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Open Access Original Research

The Course of COVID: How the Pandemic Changed Art Therapy Practice

Deborah A. Sharpe 1,*, Lisa D. Hinz 2

  1. Graduate Counseling Department, Saint Mary’s College of California, Moraga, California, USA

  2. Department of Art Therapy Psychology, Dominican University of California, San Rafael, California, USA

Correspondence: Deborah A. Sharpe

Academic Editor: Gerhard Litscher

Collection: Evidence-Based Integrative Medicine for Epidemics

Received: May 30, 2023 | Accepted: July 17, 2023 | Published: July 19, 2023

OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 3, doi:10.21926/obm.icm.2303029

Recommended citation: Sharpe DA, Hinz LD. The Course of COVID: How the Pandemic Changed Art Therapy Practice. OBM Integrative and Complementary Medicine 2023; 8(3): 029; doi:10.21926/obm.icm.2303029.

© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

This study explored how the global COVID-19 pandemic changed the ways in which art therapists use art in their therapeutic practice. Art has repeatedly been linked to healing in a variety of settings, but generally art therapists have been accustomed to conducting therapy sessions in person. Prior to the pandemic most art therapists preferred in-person sessions for a variety of therapeutic reasons. Although there are clearly downsides to meeting remotely, there have been unforeseen advantages, as well. The present study surveyed 74 art therapists from around the world to understand the changes to art therapy practice that occurred during and after COVID-19. A selection of nine individuals participated in follow-up interviews to clarify and amplify survey findings. Changes to art therapeutic practices, as well as the challenges and benefits of conducting art remotely were highlighted in quantitative and qualitative data analyses. Qualitative data analysis highlighted art therapists’ creativity and resilience in adapting their practices to the new telehealth format. Telehealth practices initiated by the COVID-19 pandemic are here to stay. This study generated a list of practical suggestions for working effectively with art therapy clients at a distance. Future research should focus on creating best practice guidelines for art therapists who will continue to provide online therapy services.

Keywords

COVID-19; pandemic; art therapy; telehealth; online art therapy; telehealth best practice guidelines

1. Introduction

In 2020, the COVID-19 pandemic forced professionals globally and across fields to reassess how to work. Expectations of what was possible were also transformed. The resulting lockdown fundamentally changed the nature of the skills and abilities necessary for art therapists to function professionally. Except for those working in shelters and medical and psychiatric settings, art therapists found themselves quickly forced to transition to online platforms where they could continue as service providers for their clients.

Historically, art therapists have gravitated toward using traditional art materials in traditional settings, and have not been receptive to using technology and digital arts [1,2]. Before the COVID-19 pandemic, art therapists were also hesitant to work with clients remotely. In-person art therapy was seen as the best and only option for ethical and effective treatment [3]. Survey data as early as 2005 demonstrates that art therapists were well informed about technological devices that could be used in art therapy [4]. However, many art therapists did not believe that training in digital art therapy had kept pace with the technology and therefore, they believed they could not use digital art therapy in an ethical manner [5].

Nevertheless, a handful of art therapists were early proponents of digital art therapy. Cantor, Johnson, and Weinberg discussed the use of digital technology in the mid-1980s [6]. Parker-Bell [7] advocated for researching graphics software programs for use as creative interactive tools. According to Kuleba [8], McNiff, Schaverian, and Wadeson also were early supporters of therapeutic technology and digital art. Collie and Cubraniç [9] developed an innovative and effective telehealth program to provide synchronous or ‘real time’ art therapy services to isolated individuals coping with traumatic illnesses, mobility issues, and living in remote areas [9].

