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I put together this mind map. The yellow boxes are references. QI's link to BAAT directory of A.T's, Mind and Samaritans

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From the article -

Children’s illustrators were quick to raise concerns about the technology on social media. Among them is author and illustrator Rob Biddulph, who says that AI-generated art “is the exact opposite of what I believe art to be. Fundamentally, I have always felt that art is all about translating something that you feel internally into something that exists externally. Whatever form it takes, be it a sculpture, a piece of music, a piece of writing, a performance, or an image, true art is about the creative process much more than it’s about the final piece. And simply pressing a button to generate an image is not a creative process.”

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'Woman reading book, under a night sky, dreamy atmosphere," I type into Deep Dream Generator's Text 2 Dream feature. In less than a minute, an image is returned to me showing what I've described. Welcome to the world of AI image generation, where you can create what on the surface looks like top-notch artwork using just a few text prompts, even if in reality your skills don't go beyond drawing stick figures.

AI image generation seems to be everywhere: on TikTok, the popular AI Manga filter shows you what you look like in the Japanese comic style, while people in their droves are using it to create images for everything from company logos to picture books. It's already been used by one major publisher: sci-fi imprint Tor discovered that a cover it had created had used a licensed image created by AI, but decided to go ahead anyway "due to production constraints".

The biggest players in AI include companies such as MidJourney, Stable Diffusion and Deep Dream Generator (DDG). They're free to use, up to a point, making them attractive to those just wanting to try them out. There's no denying that they're fun, but closer examination of the images they produce shows oddities. The face of the woman in my image has very odd features, and appears to be holding multiple books. The images also have a similarly polished, somewhat kitsch aesthetic. And, while there's an initial thrill at seeing an image appear, there's no creative satisfaction.

'It's nonsense' ... Rob Biddulph in his studio

The implications of AI image generation are far-reaching and could impact everything from film to graphic novels and more. Children's illustrators were quick to raise concerns about the technology on social media. Among them is author and illustrator Rob Biddulph, who says that AI-generated art "is the exact opposite of what I believe art to be. Fundamentally, I have always felt that art is all about translating something that you feel internally into something that exists externally. Whatever form it takes, be it a sculpture, a piece of music, a piece of writing, a performance, or an image, true art is about the creative process much more than it's about the final piece. And simply pressing a button to generate an image is not a creative process."

Beyond creativity, there are deeper issues. An online campaign - #NotoAIArt - has seen artists sharing concerns about the legality of AI image generators, and about how they have the potential to devalue the skill of illustration. To create images from prompts, AI generators rely on databases of already existing art and text. These comprise billions of images that have been scraped from the internet. Among the biggest is the open-source LAION-5B dataset, used by DDG's Text 2 Dream. Kaloyan Chernev, founder of DDG, says that the dataset comprises "largely public domain images sourced from the internet", but many artists and illustrators say that databases will often also include a lot of copyrighted images.

Harry Woodgate, author and illustrator of Grandad's Camper, which won the Waterstones 2022 picturebook prize, says: "These programs rely entirely on the pirated intellectual property of countless working artists, photographers, illustrators and other rights holders." It's a point echoed by illustrator Anoosha Syed: "AI doesn't look at art and create its own. It samples everyone's then mashes it into something else."

The real thing ... Dapo Adeola's debut Hey you!

While prompts to image generators can be very general, they can also ask for an image to be based on the work of another artist, further blurring ethical boundaries. Syed says that this could lead to the creation of images "that are intentionally meant to mimic my style" or that of other artists, without their consent. There is an argument that AI generators work no differently to humans when it comes to being influenced by others' work, but Biddulph says: "A human artist is also adding emotion and nuance into the mix, and memory - specifically, its failings."

He adds: "If I'm making a painting and decide it should be Hockney-esque, I'm not going to trawl the internet for millions of Hockney-esque images, work out exactly what traits makes these images Hockney-esque, then apply them to my picture, systematically and with forensic accuracy. I'm going to think, 'I like the way Hockney juxtaposed blocks of purple, green and ochre in that painting of a field I saw at the National Gallery.' And then I'll attempt to add that into my picture. Inevitably, I'll misremember it, and will probably end up creating something that bears a faint resemblance to something Hockney once painted, but in my own style."

AI doesn't look at art and create its own. It samples everyone's - then mashes it into something else

Syed agrees, saying "another human will never look at an image the exact same way the original artist did. They will never move their hands the way the original artist did. AI doesn't do the same - it can only copy." When a human artist does "mimic a style, or pass off a piece of artwork as their own, it is incredibly frowned upon - and in some cases could be seen as copyright infringement. This is essentially what AI art is doing."

Chernev says he recognises the "complex ethical considerations surrounding the use of non-public domain images and the potential impact on artists whose work is used in the training of AI tools like ours". But there's a more insidious danger: the ability to create images that are potentially illegal. Chernev admits that during the initial launch of Text 2 Dream, people tried to "generate images of nude children, despite the fact that no such images were present in the training dataset".

He adds: "As AI continues to advance, there is a risk that it may be able to synthesise images of inappropriate or illegal subjects based on existing content. In response to this, we have swiftly adapted our tools to prohibit the generation of any inappropriate or illegal content, including nude images of children and NSFW material. We are committed to ensuring the responsible and ethical use of our image-generating service."

Although Chernev says DDG reported the incidents to authorities, as a whole AI image generation is unregulated, something artists are quick to point out. Both Woodgate and Dapo Adeola, who won Illustrator of the Year at the 2022 British book awards, would like to see more regulation. "A welcome first step," says Woodgate, "would be to scrap the UK government's proposed copyright exception, allowing text and data mining for any commercial purpose, and instead advocate for opt-in licence-based models." That way, Woodgate adds, any future databases would be created using voluntary contributions that are properly paid for.

Adeola agrees, saying the "simplest thing is getting permissions from the artists to use their work" along with a fee. Chernev says DDG does take on board requests from artists who want to be excluded from their system, but the "asking forgiveness, not permission" model is not one that sits well with Adeola, who says seeking permission "should have been the first stage".

In his own style ... an illustration by Rob Biddulph

Although children's book illustration will, say artists, remain largely unaffected, AI image generation has the potential to do away with smaller jobs that up-and-coming artists often rely on to build up portfolios. Syed says that for things such as fan-art, self-published books, logos and family portraits, people may turn to AI. "These clients will usually care more about saving money than the quality of the finished product," she says. "They will prefer to use AI if it means keeping costs low. So a lot of these small jobs will vanish."

