POLYPHONYJournal of the Irish Association of Creative Arts Therapists
Conversations Features Observations

Growing Pains: The Creative Arts Therapies in Ireland

Published on Jul 15, 2020 by Bill Ahessy

This article explores contemporary issues affecting Creative Arts Therapists (CATs) in Ireland. It presents qualitative research data from a larger mixed-method study on practice, professional engagement and employment characteristics and trends (Ahessy 2020). Qualitative data from a survey of 96 respondents was analysed using thematic analysis (Braun & Clarke 2006). Five main themes emerged from the data: (1) challenges, (2) lack of recognition, (3) the path forward, (4) statutory recognition and (5) hope / positive growth. The Creative Arts Therapies are emerging professions but there is a sense of a growing recognition. Though there are many challenges and obstacles for CATs working in Ireland, practitioners are committed to raising awareness and desire statutory recognition to safeguard service users, protect professional titles and foster sustainable employment. It is hoped that these insights may support advocacy and stimulate development within the Creative Arts Therapies community.

Introduction

The arts provide an “aesthetic context in which to support, connect, and heal” (Camilleri 2009, p. 66). The Creative Arts Therapies are evidenced-based health professions that utilise the creative and expressive process of various art forms to induce clinical change and improve the psychological and social well-being of individuals of all ages and health conditions (Shafir et al. 2020). At their core exists the therapeutic alliance between the client and the therapist. As Dokter (1995) explains:

Creative Arts Therapists provide for their patients an environment, art media and very importantly themselves – in terms of time, attention and a clearly defined relationship. The aim of the session or sessions is to develop a symbolic language, which can provide access to unacknowledged feelings and a means of integrating them creatively into the personality, enabling therapeutic change to take place. The therapists focus is not particularly on the merits of the art work (be this dance, drama, painting, music, etc), but on the therapeutic process - that is, the patient’s involvement in the work, their perception of it, and on the possibility of sharing this experience with the arts therapist.

Dokter, 1995, p. 3)

Creative Arts Therapists work with an ever-increasing range of diverse groups. Recent publications highlight the breadth of clinical areas in which CATs work: PTSD (Baker et al. 2018), substance misuse (Megranahan & Lynskey 2018), veterans with mental health difficulties (Levy et al. 2018), stroke (Lo et al. 2019), and older adults with depression (Dunphy et al. 2019). Edwards (2017) notes how practitioners work in “many of the more complex areas of therapeutic practice”, such as: dual diagnosis, extreme significant life stressors and social challenges, severe mental health difficulties, and profound stress and trauma (Edwards 2017, p. A1).

Creative Arts Therapies in Ireland

Creative Arts Therapies are a developing field and include: art therapy, dance movement therapy, drama therapy, and music therapy. There are currently two accredited Master’s training programmes: art therapy at Cork Institute of Technology and music therapy at the University of Limerick. Both courses have increasing numbers of graduates. The four professions are accredited with the Irish Association of Creative Arts Therapists (IACAT) and members adhere to a code of professional ethics (IACAT 2020). IACAT was founded almost 30 years ago and its professional membership has grown by 30% in the last seven years. Its mission is to raise awareness and visibility of the Creative Arts Therapies in Ireland. It is difficult to gauge the exact numbers of CATs practicing in Ireland, because not all are members of IACAT. However, the recent data from the association indicates there are 341 professional members. This includes 207 art therapists, 70 music therapists, 60 drama therapists and four dance movement therapists.

Since the last two surveys of CATs in Ireland (IACAT 2013, 2014), there have been at least 16 known contracted posts established in the health and education system and in the private and charity sectors (Ahessy 2020). These posts are with a range of groups including: paediatrics (haematology, oncology, neurosurgery, and neurology), child and adolescent mental health, children with additional needs, children’s palliative care, adult mental health, homeless services, and care of older persons (Ahessy 2020). Though many CATs work within the Irish health system (Health Service Executive, HSE), and it funds the majority of contracted posts, CATs are not officially recognised by means of a designated grade and pay-scale (Ahessy 2020). Although CATs experience high job satisfaction, they report significantly lower “collective self-esteem” than their colleagues and lack of legislative legitimisation may be a major reason for this (Hod 2019, p. 99).

CATs working within the health system are endeavouring to achieve parity with their allied health professional peers, and IACAT is supporting its members who are pursuing regularisation of their posts.

The number of accredited CATs in Ireland (n=341) is a drop in the ocean when compared to registered allied health professionals (n=13,608). As of May 28th 2020, these included: occupational therapists n=2883, physiotherapists n=4034, speech and language therapists n=1986, and social workers n=4705 (CORU, 2020). Because there are so few CATs, the combined efforts of the four disciplines will be required in furthering the development of Creative Arts Therapies in Ireland and increasing recognition.

Statutory Recognition

Unlike their counterparts in the United Kingdom, who are regulated by the Health and Care Professionals Council (HCPC), CATs in Ireland await statutory recognition through the regulating body, CORU (Gaelic word meaning “to care”). “Internationally, the regulation of health professions is gaining momentum through either self-governed professional structures or legislated state bodies” (Byrne 2016, p. 10). Statutory recognition of any profession involves establishing minimum educational standards, setting standards for practice, including engagement in CPD, and providing a professional code of ethics.  For many professions, the path to statutory recognition is characterised by endless requirements and years of effort (Nöcker-Ribaupierre 2016). Although Creative Arts Therapists have different levels of professional recognition within European Countries, few have state registration. The United Kingdom is unique in having statutory recognition for art, drama and music therapists (dance movement therapists await registration with the HCPC) (d’Elia 2016). Very few other European countries enjoy this validation. Art therapy is recognised in Switzerland, music therapy in Austria and Latvia, while dramatherapy and dance movement therapy are not yet registered in European countries (d’Elia 2016; Nöcker-Ribaupierre 2016). In the pursuit of statutory recognition in some countries (Czech Republic, Germany, Hungary and Luxembourg), CATs have joined forces with the hope of success (Nöcker-Ribaupierre 2016). In a recent study, music therapists in Ireland considered why statutory recognition had not been gained to date. Reasons reported were: bureaucratic incompetence and disorganisation, lack of public awareness, and a deficit of rigorous research (Boyle 2019). Advocacy, lobbying, campaigning and working together more efficiently were proposed as measures that would help achieve statutory recognition (Boyle 2019).