The pandemic significantly increased professional interest in telehealth with many studies conducted during the COVID-19 pandemic demonstrating its efficacy with specific groups of clients and outpatient individual practice [10,11,12,13,14]. One survey of art therapists practicing in the UK focused on therapists' feelings of safety while offering art therapy online and their strategies for managing risks while providing telehealth art therapy [2]. The purpose of the present study was to explore more generally the impact of the COVID-19 pandemic on how art therapists value their profession and provide services. The authors were interested in both the impacts of moving online as well as staying in person, clients’ reactions to art making under unfamiliar conditions, changes to the types of materials used in online sessions, and any challenges and benefits identified to working with clients online. These changes were explored through both quantitative and qualitative measures in relation to the following research questions:

  • How has the pandemic impacted the use of art in therapeutic practice, both in materials used and frequency of sessions?
  • What were the impacts of moving online for those who did?
  • What was the impact of telehealth on clients’ willingness and ability to make art during therapy sessions?
  • How likely are art therapists to continue offering online art therapy sessions as restrictions ease?

2. Materials and Methods

The study was approved by the Institutional Review Board of Dominican University of California [DUOC IRB# 10988].

2.1 Participants

Participants in the study were credentialed art therapists as determined by the standards of their country with a minimum of two years in practice. Snowball sampling was utilized for recruitment. Invitations to participate were posted to online forums through the American Art Therapy Association (AATA) and affiliate member chapters primarily in Northern and Southern California, the Canadian Art Therapy Association (CATA) and the Australian and New Zealand Art Therapy Alliance (ANZ). Art therapy alumni groups were recruited within the United States through program chairpersons at 15 art therapy master’s degree programs. Participants outside of the US were recruited through professional contacts in Germany and Austria, the UK and Middle East, New Zealand and Singapore. Recruitment was pursued unsuccessfully in Latin America, the African continent, and the Pacific Islands, as well as other parts of Asia and the EU. Participation was recruited by invitation and was completely voluntary.

2.2 Measures

All materials, including invitation letter, informed consent, demographic survey, and questionnaire were in English, and interviews were conducted in English.

2.2.1 Demographic Form

The goal of the research study was to survey art therapists practicing in different parts of the world; therefore, the demographic form included geographic location, in addition to age, gender, race/ethnicity, and years in practice. The survey also identified clinical settings and clients/populations, as these factors were assumed to have been impacted by the pandemic.

2.2.2 Online Survey

The online survey was composed of 11 multiple-choice questions and one open-ended question. The questions were grouped into three thematic categories: 1) the pre- and post-pandemic use of art in therapy sessions, 2) the various impacts of the pandemic, and 3) the use of telehealth. The ‘Use of Art’ category contained a single question regarding the value art therapists place on the use of art in their therapeutic work. The ‘Pandemic Impact’ category included seven questions which inquired about overall changes to therapeutic practice, changes in how art was used in therapy sessions, and participants’ reflections on the quality of therapy offered during the pandemic. The ‘Telehealth’ category included two questions about participants’ attitudes towards online therapy since the pandemic.

2.2.3 Individual Interviews

The informed consent form asked survey respondents if they would be willing to participate in a 60-minute interview, via an audio-recorded Zoom session, where more individualized reflections were gathered through similar questions in an open-ended format. The topics again included the benefits and challenges participants discovered while using art in sessions during the pandemic, changes participants noticed in their therapeutic practices, and any potential changes the participants noted in their attitudes towards using telehealth in the future.

2.3 Procedures

Prospective participants received an emailed invitation to participate in the research study, an informed consent form, and an online survey. The survey included a demographic questionnaire, 11 multiple choice questions, and one open-ended question. Participants, who identified themselves as art therapists with at least 2 years professional experience, who continued to practice during the COVID-19 pandemic, were asked to respond to the online survey. Respondents who indicated interest in participating in a one-to-one online interview, were contacted via email to schedule the interview. Interviewees’ responses were audio recorded and transcribed.

2.4 Data Analysis

Quantitative data were collected from the demographic survey and the online questionnaire. Chi-square analyses were used to evaluate the likelihood that any observed differences within the data sets could have occurred by chance. The data were then compared for possible correlations between the demographics and survey responses. Qualitative data were collected from one open-ended survey question and nine interviews.

