4: A randomized control trial on 1-to 3-year-olds screened for externalizing behavior (Bakermans-Kranenburg, Van Ijzendoorn, Mesman, Alink, & Juffer, 2008) Treatment for children with reactive attachment disorder: Dyadic developmental psychotherapy (Retraction of November, pg 43, 2006) (Becker-Weidman, 2008) Using theraplay in shelter settings with mothers and children who have experienced violence in the home (Bennett, Shiner, & Ryan, 2006) Parent and child therapy (PACT) in action: An attachment-based intervention for a six-year-old with a dual diagnosis (Amos et al., 2007) Attachment-based treatment for vulnerable children (Dozier, 2003)

Intervention Relationelle

relationship (Broberg, 2000) and one of attachment-based interventions (Van Ijzendoorn, Juffer, & Duyvesteyn, 1995). The first review outlined the positive intervention results achieved with Toddler–Parent Psychotherapy (Cicchetti, Toth, & Rogosch, 1999) and described a comparative study of the Watch Wait and Wonder (WWW) technique (Muir, Lojkasek, & Cohen, 1999) in which mothers ‘reported significantly more satisfaction and fewer feelings of ineffectiveness in the parenting role. . . Furthermore, infants/toddlers in the WWW group made significantly greater gains in Bayley developmental scores and in emotion regulation scores’ (Broberg, 2000, p. 41). Watch Wait and Wonder and Toddler–Parent Psychotherapy were also singled out as showing good results by both Prior and Glaser (2006) and Howe (2005) in their comprehensive examinations and analyses of the field and

Attachment-Centred Parent–Child Therapy The Mothers and Toddlers Program

Attachment-Based Family Therapy (ABFT) Video-Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIIP-SD) Dyadic Developmental Psychotherapy Theraplay Parent and Child Therapy (PACT) Attachment and Biobehavioral Catch-up

so they were included in the group of interventions from which the PPCs would be derived. The final list of papers and related interventions from which the researcher-generated PPCs were identified are shown in Table 1. Descriptions of the interventions identified in the review of literature were then examined, and the relevant PPCs were identified. PPCs were selected for inclusion in the round one questionnaire if they were: shared by three or more interventions, contradictory or deemed by the researcher to be potentially contentious. The PPCs derived from interventions identified in the literature search were examined and grouped together into clusters according to common themes. Where clusters were found to have PPCs from three or more separate interventions these were highlighted as ‘shared PPCs’ and one or two representative versions were

Table 2 Shared PPCs. Cluster theme

Representative principle, practice or competence

Developing carer’s reflective functioning

The therapeutic work aims to develop the carer’s capacity for reflective functioning. (principle) Ability to maintain an intersubjective stance, communicating verbally and non-verbally the personal impact of the process. (competence) The therapeutic work includes discussions of attachment and emotion regulation. (principle) The therapeutic work addresses how the carer’s own internal working models are enacted in the relationship with the child. (principle) Ability to help carers think about the impact of their own history on their current parenting. (competence) The therapist is alert to the carer’s own affect and helps the carer to recognize, contain and eventually understand this. (practice) The carer observes the child’s behaviour and interactions and reflects on the child’s inner world and relational needs. (practice) The therapeutic work seeks to enhance the carer’s sensitivity to the child’s emotional and behavioural signals. (principle) The therapeutic work promotes carer–child relationships characterized by both connectedness and autonomy. (principle) Carers are helped to engage with their child through creative activity, non verbal attention and child-directed descriptive speech (tracking comments). (practice) The therapist meets alone with the carer to establish a therapeutic alliance characterized by safety and trust. (practice) Understanding of attachment theory. (competence)

Includes consideration of non-verbal communication

Includes psycho-educational discussions about attachment or emotion-regulation Consideration of parent/carer’s own history and internal working models

Consideration and containment of parent/carer’s own experience and emotions Parent/carer observes and reflects on period of joint activity

Seeks to enhance parental sensitivity

Focus on carer–child relationship: engagement and repair

Includes sessions just with parent/carer

Based on attachment theory

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Table 3 Contradictory PPCs. 1st position