Qualitative Research on CATs

Qualitative research has can illuminate therapists’ experiences, perceptions, attitudes, and actions in relation to a variety of phenomena and processes within practice. International papers have included: art therapists experiences of mental distress with implications for art therapy training and practice (Huet & Hultton 2016), dramatherapists’ and dramatherapy clients’ experiences of change within sessions (Cassidy et al. 2017), and dance movement therapists’ attitudes and actions towards LGBTQI and gender non-conforming communities (Kawano et al.  2018). Recent Irish contributions to the field include: the perception and practice of community music therapy (Murphy 2018), and experiences of verbal dialogue in music therapy sessions (Nelligan & McCaffrey 2020).

It is an exciting and challenging time for Creative Arts Therapies in Ireland. There are growing numbers of trainees, increased association membership and many new contracted posts across diverse clinical areas (Ahessy 2020). At the same time, there exist barriers to sustainable employment, and a lack of awareness of Creative Arts Therapies. Furthermore, CATs are not state registered or officially recognised within the health system (Ahessy 2020). It was timely and appropriate to explore contemporary issues for CATs in Ireland in the current study. To gain a deeper understanding, qualitative research was employed to gain insight into CATs perceptions of Creative Arts Therapies and to evaluate attitudes towards statutory recognition.

Picture1_3

Method

This exploratory qualitative study was part of a larger mixed-methods study using survey data to examine practice, professional engagement and employment of CATs in Ireland. An online survey was launched for qualified CATs in November 2019 and closed in December 2019. The survey was devised and then reviewed by IACAT council members. Following a pilot with a small sample of the association membership, revisions were made before dissemination. Qualified CATs who were members, and non-members of IACAT living and working in Ireland, were invited to take part in the survey. IACAT members were recruited directly by email through the association, with a reminder email sent one, two and three weeks later. The survey was also linked on social media posts on the IACAT Facebook page for four weeks to invite other CATs in Ireland who were not association members. Members of the “Music Therapy Ireland” Yahoo email group were also recruited through email to invite any music therapists who were not IACAT members.

Respondents were assured of confidentiality and all responses were anonymised, with numeric codes automatically assigned to each respondent. The researcher ensured the highest level of compliance with GDPR guidelines (GDPR 2018). Qualitative data from open-ended questions were transcribed and thematic analysis was conducted. It involved: familiarisation with the data, generating the initial codes, generating and reviewing themes, naming themes and producing the report (Braun & Clarke 2006). This enabled the researcher to produce meaningful groups and themes that provide rich and detailed descriptions of the data set and determine common perspectives among participants (Creswell 2012). Data was stored in an encrypted online server with a two-factor authentication and participants had access to their data, with the right to export or delete it.

Results

Ninety-six CATs responded to the survey, resulting in a membership response rate of 26%. Over two thirds of respondents (69%, 66/96) answered open-ended questions related to Creative Arts Therapies in Ireland and statutory recognition. In accordance with the conducted data and their thematic analysis (Braun & Clarke 2006), five main themes emerged: (1) Challenges, with the sub-themes: Creating Employment, Isolation and Financial; (2) Lack of Recognition, with the sub-themes: Feeling Misunderstood and Barriers; (3) The Path Forward, with the sub-themes: Advocacy and Development; (4) Statutory Recognition, with the sub-themes: Protecting Clients and Titles, Sustainable Employment, Defining the Professions and Limitations; and (5) Hope / Positive Growth. Each theme and its sub-themes will be outlined and accompanied by exemplar responses and will then be presented and supported by participant responses.

Theme 1: Challenges

Sub-themes Exemplar Responses
Creating Employment 

“Having spent many years as a PAYE member in a different sector, the transition is a little more difficult.”*

Isolation

“This work can be lonesome, particularly working in rural areas of the country and a little defeating at times.”

Financial

“As CAT working in private practice and sessionally, I am struggling to make a living.”

Figure 1. Challenges, sub-themes and exemplar responses

CATs in Ireland experience many challenges. Creating sustainable employment can be arduous. This was especially true for those living in rural areas. Some CATs felt isolated in their work and separated from their professional community. Financial pressures were also acknowledged.

Creating Employment

An “up-hill battle,” was how two CATs described their professional life. It was “a struggle” to find sustainable work. Having to constantly “sell one’s service” was seen as a “draining part of the profession.” One deflated respondent commented that it was a “difficult, demotivating and an un-creative area to be working in.” Another reported that the lack of appreciation of CATs posed difficulties: “It is challenging to present a professional service in an environment where the creative arts therapies are not really valued.” Self-employment brought “extra challenges” compared to contracted work, with CATs who had transitioned from the latter to self-employment noting these difficulties. Some emphasised that they did not have adequate training or feel prepared to run a business. One respondent felt that the CAT training programmes should: “equip students better about the reality of working as a therapist and more help and support with starting your own business.” Another highlighted that a British Association offers relevant workshops for recently-graduated therapists.

There were several self-employed CATs within the health system who worked in long-term posts without contracts for up to 24 years. Although these therapists engage in multidisciplinary team working and have integrated successfully into the services and are retained over long periods, permanent contracts still elude them. One of the posts was located in an age related unit in a general hospital, while four posts were in the area of adult mental health. A number of these therapists were endeavouring to have their posts validated with a contract. Many therapists balance their CAT work with other employments, but the strain of working in multiple employments in therapeutic and non-therapeutic settings can be difficult: “professional music making provided additional revenue to support my practice (paying for resources/CPD etc) but I simply cannot keep this all going.”

Establishing work in rural areas was reported to be more difficult. One respondent was “saddened” by the lack of opportunities “outside of Dublin.” Another commented that at times they felt “defeated,” while another was “disillusioned.” One therapist considered emigrating to find more sustainable employment: “Underwhelmed by the lack of employment opportunity and exhausted at fighting an uphill battle to find work. Considering leaving Ireland to find a more stable employment environment.” While another’s hopes their career were dampened: “Feeling very disheartened about the job prospects for the future.”