2.4.1 Trustworthiness

Researcher Stance. The research was conducted by the first author in partial fulfillment of the requirements for a doctorate in art therapy. The primary researcher identifies as an art therapist who has been practicing in clinical settings for 30 years and as an educator for 20 years. Being an art therapist who was impacted professionally and personally by the COVID-19 pandemic, the primary researcher was aware of the potential bias in analyzing the data; therefore, ensuring trustworthiness of the data is addressed below.

Reflexivity. The researcher employed reflexivity as one method to increase the validity of the qualitative results. According to Johnson [15], reflexivity is “critical self-reflection about potential bias” ([15], p.284). The researcher addressed potential biases by practicing self-awareness about personal opinions [16,17], discussing personal opinions and potential biases with the research committee and professional peers, and bracketing identified biases [18].

Triangulation. Triangulation, as a strategy to test the validity of qualitative data, was employed to increase the trustworthiness of the overall results. The qualitative data were compared to the quantitative data to confirm that the categories and themes emerging from the qualitative data were supported by the frequency of responses found in the quantitative data. To provide further credibility to the qualitative analysis, the researcher used an inductive coding process to extract the raw data and systematically built the categories, themes, and sub-themes from the transcribed interview data [19].

Analytic Memo. An analytic memo was created to track rationales during the ongoing coding and recoding, and which also provided a record of the data analysis throughout the process [20,21]. The analytic memo included the researcher’s notes on questions, reflections, and rationales used during the coding of the data. As the memo tracked the coding process, it was also helpful for quickly highlighting any obvious weaknesses in the researcher’s logic during the coding and analysis processes [20]. In addition, the researcher consulted with colleagues and dissertation committee members about the coding, categories, themes and sub-themes.

3. Results

3.1 Demographic Characteristics

Eighty-three (83) people initially attempted the survey. Nine (9) people declined to complete the survey when they realized that it was investigating the experiences of participants active in art therapy practices during the pandemic, some stating that they were not currently practicing art therapy. Thus, a total of 74 participants completed all 11 of the quantitative survey questions. A subsample of 36 people provided comments on the open-ended question. Finally, 11 participants who answered the open-ended question were later contacted and asked to participate in an individual interview and, of the 11 contacted, 9 participated.

Demographic characteristics of the 74 participants demonstrated that the sample drew from people across the world with most coming from North America (78%) but with participants representing the Middle East, Europe, and Asia as well. Most participants were female (86.7%), middle-aged (42.2%) and Caucasian (71.1%) which is representative of the art therapy profession in the United States [22]. Place of work was primarily reported as private practice (47.0%) and, because of the pandemic, online therapy/telehealth was the second largest category (34.9%). The majority of art therapists (81.9%) reported working with adults, secondly with children (60.2%) and lastly with adolescents (51.8%).

The 74 participants who completed the online survey were asked to reflect on the impact of the COVID-19 pandemic on their art therapy practice, including their belief about the importance of art making with clients, frequency of art making in sessions prior to and during the pandemic, whether the number of clients they saw during the pandemic changed, and finally, their perception of client willingness to make art in sessions during the pandemic. Results showed that 57.7% of respondents moved to providing at least 50% telehealth services. While 18.9% of participants were 100% online, 23.9% were approximately 75% online, and 14.9% were at least 50% online. Because they worked in hospital or residential settings, 27.0% of participants reported that they continued to see 90 to 100% of their clients in person.

Regarding participants’ attitudes about conducting art therapy via telehealth, the results displayed in Table 1 demonstrated that 40.5% of respondents saw advantages to telehealth in some situations and planned to continue to offer an online option. One fifth of participants (20.3%) lauded the convenience and flexibility of telehealth and planned to continue to see most of their clients online. An equal percentage reported that they would return to seeing clients in person and only use telehealth when absolutely necessary, and 10.8% stated that they had no desire to work with clients online. A majority of participants (45.9%) expressed their continued commitment to using art with clients since moving to online sessions. An additional 18.9% reported an equal or greater value in the use of art in their therapy online. In contrast, 32.4% of participants found it more difficult to adapt the use of art to their online sessions.