The increasing use of AI, says Adeola, will also lead to a devaluing of the work of artists. "For me," he says, "there's already a negative bias towards the creative industry. Something like this reinforces an argument that what we do is easy and we shouldn't be able to earn the money we command." Biddulph goes further. "There's no question that AI-generated art devalues illustration," he says. "People will, of course, begin to think that their 'work' is as valid as that created by someone who has spent a career making art. It's nonsense, of course. I can use my iPhone to take a nice picture of my daughters, but I'm not Irving Penn."

For the moment, AI image generation is largely being used for fun, but Chernev says it's "rapidly approaching a level of sophistication and complexity that will allow it to generate highly realistic and nuanced images. I am convinced AI-generated content has the potential to not only enhance the work of artists and designers, but also to enable the creation of entirely new forms of art and expression."

Artists and illustrators aren't so sure. "AI-generated art has a specific 'look' to it," says Syed. "As time goes on, users will become more attuned to it and start to turn away from it because of its inauthenticity and 'cheapness'. I also think that, in response to AI, we might even see a reemergence and appreciation of traditional media."

What's more, illustrators firmly believe their most honest critics and biggest fans - children and young people - won't be convinced by AI art. "Children's books are highly complex, multimodal forms of communication," says Woodgate. "The kids who read them expect a great deal, not only from the stories and illustrations, but from the people who make them."

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'It's the opposite of art': why illustrators are furious about AI

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AI art generators may provide five minutes of fun for most users, but the blurring of creative and ethical boundaries is leaving many artists raging against the machine

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I've made myself some notes and quotes from texts that I'll try to chip in with on the day, and will bring in my physical art. But I also made this PPT in case anyone also wanted to add on to it. I'm aware that we may be unlikely to put up a PPT, so what I've done is made a QR code of the current PDF of slides. If people do want to add to it, then I can create a new QR code, but it would need to be before the end of Monday. I'll then print off some of the QR codes so that people can scan and look at the PDF whilst the debate goes on (useful for images particularly). I'm aware this may be OTT and a bit last minute and it's hard to organise such a big group, so I understand that on the day it may be as simple as what happened when we met last Tuesday! My printer is also very old, so the QR codes may even end up malfunctioning...

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The handbook of Art Therapy by Caroline Case- Pages 91-92

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The handbook of Art Therapy by Caroline Case- Pages 91-92

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"The transference may be an illusion, but without genuineness, which endorses reality, a transference relationship may not develop. The setting in which therapy takes place is 'secure' in the sense that there are physical walls and a door which is closed, which serve as reminders to both art therapist and client that therapeutic space has physical limits. The physicality of the walls, doors and windows provides the possibilities of going in or out though the physical boundaries of the space. In this sense the therapeutic space is an exact opposite of an illusion and the confinement to a space of a room intensifies rather than diminishes the feeling of safety. There is the symbolic space and the mixture between symbolic and literal intensifies transference phenomena and therefore facilitates the therapeutic process."

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VENSTER translated in English means window, and this study was using an interactive art installation that acts as a window to the 'outside world'. Is there's symbolism for connection to the clients individual external world or reconnecting compartmentalised aspects of their internal world?

Human-artwork meant one person was interacting with the installation.

Human-human mean't two or more people were involved and their responses were directed at each other.

There was 1417 responses picked up within eight sessions. Over half of the responses were human-human and around one-third were human-artwork responses. Showing how this installation was stimulating the individual but also connecting them to others.

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How nursing home residents with dementia respond to the interactive art installation 'VENSTER': a pilot study

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Nodes are locations in the document that facilitate reading from beginning to end. You can navigate node by node or select one to jump to.

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Interactive digital art for individuals with intellectual disabilities

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Interactive digital art for individuals with intellectual disabilities

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Forms of interactive digital art can teach individuals how to communicate efficiently in different ways, as well as encourage social skills and self expression (relational to art psychotherapy). it can be adaptable and accessible to everyone which is inclusive and allows active participation.

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Towards the development of a technology for art therapy and dementia: Definition of needs and design constraints

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Art therapy is a growing field of interest in the care and maintenance of quality of life for persons with dementia. This paper describes research tha...

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Gluing the pieces together: Female adolescents' construction of meaning through digital metaphoric imagery in trauma therapy

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This paper describes the construction of meaning through digital metaphoric imagery in trauma therapy with four female adolescents. These artworks sup...

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The British Association Of Art Therapists

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Art therapist and member Gudrun Jones tells us about her art therapy practice using Telehealth technology in a rural setting...
Introduction
I work within a rural palliative care team. I first used video conferencing technology twelve years ago, to provide supervision to an art therapist working 85 miles away; technology made the 170 mile round trip unnecessary. We were able to see the art work on screen and discuss it. Since then, the team has used this technology for our meetings and training. Our NHS Arts Therapies pan-Wales meetings are also held using this mode of electronic communication.

In 2014 our team was approached by a doctorate student from the Psychology Department at a local University. He was undertaking a research study into the use of telehealth technology in palliative care. The aim of the longitudinal case study explored how rural living patients made sense of the psychological support facilitated through the implementation of telehealth (Keenan, J. et al, 2014).

Eight laptops were made available for patients or carers to use at home, so that they could connect remotely with health professionals at our palliative care resource centre. As part of the research, I worked with three patients using this technology. Both the patient and I dialed into a secure number for the virtual meeting at an allocated time. This is like a 'Skype' link up, but is secure to protect confidentiality.

Distance and transport were a barrier for all three patients, preventing them from accessing our palliative care service. Without this technology I would not have been able to provide therapy sessions face-to-face, because of the time and distance required for me to travel to their homes.

Collie, et al (2006) describe the findings from various focus groups to discuss flexible ways of providing art therapy support to cancer patients at a distance The study concludes that in order to overcome the barriers for women with cancer, living in a rural area, the use of computers, e-mail and telehealth technology, offered a flexible and inclusive service.
First thoughts and concerns
I was familiar with using technology for meeting and training sessions, but not with providing art therapy and emotional support to patients by this means. My initial concerns were as follows:

*What would be the impact of missing non-verbal cues?
*What would happen if there was of a technological break down of connectivity in the middle of the session?
*Would the intervention feel distant and unsupportive?
*How would the flow of conversation be affected by a delay in technology? I was reminded of interviews on the television; presenters talking to someone over a satellite connection with an unnatural delay in reply.
*Would the quality of the image viewed on screen be good enough?
*Would not seeing the mage being made have an impact on the therapy process?
*How would the impact of the abrupt ending of the session - the hang up - affect the therapeutic relationship? (After the hang up the therapist is left with an image of yourself on the screen, as the other person will have left the virtual meeting room).
What happened during the interface with the screen (and the patient)?
1.Non-verbal cues
I was certainly able to see when the patient was struggling to speak with emotion or was crying. Whilst I did miss out on observing how someone was holding themselves or moving as they walked into the therapy space, it did feel that there was enough visual information available there for discussion about how that person was feeling at that point in time. I had worked with these three patients on a face-to-face basis in assessment before the research opportunity was offered. I feel that the initial face-to-face session enhanced the knowledge I had about them. Perhaps this is why some loss of non-verbal cues did not feel as if it was detrimental to the therapy process.