Isolation

Isolation was a subtheme that emerged from the data, especially for self-employed practitioners and those working alone. It was experienced by those working in rural areas, where CATs felt “isolated” and “disjointed”. The lack of colleagues, other CATs in the vicinity, or regular opportunities to network increased feelings of isolation. Another respondent felt that amongst CATs, there was poor alliance and support for one another: “There is good energy around the CATs here, but a lack of connectedness - everyone seems to be working in their own corner.”

Financial

Many found working as a CAT financially challenging. One respondent was concerned about sustainable employment and being able to make a living from CAT work: “I worry about job security and how realistic it would be to work solely as a CAT.” Considering their level of training and experience CATs felt they had, many reported that there was “high responsibility but low financial reward” in the Creative Arts Therapies. Professional costs such as supervision, association fees and travel expenses were prohibitive for some:

Working in private practice and sessionally I am struggling to make a living. I have been a member of IACAT since 2006 but last year could not afford to renew my membership. I feel very isolated. Group supervision is an option but it costs money to travel and I am not earning enough. I am concerned as having to pay to register with different associations to practice. Will we have to join IACAT and CORA to practice going forward?

Theme 2. Lack of Recognition

Sub-themes Exemplar Responses
Feeling Misunderstood

“There still seems to be a sense in Ireland that art therapy is just recreation, fun and for children and the elderly.”

Barriers

“Having to finish treatment due to a lack of funding while making gains is detrimental to any client.”

 Figure 2. Lack of recognition, sub-themes and exemplar responses

CATs felt that there was a lack of recognition from the public, professionals and services. They felt that Creative Arts Therapies were misunderstood and seen by some as recreational. Not being “as validated” as other therapeutic disciplines, CATs felt the pressure to educate services and other professionals, leading to strain. The lack of recognition within systems also blocked establishment of posts and service development.

Feeling Misunderstood 

Many CATs voiced that Creative Arts Therapies are not adequately recognised in Ireland. This was especially true for dance-movement therapy, due to the low number of practitioners. Often, these professions are associated with artistic endeavour or recreation: “There still seems to be a sense in Ireland that art therapy is just recreation, fun and for children and the elderly.” Some CATs did not feel that Creative Arts Therapies were taken seriously and felt that their role was not clearly understood. One respondent reflected on changing their professional title to emphasise the psychotherapeutic element to their role: “Am I an Art Therapist or Art Psychotherapist? I personally prefer the title Art Therapist however I have to use the term art psychotherapy do give a clear notion of what we do as Art Therapists.”

A number of CATs felt that the Creative Art Therapies were not as widely recognised or “validated” as play therapy and psychotherapy. There was also a sense that even in the charity and health sectors the Creative Arts Therapy professions were still under the radar: “The profile of IACAT is not yet as high as counselling/psychotherapy professional bodies. At recent interview for Pieta House I was asked what IACAT was.”

Some CATs felt that there was a lack of understanding and awareness amongst services and professionals about what CATs do. Though the need to educate others was acknowledged, it was perhaps experienced as tiring: “I feel you are constantly advocating for this approach and for working through the arts in general.” Another respondent emphasised the pressure and extra time it takes to educate service providers and teams: “It is often very hard to engage with facilities who are unsure about the creative arts and having to go beyond your work to give presentations and taking time to inform staff and management about the work.”

An increase in contracted posts was seen as key to gaining recognition within services: “Creative Arts Therapies need a lot more recognition and less self-employment. They need to be present in institutions.” Though many were disheartened by the lack of recognition, other CATs were more optimistic that change would come: “It's getting there. Soon the recognition will come.”

Barriers

The lack of recognition of Creative Art Therapies also resulted in barriers to treatment for service users and clients. As CATs do not have their own grade and pay structure within the health service, difficulties arise in establishing and developing posts where they are most needed: “The potential is not being accessed due to restrictions on entry to statutory and other bodies notably HSE and others.”

In some situations, clients are impacted negatively when funding is discontinued: “funding needs to be a priority, having to finish treatment due to a lack of funding while making gains is detrimental to any client.” In other situations, therapeutic services are threatened or terminated because Creative Arts Therapies are not understood or appropriately integrated into the services and systems:

In my job this support is being taken away as a service from those who need it in schools. Tulsa say that it is a mental health service and so it cannot be part of The School Completion Programme which is an educational service. Most of the children who attend therapy in school will miss out because they will not get on CAMHS waiting list and their parents will or cannot bring them to therapy outside of school.

The dearth of published research was cited as another barrier to Creative Arts Therapies being integrated into services: “They are being recognised less and less and not considered adequate (due to lack of research), for adding to MDTs in medical environments.”

Theme 3. The Path Forward

Sub-themes Exemplar Responses
Advocacy 

“It is about making contact with decision makers and providing them with evidence of the benefits of working this way.”

Development 

“I would really like to see them become a regular part of school life for children and also become the norm in Ireland.”

Figure 3. The path forward, sub-themes and exemplar responses

Advocacy was viewed as central to cultivating Creative Arts Therapies in Ireland, through active campaigning, research, and engagement with decision makers within the health system and government. Areas for development that were highlighted included: ensuring parity amongst training courses, seeking coverage by health insurers, and developing access to Creative Arts Therapies within the education system. For successful growth, it was felt that all disciplines need to work together.

Advocacy

Many CATs felt that the profile of Creative Arts Therapies needed to be raised through “advocacy” to help “distinguish IACAT members as mental health practitioners.” One respondent felt it would be advantageous to educate and inform medical, mental health and other HSE employees “so they can advocate for IACAT amongst their profession.” The importance of clear and clinical language was emphasised: “I think we could be more clear and professional in our communication. I think we need to be clear about who we are and what we do and do not do in our communication. It gets too woolly for people to understand.” Many felt that it was time for “active campaigning and direct action!” In relation to registration with CORU, one respondent felt that we need to “push harder to be included in the register” and that the best way to do this was to raise the public profile of Creative Arts Therapies. Another asserted that “raising awareness and understanding in the wider context of what we do is more important than gaining statutory recognition.” One respondent proposed employing professionals to market CATs within IACAT would be highly beneficial: “It would up the profile of the profession and give more scope to alleviate the relative lack of status and recognition of our practice in comparison to other allied health care professions.”

