Keaveny, R. 2020, Revolve. Example of digital image made using the Colour Touch app. Birr, Offaly: Private Collection.
In 2016, as a training art therapist, I surveyed IACAT members about their experience of using digital technology within their practice and received three responses. Fast forward to April 2020, and wondering how the Covid-19 crisis was impacting creative arts therapists in Ireland, I decided to survey the membership again. As well as their experiences of digital resources, I also wanted to establish a clear picture of how many had moved their practice online, and the reasons that may have informed those decisions. Between April and June 2020, I asked a series of ten questions covering specific areas of practice, including clinical practice delivery during COVID-19, training, digital confidence, and utilising online therapy. There were seventy survey respondents from across five modalities. With the option to expand on an answer built into each question, an additional two hundred and seventy-three written answers were contributed. This article explores and expands on the themes raised by the respondents - including the ethics of digital practice, digital competency, and implications for training - and further considers the future of creative arts therapies in Ireland.
The disconnect between digitally literate clients and creative arts therapies is a reality long acknowledged within the literature (Carlton 2015; Orr 2011), with creative arts therapists identified as having, "Little experience and skills in facilitating the use of digital arts in therapy" (Choe cited in Garner 2017, p. 54).
Correspondingly, not feeling sufficiently trained in digital and/or online practice was a predominant concern identified by respondents, observing, for instance, that, “We have all found ourselves at a loss to know how to practice safely if at all, we need to be educated properly to provide best practice for ourselves and clients” (#54).*
Given the lack of training in regard to digital practice across all modalities, it is perhaps not surprising that 98% of respondents, when asked in question seven, “Do you think that future training creative arts therapists should receive online therapy training accompanied by additional training in arising ethical and confidentiality issues?”, answered that future creative arts therapists should receive training in online therapy, and they observed the arising implications for practice should digital competency training not be implemented.
Keaveny, R. 2020, Sparks. Example of digital image made using the Linear Art app. Birr, Offaly: Private Collection.
It’s also interesting to note that in order to undertake online practice during COVID-19, 50.72% of respondents undertook additional training. One participant observed: “I think it would be prudent as I fear that this crisis will not be over for some time; the world is a changed place, and technology will be at the forefront of human connection going forward” (#60). Working ethically online was also identified as a significant reason for future training, with it being regarded as “Vital that we know ethical and confidential issues on all forums for our profession” (#51). Carlton (2019) argues that teaching digital literacy to training students is a social and professional responsibility rather than a choice. The respondents also reported this sense of responsibility, given the layers of complexity inherent to digital practice: system of delivery, storage of clinical work, informed consent, ethical social media use, digital literacy and professionalism. It is timely to consider whether training courses will now integrate online therapy and the clinical use of digital media in preparation for a return of a similar, or a subsequent future, emergency, or will digital training continue to be primarily self-initiated and post-qualification?
It is also important to acknowledge that there has been a substantial financial impact of COVID-19 on the income of creative arts therapists, with the largest group, 54.41%, responding that 75-100% of their income had been impacted. In total, 70.59% have had 50% of their income affected, while 22.06% have experienced a lesser drop of 0-25%. Lack of income was cited by some respondents as being a factor in why they were not in a position to undertake online training: "My reason as to answering no for this question is because my income is significantly reduced as I have very little work and so my living expenses are my first priority” (#40). Given the often non-contracted and sessional nature of creative arts therapies work, it is not surprising but still shocking that incomes have been so significantly impacted, and it will be important to monitor how soon or whether they return to pre-COVID-19 levels.
There has been a long-standing belief in creative arts therapies that the use of digital technology renders the experience as being "Fast food" (Potash 2009) or "Inauthentic" (Klorer 2009) compared to "face to face", or traditional, therapy.
While creative arts therapists expressed needing training in the digital realm, there is also evidence that they retain some concerns in relation to confidentiality, storage of images made, exploring trauma in the very place it may have happened or may be happening in, and the physical absence of both, "going" to and "leaving" the therapeutic space.