2.Technological break down
In terms of the technological problems, the researcher could have gone out to their home if they needed help with the connection. I agree with Wood (2015) in her reflections that technical support is important. I would add that having technical support and equipment that is well looked after is also crucial. We have a supportive tele-medicine manager, who I could depend upon, either on site or at the end of a phone. On one occasion when a technical difficulty arose, phone contact replaced the telehealth session. I learned to always carry a mobile phone to the room, so that immediate contact could be made between the patient and myself. During the research only one session was conducted over the phone for technical reasons. As with face-to-face sessions, should a patient need to make contact between sessions, this could be made by phone or now increasingly patients choose e-mail.

3.Distant or unsupported
I was anxious for the first few session, about the physical distance, and found myself sitting forward and pushing against the table top in a strange attempt to reduce the distance. This concern lessened as time went on and both myself and the patients relaxed into a more comfortable sitting position.

4.Time delay
The pacing in the conversation became more familiar with time. There were moments when we spoke over each other, but these were infrequent and no more problematic than when meeting in person. However, it is a new pace to get used to, which comes with time, confidence and relaxing into the session.

5.Quality of image on screen
In order to view the art work clearly it has to be held still in front of to the camera in the laptop. Like a face-to-face session, discussion takes place about the images and their significance. Sometimes additional questions need to be asked in order to make sure you have understood the different elements in the art work that may not have been clear in the showing on screen.

Seeing oneself on screen is something to get used to! For one patient, it was important not to have to look at themselves on the large screen, but to have a small image of themselves in a square in the corner of the laptop screen.

In terms of how I position myself in the room, I was careful to arrange the camera before each session centering myself in the screen, not too distant and not too close. This would be similar to the mid-distance you would see when watching a newsreader on television. I cleared away any clutter, such as my diary, files or bits of papers in order to gives an impression that there is space for the work in the session; it and the client have my full attention.

6.Movement delay
I found that moving in the chair, or waving arms and hands around highlighted the time delay and could be distracting. I have learned to sit quite still. Although having a patient on screen, who moves around a lot, is something you will get used to as time goes on. Like the sound delay there is a movement delay, the picture can become stuck for a short space of time.

7. Not observing the image being made
Depending on the camera position, it can be a private making process for the patient if they wish it to be. It was also possible to change the position of the camera and be able to view the work being made. In terms of being present and observing the production I have missed this experience, perhaps this is where the distance is felt most from my perspective. It was often left to the verbal discussion to offer information about the making experience.

8. Ending the session
I experienced the 'hang-up' as abrupt and I was uncomfortable if I hung up before the patient. It gave me the experience of cutting off that person, despite having verbally brought the session to an end, arranged the date of the next session and said goodbye. Discussing this with the tele-medicine manager, she suggested that I put the system on mute and wait until the patient has hung up, this surprisingly simple piece of advice, helped me to feel that the ending was more contained. As this element of the experience was not mentioned in the research findings, I assume it was more about my own anxieties.
Other factors to be aware of
External noise in the background can drown out the sound of someone speaking, and disturbs the sense of privacy and confidentiality. In this study, this was not a problem, but in the future I would discuss this with the patient at assessment to ensure that they make a quiet, private space for themselves within their home for the session duration.
The art therapy process
The following is a quote from the research; the participant was asked what the Art Therapy session entails:

"Well really what we do, we just work on images that reflect how I am
feeling and help then to kind of reflect back to you, you know, when we
discuss it, about things maybe I haven't realised that was going on with
myself, that sort of thing."

The activity in the session is the same as in a face-to-face art therapy session. There is time to reflect on the previous week; then moving into using art materials and image making to illustrate thoughts, issues and feelings; with the latter half of the session, for discussion on the significance of the image.

Unlike a face-to-face session, the image has disappeared once the patient has moved it away from the camera, out of view. I was more aware that I needed to hold the image in mind and revisit it during the session. The patient quoted above had a small A4 drawing pad, which was easy and manageable to hold up to the screen. I missed not having the image available should I need to reflect on a previous session, in preparation for the next session. However, having the image in our minds, added an extra dimension to the communication. The use of imagery, metaphor and visualisation throughout the Art Therapy process, enhanced the communication possible via telehealth. Perhaps this advantage can offer some compensation for the loss of direct face-to-face contact.
Research findings and feedback from participants
As part of the research project conducted by Keenan, et al. (2014) participants were interviewed once a month. The results of the findings identified two main themes (with some sub-themes) which are explored below:

1.'Facilitation of a relatedness supportive environment'

This was explained as telehealth helping to enhance the sense of connection between the medical professional and the patient. The therapist was perceived as providing a sense of companionship and diminishing the sense of burden experienced. Patients indicated that telehealth provided them with an immediate access to psychological support services. Making appointments was easier than organising face-to-face contacts which involved more time, travel and physical effort.

2.Empowerment - Control, Liberation of Choice, Emotional Self Awareness

2.1 Control
It was identified that telehealth offered a more equal dynamic, between the therapist and patient through the patient being in their own home. The researchers stated that there was a perceived sense of control for patients through not having to visit the health professional in the health setting - this removed a power divide.

"... you're in their space aren't you. Whereas at home you're on
your own grounds, so you're kind of more confident anyway".

I had been very concerned about the physical distance causing a psychological distance. I wasn't prepared for the experience to be reported by the patient as offering a more equal dynamic, with one participant saying: "there isn't that sense of divide".

It was also perceived that being able to see the therapist, ensured patients had their full attention during the session; as opposed to a phone contact where therapist could be engaged in other activity, such working on the computer.