Table 1 Participants’ Attitudes Towards the Use of Telehealth.

Table 2 outlines a summary of the results of the quantitative data gathered through the online multiple-choice surveys.

Table 2 Summary of Online Survey Results.

As can be seen from the frequency data in Table 2, most art therapists saw more clients during the pandemic than before it. They reported that they used art making more frequently during COVID than before it, and that they valued art making more during the pandemic than before. Finally, client willingness to make art was rated the same pre and during the pandemic by many of the art therapist participants.

Chi Square analyses were used to investigate the associations between survey responses and demographic information; the significant associations are shown in Table 3. Analyses demonstrated that increased positive value of art in therapeutic practice was significantly associated with more years in practice χ2(2) = 7.385 (p = 0.025). Also, from Table 3, participants running groups showed a much higher percentage of positive change in the value of art χ2(2) = 5.840 (p = 0.016).

Table 3 Associations between Therapist Characteristics and Value of Art.

3.2 Qualitative Data Results: Online Survey Open-ended Question

3.2.1 Content Analysis

Thirty-six participants (48.6%) responded to the open-ended question asking for additional input. Responses were coded for categories and related themes that reflected the experiences of the participants during COVID (shown in Table 4). As can be seen in Table 4, the Challenges of Telehealth was the dominant category, mentioned by 44.7% of the respondents. Participants mentioned such challenges being their own and their clients’ discomfort with technology, clients having limited access to or changes in the types of art materials available, clients’ reluctance to participate in online art therapy, communication issues, and ongoing concerns about client safety and privacy. Benefits of Telehealth was mentioned by 35.8% of participants and these included: improved access, convenience, and comfort for clients, especially for those isolated in the early days of the pandemic. Other themes in the benefit category were increased client creativity and/or resilience, improved feelings of connection, and demonstrations of client adaptability. The final category found in response to the open-ended question was called Environmental Concerns, mentioned by 20.8% and which described people who preferred meeting in-person, did not offer services online because their job demanded that they stay in person, or those whose employment situations changed during the pandemic and perhaps they were no longer able to see clients.

Table 4 Summary of Content Analysis Results of the Open-Ended Question.

3.3 Qualitative Data Analysis: Participant Interviews

As was mentioned previously, nine art therapists residing and working in different regions of the world were interviewed to add additional qualitative data. One interview participant lived in Asia, one in Canada, one in the United Kingdom, and the remaining six in the United States. One interview participant identified as male and the remaining eight as female. Two participants identified as African American, two as Asian, and five as white/Caucasian.

3.3.1 First Level: Open Coding

The interview transcripts were printed and read several times by the researcher to become familiar with the content. Open coding was implemented to determine initial categories [21]. Words and phrases that surfaced were identified using an inductive, or data-driven, coding process [23]. Responses were highlighted in different colors to create a visual structure that showed the weight of each category and its relevant themes [24]. During open coding, the analytic memo that was generated explored the relevance of the categories as they were identified and was useful in capturing first impressions of the emerging themes within the categories. Eleven categories were initially identified from the interview data. These included: Value of Art/Art Therapy, Pandemic, Telehealth, In Person, Benefits, Challenges, Changes, Media, Frequency, Clients/Populations, and Art Making in Session.

3.3.2 Second Level: Axial Coding

Second level or axial coding was applied to the emerging categories to look for connections and/or relationships among the categories, and to identify any themes grounded within the participants' responses [21]. Data from the analytic memo helped highlight themes and suggest links [21]. During this second phase of coding, some themes were combined or collapsed, and others were relocated to more relevant categories. The original 11 categories were condensed into seven. The final seven categories determined to have unique characteristics were: Value of Art/Art Therapy, In Person, Benefits of Telehealth, Challenges of Telehealth, Media, Frequency of Sessions, and Art Making in Session.