2nd position

PPCs illustrating contradiction

Includes periods of child-led activity

Adults lead activity

Constructing narrative of past events

Focus on here and now

The therapeutic work includes periods of child-led activity. (principle) The therapist takes charge of the interaction during the session and guides the carer to do the same. (practice) The story of the relationship between carer and child is retold with emphasis on emotional meaning of shared events. (practice) Ability to use within-session events to address carer’s affective responses and understanding of child’s behaviour. (competence)

included as a potential PPC in the round one Delphi questionnaire. Table 2 displays the cluster themes and the representative PPC. As well as including common and shared PPCs, guidance was sought from the Delphi panel when PPCs relating to different interventions appeared to be contradictory. Where interventions were found to have contradictory PPCs, a version of one or more of them was included in the round one questionnaire. This is shown in Table 3. In addition to shared and contradictory PPCs, the Delphi experts were also asked to consider potentially contentious PPCs. Table 4 shows the themes that were judged to be potentially contentious, and the PPC that was selected to be included in the first round Delphi questionnaire. Panel members were asked to rate the validity of each researcher-generated PPC, i.e. how appropriate they considered each potential PPC to be for the delivery of dyadic art (or arts) psychotherapy with a particular emphasis on working with children in ‘middle childhood’ (roughly between the ages of 5 and 12) with attachment related difficulties. Rating was on a nine point scale where 1 = not at all appropriate and 9 = very appropriate. For consensus to be achieved, a PPC needed to have been rated by 80% or more of the panel within the same tertile. Consensus on a PPC falling into the first tertile (1, 2 or 3) would equate to agreement that the PPC in question was ‘not’ appropriate; consensus on a PPC falling into the second tertile (4, 5 or 6) would equate to agreement that it was ‘only moderately appropriate’; consensus on a PPC falling into the third (top) tertile (7, 8 or 9) would equate to agreement it was ‘highly appropriate’. A PPC was retained if 80% or more of the panel rated it between 7 and 9 on the 9-point scale. Responses to the first round questionnaire were analysed and those PPCs rated between 7 and 9 by 80% or more of the panel were retained for inclusion in the final list of agreed PPCs. If any PPCs had been rated between 1 and 3 by 80% or more of the panel at round one they would have been discarded at this stage. Those PPCs that had not achieved consensus at round one were included in the second round questionnaire for panellists to re-rate. The second round questionnaire was sent out in October 2011. Panel members were told which PPCs had been retained and were also asked to re-rate the PPCs on which consensus had not been achieved at round one. As well as being given the mean rating of Table 4 Contentious PPCs. Contentious theme

Representative PPC

Use of touch

The therapist uses touch to enhance his or her interpersonal connection with the child. (practice) The therapeutic work is psychodynamic. (principle) The therapist provides sensory-motor stimulation and rhythmic movement and guides carers to do the same. (practice)

Psychodynamic Sensory-motor stimulation

each PPC from round one, the panel were also provided with the distribution data (i.e. the number of responses for each point on the nine-point scale) and an appendix of anonymised comments made by panel members in response to the round one questionnaire. The experts had also been asked, in the first round questionnaire, to provide additional PPCs based on their own clinical experience and judgement. These newly generated PPCs were included in the second round questionnaire for panellists to rate on the 9-point scale. Results Ten art psychotherapists and three specialist attachment therapists trained in one of the other arts therapies (i.e. drama, music or creative therapy) were invited to join the Delphi panel. Of those thirteen, eight individuals agreed to join the process and completed both the first and second round questionnaires. Of those eight participants, seven were trained as art therapists and one as a drama therapist. All participants met the pre-determined criteria of required expertise. During the conduct of the study, the Delphi panellists had quasi-anonymity with all their ratings and comments being shared amongst panellists anonymously. However, panel members were offered the option of having their participation acknowledged and all panel members were happy to have their involvement made public (see the acknowledgement section for the names of panel members). A pre-determined level of acceptable consensus for this study had been set at the outset at 80%, which in this case of an eight-person Delphi panel translated as either 7/8 or 8/8 of the participants. If more than one participant disagreed then no consensus was achieved. Ten of the nineteen researcher-generated potential PPCs presented in the round one questionnaire achieved consensus with 80% or more of the panel rating these PPCs in the same tertile, which in every instance was the top tertile (7–9). The third tertile consisted of the “highly appropriate scores” i.e. 7, 8 and 9, thus indicating that the panel agreed that these ten PPCs were very appropriate for the implementation of dyadic art psychotherapy. These PPCs are shown in Tables 5–7 along with their designated tertile and level of consensus. In the Round 2 questionnaire, panellists were asked to re-rate the PPCs that failed to reach consensus at Round 1. They were also asked to rate the experts’ own suggested PPCs that were generated from Round 1. None of the original Round 1 PPCs that were represented and re-rated in Round 2 achieved consensus. Sixty new PPCs were generated from suggestions made by the Delphi experts, and of these sixty PPCs, twenty-one achieved consensus in Round 2. All those achieving consensus were rated in the top tertile (7–9) indicating agreement that these PPCs are very appropriate. These PPCs were therefore retained and are shown in Tables 8–10 along with their level of consensus. Free text comments were invited at both Round 1 and Round 2. Each of the PPCs retained from either Round 1 or Round 2 is

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E. Taylor Buck et al. / The Arts in Psychotherapy 41 (2014) 163–173 Table 9 Practices achieving consensus at Round 2.