2.2 Liberation of choice
The patients involved in the study were either living in a remote area, unable to drive, too ill to travel or had an existing physical disability. Patients often make numerous visits to the hospital, which costs them time and money. Telehealth saved their resources, as one participant said:

" ...if I'd gone to (town), it's pretty much the whole day really......, but
because I get tired when I do that sort of thing, then that would be me
finished for the rest of the day. Whereas sitting here in your own lounge
on a computer is not as tiring by any stretch of the imagination, so it
kind of leaves you more time to do other things"

2.3 Emotional self-awareness
The study recognised the process of growing self-awareness taking place during the art therapy process. This happened through the patients talking about their images and their symbolic importance in their experience of their cancer journey. They identified that therapy via telehealth, without the time and effort spent getting to a health setting, enabled them to have more time to reflect on the work before and after the session, and thus, enhancing the process of self-development. The study findings suggest that telehealth in its remote monitoring, can play a role in establishing patient empowerment and also, in managing their own psychological well-being and emotional needs.
Conclusion
These were three patient who had never experienced telehealth before and only one of whom was familiar with computers. Very quickly all three became relaxed with this method of communication. When used alongside clear boundaries and structure in the art therapy session, it did not appear that the therapeutic process or therapeutic relationship was adversely affected by the perceived limitations of the technology.

I valued the opportunity to work with the University researchers last year. It enhanced my learning regarding setting up a research study and I can see that in the future, working like this will make it possible for oncology and palliative care patients and families to have a choice in terms of the psychological support that they can access. There is much to learn about working in this way. I am both excited to be working again with researchers and nervous about this next pilot project.

In the future, I am certain that further research from the perspective of patients and therapists will develop a body of knowledge about offering art therapy using this technology. Other art therapist and psychological therapists working in this way, will contribute to understanding the experience of offering and receiving psychological support in this way.
Written by Gudrun Jones References
Keenan, J. ( 2014) 'Professionals attitude to telehealth, patients and carers experience of rural palliative care and exploring patients experiences of accessing psychological support through telehealth', unpublished doctorate study

Keenan, J. et al. (2014) 'Exploring palliative care patients' experience of accessing psychological support through telehealth', unpublished

Wood J. (2015) 'A summer researching digital art therapy' in Newbriefing British Association of Art Therapists (BAAT), December

Weitz, P. (Ed.) (2014) 'Psychotherapy 2.0: Where Psychotherapy and Technology meet', Karnac Books

Collie, K., Bottorf, J.L., Long, C.B., Conati, C. (2006) 'Distance art group for women with breast cancer: guidelines and recommendations'. Online Resource. Available at: https://www.researchgate.net/publication/7281566_Distance_art_groups_for_women_with_breast_cancer_Guidelines_and_recommendations

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Providing art therapy in palliative care using telehealth technology - The British Association Of Art Therapists

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Art therapist and member Gudrun Jones tells us about her art therapy practice using Telehealth technology in a rural setting... Introduction I work within a rural palliative care team. I first used video conferencing technology twelve years ago, to provide supervision to an art therapist working 85 miles away; technology made the 170 mile round trip unnecessary.

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Here’s How Art Schools Are Dealing With The Rise of AI Generators

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https://www.vice.com/en/article/jgpzz3/ai-art-in-schools

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Image by Janus Rose, generated with Stable Diffusion

To prepare for the 2023 spring semester, New York University professor Winnie Song did something she's never had to do before: she created AI art guidelines for her students. Song, an assistant arts professor in the Game Center at NYU's Tisch School of the Arts, is not the only art instructor thinking about this. With the rapid rise of automated systems like Stable Diffusion, Midjourney, and DALL-E 2 within the past year, instructors at post-secondary art institutions are trying to figure out how to broach the topic with their students while still learning the intricacies of AI art themselves.

"My worry was that they would use the AI generators to come up with mood boards and references of things that don't exist in real life. So I just set a policy where, within the bounds of this class, it's discouraged to use the generators," Song told Motherboard. "I really didn't ever imagine that it would get to this point where people would be, like, trying to legitimize it as a craft." AI-generated art has flooded the internet since users began generating elaborate images with just a written phrase or highly stylized portraits by uploading a selfie. The tools have been met with fierce backlash from many artists, who note that the AI systems produce derivative images after ingesting millions of original artworks without permission from their creators. But while the growing sophistication of AI generators is raising profound questions about the nature of art and the creative process, it is also creating very tangible dilemmas for art educators who want their students to develop skills that go beyond typing a phrase into a text prompt and turning it in as their own work. "I think we endeavor to teach them to become independent of tools and also make sure that they remain sort of agnostic, not reverent and dependent on one thing to get presentable work," Song said. "You can learn this, and you can think about it, but that can't be your one main thing to get to where you need to be."

The ways professors have been introducing AI art in the classroom varies between classes and disciplines. Song said she's teaching a drawing class in which students are supposed to derive inspiration from nature and the physical world, hence her AI art policy. On the other hand, Kurt Ralske, a digital media professor and department chair of media arts at Tufts University's School of the Museum of Fine Arts, is taking a different approach. "Personally, I've been encouraging students to explore this. I think they should know what the tools are, what they're capable of and maybe develop a personal vocabulary of how to use them," Ralske told Motherboard. "But we really are overdue for actually maybe having a larger discussion within the university of how we should handle these things." Doug Rosman, a lecturer in the Art and Technology Studies department at the School of the Art Institute of Chicago, is also having students explore the generators in his machine learning class. But, in his professional practice class, a more career-focused course, AI art and its impact on working artists is a different discussion. "In that context, the outputs of DALL-E and Stable Diffusion feel more threatening," Rosman told Motherboard. Instructors aren't the only ones thinking about the products of AI art generators. Art students are also dealing with the effects of AI art saturating the market for artists and what that could mean for their careers. "The way that artists are embracing crazy capitalist, hyper-technology culture is just really disheartening," said Marla Chinbat, an art student at the University of Illinois-Chicago. "I wouldn't be surprised if AI art actually begins to hold merit because of a side of the art world that I don't align myself with." None of the instructors or students at the institutions interviewed by Motherboard said their department or school had issued AI art guidelines or a policy for using AI art generators for projects. Charlotte Belland, a professor and chair of the animation program at the Columbus College of Art & Design, said setting parameters is left to individual instructors depending on the topics and concepts being taught in class. "As long as they establish what their parameters are, then that's an open forum to be able to either use or not use AI technology," Belland told Motherboard. However, learning how these programs work and how to help students use them takes time and effort on behalf of the instructor. If an instructor is not already familiar with machine learning or computer science, navigating the ways AI-art generators are shaking up the art world and understanding the algorithms could take extra work. "Teaching is hard. It's so much work and it's not well compensated," Rosman said. "It's not fair that a small demographic of people in Silicon Valley can just throw this thing out into the world, and we've got to just run around picking up the pieces."