3.3.3 Third Level: Confirmatory Coding

A third review of the categories and themes revealed additional connections and linkages, which led to further refinement of the data [20,21,23]. The final collection of seven categories contains the most notable and relevant themes and sub-themes and reflects their interrelationships. To further solidify the qualitative results, the seven categories and their weighted themes also parallel the frequencies discovered in the quantitative data analysis.

3.3.4 Resulting Categories and Themes

The categories and themes that resulted from the interview data analysis are displayed in Figure 1 and discussed below.

Click to view original image

Figure 1 Categories and Themes Resulting from Analysis of Interview Data.

In Person. This category was divided into five themes: Adaptability, Ethics Risk, Connections, and Necessity. These five themes reflected the challenges faced by art therapists who remained in person and highlighted the resiliency of these participants during the pandemic crisis. As can be imagined, the necessity of remaining in person was directly related to the settings in which art therapists worked. Participants who remained in person recounted grueling work hours and working under extreme pressure. Shortages of protective equipment (PPE), such as masks and gloves, were part of the daily struggle of working in person. Respondents also explained how they attempted to maintain professional and ethical standards within a frequently evolving work situation. Risks to art therapists who stayed in person, especially during the early months of the lockdown, included uncertainty and fear due to the scarcity of protective equipment for employees and basic cleaning and sanitizing supplies. Some art therapists who remained working in person described their decision to use fewer and simpler materials that were easy to clean and sanitize between sessions with clients.

The themes of Connection and Adaptability provided an antidote to the challenges art therapists faced while working in person. Adaptability was reflected in modifications to the art space and use of materials, not only to reduce risk and ensure safety of their clients but also to increase opportunities for creativity. Adaptability also referred to the creativity with which therapists conceived and carried out art interventions in the adapted spaces and with limited or different materials. The theme of Connection related to art therapists’ acknowledgement that they were often a crucial lifeline for their clients who belonged to vulnerable groups.

Value of Art/Art Therapy. Under the Value of Art/Art Therapy category, two subcategories emerged: Art Therapist and Client. Four themes were discovered: Importance to Identity, Importance as a Tool, Love of Art and Equality. Importance to Identity and Importance as a Tool themes fit within the Art Therapist subcategory. Art Therapists indicated that creating art with clients was an integral part of their art therapist identity. While this may seem like an obvious statement, it was noteworthy that several interview participants highlighted this theme specifically, stating, “It is part of who I am” and “It is essential to what I do.” In addition, art therapists did what they could to maintain an art therapy practice even within the new telehealth parameters. Conversely, the Love of Art and Equality themes fit under the Client subcategory. Art therapists mentioned that the intense enjoyment of creating art drew clients back to art therapy and that their clients valued art as a tool for expression and empowerment.

Benefits of Telehealth. This category had four themes: Creativity, Resilience, Resource(s), and Flexibility. Interestingly, these four themes were similar to themes noted by art therapists who remained working in person. Participants remarked on the creativity and resilience demonstrated by their clients in response to the changes in the format of their therapy. Resource(s) also consistently emerged as a theme; art therapists mentioned how they had to look for opportunities, materials, and processes that were different than before. Flexibility contained two subthemes (Convenience and Access) which demonstrated clients’ views of telehealth. Art therapist respondents indicated that they would continue to utilize telehealth because of its increased access and convenience for their clients.

Challenges of Telehealth. This category included five themes: Space, Ethics, Materials, Communication, and Motivation. The challenges of telehealth began with technical issues such as access to a computer and/or the internet, poor internet connections, computer malfunctions, as well as unfamiliarity with online platforms and digital art making programs. Any of these factors can disrupt therapy sessions and make it difficult for clients to engage in art making. Telehealth can highlight or exacerbate the sense of distance between therapist and client and impair the ability to communicate. Telehealth can interfere with nonverbal communication, and it can limit the art therapist's ability to view the art and to observe non-verbal cues and body language. Participants expressed their concern that these challenges hindered their ability to assess clients’ emotional state and the presence of risk factors.