One respondent highlighted how awareness of the Creative Arts Therapies is being nurtured in counselling, psychotherapy and allied health training programmes in Ireland who employ CATs to facilitate workshops on creative skills and personal therapy for trainees: “I find this is very useful, as other professionals get what we do from attending these workshops and it encourages referral paths between disciplines. I think we need to encourage more of this interdisciplinary work when we get our protected title.”

Development

To promote the development of Creative Arts Therapies, it was acknowledged that the standards across the four modalities needed to be raised, as well as furthering parity amongst training courses. One respondent argued that the criteria for approved courses needed to be uniform across the four professions in IACAT. Another felt that the Master’s training programmes could extend to include a recognised psychotherapy qualification, while another suggested an “add on training” organised by IACAT to prepare for CORU registration.

A more robust research bank and promotion of evidence-based practice were highlighted  as vital elements in raising the profile of Creative Arts Therapies and successful advocacy within the health system: “It is about making contact with decision makers and providing them with evidence of the benefits of working this way.” Another respondent contended, “We need increased research studies in all 4 disciplines if we are going to be registered together.” Being affiliated with CORU was viewed to be essential for validation and job creation: “It would help with credibility and help with promoting posts.”

A number of CATs hoped that students in primary and second-level education could access the Creative Arts Therapies: “I would really like to see them become a regular part of school life for children and also become the norm in Ireland.” One respondent identified “well-being” as an area for focus: “CATs are doing amazing work. I am an art therapist and art teacher, and am identifying the commonalities for the benefit of CATs who wish to work in schools, particularly in the area of well-being in secondary schools.”

A couple of CATs commented that the availability of Creative Arts Therapies to medical card holders and private health insurance policy holders would increase engagement and reduce costs for those paying privately: “A sizable number of additional clients would attend the service I offer.” Another respondent felt action was critical: “This is an issue urgently requiring Government attention…50% of children referred to me by a G.P. are unable to attend sessions due to cost.” Access to Creative Arts Therapies through these channels would provide services to those who most require them, while simultaneously raising their public profile.

Theme 4. Statutory Recognition

Sub-themes Exemplar Responses

Protecting Clients & Titles

 “Statutory recognition…will provide safety for service users…”

Sustainable Employment

“This is important in building a sustainable career as an MT.”

Defining the Professions

“I would like to see the Arts Therapies state registered as in the UK, with their own titles…”

Limitations

“I welcome it but also worry about it. With statutory recognition can come a lot of red tape, which can lead to the work being stifled and controlled.”

Figure 4. Statutory recognition, sub-themes and exemplar responses

CATs overwhelmingly felt that gaining statutory recognition was “urgent” and something that needed to happen “imminently”.  It was seen as the only way for a more “accepted standing in the wider community” and for Creative Arts Therapies to thrive in Ireland. CATs highlighted the importance of statutory recognition in protecting clients and professional titles, creating sustainable employment and formalising and differentiating the Creative Arts Therapies from related fields.

Protecting Clients & Titles

Many emphasised the importance of protecting service users by ensuring that practitioners are fully registered and regulated through a statutory body. One therapist commented: “Statutory recognition…will provide safety for service users, in that it will ensure that only qualified professionals…will be facilitating services.” Another commented, “I also think we should have some form of support to address the issue of unqualified practitioners and people claiming to be therapists or misleading organisations.”

A number of CATs highlighted previous knowledge of rogue practitioners offering ‘therapy’ services when they did not hold an accredited Creative Arts Therapy qualification. It was felt that recognition would “alleviate imposter syndrome” and ensure that “qualified” professionals facilitate services. It would also give a clear pathway and protocol in reporting such cases: “I’ve heard of non-qualified people offering ‘art as therapy’ groups and similar. I fear that this undermines the work that qualified CAT’s do. I would dearly like to know what to do about this but without state registration it’s difficult to challenge.” Another respondent argued, “It is near impossible to deal with complaints in the absence of a registration situation.” Protection of titles was seen as important in protecting the work of qualified therapists: “CATs could possibly be brought into ill repute as a result of others claiming to be art therapists, when they are not even members of IACAT.”

Sustainable Employment

Statutory recognition could increase professional opportunities for CATs and lead to sustainable employment and was seen as “essential when looking for work in a competitive job market.” Self-employed CATs already carrying out sessional work in health services felt that registration could give Creative Arts Therapies “more weight” and be a catalyst for sessional positions becoming permanent posts. Gaining registration was considered critical in building confidence in employers, reassuring them that practitioners had the relevant therapeutic training required for advertised posts. It could also afford institutions a grade structure to commission and fund posts. Furthermore, it would foster more viable full-time career options. One music therapist commented: “I feel this will aid in gaining full-time employment with regular employment benefits. This is important in building a sustainable MT career.”

Defining the Professions

The urgency for Creative Arts Therapies to rank among the variety of health professions within the HSE and for statutory recognition was prevalent in the survey: “I feel it is a shame that we are readily available to provide a service and are unable to get that message out there because of statutory recognition. Other countries recognise Art Therapy as a profession why is it not recognised here?” It was seen as especially important in differentiating Creative Arts Therapies from Arts and Health practices. CATs commented on the blurred boundaries that existed between the two professions. They felt that having statutory recognition would support health professionals and the public in understanding the differences between the two professions and their unique roles: “Tackle the issue of non-registered Art therapies and similar training courses that tend to confuse the general public in understanding the difference between therapeutic art and masters level creative art therapies.” For Arts in Health practitioners working in health settings, it was suggested that specific training would be valuable: “It is not a positive move that frequently artists are being employed to work in clinical environments without therapeutic training.”

Limitations

Although CATs acknowledged the benefits of statutory recognition, some did remark on the restrictions it might bring and were concerned about having “less freedom.” It was emphasised that it was important to be clear regarding the advantages and disadvantages. One responded noted how in the United Kingdom, statutory recognition has “imposed a lot of things” on practitioners and that in Ireland there is greater freedom in setting up work. Another respondent echoed this sentiment: “I welcome it but also worry about it. With statutory recognition can come a lot of red tape, which can lead to the work being stifled and controlled.” A further respondent worried about the limitations it may place upon the field and wondered if it would result in more training being required to work with specific clinical populations or age groups.