I was surprised that this ongoing polarity between digital and face to face therapy was also present in my recent research findings, for example: “I don’t feel that online therapy despite the situation we are in, is really that helpful when you take out the physical from the therapeutic intervention it is diminished” (#42) and “I will not be continuing this practice after Covid 19, the authenticity of the sessions are lost, laptops and phones freeze” (#14). Although digital practice was hastened by the COVID-19 situation, these responses mirror a specific absence within the literature, namely what informs a therapist's choice to use digital media. Orr, in particular, has done a lot of work around this issue in relation to the emotions around engaging with technology. Having carried out an initial survey in 2005, she repeated it in 2011 to see whether engagement had increased, or whether reasons for not doing so had changed, given advances in technology and it’s diffusion into the community.
Keaveny, R. 2020, Cyber Bullying. Example of a digital image from Kloog 2, social skills app. Birr, Offaly: Private Collection.
While the concerns identified are valid, particularly in the context of an emerging field of practice, it could be argued that such critiques place too much emphasis on the technology or system of delivery. It seems counter-intuitive that when as therapists we learn, experiment and educate ourselves about the different properties of a wide variety of materials and methodologies, that when a new media emerges and has transformed the ways in which we communicate, that as a profession we wouldn’t also explore it.
Indeed, some respondents reported their surprise at what they expressed as being unexpected benefits of working in an online context, for example, “I was very concerned initially as I imagined that it would in no way compare to face to face sessions. I am very glad that I embraced it as it provided a necessary support to a small portion of clients that I work with and I would be open to continuing with this platform should the need arise” (#61).
With the respondents who have adopted digital practice, learning new digital-based skills was also identified as an unforeseen outcome: “I have found working online with clients during Covid 19 a useful learning process for myself which I might not have undertaken otherwise” (#32). With the element of choice greatly altered in relation to digital practice, respondents reported that had the COVID-19 situation not occurred, they would not have considered delivering online therapy. For some, it opened them up to possibilities afforded by digital practice, while for others it confirmed their belief that it is not suitable for them or their clients.
Respondents also referred to an increased sense of community within the creative arts therapies profession: “The support offered by peer groups and training has been fantastic. Also a big plus, has been meeting all those wonderful therapists music and art who I feel I may not have met outside of this. I feel much more connected to members in IACAT” (#24). The COVID-19 crisis created situations and an environment in which therapists engaged with each other and outside of their modality in ways that they wouldn’t normally, such as through online peer support groups and online training. It will be intriguing to see if this continues as the world starts to reconstitute itself.
A small but significant number of respondents, approximately ten per cent, identified environmental concerns as a reason for engaging in online therapy, which I haven’t seen evident in creative arts literature. For instance, “It's better for the environment as it reduces traffic on the roads” (#15), and, “These emergency situations are going to become more regular as we move into climate change. More services will be offered online to cut down on travel and rental of spaces” (#30). Environments, if referred to at all in the literature, tend to be both immersive and digital, for example, "In the clinical space, digitally enhanced environments may become more readily available to offer art therapy clients opportunities to explore emotions, sense of self” (Brown & Garner 2016, p. 189). Within this area, quality of life was a further reason outlined by survey respondents as a reason for digital adoption: “I will continue offering online spaces and I wish, in fact, to extend my practice this way, as I eventually would like to move to the countryside and do not wish to commute” (#30). Personally speaking, I know that I haven’t missed my usual 4.5hr commute to Dublin and while working online with the same clients, the staircase commute to work is a lot more appealing than the M50 or Dublin city centre at rush hour!
Client Image, 2020, This is My Day. Digital still from collaborative short film. Birr, Offaly, Private Collection.