Managing online risk was a significant component of the Ethics theme as were concerns about ensuring the privacy and security of clients’ personal information and the therapy sessions themselves. Therapists noted that they were often forced to enlist caregivers to help create a safe, private, and contained space for therapy. This meant that art therapists had to give up some control in providing the therapeutic container for clients; therapists did concede, however, that this shift also provided an opportunity for clients to collaborate meaningfully in their therapy.

Most interview participants who transitioned to online therapy identified the therapy space as presenting a challenge to both therapists and clients. Likewise, materials presented a challenge, hindering clients’ access to them overall or to the types of materials that were available. Finally, motivation to create art was described as more frequently lacking in telehealth sessions reflecting difficulties with technology and communication issues. Due to decreased client motivation to create, art therapists reported that they employed more verbal prompts and encouragement with their clients, and also needed to manage their own frustrations with unmotivated clients.

Media. The Media category generated five themes: Type, Amount, Found Objects, Kits, and Technology. Regardless of whether art therapists moved their therapy practice online or stayed in person, most participants agreed that the pandemic had a significant impact on material use. Those participants who stayed in person reduced both the number and type of materials used in sessions; the decision being based on how easily materials could be cleaned, sanitized, and reused between sessions. Most participants transitioned to telehealth and were confronted with the issue of clients’ access to materials. A few participants were able to mail art kits to their clients which improved accessibility and convenience for clients but increased challenges for art therapists.

Most art therapists described working with the materials that clients had on hand and many redefined what they considered art media including found objects, materials from nature, and household objects. Thus, the Media category also was related to Benefits of Telehealth as the scarcity of art materials required art therapists to creatively employ resources that they would not otherwise have used. Some participants also described incorporating technology such as whiteboards, digital art apps, and webcams into their online therapy practice.

Art Making in Session. This category demonstrated two themes: Connection and Do Not Make Art. Respondents who had not used online therapy prior to the pandemic reported a much larger increase in the use of art with clients than did art therapists who had been using art in telehealth prior to the pandemic. Interview participants explained that they had begun to adapt the ways they explained art directives to their clients and often increased verbal processing of art activities.

Frequency of Sessions. Frequency of Sessions was a stand-alone category with no associated themes. Most art therapists who reported that they worked with adults identified an increase in their therapeutic work during the pandemic. This category showed a connection to Benefits of Telehealth because art therapists reported that the convenience of connecting via online platforms allowed them to see increased numbers of clients both individually and in groups.

4. Discussion

The COVID-19 pandemic has had a significant impact on the field of art therapy, requiring art therapists to adapt their practices to online platforms despite previous resistance to technology [1,2]. The present study revealed that the fast adaptation necessitated by the pandemic and lockdown generated feelings of uncertainty often followed by resiliency. Although studies conducted during the COVID-19 pandemic demonstrated the efficacy of telehealth with specific issues or circumstances [10,11,12,13,14], only one survey focused on art therapists' experiences while offering art therapy online [3]. The purpose of the present study was to add to the literature describing the impact of the COVID-19 pandemic on art therapy practice. The researchers attempted to elucidate some of the adaptations made by art therapists through an online survey about their COVID-19 experiences. Results from the study indicated that despite experiencing ongoing challenges with technology, all of the interview participants and a number of survey respondents reflected on the unexpected benefits of working through telehealth, expressed in terms of the creativity and resiliency of both art therapists and clients.

The current study found that frequency of sessions increased as a response to the COVID-19 pandemic and this mirrors other research findings demonstrating significant increases in anxiety and depression related to the pandemic, as well as increased demand for mental health services due to COVID-19 [25]. Survey respondents in the current study who worked with teens and children also reported increased numbers of clients during the pandemic, which corresponds to research measuring spikes in anxiety and depression among adolescents and children caused by the pandemic [26,27]. Disruptions to everyday life, grief and loss, fear of the coronavirus, isolation and disconnection, and uncertainty about the future were reasons reported by clients of all ages for seeking mental health services in larger numbers than before the pandemic [26,27]. For adults, additional stressors related to job loss and/or instability, and the challenge of maintaining a work/life balance were also cited as the impetus for pursuing therapy during the pandemic [27].