Although some limitations were observed, statutory recognition is something that CATs in Ireland overwhelmingly desire: “I would like to see the Arts Therapies state registered as in the UK, with their own titles, if possible, as this is where our strength and unique selling point lies.” The work of CATs was viewed as important and deserving of validation: “I would like to see them properly valued for what they have to offer and as the professionals they are.”

Theme 5. Hope / Positive Growth

Theme Exemplar Responses
Hope / Positive Growth 

“The recognition of the value of the Creative Therapies is continually growing.”

Figure 5. Hope / positive growth, sub-themes and exemplar responses

A number of CATs were hopeful about the future, and felt that the profile of Creative Arts Therapies is “growing…more people are talking about them” and they are “gaining more recognition slowly.” In a small country like Ireland, verbal referrals and testimonials were considered invaluable: “Every employment opportunity I have gotten in the past few years has been as a result of individuals witnessing or hearing about my work.”

Though there is a need for continual education to promote emerging professions such as the Creative Arts Therapies, the progress that has been made thus far was acknowledged: “It is in a much better place than it was when I began working as a CAT but there is still a long way to go. It is much more recognised as a profession but there needs to be constant education given to public and health professionals.” Another respondent highlighted the growth they perceived over their career: “My experience dealing with HSE, TUSLA, Brothers of Charity Services and G.P.s over a number of years is that the recognition of the value of the Creative Therapies is continually growing.” Many CATs were optimistic about the future. One felt “excited” to be part of a developing profession and highlighted the professional responsibilities that come with recognition: “I think that as the field grows in numbers and in recognition, we will need to get stricter in relation to adherence to best practice, supervision etc.”

There were many positive comments in relation to IACAT and the work of its council: “The current committee is working really hard and is very strong in going forward.” The importance of all four disciplines working together was highlighted. The association’s unique status in a European context of representing four Creative Arts Therapy professions under one umbrella organisation was seen as unique and positive. In a country like Ireland with a small population, the bringing together of a larger combined group of professionals was seen as a potent force: “Keep it one group!...Strength in numbers.”

tim-mossholder-zs-PAgqgenQ-unsplash (1) bh

Discussion

This paper identifies contemporary issues for CATs, to understand their perceptions of the Creative Arts Therapies and their attitudes towards statutory recognition. Contemporary issues identified for CATs are presented under five main themes: (1) challenges, (2) lack of recognition, (3) the path forward, (4) statutory recognition and (5) hope / positive growth.

Job opportunities were of concern for some CATs, who felt ‘“disheartened” by the lack of options. They drew attention to the struggle in securing contracted and sustainable employment in the sector. This was especially the case for CATs living in rural areas, some of whom experienced isolation. An added stressor in rural areas can be manging multiple relationships, “because the clear social and professional boundaries that are discussed as ideal for those who work in larger communities are not possible” (Oetinger et al. 2014, p. 50).

Within the CAT community, a need for more “connectedness” was identified.

The development of regional online groups and, recently, increased online CPD may support those working in rural areas, connecting practitioners who are geographically isolated (Ahessy 2020).

Some CATs felt “ill-equipped” for running a business, and training needs in this area were identified. Ledger (2010, 2016) highlights that although music therapists “distanced themselves from the business world” they did display “qualities commonly attributed to entrepreneurs, such as creativity, passion and persistence” (Ledger 2016, p. 38). When the World Economic Forum identified the skill sets the workforce of 2020 needed, Creativity moved from the Number 10 skill in 2015 to Number 3 in 2020 (World Economic Forum 2015). In developing their entrepreneurial skills, a combination of increased pre and post qualification training in this area and developing the transferrable skills CATs already possess will be beneficial.

Financial challenges were experienced by many, and the costs of association membership, supervision, insurance and CPD were prohibitive for those who worked few hours.

Many voiced that it was not possible to earn a sustainable income from CAT work, which was highlighted in the most recent Irish survey (Ahessy 2020), where over half of CATs worked in non-CAT or related employment due to lack of opportunities.

This was also paralleled in the largest US survey of music therapists to date, where lack of jobs and funding and difficulty in making a living exclusively from CAT income was highlighted (Kern & Tague 2017). It can be similarly difficult for psychotherapists and counsellors to find sustainable work, and many engage in non-counselling work to support themselves (BACP 2017).

CATs in Ireland emphasised a lack of recognition of Creative Arts Therapies from the public and other professionals and felt that they were misunderstood and in some cases viewed as “recreational” rather than “therapeutic”. CATs have had a “lengthy involvement” with supporting children and adolescents in educational settings (Karkou 2010, p. 10). CATs in this survey desired that students in primary and second-level education should have more access to Creative Arts Therapies and it was suggested that lack of recognition was a barrier to this. It was seen to impede service development and in some cases negatively impact clients, when programmes were discontinued abruptly. This may be especially true in the health and education systems, where there are no formal recruitment pathways for contracted posts. Increased recognition would encourage the development of posts in school environments and the recognition of CATs as health professionals would differentiate Creative Arts Therapies from arts education (Karkou 2010).

The potential of contracted posts to foster understanding and raise the profile of Creative Arts Therapies was acknowledged.

This is particularly true for CATs working in prominent and visible services that may have increased media engagement or advocacy opportunities. Many contracted CATs have integrated into multidisciplinary teams, especially in work with children  (Twyford and Watson 2008). Educating and informing other professionals can be a burdensome part of professional responsibility and was experienced by some CATs as a “strain” (Sutton 2008). However, an important value of multidisciplinary team engagement is bringing a deepened understanding of the role of CATs to allied professionals. Other efforts, such as the provision of Creative Arts Therapy modules in allied health training courses, were considered a positive force in raising awareness amongst future professionals.

Raising the public profile of Creative Arts Therapies through lobbying and campaigning was seen to be vital. Although gaining state registration was viewed as essential, some felt that increased recognition in the wider context is possibly more important and therefore continuous advocacy is required. Raising the standards across the four professions and increased alignment amongst the Master’s training programmes were highlighted as important in preparation for registration. Further provision of verbal therapy skills, either pre or post qualification, were also indicated.