As we start to consider returning to our former workspaces and clients in whatever form that may take, it’s interesting to observe that 35.21% of respondents stated that creative arts therapies should only utilise online therapy during the COVID-19 crisis, as they believed, for example, that “Too much is elicited by the physical and emotional processes of art making. I don't feel it is safe for the client to be physically on their own in that space with those feelings. Too much is lost over the phone, or even through the likes of zoom” (#54). 5.63% felt that online therapy shouldn’t be used at all, for example stating that "Digital life/computers/the internet is currently involved in the appropriation of all things human (by corporations mostly from Silicon Valley) including friendship, they are attempting to claim that the virtual world is equivalent or at times superior to ancient human qualities, that privacy is not a right and so on. Digital technology is not, it is disruptive and intrusive and I am only using it as a last resource, or as a poor relation to face-to-face contact” (#48).
Further reasons most frequently cited for not utilising online therapy range from concerns about confidentiality, privacy and therapeutic authenticity, for example, “My guess is that many of those who see clients online do not take into account the security of the session” (#47), to specific technical concerns, such as poor internet signal, screens freezing and screen induced fatigue due to the extra concentration required. These concerns echo Austin’s (2009) questioning of whether creative arts therapists will limit themselves to the role of "critical observer" or as "contributors" to a fast-evolving field of practice. I would agree with his position that it’s precisely because as therapists we work with metaphor, symbols, fantasy, projection and the unconscious, that creative arts therapies as a profession are in a unique position to contribute to the conversations about the relationship between therapeutic practice and the digital realm.
While the majority of respondents commented that they found face to face therapy to be the most ethical and effective method of therapeutic engagement, 59.30 % felt that digital therapy should be utilised, with the most common reasons given that: it offers flexibility to both client and therapist; it is a useful option for those who can’t attend physically; it is being driven by client demand; the online platform can itself become a medium that brings a new dimension to the creative space and provides a useful learning opportunity.
As the field expands, I think that the need to position oneself as being either "for" or "against" digital practice will reduce, and, as indicated by my research findings, digital practice will become another option in the vast array of therapeutic tools, especially since the development of digital practice is largely client-driven.
Client Image, 2020, Run. Digital still from collaborative animation made using the Drawing Cartoons 2 app. Birr, Offaly: Private Collection.
The dilemmas involved in working online, or through digital means, in many ways mirror those offline; primarily confidentiality, but also isolation resulting from limited social interaction, and addiction, albeit to a screen rather than a substance or specific behaviour. These themes may become associated with technology or technological-based situations when in reality they are relevant to both online and face-to-face practice. For example, there is a concern about software location apps breaching client privacy, and while I appreciate how this can occur and the subsequent impact on privacy, a client could equally be observed entering a building, revealing that they were attending therapy. It is notable that one respondent suggested that online therapy “Offers privacy for clients living in small towns” (#30). That similarity doesn’t mean, however, that as a profession we wouldn’t always be mindful of ethical issues arising.
Although undertaken at a unique point in time, from the findings of this research it is clear that there is still a duality of opinion regarding digital culture and the use of online therapy in current creative arts therapy practice in Ireland. One side of the debate cautions that art therapists shouldn't accept online therapy due to, “The ethical issues, also maintaining confidentiality” (#31), and maintains that there is, “Not enough evidence of efficacy and not enough protection for therapists .... not comparable to face to face in a physical space it is different therapeutically within and of itself” (#52). The other side maintains that creative arts therapy should be embracing the digital realm, “I am considering offering more supports online. It will take some work, reframing etc but I do think there is a space for it" (#26), and that, “It has also been incredibly beneficial in facilitating some significant shifts in the therapy process of clients that I believe would not have happened so easily if it had not been for the online therapeutic space” (#4).
Keaveny R. 2020, Dancing. Example of a digital image made using the Pixel Engine app. Birr, Offaly: Private Collection.
I’m not suggesting that creative art therapists should be obligated to adopt a method of practice that does not fit with their theoretical or personal framework. It is also important to acknowledge the long-standing conflict evident in the literature between moving towards engaging with digital practice/online therapy and a resolute position in not diverting away from traditional roots and materials. However, until an evolving awareness of both the limitations and potential surrounding the use of digital media and online therapy are explored and comprehended, how can an informed choice be made about technological adoption and integration within clinical practice? When we live in a world that is becoming evermore technology-based, it could be argued that as creative arts therapists we have a digital responsibility to our clients, requiring us to be digitally competent and literate.