The literature related to the changes brought on by the pandemic reflects the obstacles faced by practitioners transitioning to telehealth art therapy. Technology was found to be a challenge in a number of studies [3,10,28,29,30,31]. Some authors cited lack of familiarity with telehealth and telehealth technology as being particularly difficult [28,31]. A common theme cited was the loss of the shared physical environment [28,30,31,32]. Scheduling and communication issues also were pandemic-related challenges [28].

It is clear from several research findings that verbal and non-verbal communication for both clients and therapists were affected by meeting within the limitations of an online platform. Remote therapy can be especially challenging for clients who struggle with forming relationships or experience social isolation [32]. Telehealth can limit therapists’ ability to observe body language and non-verbal cues and can interfere with therapists’ ability to view clients’ artwork. Both factors can hinder communication as well as art therapists’ ability to make accurate assessments about clients’ emotional states or notice potential risk factors. Clients may be concerned about the privacy and security of stored personal information and the therapy sessions themselves. Therapists have been faced with modifying informed consent forms. They must often trust caregivers to create a safe, private, and contained space, and to supply appropriate materials. While this has forced art therapists to relinquish some control of providing the therapeutic container for clients, it has increased opportunities for clients to be partners in their own therapy.

Although some art supplies can be provided to clients and by clients, the variety of therapeutic tools available during a telehealth session is often limited. The number and types of materials used in art therapy changed with the COVID-19 pandemic, as did the frequency with which art was used in sessions, both online and in person, by necessity or choice. Client willingness to engage in art online was reflected in the interview responses and showed both the challenges and resilience evoked in client and therapist during the pandemic. Results of the present investigation emphasized that due to its flexibility and convenience, art therapists will continue to offer online services. Telehealth increases access for clients with mobility and geographic challenges. Increased access to services was an unforeseen advantage of the COVID-19 pandemic [29,33]. Telehealth reduces costs for both clients and therapists. Some clients may feel more comfortable participating in online therapy, which in turn may increase their willingness to engage more fully in the therapeutic process.

The current literature acknowledged similar benefits to those found in the current study [29,33]. An additional benefit noted was the discovery that online therapy reduced the stigmatization of clients by their families [29]. For some art therapy clients, improved communication skills resulted from participation in an online art therapy group [32]. Skill sharing and the development of daily routines were the beneficial results of an online program for refugee families, which also increased support and resource sharing, and reduced families’ exposure to discrimination [34]. For art therapy trainees, learning to use telehealth effectively created significant improvements in therapeutic skills [30]. For the field of art therapy, conducting research to address the challenges and benefits of telehealth can encourage programs to develop future best practices [3,10].

4.1 Practical Considerations

Several tools emerged as practical considerations for enhanced telehealth art therapy. Participants in the research study recommended using a webcam in addition to the primary screen, allowing both client and therapist to simultaneously observe each other’s faces, hands, and art pieces in progress. Another suggestion was the use of short videos to provide inspiration and/or explanation of art activities or relevant topics, and to initiate and support exploration and discussion. Some art therapists suggested recording directions for art activities ahead of time, especially for those activities with complicated explanations. Finally, guided imagery was mentioned as a helpful resource to inspire clients and/or when materials were limited or not available.

Because art therapists cannot control clients’ environments outside of the therapy office, the use of telehealth has necessitated re-envisioning informed consent. Regulatory bodies and professional organizations are also regrouping to understand the complexities that online therapy presents to the profession. Therefore, updated guidelines and best practice details are currently being developed, and art therapists must adapt previous consent forms to encompass the unique factors that exist in an online therapy practice.

Some art therapists sent “art kits” to their clients to ensure that they had appropriate art materials. They did not have to be expensive, but supplying these materials was a practical consideration. Without pre-assembled art kits, art therapists had to collaborate with clients and client caregivers to provide adequate materials and space to participate in online art therapy. These are permanent alterations that will continue to be a part of the landscape as art therapists continue using telehealth. Formulating the creation and efficient delivery of art kits and creating guidelines for collaborative interactions with clients and caregivers will be important considerations going forward.