Table 5 Principles achieving consensus at Round 1. Principles

Practices

80% or more rated the following principles as highly appropriate (rating of 7, 8 or 9):

Consensus

80% or more rated the following practices as highly appropriate (rating of 7, 8 or 9):

Consensus

The therapeutic work aims to develop the carer’s capacity for reflective functioning. The therapeutic work addresses how the carer’s own internal working models are enacted in the relationship with the child. The therapeutic work promotes carer–child relationships characterized by both connectedness and autonomy. The therapeutic work seeks to enhance the carer’s sensitivity to the child’s emotional and behavioural signals. The therapeutic work includes discussions of attachment and emotion regulation.

100% 3rd tertile

The therapist observes attachment related behaviour. The therapist does not become the child’s therapist or the carer’s therapist. The art therapist is the RELATIONSHIP’s therapist. Through observations the therapist determines the functional emotional level of the child. The therapist receives supervision.

100% 3rd tertile 87.5% 3rd tertile

100% 3rd tertile

100% 3rd tertile

87.5% 3rd tertile 87.5% 3rd tertile

87.5% 3rd tertile

87.5% 3rd tertile

presented below with the associated comments from the experts. All comments have been anonymised and are therefore not attributed. Principles

Table 6 Practices achieving consensus at Round 1. Practices 80% or more rated the following practice as highly appropriate (rating of 7, 8 or 9):

Consensus

The therapist is alert to the carer’s own affect and helps the carer to recognize, contain and eventually understand this.

87.5% 3rd tertile

The therapeutic work aims to develop the carer’s capacity for reflective functioning. All members of the panel rated this principle as very appropriate for the delivery of art psychotherapy. Panellists saw this principle as ‘one of the core aims’ or ‘an important component of the work’. One expert described how the art psychotherapy process might achieve changes in reflective functioning ‘through the process of working together with the art materials with the art therapist acting as container and reflecting on what is happening in the room’. Other panellists unpacked the importance of enhancing reflective functioning, one commented that ‘the child is helped Table 10 Competences achieving consensus at Round 2.

Table 7 Competences achieving consensus at Round 1.

Competences

Competences 80% or more rated the following competences as highly appropriate/relevant (rating of 7, 8 or 9): Understanding of attachment theory. Ability to use within-session events to address carer’s affective responses and understanding of child’s behaviour. Ability to maintain an intersubjective stance, communicating verbally and non-verbally the personal impact of the process. Ability to help carers think about the impact of their own history on their current parenting.

100% 3rd tertile 87.5% 3rd tertile

87.5% 3rd tertile

87.5% 3rd tertile

Table 8 Principles achieving consensus at Round 2. Principles 80% or more rated the following principles as highly appropriate (rating of 7, 8 or 9):

Consensus

Great flexibility is employed in the planning of the treatment programme, respecting diversity of family history, culture and individual experience. Therapeutic work creates links with the present and past, in a historical, developmental and social context. Within the safe, boundaried space of art therapy the child is encouraged to expand their ability to recognise his/her own feelings in the context of being together with the carer. Focusing on moments of attunement when warmth and playfulness emerge is at the heart of the work. Therapeutic work aims to enhance the carer’s capacity for openness, working with experiences as they occur within the session.

87.5% 3rd tertile

87.5% 3rd tertile 87.5% 3rd tertile

87.5% 3rd tertile 87.5% 3rd tertile

80% or more rated the following competences as highly appropriate/relevant (rating of 7, 8 or 9):

Consensus

Understanding developmental trauma and the impact this has on every aspect of the child’s development. Understanding trauma in the context of therapy, Post Traumatic Stress Disorder (PTSD) symptoms, and sensitivity to the child’s ability to tolerate traumatic memories being exposed etc. Ability to make a broad assessment of an adult’s and a child’s attachment style. In particular to recognise unresolved trauma in an adult. Knowledge of parenting strategies particularly those for working with children with disturbed attachment behaviours (it is not enough to understand disturbed behaviours, a carer also has to respond to them, so this inevitably will be part of the work with the carer). Developing an understanding of the child for the carer and for the child, so that the child’s feelings can be seen and acknowledged, and so the child can begin to regulate his/her own feelings and the carer can help to soothe and contain them. Knowledge of stages of a child’s art development. An understanding of child development. Knowledge about the nervous system and how this is impacted by trauma and stress and how to help it calm as well as how to assess whether a child is being activated into a stress response (fight, flight or freeze) or whether they are able to manage higher level reflective functioning. Ability to recognise contra-indictors to Dyadic Art Therapy. Understand the difference between therapy with a birth parent and their child and therapy with a fostered or adopted child. Awareness of alternative theoretical frames and an openness to many ways of working. Understanding of psychotherapeutic ideas of how the self is built up and strengthened including infant–parent psychotherapy, Winnicott, Daniel Stern.