Even if their instructors have not brought up AI art in classes, students are still thinking about how AI art generators are affecting the art world. Susan Behrends Valenzuela, an art student at NYU Steinhardt, said the subject has only come up once in just one of her classes, but would be interested in further discussions in other classes. "I do wish we had talked about it a little bit more," she told Motherboard. "But at the same time, I think in order for that to happen, my professors would need to kind of know a little bit more about that type of technology, and I just think it's not something they're really focused on." Students are also thinking about how they could use these tools as part of their processes. Rhode Island School of Design painting student Julia Hames said they played around with AI generator Wombo for inspiration. "For a while, I didn't have any ideas of what to paint, so I'd just put in random prompts into Wombo to see what it created," Hames told Motherboard. "I didn't really like anything, but maybe it could be used for that because the images are so absurd and it just lets you into this uncanny valley that honestly humans can't even get to sometimes."

Song, Ralske, Rosman, and Belland all said they have not had students use AI-art generators for projects without their knowledge. If a student did use AI for a project, the way they used it was clear to the instructor. Belland said that if a student did try to use AI without consent from an instructor, being in a community with diverse perspectives and skills would help catch it. "The nice thing about an educational community is you have so many eyes on a project," she said. "Even when a student makes an unfortunate decision to copy something in just a very traditional method, plagiarism, it's pretty easy to spot." As for Song, she is also not too concerned with her students passing off AI-generated images as their own because she is already familiar with their work. She's more worried about the students she hasn't even had in class yet. "In admissions, these new students are coming in from high school, from another life that we don't know," she said. "I think it could be possible for them to have created a portfolio out of thin air overnight using these generators, depending on how good they become."

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Here's How Art Schools Are Dealing With The Rise of AI Generators

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Automated tools like DALL-E and Stable Diffusion are changing how instructors teach their students, but many won't ban them outright.

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Telehealth-based creative arts therapy: Transforming mental health and rehabilitation care for rural veterans

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Arts programs are increasingly recognized for their ability to enhance healthcare and promote health outcomes such as improved quality of life, increa...

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Telehealth-based creative arts therapy: Transforming mental health and rehabilitation care for rural veterans

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Arts programs are increasingly recognized for their ability to enhance healthcare and promote health outcomes such as improved quality of life, increa...

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BAAT article about the use of online therapy. 

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BAAT article about the use of online therapy. 

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Mentions a book called ‘Art Therapy and Computer Technology: a virtual studio of possibilities’ by Cathy Malchiodi that I am also currently reading (slightly outdated from the 2000s) and this talks about Tele-health and how it had grown in the area of mental health services.         Another area of the article that was intriguing was the term “blending method” which unfortunately I couldn't find much research in relation to this when searching online. But in the article it mentions this is the combination of face-to-face and online art therapy, mobile and email. This seems to be the middle ground where some Art Psychotherapists feel most comfortable in regards to digital media incorporated into the therapeutic relationship.

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The British Association Of Art Therapists

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I have been working in two locations, London and Fuerteventura for the past five years, during this time I have provided online art therapy developing my practice in this area. In this article I describe switching between face-to-face art therapy and online art therapy as a 'blending method'. Switching between the online and the face to face art therapy practice has allowed me to work within two different settings/locations and introduced technical and practical experiences of connection, interruption, disconnection and re-connection which enabled one client to build capacity to cope with physical proximity and distancing. Introduction
Practising art therapy online seems to raise many questions, reactions and some interesting debates between art therapists. Following an online discussion with several art therapists and receiving feedback about my practice, it seems that some art therapists appear to resist engaging with the internet therapeutic world believing that it is not a real "face-to-face meeting" and that it might make service users "feel as if they are being pushed through the system". Some believe that it could only "compound client's feelings of worthlessness". However, developments in the area of 'tele-health' and tele-counselling have been growing, and although many colleagues feel that we should embrace working online, we "do not seem to know much about it".

In 2000, Cathy Malchiodi published 'Art Therapy and Computer Technology: a virtual studio of possibilities' where she provides an overview of online counselling and therapy initiatives in North America. The term tele-health care developed in the 1980's and 1990's as 'technology cost decreased and became more accessible to the public' (Malchiodi, 2000: p.15). Tele-health is described as: 'the use of telecommunications to provide access to health assessments, diagnosis, interventions, consultation, supervision, education and information across distance' (Malchiodi, 2000: p. 16). Giving health care advice, assessments and diagnostics are now common place in the United Kingdom and tele-counselling has also grown in the area of mental health services, however the practicalities involved in transferring art-based relational therapies to a remote online format is new, challenging and its efficacy has not been researched. Research of online supervision has received some coverage by Brandoff & Lomdardi (2012) who wrote about their online art therapy supervision experiences which facilitated the use of video conferencing.

There are several research papers cited by Malchiodi, one by doctoral student Collie (1998) and Collie & Cubranic (1999). In the UK the most recent published article was by Gudrun Jones (2017) who describes providing tele-health art therapy sessions to palliative care patients in rural communities in Wales. The sessions described in this article formed part of a wider tele-health research project coordinated by the health care provider and a local university, the online art therapy work is evaluated through the use of post-session questionnaires and transcribed feedback. As well as giving helpful advice regarding the technical equipment and issues around viewing the art-making process and final artwork during sessions, the research provided more in-depth qualitative information about the relational experience for patients. The experiences quoted refer to the positive levelling of the power dynamic between therapist and patient, also a sense of control as the patient was in their own home and had planned and immediate access to therapy at the agreed appointment time. The research also showed that patients were able to prepare for the sessions and reflect on the relational work post-session and thus benefited by supporting individuals to manage their own psychological well-being and identify their emotional needs. The transition to online therapy did not seem to inhibit engagement in the work: 'When used alongside clear boundaries and structure in the art therapy session, it did not appear that the therapeutic process or therapeutic relationship was adversely affected by the perceived limitations of the technology' (Jones, 2017).
Blending: Art therapy referrals and initial appointments
The "blending method" is a broad-based art psychotherapy practice approach that combines the use of face-to-face and online art therapy, mobile and emails. Using the "blending method" digital and face-to-face formats complement each other and can be adjusted to a clients' mental health needs. This practice alternates every sixth week between face-to-face and online art therapy and can also be adjusted between online art therapy and asynchronous emails and texts. Most referrals come from a multidisciplinary team or the GP in Fuerteventura.