One key objective identified for the development of Creative Arts Therapies was increased evidence. A dearth of Irish research was cited as a reason why Creative Arts Therapies are less recognised and not being integrated more frequently into services. Integrating peoples “unique preferences, concerns and expectations,” are a cornerstone of evidence-based practice (Sackett et al. 2000, p. 1). Client-centred research in the Creative Arts Therapies can be a powerful advocacy tool, highlighting “the service user voice” or “lived experience.” This can illuminate the specific health challenges faced by different clinical groups and can be a positive influence in the commissioning of posts (Walton 2018, p. 58).

Though there is a growing research output in Ireland, it is not equally balanced across the disciplines and there is a need for increased publications.

The new IACAT journal, Polyphony and its editorial team encourage and mentor CATs to submit research as well as providing CPD to support writers. Though research can be daunting, a stepping stone into research might be “programme evaluation”, which can “help generate evidence for funding opportunities” (Kaimal & Blank 2015, p. 89). Another springboard for practitioners could be the clinical case report. Edwards (2019) emphasises the value of the case report in providing “essential insight into practice and care in the Creative Arts Therapies” (Edwards 2019). This type of research can be useful in educating other professionals on how Creative Arts Therapies work. For private practitioners, involvement in research, can enable the therapist to better “understand the research literature they may use to inform best practice and understand their client’s needs” (West 2018, p. 275).

Reimbursement and recognition from insurance companies makes it easier for people to receive services and was a highlighted theme in a recent survey of music therapists (Kern & Tague 2017). CATs in this survey identified lobbying for Creative Arts Therapies to be available to medical card holders and private insurance customers as an important way of reaching clients, many of whom cannot afford private therapy. In Ireland, one in four people see affordability as a potential barrier to seeking therapy and there was is strong support (86%) for state funding of therapy (IACP 2019). Supported access to Creative Arts Therapies would allow many people who need the services to receive them, and simultaneously increase public awareness.

Statutory Recognition is seen by almost all as essential and could increase “collective self-esteem” in, and afford feelings of appreciation and equality for, CATs (Orkibi 2019). It was viewed as paramount for protecting clients and professional titles. This is important when one in two practitioners were aware of un-trained workers posing as CATs and felt that without regulation service users and clients were vulnerable to harm (IACAT 2013).

Regulation works on many levels in protecting the public, maintaining their confidence in the profession and ensuring fitness to practice through the establishment and enforcement of standards of professional practice and education. It can cultivate increased employment opportunities and govern public, charitable and private settings.

Irish music therapists overwhelmingly support statutory recognition (94%) and, like the CATs in this survey, felt that advocacy and lobbying are crucial to attaining it (Boyle 2019). Forming allies with influential professionals from a range of sectors was deemed paramount in the process. Statutory recognition may help define the Creative Arts Therapies and differentiate them from arts and health practice, increasing awareness on the unique roles and remits of both professions. There is a need for professionals to differentiate their roles, but Moss (2016)  encourages mutual respect and offers us a continuum of arts and health, which seeks to “counter the artificial and defensive barriers constructed between practitioners and professional groups within the field, encourage greater respect and understanding between practitioners” (Moss 2016).

Although statutory recognition would be a long-anticipated turning point for Creative Arts Therapies in Ireland, it should be noted that some CATs raised the question of the limitations or impositions it might place on practice, including mandatory CPD. Edwards highlights that statutory recognition may bring over-regulation (Edwards 2015). There is a risk that statutory recognition may dilute the essence of Creative Arts Therapies and concerns have been raised about the influences it may have on professional identity: “the risk of adjusting our practices too much to a medical model, while service users often highlight the value of the non-medical nature of these practices” (Stige 2017, p. 13).

While state regulation for allied health professions in the United Kingdom has resulted in greater status, Nöcker-Ribaupierre (2016) highlights that “understanding and recognition of the value of music therapy varies regionally and also within statutory providers of health education and social care” (p. 931). This indicates that not only is advocacy of Creative Arts Therapies through campaigning and lobbying in Ireland of acute importance, but something that requires ongoing commitment and energy, even after recognition has been achieved. Byrne (2016) highlights that for many, statutory, recognition “is closely associated with recognition as a profession. Yet regulation alone does not constitute professional status. This must be driven from within the profession itself, by developing a shared professional identity which promotes high standards of practice and recognition of the quality and value” (Byrne 2016, p. 25). Because the Creative Arts Therapies are an emerging profession with low numbers, it is critical that the community strives to promote parity between the disciplines and to uphold the highest standards in education, research, practice and professional engagement.

Finally, each CAT has a responsibility to ensure that advocacy and raising awareness is at the forefront of their professional life.

Limitations & Future Research

This is the first qualitative study to examine the perceptions of CATs in Ireland towards Creative Arts Therapies and their attitudes towards statutory recognition. However, this investigation was part of a much large mixed-method study and so limited attention was focused on this area. If this study has been an independent survey in its own right, more pointed and specific questions could have been asked, affording deeper understanding. Although the response rate was high for a membership survey, IACAT accredited art therapists and dramatherapists were under-represented at 20% or less.

Future directions for research might address these lacunae and explore statutory recognition in more detail. Another area of interest is the experiences of CATs specifically working in rural areas. The challenges of self-employment could be further explored. Research identifying relevant business skills for CATs would also be valuable. This could explore experiences of CATs who have created successful private practices and businesses. Increased research into the demand for, and access to, Creative Arts Therapies in schools might foster development and employment pathways in this sector.

Surveys of other professionals’ perceptions of CATs would be illuminating and help in raising awareness. Finally, survey research examining the experiences of allied health professions who have received statutory recognition in Ireland would be enlightening. What were the initial challenges they experienced? Related training programmes could be assessed on the impact of state registration on their programme content.  

Conclusion

This study aimed to explore contemporary issues for CATs in Ireland, to understand their perceptions of Creative Arts Therapies and their attitudes towards statutory recognition. The five main themes illuminated the key concerns for CATS. They were: the challenges that therapist experienced, which included the difficulties in creating sustainable employment, isolation, and financial difficulties. The lack of recognition of the Creative Arts Therapies and how it impedes progression and creates barriers to therapeutic access. Some CATs felt the professions were misunderstood and the need for the continual education of other professionals was acknowledged. Advocacy and raising awareness were considered to be of key importance and areas for development were considered. CATs felt that statutory recognition was paramount to safeguard service users, protect professional titles, define CATs as allied health professionals and promote sustainable employment, though possible limitations were acknowledged. The progress that has been made thus far and the growth of Creative Arts Therapies was acknowledged and celebrated, and IACAT was seen as a unique and important for many.