100% 3rd tertile 100% 3rd tertile

100% 3rd tertile

100% 3rd tertile

100% 3rd tertile

87.5% 3rd tertile 87.5% 3rd tertile 87.5% 3rd tertile

87.5% 3rd tertile 87.5% 3rd tertile

87.5% 3rd tertile 87.5% 3rd tertile

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to become aware of himself and others as separate in relation to the mental state of himself and others’, and another described how if the system around the child ‘is able to respond in a way that does not replicate or increase unhelpful attachment behaviours it will increase the potential for the child to learn healthy attachment behaviour’. However, one expert sounded a slightly more cautious note qualifying that development of the carer’s reflective functioning should not be ‘at the expense of the child’s needs’ adding that ‘Separate sessions with another clinician may sometimes be advisable for a carer with significant personal issues’. The therapeutic work addresses how the carer’s own internal working models are enacted in the relationship with the child. This principle achieved 100% consensus as very appropriate, and was helpfully unpacked by one panellist who wrote: ‘It is important to understand the responses in the carer and developing an understanding of these reactions can facilitate the carer to respond differently and to increase more appropriate (to the context) attachment behaviours. It is important for the carer to understand that attachment behaviours are adaptive survival strategies that become unhelpful for the child once their context becomes safe – yet these strategies have become the child’s pattern of relating. Equally the carer will also produce their own adaptive survival strategies under stress – which can be when a child is acting out their survival strategies – so in these interactional dances the interactions between the carer and child can be very maladaptive. If one side changes their interaction then inevitably the other has to change’. However, many panellists also commented on the need to strike the right balance and the importance of ‘keeping the development of the relationship between child and carer in central focus’, and many concurred that a focus on the carer’s internal working models was best ‘addressed and considered in separate parent sessions.’ The therapeutic work promotes carer–child relationships characterized by both connectedness and autonomy. This principle achieved full consensus as being very appropriate with one panellist commenting: ‘The use of art making within the therapy session has the capacity to give the child an experience of both connectedness and autonomy, this experience should not to be underestimated.’ This is echoed by another expert who writes: ‘You want to encourage the connections of parent and child and seeing each other in new ways. Also the expressive autonomous potential of the child within clear, firm boundaries’. A third panellist confirms that: ‘Therapeutic work promotes carer–child attachment relationship. This relationship will promote autonomy as the child begins to feel secure.’ The therapeutic work includes discussions of attachment and emotion regulation. The majority of the panel (87.5%) thought that this principle was highly appropriate, although there were different views on when such discussions should take place as well as the relative importance of such discussions. One panel member thought it would be useful for carers to have some prior attachment training thus establishing ‘theory to refer back to especially with foster carers’; another expert thought such discussions would most likely be in carer only sessions, a thought echoed perhaps by a separate panellist who commented: ‘Discussion and thinking together are important, but should not dominate the session. The potential for change contained in image making and art therapy process should not be underestimated and deserves mention here’. In terms of pitfalls, one panellist cautions that such discussions should take place ‘after trust has been built up so parent/carer does not feel criticised or judged. The discussion can evolve naturally out of the sessions.’ Whilst the only panellist not to rate the principle in the top tertile commented, ‘This might be discussed with the parent before the therapy begins, but not during the dyad art therapy sessions.’ The therapeutic work seeks to enhance the carer’s sensitivity to the child’s emotional and behavioural signals. All but one of the panel considered this principle very appropriate. One panellist

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commented that ‘This is definitely another core aim of the work’. The significance of this principle was commented on as follows: ‘Respect for the child’s art/mark making process and the equal care taken of child and adult images alike fosters belief in, and sensitivity to the child’s inner world’; ‘By allowing such sensitivity to develop, the child experiences a congruency of their actions, which in turn develops a sense of self as they learn to trust that their efforts of communication are actual and can be responded to’; ‘In the process of the work the child is being “known and contained”. Dyadic art therapy develops co-operative and expressive ways of being between carer and child. It gives a space for thoughtfulness and fun’; ‘The ability of the carer to read and understand the child’s signals means that they are able to respond in a thoughtful, reflective and responsive way, avoiding repeating negative interactions’; ‘The therapeutic work is to strengthen the parent–child attachment. The process of the work is to help the carer become attuned to the child’s needs.’ Great flexibility is employed in the planning of the treatment programme, respecting diversity of family history, culture and individual experience. This principle achieved 87.5% consensus. Some panellists saw it as non-specific commenting, ‘I agree but this should be the case for any child in any therapy’ and from another, ‘Background knowledge can only but help in creating an appropriate treatment plan’. However, other panellists saw specific resonance with dyadic art psychotherapy, and one commented that ‘One of art therapy’s advantages is the flexible nature of the process which opens up many possible ways of working with the parent–child relationships’. Therapeutic work creates links with the present and past, in a historical, developmental and social context. Seven of the eight panellists rated this principle in the top tertile. The expert who did not do so commented, ‘I think this is about integration of experience but I am not sure I would put it this way’. Another panellists considered this appropriate as an ‘aim’, and a third expert commented that ‘this will inevitably happen if the work is successful’. Within the safe, boundaried space of art therapy the child is encouraged to expand their ability to recognise his/her own feelings in the context of being together with the carer. All but one rated this principle in the top tertile and their comments echoed this high rating. However one of the panellists rated it in the second (middle) tertile and added ‘I would not see this as the main aim.’ Focusing on moments of attunement when warmth and playfulness emerge is at the heart of the work. Comments on this principle echoed the strong consensus (87.5%), highlighting the use of ‘positive reinforcement’ and also pointing out that ‘everything needs attention’. Therapeutic work aims to enhance the carer’s capacity for openness, working with experiences as they occur within the session. Panellists also rated this principle as very appropriate (87.5% consensus) with one expert clarifying, ‘If this means tackling issues as they arise rather than avoiding difficulties then yes. Difficult behavior can be positively reframed’.