The initial contact with clients takes place over the phone or via email, giving a layer of distance and anonymity. Following the initial telephone appointment, I email an art therapy information personalised pack. It contains consent forms, a confidential and private mental health questionnaire that must be completed before the initial face-to-face art therapy appointment takes place. Consent forms are signed in the art therapy studio during the initial face-to-face art therapy appointment. The initial appointment lasts 90 minutes. Combining the two art therapy practices enables me to internalise the client's emotional difficulties and gather quite detailed information. Some clients may require a follow-up appointment to cover the online art therapy structure and boundaries agreement. The art therapy evaluation review is made face-to-face or on Skype every six weeks. Online art therapy sessions usually take place once a week at the same time, for 50 minutes on Skype.
Online art therapy intimacy and space
I facilitate online art therapy sessions from my art therapy studio, the background wall is white. The white wall enables clients' imagination to run or to relax. In the pre-session information pack, I ask the client to prepare a space from which they can comfortably speak, and with a surface that they can work on; sometimes I find myself distracted by the background decor, the atmosphere and noises. Sometimes the living room is tidy, bright and gives the impression of an airy and warm space, as the sun shines through the open window. Occasionally an outside 'intruder' will disrupt the online therapeutic process, a dog barks or someone knocks at the door.

The client's home space seems to change more frequently with adolescents than with adults. By the end of the day I feel like I have visited many houses, seen many kitchens, living rooms, bedroom floor, or even been distantly sitting on a clients' bed (this makes the art engagement more difficult unless clients are using ballpoint pens). Some clients talk about tidying and cleaning their private space before their online art therapy session starts. A client's room might also reflect the family dynamic or their state of mind and can give me new information to think about. I wonder if I can ask questions or would this be crossing a client's private space boundaries?

When meeting online we ensure that we are mutually wearing earphones, it makes us feel connected, close but distant, private, and intimate. I am aware that all we can see of each other is our upper body and wonder whether this viewpoint might trigger ambiguous feelings. Only seeing the upper body seems to have a predominant affective element in the online art therapy space. The empathic gaze seems to feel more consciously intense than in face-to-face art therapy because we mainly focus on the face. Non-verbal communication is different with each client, and cultural identity and social cues are reflected in behavioural mannerisms and eye contact. Those qualities enable the client to become emotionally attached, and encourage a balanced emotional attachment enabling the client's inner-self to tolerate the healthy distance with and from the warm and containing e-therapist.
Relational dynamics: virtual relationships
Evidence suggests that 40% of the effectiveness of the therapeutic work can be attributed to the quality of the therapeutic relationship (Lambert, 1992). The concern that we may experience when working online is in maintaining the therapeutic alliance and creating a secure attachment. According to Mikulincer & Shaver (2007) secure attachment is related to positive relationship qualities. It does not matter how clients and art therapists are connected, as long as the therapeutic process is constant. An important part of online therapy is to allow clients to express difficult feelings and emotions relating to the virtual relationship, and how the current relationship may evoke thoughts and feelings about not being able to form a secure attachment.

I find that the virtual relationship requires more emotional and practical involvement from both the art therapist and the client. When I look at a clients' creative engagement or when we are mutually looking at the images, I am aware that I often move forward or backward from the screen, which may create a sense of closeness that does not seem a threat to the client. Warmth and presence can be developed through distant positive cues such as smiling, having a friendly look, being empathic and attuned, being non-verbally responsive and having the ability to adjust the cues' intensity and emotional tone to match the client's state of feeling and their perceived needs.

Online creative engagement can unveil difficult feelings and behaviours such as feeling hopeless, angry if the session is interrupted, feeling abandoned when the signal is disconnected, or feelings of controlling the other or feeling powerless. Although the client engages alone under my constant yet distant presence, I am watching her and I take care to promote the therapeutic relationship.
Interruptions- disconnections - ruptures - reparation - reconnection
According to Scharff (2013: p.16) working online can endure technical difficulties and each situation will be experienced differently depending on the negative or positive transference context. Online technical difficulties such as WIFI signal constancy, sync delay or loss of signal can interrupt the online connection and communication between client and therapist, introducing more complexity to the online art therapy relational dynamic. These technical difficulties can challenge and compromise the online therapeutic frame. Despite having issues with internet connection failing or the signal becoming weak or just being interrupted, I decided to monitor and examine both the clients and my own responses to sudden separations. Over time I have been begun to perceive internet interruption as a threat that activates attachment concerns.

Early on in the therapeutic process, I noticed that when the internet connection failed, it triggered powerful emotions in me, feelings of insecurity, being frustrated, bringing up anger, feeling of hopelessness or even becoming avoidant. Once the connection was re-established, I found that I felt relieved and calmer. Some clients appeared emotionally distressed as if their depressed state of mind was triggered by a sudden disappearance, a fear of abandonment perhaps? Whilst others had no reactions as if they were numb, perhaps this was presenting a client's emotional defence mechanism.

At the same time as the online art therapist is briefly off-line and the relational rupture is triggered, some clients may still engage in the creative process while others stop or may try to reconnect. The images sometimes seem to reveal disrupted relationships. The images varied including visceral, abstract, symbolic, colourfully bright, monochrome doodles, and very messy imagery. The images made during the disconnection gave me further information to inform my understanding of their state of mind and relational attachment. The off-line ruptures often become an opportunity to explore the experience of relational attachment further. Afterwards, when we reconnected, reparation could occur, as the client sees my empathic attuned gaze and our synchronised sitting upper bodies. Additionally, our shared attention is reflective, and we discuss the images and how the client experienced the off-line rupture. This therapeutic process enables the client to develop thoughtful and behavioural awareness as well as understanding and acknowledging the relational dynamics and the attachment rupture. The aim is that, consequently, the new interpersonal relational experience will be internalised and changes to defence mechanisms may occur.