4.2 Limitations

There were several limitations to this research study. The study focused only on art therapists who continued to work during the COVID-19 pandemic. It would have been improved by input from art therapists who stopped working, either temporarily or permanently, during the pandemic. Including those voices would have provided information that might have revealed some of the barriers art therapists faced to practicing during the pandemic.

The small sample size was a limitation, and most respondents were middle aged white women from the United States. While these demographics reflect the field of art therapy in the U.S. [22], the sample did not represent the overall level of diversity of the profession, nor the variety of participant experiences the researcher had hoped to discover. Nevertheless, the study did include representatives from several racial and ethnic groups, genders, and countries. Finally, the quantitative analyses were limited by the nature of the multiple-choice questions. While some comparative analyses provided relevance to the data, and several comparisons showed statistical significance, the bulk of the analysis relied on the qualitative interview data. In addition, the data analysis would have demonstrated more rigor had the interview data undergone participant checking of transcript accuracy, or had participants been included in checking for agreement with categories and themes [19].

4.3 Recommendations for Future Research

The COVID-19 pandemic has made significant impacts on the field of art therapy, and art therapists have discovered valuable lessons over the past three years, leading to several recommendations from this research study. First, the findings described in the Practical Considerations section should continue to be modified and implemented to eventually provide a roadmap for new best practices for art therapy in a ‘post-pandemic’ world. As suggested by Snyder [14], it will be important to continue the research that will develop these standards to determine what types of clients or concerns can best benefit from the use of art therapy delivered via telehealth.

Perhaps the most significant discovery highlighted by the pandemic has been the advantageous role technology can play in art therapy. As art therapists have had to adapt to telehealth technologies, they have realized the benefits of using technology to expand both accessibility and diversity. As the art therapy profession continues to use telehealth, future research can investigate its benefits and challenges to improve services provided. Connection and communication were two themes discovered in the present study that require further investigation as well as research into creating a sense of community and developing social connection and support among clients participating online. It will be important to develop and strengthen education and training in online and digital resources for therapists to continue providing safe, high-quality care. Our professional community must prioritize research efforts to address the new realities of art therapy, whether in person or online. These include modifying therapy techniques, using a wider variety of non-traditional art materials, accommodating clients' needs in different ways, and embracing adjustable schedules.

5. Conclusions

The effects caused by the COVID-19 pandemic have been fundamental and widespread. Most art therapists ‘pivoted’ to working in the unfamiliar terrain of telehealth. The art therapy profession has been irreversibly changed as art therapists have learned new technologies, introduced the use of alternative materials with clients, and navigated the intricacies of working with clients remotely. Results from the study presented in this article have highlighted the recognition that the COVID-19 pandemic provided an opportunity for art therapists to fully embrace creativity and flexibility in the ways they approached using art in therapy. The pandemic created many challenges, and we have also begun to recognize the opportunities for growth and innovation it has also provided. Telehealth has introduced a valuable platform for providing art therapy, and though not appropriate for all clients or situations, it will be an important option for many practitioners. Art therapists must continue to weigh the benefits and challenges of telehealth and determine the best approach for the needs of individual clients. Ultimately, the field of art therapy must be responsible for developing best practices for telehealth services.

Acknowledgments

The authors would like to thank Arnell Etherington Reader, Ph.D., ATR-BC for her assistance as dissertation chairperson, and Nancy Choe, Ph.D., ATR-BC for her help as dissertation reader. Anton Svendrovski provided invaluable help in analyzing the quantitative data. In addition, Jen Mank, Ph.D., ATR-BC provided editorial support.

Author Contributions

Deborah Sharpe conceived and designed the study, acquired and analyzed data, drafted and revised the manuscript. Lisa Hinz served as dissertation advisor, helping to draft and revise the manuscript.

Competing Interests

The authors have declared that no competing interests exist.

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