Practices The therapist observes attachment related behaviour. This was one of only two practices rated by every member of the Delphi panel in the third (i.e. top) tertile. Two panellists expanded that the therapist not only observes this, but also reflects on it and makes a choice about whether or not to comment or feedback, as one panellist explains: ‘They may or may not comment on it. They certainly need to be observant to foster the understandings of parent and child’. A third panellist suggests that: ‘Through assessment of attachment, the carer and therapist can determine when the work is ready to come to an end’.

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The therapist develops an understanding of the child for the carer and for the child, so that the child’s feelings can be seen and acknowledged, and so the child can begin to regulate his/her own feelings and the carer can help to soothe and contain them. This expert-generated suggestion was originally given as a competence, but as the wording is describing a practice the researchers moved it to the appropriate section. The suggestion achieved 100% consensus with no additional comments except ‘part of the aim of the work’. The therapist is alert to the carer’s own affect and helps the carer to recognize, contain and eventually understand this. 87.5% consensus was achieved for this practice. At least one panellist felt that with careful handling this could be a feature of the joint sessions, commenting: ‘Yes, it is complex work – a lot goes on therefore reflecting subtly, gently and non-judgmentally on the carer’s state, possibly through the art work could be useful.’ Whilst another was adamant: ‘Only in private never in the sessions’ and two other panellists point out that the therapist must also be alert to their own ‘process’ or ‘story’. The therapist does not become the child’s therapist or the carer’s therapist. The art therapist is the RELATIONSHIP’s therapist. ‘I like this one: simple, clear and accurate’ commented one of the seven panellists (87.5%) who rated this practice in the top tertile. Another panellist explored the idea in her own way, ‘This is about therapeutic boundaries. Should the carer need some form of extra help then that is arranged separately outside of the work with the child and RELATIONSHIP therapist’. A third panellist thought it related to ‘Stern’s concept of the “grandmother transference”’. Through observations the therapist determines the functional emotional level of the child. This practice achieved 87.5% consensus. One panellist commented that the functional emotional level ‘will probably fluctuate through the session’, another that it can be ‘part of the assessment process’. The therapist receives supervision. Although this practice did not achieve full consensus (87.5%), the only panellist not to place it in the top tertile clarified that she was not querying the necessity of supervision but clarifying, ‘This is a professional requirement not specific to dyadic art psychotherapy’. Competences Understanding attachment theory. All panellists rated this competence as highly appropriate, some describing it as ‘important’, ‘essential’ or ‘imperative’ and one expanding it to, ‘Understanding of attachment theory and knowledge of attachment research and clinical applications.’ However, one panellist pointed out that ‘other ideas enlarge and enrich the work along side it’ and another expert advised: ‘Hold the knowledge lightly.’ Understanding developmental trauma and the impact this has on every aspect of the child’s development. This competence was deemed very appropriate by all the panel who described it variously as ‘important’, ‘essential’ and ‘vital’. One panellist expanded, ‘By understanding the impact of trauma on the psyche the carer is helped to make sense of the child’s behavior and interactions.’ Understanding trauma in the context of therapy, PTSD symptoms, and sensitivity to the child’s ability to tolerate traumatic memories being exposed etc. ‘Essential’ and ‘part of on going training’ were the comments from the panellists on this competence which achieved 100% consensus. Ability to make a broad assessment of an adult’s and a child’s attachment style. In particular to recognise unresolved trauma in an adult. Panellists thought this competence would be ‘important’ and ‘thoroughly useful’ and all of them rated it as very appropriate. However, one panellist pointed out that ‘these skills can be learnt over time’. Knowledge of parenting strategies particularly those for working with children with disturbed attachment behaviours (it is not enough