Through the creative art engagement and process, the client understands and acknowledges the relational dynamics and her attachment rupture. During the disconnection, the experience of the client-art therapist relationship can be challenging. Consequently, this is revisited in a face-to-face art therapy session. So far, there has been no research into the use of internet interruption being used as a treatment tool to reconnect. However, this seems to play an important role in this online art therapy process and practice.
Disinhibition online
The virtual art therapy practice uses different online communication modalities in addition to the online clinical hour. I have incorporated the use of email, text, and telephone to connect with clients which creates an "invisible" exclusive online auditory presence. Initially, the use of the phone made me feel slightly anxious at not being able to see clients. The client's voice amplified in my ears and different "invisible" hearing cues developed. The client voice is stressed, sad, angry, frustrated or happy. The client pauses, is this used to emphasise her issues? Her intonation, punctuation, long and short breathing seems to reflect anxiety. Most of my clients have different accents so I find myself adapting to distinctive cultural cues.

Text-based communication can enable online art therapists to find out more about clients' personalities that might emerge in face-to-face art therapy sessions. Perhaps using email and text ("asynchronous") with or without images and sound attachments may encourage clients to feel safer and less self-conscious while hiding behind the screen. Consequently, clients may relax their inhibition. According to (Suler, 2004), each digital setting allows therapists to examine different perspectives on a clients' identity. He referred to it as "variables in personality" which influences clients' disinhibition. Therefore, disinhibition might be associated with positive and negative online behaviours showing the true personality traits.

The use of texts and emails could suggest that clients might feel a need for further emotional support. Text-based communication can reflect inner-emotions and sometimes trigger compulsive behaviour, e.g., some clients may send emails and texts obsessively. These communication modes can be carefully used with clients who are too overwhelmed at the idea of proximity, feeling shameful, have social anxiety or feeling stigmatized. Clear boundaries are essential when working online and require guidance, support and strong planning so clients and virtual art therapists remain safe.
The online art therapist self-presence
Through the use of a Skype camera, I have developed an awareness about myself being reflected in the top right corner of the screen. This little rectangular window initially distracted me, as I never saw myself engaging with clients. I became aware of my empathic presence and stance as my face changes expression.
Storage and creation of a digital portfolio
I use my Gmail e-mail account to receive digital images from clients. Most clients capture their images made during or after the online session with their mobile phone which is synchronised with iPhoto. Clients are now in charge of their virtual art portfolio and their art therapy portfolio. All images received on my Gmail work account are exported in an external safe and code protected hard drive. The confidential hard drive is kept in a locked cabinet.
Digital artwork review
The digital artwork review structure is straight forward. Clients can retrieve their images from their computer or their art therapy portfolio. The asynchronous written record of online art therapy sessions (e.g. emails and texts), can be used as a reminder of the issues that had been previously expressed. For example, clients are able to re-read e-mails and see images that had been sent or received. This enables both therapist and client to evaluate the progress and review of the online art therapy sessions which focus on progress and clinical treatment plan. Images can be viewed mutually from a distance; however, most clients prefer to view the original images stored in their art therapy folder.
Conclusion
The provision of online art therapy during this critical pandemic emergency enables people to have immediate early intervention access to mental health services. The nature of social isolation, confinement and social distancing will impact us all during lockdown as the restrictions ease and the full impact of changes are felt. Online art therapy can and must be used with precaution and preferably with training by online qualified and registered art therapists. However, there is an immediate and ongoing need for art therapy from the general population and particularly for those with pre-existing mental health needs. Feeling overwhelmed from being isolated is also leaving us in a vulnerable position, especially when an emergency crisis occurs as we are not sharing the same space. This requires clear parameters around expectations, safety protocols and risk assessments, particularly at the assessment stage and defined in the initial online art therapy information pack.

The use of asynchronous communication, e.g. email and text, seems to be a necessary part of online art therapy as we arrange or confirm appointments, receive digital images and send invoices and receive payment confirmation by email. Developing clear protocols around email contact is essential in order to define therapist's boundaries and information sharing. E-mail communication can even be an advantage for online art therapists as it enables them to have more time to think about client's issues and enables both the client and art therapist to revisit email exchanges. However, it can become a risk if the online space doesn't remain safe and confidential. Confidential online file storage is not safe as it can be hacked and lost if the digital world breaks down. I suggest always copying and saving clients' files onto a hard drive where they can be secured with password access only. The art therapy review can be facilitated online by using shared online folders alongside clients' physical art therapy folder.

The assessment, the art therapeutic frame and methods such as evaluation and the retrospective review, do change when delivering art therapy online. By reformulating the art therapy working frame we are in a better position to understand client's mental health difficulties and better equipped to support emotional distresses and psychosocial disturbances associated with coronavirus. However, the pandemic will increase many underlying mental health conditions. With the aid of specific creative tools, by sharing problem-solving strategies and facilitating directive group and individual online sessions, clients may be able to regain a sense of self control and a feeling of empowerment over the COVID-19 pandemic. I suggest that online art therapy can foster the development of better coping mechanisms and increase resilience, enabling clients to feel heard and connected whilst being isolated. It can also reinforce feelings of hope and strength towards the future to overcome and seek, as well as continue, treatment for any underlying mental health conditions.
Article by Sophie Benoit, first published in Newsbriefing Summer 2020, British Association of Art Therapists. References
Bowlby, J., 1969. Attachment and Loss. London: Hogarth Press, p.xviii.

Brandoff, R. & Lomdardi, R. (2012) Miles Apart: Two Art Therapists' Experience of Distance Supervision. Art Therapy: American Journal of Art Therapy, 29:2, 93-96, DOI: 10.1080/07421656.2012.683729

Cundy, L. (2015) Love in the Age of the Internet. Attachment in the Digital Era. London: Routledge, https://doi.org/10.4324/9780429476938

Jones, G., (2017) Providing Art Therapy in Palliative Care using Telehealth Technology in Newsbriefing, April edition. London: British Association of Art Therapists.

Lambert, M.J. (1992) 'Implications of Outcome Research for Psychotherapy Integration', in Norcross and Goldstein (1992), pp. 94-129.

Malchioli, C. A., (2000) Art Therapy and Computer Technology: a virtual studio of possibilities.
London: Philadelphia: Jessica Kingsley Publishers.

Mikulincer, M. and Shaver, P. R. (2007) Attachment in adulthood: Structure, dynamics, and
change, New York: Guilford Press. pp.424-579.

Mikulincer, M. and Shaver, P., (2007) Attachment Theory and Affect Regulation: The Dynamics, Development, and Cognitive Consequences of Attachment-Related Strategies. Psychological Inquiry, [online] 18(3), pp.197-209. Available at:
<https://www.researchgate.net/profile/Mario_Mikulincer/publication/285623488_The_Attachment_Behavioral_System_In_Adulthood_Activation_Psychodynamics_And_Interpersonal_Processes/links/573d709808ae298602e5a533/The-Attachment-Behavioral-System-In-Adulthood-ActivationPsychodynamics-And-Interpersonal-Processes.pdf> [Accessed 5 July 2019].