Though still not fully-fledged, Creative Arts Therapies in Ireland are emerging professions with the potential to flourish.

While many challenges and barriers exist for CATs, most are determined, energised and hopeful for the future.

Statutory recognition will no doubt be a watershed moment and go a long way towards affording accredited CATs the status, increased work opportunities and job protections they deserve. However, it is important that members of the CAT community support one another on the journey, building mutual strength and resilience from within the profession. That CATs continue to raise professional standards, foster research and advocate for the Creative Arts Therapies. These endeavours will bring to fruition the aspirations, efforts and commitments of all.

*Quotation marks without a citation indicate that the quote is from a survey participant.

Read the survey.

View the questionnaire.

Acknowledgements

I wish to thank Professor Tom Hayden for his support and assistance in editing this paper. I also wish to thank Kerrie O’Connor for editing and reviewing. Special thanks to the respondents of the survey for their participation and support.

References

Ahessy, B. (2013) Creative arts therapies: What psychologists need to know, Irish Psychologist, 39 (11), 274-281.

Ahessy, B. (2020). Creative Arts Therapists in Ireland: Practice, professional engagement & employment, Polyphony: Journal of the Irish Association of Creative Arts Therapists. Available: http://polyphony.iacat.me/features/creative-arts-therapists-in-ireland-practice-professional-engagement-employment [Accessed 14th July, 2020].

Baker, F. A., Metcalf, O., Vaker, T. and O’ Donnell, M. (2018) A systematic review of the efficacy of creative arts therapies in the treatment of adults with PTSD. Psychological Trauma, 10 (6), 643-643.

Boyle, T. (2019) Music Therapy in Ireland. Irish Association of Creative Arts Therapists Journal, 6 (1), 39-52.

Braun, V. and Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2), 77-101.

British Association for Counselling and Psychotherapy [BACP]. (2017). Results of the 2017 BACP membership survey [online]. Available: https://www.bacp.co.uk/about-us/about-bacp/2017-bacp-membership-survey/ [Accessed 25th May, 2020].

Byrne, C. (2016) Ready or not? Statutory registration, regulation and continuing professional development for social care workers in Ireland. Administration, 64 (2), 9-29 [online]. Available: https://doi.org/10.1515/admin-2016-0014 [Accessed 4th June, 2020].

Camilleri, V. A. (2007). Therapy with inner-city at risk children. In: V. A. Camilleri, ed. Healing the Inner City Child: Creative Arts Therapies with At-risk Youth. London, United Kingdom: Jessica Kingsley Publishers, 57-72.

Carr, S. M. D. and McDonald, A. (2019) The state-of-the-art: building a positive future for art therapy through systematic research. The International Journal of Art Therapy, 24 (2) [online]. Available: https://www.baat.org/About-BAAT/Blog/222/International-Journal-of-Art-Therapy-Inscape-Volume-24-Issues-12-JanuaryJune-2019 [Accessed 18th May, 2020].

Carr, C. E., Tsiris, G. and Swijghuisen Reigersberg, M. (2017). Understanding the present, re-visioning the future: An initial mapping of music therapists in the United Kingdom, The British Journal of Music Therapy, 31 (2), 68-85.

Cassidy, S., Gumley, A. and Turnbull, S. (2017) Safety, play, enablement, and active involvement: Themes from a Grounded Theory study of practitioner and client experiences of change processes in Dramatherapy. Arts in Psychotherapy, 55, 174-185.

CORU (2020) Registration statistics. Available: https://coru.ie/news/news-for-health-social-care-professionals/coru-registration-statistics-may-2020.html [Accessed 2nd June, 2020].

Creswell, J. W. (2015) Educational Research: Planning, Conducting, and Evaluating Quantitative and Qualitative Research, 5th ed., Upper Saddle River, NJ: Pearson Education.

d’Elia, M. (2016) Art therapy in Europe. In: D. E. Gussak and M. L. Rosal, eds. The Wiley Handbook of Art Therapy. West Sussex, United Kingdom: John Wiley & Sons, 701-709.

Dokter, D. (ed.) (1995) Arts Therapies and Clients with Eating Disorders: Fragile Board. London: Jessica Kingsley Publishers.

Dunphy, K., Baker, F. A., Dumaresq, E., Carroll-Haskins, K., Eickholt, J., Ercole, M., Kaimal, G., Meyer, K., Sajnani, N., Shamir, O. Y. and Wolsch, T. (2019). Creative arts interventions to address depression in older adults: A systematic review of outcomes, processes, and mechanisms. Frontiers in Psychology, 9:2655.  [online]. Available: https://doi.org/10.3389/fpsyg.2018.02655 [Accessed 11th May 2020].

Edwards (2015) Paths of professional development in music therapy. Training, professional identity and practice. Approaches: Music Therapy & Special Music Education, 7 (1), 44-53.

Edwards, J. (2017) The therapist’s use of the self in creative arts therapy practice. The Arts in Psychotherapy, 55, A1-A2.

Edwards, J. (2019) The case report in providing essential insight into practice and care in the Creative Arts Therapies. Editorial. The Arts in Psychotherapy, 64. Available: https://doi.org/10.1016/j.aip.2019.101576  [Accessed 30th May 2020].

General Data Protection Regulation [GDPR] (2018) Principles relating to processing of personal data [online]. Available: https://gdpr-info.eu/art-5-gdpr/ [Accessed 15th May 2020].

Huet, V. and Holttum, S. (2016) Art therapists with experience of mental distress: Implications for art therapy training and practice. International Journal of Art Therapy, 21 (3), 95–103. https://doi.org/10.1080/17454832.2016.1219755

Irish Association for Counselling and Psychotherapy [IACP]. (2018) IACP Members’ Survey 2018 Summary Report [online]. Available: https://iacp.ie/files/UserFiles/Publications/IACP-Member-Survey-2018-Report.pdf [Accessed 10th May 2020].