to understand disturbed behaviours, a carer also has to respond to them, so this inevitably will be part of the work with the carer). 100% consensus was achieved for this competence. One panellist suggested carers may be asked to attend parenting courses. Another provided a clinical vignette to demonstrate how difficult it can be for carers to compassionately parent disturbed children, ‘The carer needed help to feel compassion for this child as they themselves were so appalled by the child’s behaviour. . .going through the child’s background and listening to the carer’s own sense of outrage did help this particular carer continue to look after this child.’ Ability to use within-session events to address carer’s affective responses and understanding of child’s behaviour. This competence achieved consensus with 87.5% of panellists placing it in the top tertile. Those in favour of this approach liked the directness of the here and now, commenting: ‘It is vital to use what happens in the session in the here and now as part of the work to make sense of what both carer and child are bringing to the session’; ‘Being able to draw from events that have just happened I would see as being helpful as children can at times not recall events/memories/feelings from the past in detail.’ However, other experts qualified the statement: ‘Also the ability to hold back and let the relationship evolve at its own pace. Given the chance and encouragement people are creative in finding their own idiosyncratic ways of relating to one another.’ And the one panellist who did not rate it in the top tertile felt it was not appropriate for the dyadic sessions, only the separate parent meetings. Ability to maintain an intersubjective stance, communicating verbally and non-verbally the personal impact of the process. This competence was rated as very appropriate by seven of the eight panellists (87.5%). Two experts linked this to the art making, one saying: ‘Such a lot can be done through the mediation of the art work – whatever happens, including mess and gaps’ and the other: ‘In some circumstances the art therapist may choose to be involved in the image making process, thus adding to the process of verbal/nonverbal communication.’ Ability to help carers think about the impact of their own history on their current parenting. The majority of the panel (87.5%) thought this very appropriate; ‘important’; even ‘essential’. However, many also recognised that this could be a very painful process and the carers needed to be willing and able to take risks. As such the therapist needed to judge the appropriate depth and intensity depending on the carers own beliefs, ability to understand and relationship to the child ‘e.g. birth or step-parent, adopter, long or short term foster carer etc., original or reconstituted family or institution’. Knowledge of stages of a child’s art development. 87.5% rated this competence as very appropriate highlighting that whilst this is perhaps normal for an art psychotherapist it is also ‘very useful’. An understanding of child development. ‘Without this knowledge it would be difficult to assess the work in progress’, commented one panellist. Another saw it as ‘essential’ as demonstrated by the ratings of the panel, 87.5% of whom placed it in the top tertile. Knowledge about the nervous system and how this is impacted by trauma and stress and how to help it calm as well as how to assess whether a child is being activated into a stress response (fight, flight or freeze) or whether they are able to manage higher level reflective functioning. Whilst seven of the eight panellists rated this in the top tertile (87.5%), one panellist rated it as only moderately relevant and clarified, ‘If the basic principles are understood then this can come later’. Ability to recognise contra-indictors to Dyadic Art Therapy. Although only seven of the eight panellists rated this between seven and nine, the remaining panellist rated it only slightly lower, at six, indicating that in her opinion the competence was only moderately appropriate. However the accompanying comment is: ‘Essential in

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any therapy’, which would appear to clarify that the issue is that the competence is not specific to this intervention. Other panellists emphasised how important this competence is: ‘Yes, very important particularly with parents whose behavior verges on emotional abuse, a lot of work then needs to be done prior to dyadic work being considered’; ‘Yes if the parent is not in the right place for this work or they cannot admit their ambivalent feelings for instance . . .’; ‘At times the carer may have too many unresolved problems to be able to attend to the child in Dyad work’; ‘Children who come into care will already be suffering an attachment loss, having been taken away from their family. Keying into the needs and care issues of these children already gives carers insight. The ability to recognize contra-indicators will be in progress, noting these indicators can become part of the work the carer is engaged in on a more formal basis’. Understanding the difference between therapy with a birth parent and their child and therapy with a fostered or adopted child. With 87.5% agreement, panellists commented that this is ‘relevant and important’; that it is ‘all about understanding who is the child’s attachment figure’; that there will be ‘a different emphasis, yet the basic principles are the same’. One panellist explained that with each parent ‘the child that was hoped for and the child they actually have needs exploring’. Awareness of alternative theoretical frames and an openness to many ways of working. The general consensus (87.5%) was that this is an appropriate competence that is part of ‘ongoing learning aims’. Understanding of psychotherapeutic ideas of how the self is built up and strengthened including infant–parent psychotherapy, Winnicott and Daniel Stern. Seven out of the eight panellists rated this competence highly (i.e. 7–9). One panellist commented, ‘These books and papers all contribute to the bigger picture and should be encouraged to be read’.