Keaveny, R. 2020, Mirror. Example of digital image made using the Finger Paint Magic app. Birr, Offaly: Private Collection.
The issues presented through the findings of this survey are only a glimpse into an emerging practice in Ireland, but following the rupture in traditional practices and situationally hastened digital adoption, it is clear that creative arts therapies in Ireland have been given a once in a generation opportunity to consider the road down which they want to travel.
However, regardless of the future outcome, creative arts therapy has used it’s very essence to meet client needs in ways that, while seeming initially radically different due to their technological-based delivery, used the solid evidence-based structures of therapeutic principles, ethics and methodologies to support both clients and peers.
Albeit through the lens of the digital platform, that at times challenged, stretched, excited, exasperated, surprised and infuriated creative arts therapists during the COVID-19 crisis.
In a 2007 special edition of Art Therapy; The Journal of American Art Therapy Association, dedicated to exploring the emerging role of technology in the creative arts therapies, Dr Lynn Kapitan asked, "Will Art Therapy Cross the Digital Culture Divide?" She explored art therapies' relationship with technology, and the growing demand for interaction with it, but also identified both training and literature as distinctly lacking. These themes are still relevant today and were also present in my current findings, thirteen years later. This research contributes to the growing debates surrounding digital practice and exploring what informs digital adoption. It may have taken a global pandemic to induce it, but it can be argued that creative arts therapies in Ireland have indeed crossed the digital divide. However, the question remains, will it stay there and, if so, in what capacity?
* Please note, the # followed by a number contained within brackets, refers to the survey respondents' allocated number, with each being identified by a number rather than name, ensuring anonymity.
Read: Creative Arts Therapy Practice During COVID-19: Survey Findings
Austin D.B. (2009) 'Renewing the Debate: Digital Technology in Art Therapy and the Creative Process'. Art Therapy: The Journal of the American Art Therapy Association 26(2), 83-85.
Carlton N. (2014) 'Digital Culture and Art Therapy'. The Arts in Psychotherapy Vol 41, 41-45.
Carlton N. (2018) 'Digital Media Inclusion in Art Therapy Coursework' in C. Malchiodi (ed.), Art Therapy and Digital Technology. London: Jessica Kingsley Publishers, 373-393.
Choe N. (2017) 'Utilizing Digital Tools and Apps in Art Therapy Sessions' in R. Garner (ed.), Digital Art Therapy, Materials, Methods and Applications. London: Jessica Kingsley Publishers, 54-66.
Kapitan L. (2007) 'Will Art Therapy Cross the Digital Culture Divide?' Art Therapy: The Journal of the American Art Therapy Association Vol 24, 50-51.
Klorer (2009) 'The Effects of Technological Overload on Children'. The Journal of The American Art Therapy Association, V2 N2, 80-82.
Orr P. (2012) 'Technology Use in Art Therapy Practice: 2004 and 2011 Comparison'. The Arts in Psychotherapy, 39(4), 234–238.
Potash J.S. (2011) 'Fast Food Art, Talk Show Therapy: The Impact of Mass Media on Adolescent Art Therapy'. Art Therapy: Journal of the American Art Therapy Association. Special Issue on Art Therapy's Response to Techno-Digital Culture, 2(26), 52-57.
Rowena is an artist and art therapist based in the Midlands, Ireland. Her work uses digital media, photography, animation and socially engaged practice to explore the diverse issues surrounding social inclusion, disability and access to cultural participation experienced by marginalised groups.
As an art therapist, Rowena has a special research interest in and focus on the use of digital practices and online therapy. She also works with film-making through digital narrative to facilitate an understanding of individual experience and its impact, and as a tool to aid self-discovery and recovery.