Irish Association of Creative Arts Therapists [IACAT]. (2013) Membership survey.

Irish Association of Creative Arts Therapists [IACAT]. (2014) Salaries survey.

Irish Association of Creative Arts Therapists [IACAT]. (2020) Code of professional conduct and ethics for creative arts therapists: art therapists, dance movement therapists drama therapists and music therapists [online]. Available: https://www.iacat.ie/uploads/ed/Code-of-Professional-Conduct-and-Ethics.pdf Accessed 15th May, 2020).

Kaimal, G. and Blank, C. A. L. (2015) Programme evaluation: A doorway to research in the creative arts therapies. Art Therapy: Journal of the American Art Therapy Association, 32 (2), 89-92.

Karkou, V. (2010) Introduction. In: V. Karkou, ed. Arts Therapies in Schools: Research and Practice. London, United Kingdom: Jessica Kingsley Publishers.

Kawano, T., Cruz, R. F. and Xueli, T.  (2018) Dance movement therapists’ attitudes and actions towards LGBTQI and gender non-conforming communities. American Journal of Dance Therapy, 40 (2), 202-223. 

Ledger, A. (2010). Am I a founder or am I a fraud? Music therapists’ experiences of developing services in healthcare organizations (Unpublished doctoral thesis). University of Limerick, Limerick, Ireland.

Ledger, A. (2016). ‘Entrepreneur in arts therapies not just making a swift buck.’ In: D. Thomas and V. Abad, eds. The Economics of Therapy: Caring for Clients, Colleagues, Commissioners and Cash-Flow in the Creative Arts Therapies. London, United Kingdom: Jessica Kingsley Publishers, pp. 38 – 50.

Levy, C. E., Spooner, H., Lee, J. B., Sonke, J., Myers, K. and Snow E. (2018) Telehealth-based creative arts therapy: Transforming mental health and rehabilitation care for rural veterans. The Arts in Psychotherapy, 57, 20-26.

Lo, T. L. T., Lee, J. L. C. and Ho, R. T. H. (2019). Creative Arts-Based Therapies for Stroke Survivors: A Qualitative Systematic Review. Frontiers in Psychology, 9 [online]. Available: https://doi.org/10.3389/fpsyg.2018.01646 [Accessed 28th April 2020].

Megranahan, K. and Lynskey, M.T. (2018) Creative arts therapies reduce substance misuse? A systematic review. The Arts in Psychotherapy, 57, 50-58.

Murphy, L. (2018). The perception and practice of Community Music Therapy in Ireland. Voices: A World Forum for Music Therapy, 18 (2) [online]. Available: https://doi.org/10.15845/voices.v18i2.947 [Accessed 1st  June, 2020].

National Coalition of Creative Arts Therapies Associations, Inc. (2018) Annual Report [online]. Available: https://www.nccata.org/aboutnccata [Accessed 28th April, 2020].

Nelligan, S., and McCaffrey, T. (2020). An Investigation of music therapists’ experiences of verbal dialogue in music therapy sessions. Voices: A World Forum for Music Therapy, 20(1) [online]. Available: https://doi.org/10.15845/voices.v20i1.2868 [Accessed 1st  June, 2020].

Oetinger, M. A., Flanagan, K. S. and Weaver, I. D. (2014) The Decision and Rewards of Working as a Mental Health Professional in a Rural Area. The Journal of Rural Health, 38 (1), 50-60.

Orkibi, H (2019) Creative Arts Therapists Report Lower Collective Self-Esteem but Higher Job Satisfaction Than Other Professionals. Art Therapy: Journal of the American Art Therapy Association, 36 (2), 98-102.

Sackett, D. L., Straus, S. E., Richardson, W. S., Rosenberg, W. and Haynes, R. B. (2000) Evidence-based medicine: How to practice and teach EBM, 2nd  edition., New York: Churchill Livingstone.

Shafir, T., Orkibi, H., Baker, F. A., Gussak, D. and Kaimal, G. (2020) Editorial: The state of the art in creative arts therapies. Frontiers in Psychology, 11 [online]. Available: https://doi.org/10.3389/fpsyg.2020.00068 [Accessed: 21st May, 2020].

Stige, B. (2017) ‘Phases of transition in the economics and ethics of the arts therapies.’ In: D. Thomas and V. Abad, eds. The Economics of therapy: Caring for Clients, colleagues, Commissioners and Cash-Flow in the Creative Arts Therapies. London, United Kingdom: Jessica Kingsley Publishers.

Sutton, J. (2008) Introduction. In: K. Twyford and T. Watson, eds. Integrated Team Working: Music Therapy as Part of Transdisciplinary and Collaborative Approaches. London, United Kingdom: Jessica Kingsley Publishers, pp. 11-28.

Twyford, K. and Watson, T. ‘Introduction.’ In: K. Twyford and T. Watson, eds. Integrated Team Working: Music Therapy as Part of Transdisciplinary and Collaborative Approaches. London, United Kingdom: Jessica Kingsley Publishers, pp. 11-28.

Walton, F. (2018) ‘From public to private and back: Art therapy in the NHS and in private practice. In: J. D. West, ed. Art Therapy in Private Practice: Theory, Practice and Research in Changing Contexts. London: Jessica Kingsley Publishers, pp. 11-13.

West, J. D. (2018) ‘The scene of research for private practitioners.’ In: J. D. West, ed. Art Therapy in Private Practice: Theory, Practice and Research in Changing Contexts. London: Jessica Kingsley, pp. 274-289.

Bill Ahessy

fullsizeoutput_6347

Bill Ahessy is a music therapist and clinical supervisor based in Dublin. He works with older adults and children with visual impairment and additional needs. Bill trained as a music therapist in Australia and in Spain and has since completed a diploma in person-centred dementia care and in clinical supervision. He has guest lectured at the University of Limerick, Trinity College Dublin and Dublin Business School and supervises music therapy trainees and practicing music therapists.  Bill has published peer-reviewed articles on his work, contributed to two books and has continuing research interests in creative arts therapies, choir interventions in music therapy and music therapy with people with dementia.



Associated articles