Themes emerging from the Delphi findings Thematic analysis of the group of retained PPCs identified a number of shared themes. Seven of the retained PPCs highlighted the importance of a sound understanding of attachment and trauma. There was a similarly strong emphasis on the need to work with parents and carers to address past or present relational issues and to enhance parental sensitivity and reflective functioning, with six of the retained PPCs relating to this. A smaller number of the retained PPCs highlighted the need to focus on the relationship between the carer and child; the need to focus on the child’s affect recognition; provision of parent/carer psycho-education and parenting strategies; knowledge of child development; and flexibility. Themes were also identified from the PPCs that did not achieve consensus. One predominant theme that emerged was a disinclination towards highly specific or prescriptive recommendations. It is surprising perhaps that the emphasis appears to be more on pluralism and flexibility rather then theoretical rigour or orthodoxy. One PPC suggesting that the work should be psychodynamic and another recommending that the therapist have an understanding of psychoanalytic theory (in line with traditional models of art therapy) failed to achieve consensus. Also, the expert-generated suggestions that did not achieve consensus included a small number that focussed on the applications or operationalisation of dyadic art therapy, which panel members may possibly have seen as beyond the remit of the PPCs, e.g.: ‘Dyadic Art therapy can be used to promote attachment with foster parents and adoptive parents’ ‘Dyadic Art Therapy can be used in supervised visits to help create an attachment with the estranged parent’

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‘Sessions include only one parent or carer and the child at a time. If both parents want to participate, they can be given separate appointments. Several appointments can be arranged consecutively with one parent and then the same number with the other parent, followed by a meeting with both parents to discuss the experience with them.’

Discussion This Delphi process produced a set of thirty-one consensusderived PPCs for the delivery of dyadic art psychotherapy, developed by a panel of experts who predominantly trained as art therapists and which also included one attachment specialist trained in a related arts therapy. As such, the findings of this paper constitute an important step in clarifying and defining the process of one specific art psychotherapy intervention. Not only do they give practising art psychotherapists a window into the minds of those with expertise in the field, but they also provide a basis for training, continuing professional development (CPD), and future outcome-based research. Those PPCs which were not rated as appropriate for inclusion may have failed to reach consensus because they did not fit well within the designated groupings of practice, principle or competence. Alternatively, they may have seemed incongruent with the other PPCs, none of which focused on issues of applications or operationalisation. For example, the panel was not asked about specific operational issues such as timing or structure of sessions, nor was there a category relating to the application of dyadic art psychotherapy. Further research may be indicated into these areas. Twenty years ago, there was little emphasis on attachment in the syllabi for training British art psychotherapists. Although in recent years there has been an increase in interest amongst art psychotherapists in attachment and attachment-based ways of working, this has yet to translate into a large body of academic writing. As such the nascent field of dyadic art psychotherapy for the treatment of attachment difficulties presents meagre opportunities for both a productive trawl of the literature and the convening of a substantial Delphi panel, and there would be a danger of consulting the same experts for both sources of data. For this reason the researcher-generated PPCs given in Round 1 of this Delphi process were not derived from dyadic art psychotherapy texts, but from other attachment-based interventions. This limitation, however, may also be a strength as it opens the up the possibility of cross-pollination between interventions and a hybrid view that has potential to bring fresh perspective and understanding to the field. The panel of experts was small, as it was derived from a relatively specialist field. To ensure that sufficient attachment specialists were included, the membership included other arts therapists, specifically a drama therapist. The panel members were largely, although not exclusively, UK based, although more than one panel member had extensive experience of working outside the UK. The study was designed as a two-round Delphi which meant that the expert-generated PPCs were only presented for rating on one occasion (in Round 2). A third round would have allowed experts to re-rate these expert-derived PPCs in light of the comments of other panel members. The two-round design was chosen to minimise the time commitment required of panel members, but must be balanced against the possibility of greater clarity that a third round might have brought. One panel member expressed regret at the lack of a third round. The development of guidelines or indeed a manualised version of dyadic art psychotherapy requires the synthesis of many different voices. This Delphi process has given voice to a group of clinicians with demonstrable expertise in the field of dyadic art psychotherapy, yet there are other stakeholders from whom we

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also need to hear. Service users and regular practicing clinicians can provide important information on issues relating to the usability of the intervention, particularly the ‘helpful and hindering aspects’ (Elliott, 2002), and on practical issues relating to the operationalisation of dyadic art psychotherapy. Given that the image and the creative process are central to the practice of art psychotherapy, it will be important also to include their perspectives. ‘The output from consensus approaches. . . is rarely an end in itself. Dissemination and implementation of such findings is the ultimate aim of consensus activities’ (Jones & Hunter, 1995, p. 380). It is hoped that, in terms of practice, this study will enrich and inform the practice of art psychotherapists working with children and young people who will now have recourse to a core set of consensus-derived PPCs for the delivery of dyadic art psychotherapy. The PPCs generated by this Delphi process can also be incorporated into professional training courses and as part of continuing professional development. Conclusion The Delphi process reported in this paper has established a core set of consensus-derived principles, practices and competences for the delivery of dyadic art psychotherapy which can be used in practice, training, evaluation and as the basis for future outcomebased research. Acknowledgements The authors would like to acknowledge and express their gratitude to all the members of the Delphi panel: Teresa Boronska; Caroline Case; Penelope Hall; Lesley Hanney; Anthea Hendry; Hilary Hosea; Lucille Proulx; Jay Vaughan. Thank you all for generously sharing your thoughts, experience and time. We would also like to thank Susan Allaker and Michael Daniels for trialling the questionnaire. This study has been funded by the NIHR as part of a Clinical Doctoral Research Fellowship. The first author would like to express thanks to all those at the NIHR Trainees Coordinating Centre for their support. This article presents independent research and as such the views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. References Ambridge, M. (2001). Using the reflective image within the mother–child relationship. In J. Murphy (Ed.), Art therapy with young survivors of sexual abuse: Lost for words (pp. 64–81). Hove, East Sussex: Brunner-Routledge. Amos, J., Beal, S., & Furber, G. (2007). Parent and child therapy (PACT) in action: An attachment-based intervention for a six-year-old with a dual diagnosis. ANZJFT Australian and New Zealand Journal of Family Therapy, 28(2), 61–70. BAAT, & AMICUS. (2005). BAAT and Amicus joint announcement information for non-early implementing sites. Retrieved from http://www.baat.org/ baatagendaforchangeannouncement05.pdf#search=“protected%20title” Bakermans-Kranenburg, M. J., Van Ijzendoorn, M. H., Mesman, J., Alink, L. R. A., & Juffer, F. (2008). Effects of an attachment-based intervention on daily cortisol moderated by dopamine receptor D4: A randomized control trial on 1- to 3-year-olds screened for externalizing behavior. Development and Psychopathology, 20(3), 805–820. Becker-Weidman, A. (2008). Treatment for children with reactive attachment disorder: Dyadic developmental psychotherapy (Retraction of November, pg 43, 2006). Child and Adolescent Mental Health, 13(1), U52–U66. Bennett, D., & Parry, G. (2004). A measure of psychotherapeutic competence derived from cognitive analytic therapy. Psychotherapy Research, 14(2), 176–192. Bennett, L. R., Shiner, S. K., & Ryan, S. (2006). Using theraplay in shelter settings with mothers and children who have experienced violence in the home. Journal of Psychosocial Nursing and Mental Health Services, 44(10), 38–48. Boote, J., Barber, R., & Cooper, C. (2006). Principles and indicators of successful consumer involvement in NHS research: Results of a Delphi study and subgroup analysis. Health Policy, 75(3), 280–297. Boronska, T. (2000). Art therapy with two sibling groups using an attachment framework. Inscape, 5(1), 2–10.

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attachment-based interventions on materanl sensitivity and infant security. Journal of Child Psychology and Psychiatry, 36(2), 225–248. Waller, D. (2006). Art therapy for children: How it leads to change. Clinical Child Psychology and Psychiatry, 11(2), 271–282 (case reports). Wallis, J., Burns, J., & Capdevila, R. (2011). What is narrative therapy and what is it not? The usefulness of Q methodology to explore accounts of White and Epston’s (1990) approach to narrative therapy. Clinical Psychology & Psychotherapy, 18(6), 486–497. Elizabeth Taylor Buck is a qualified, registered, art therapist. She has been working with children, young people and families for the last 17 years, initially for the NSPCC, and subsequently within a Child and Adolescent Mental Health Service. In 2009 she was awarded an NIHR Clinical Doctoral Research Fellowship from National Institute of Health Research. Her doctoral research, which is hosted by the University of Sheffield, is exploring the practice of dyadic art psychotherapy. Dr Kim Dent-Brown trained as a Dramatherapist and a practitioner of Cognitive Analytic Therapy. He worked in the UK National Health Service for 24 years, winning a doctoral Fellowship to research a dramatherapy storymaking technique. He has worked at the University of Sheffield as a psychological services researcher and now teaches MSc students as a lecturer in Psychology at the University of Hull. Professor Glenys Parry is a clinical psychologist and psychotherapist, who worked in the UK NHS for 38 years. Her career has spanned clinical practice, research, policymaking and health services management. She is Professor of Applied Psychological Research at the Centre for Psychological Services Research at the University of Sheffield School of Health and Related Research. Dr Jonathan Boote is a Research Fellow based in the School of Health and Related Research, University of Sheffield. His research interests include patient and public involvement (PPI) in the health research process, and the use of qualitative methods nested within randomised controlled trials. Dr Boote is a member of INVOLVE and the International Collaboration for Participatory Health Research.