Scharff, J., (2013) Psychoanalysis Online: Mental Health, Teletherapy And Training (Library Of Technology And Mental Health). London: Karnac Books. pp.15,16-272

Suler, J., (2004). The Online Disinhibition Effect. CyberPsychology & Behavior, 7(3), pp.321-326

Winnicott, D., (1971). Playing And Reality. London: Tavistock.

Weinberg, H., (2014). The Paradox Of Internet Groups. London: Karnac Books.

Weinberg, H., (2020). From The Circle To The Screen Gasi Webinar. [Vimeo video].
https://vimeo.com/399456923

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Online art therapy - The British Association Of Art Therapists

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I have been working in two locations, London and Fuerteventura for the past five years, during this time I have provided online art therapy developing my practice in this area. In this article I describe switching between face-to-face art therapy and online art therapy as a 'blending method'.

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Using distance technology to deliver the creative arts therapies to veterans: Case studies in art, dance/movement and music therapy

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Three case studies of veterans are presented who received either art therapy, dance/movement therapy or music therapy via in-home, synchronous clinica...

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Using distance technology to deliver the creative arts therapies to veterans: Case studies in art, dance/movement and music therapy

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Three case studies of veterans are presented who received either art therapy, dance/movement therapy or music therapy via in-home, synchronous clinica…

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Distance art groups for women with breast cancer: guidelines and recommendations - Supportive Care in Cancer

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To overcome barriers that prevent women with breast cancer from attending support groups, innovative formats and modes of delivery both need to be considered. The present study was part of an interdisciplinary program of research in which researchers from counseling psychology, psycho-oncology, nursing, computer science, and fine arts have explored art making as an innovative format and telehealth as a mode of delivery.

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An exploration of the qualities and features of art apps for art therapy

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An exploration of the qualities and features of art apps for art therapy

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"Will Art Therapy Cross the Digital Culture Divide?"

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"Will Art Therapy Cross the Digital Culture Divide?"

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Written in 2007 - Kapitan writes about art therapy as a practice perhaps wanting to retain some kind of "purity" by not using digital art and media, and goes on to challenge this. Nice and short - only 2 pages!

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Will Art Therapy Cross the Digital Culture Divide

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"COVID-19: Creative Arts Therapies Crossing the Digital Divide"

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"COVID-19: Creative Arts Therapies Crossing the Digital Divide"

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Survey of Art Therapists in Ireland, about how their work has adapted during COVID. Interesting to capture resistance / support for online working

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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
References

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 Keaveny

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.

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COVID-19: Creative Arts Therapies Crossing the Digital Divide

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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.

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"Lifeline, frontline, online: Adapting art therapy for social engagement across borders"

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"Lifeline, frontline, online: Adapting art therapy for social engagement across borders"

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Article on working during COVID, virtually, with migrant groups in Calais. Considers therapeutic boundaries alongside geographical borders. Argues for the online space being a way of forming community in a time of intense isolation. Made me wonder if the work they were doing was "art therapy", or more community arts - where's the line?

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Lifeline frontline online adapting art therapy for social engagement across borders

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https://chat.whatsapp.com/Kkvaa6pa3wm32xg4nDld7e

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I may be jumping the gun, but made a Google doc with a couple of first thoughts and divided it into sections based on the outline we were given. Feel free to add to it!

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“The house believes digital formats are an essential component of contemporary art therapy.”

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1994: "Today Show": "What is the Internet, Anyway?"

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Using Artificial Intelligence to Enhance Ongoing Psychological Interventions for Emotional Problems in Real- or Close to Real-Time

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Machine Learning and Natural Language Processing in Psychotherapy Research- Alliance as Example Use Case

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Efficacy of Artificial Intelligence-Assisted Psychotherapy in Patients With Anxiety Disorders

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Computer judgment of main color in a drawing for art psychotherapy assessment

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Attitudes and perspectives towards the preferences for artificial intelligence in psychotherapy

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Something I was introduced to whilst searching for a therapist. You can draw or paint or use stickers and the therapist can watch you do this in real time. Clients can also work in groups

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Draw a picture together with your friends in real-time over the internet in your browser

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Making Art Therapy Virtual: Integrating Virtual Reality Into Art Therapy With Adolescents

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Making Art Therapy Virtual: Integrating Virtual Reality Into Art Therapy With Adolescents

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In recent years, the field of art therapy has sought to adapt traditional treatment approaches to today’s innovative technological environments when working with adolescent “digital natives.” In their clinic, art therapists often struggle with lack of cooperation when treating adolescents during ses…

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Art Therapy in the Digital World: An Integrative Review of Current Practice and Future Directions

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Institute of Health Research and Innovation, University of the Highlands and Islands, Inverness, United Kingdom

Independent Researcher, Moray, United Kingdom

Population Health Science Institute, Newcastle University, Newcastle upon Tyne, United Kingdom

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, United Kingdom

Background: Psychotherapy interventions increasingly utilize digital technologies to improve access to therapy and its acceptability. Opportunities that digital technology potentially creates for art therapy reach beyond increased access to include new possibilities of adaptation and extension of therapy tool box. Given growing interest in practice and research in this area, it is important to investigate how art therapists engage with digital technology or how (and whether) practice might be safely adapted to include new potential modes of delivery and new arts media.

Methods: An integrative review of peer-reviewed literature on the use of digital technology in art therapy was conducted. The methodology used is particularly well suited for early stage exploratory inquiries, allowing for close examination of papers from a variety of methodological paradigms. Only studies that presented empirical outcomes were included in the formal analysis.

Findings: Over 400 records were screened and 12 studies were included in the synthesis, pertaining to both the use of digital technology for remote delivery and as a medium for art making. Included studies, adopting predominantly qualitative and mixed methods, are grouped according to their focus on: art therapists' views and experiences, online/distance art therapy, and the use of digital arts media. Recurring themes are discussed, including potential benefits and risks of incorporating digital technology in sessions with clients, concerns relating to ethics, resistance toward digital arts media, technological limitations and implications for therapeutic relationship and therapy process. Propositions for best practice and technological innovations that could make some of the challenges redundant are also reviewed. Future directions in research are indicated and cautious openness is recommended in both research and practice.

Conclusion: The review documents growing research illustrating increased use of digital technology by art therapists for both online delivery and digital art making. Potentially immense opportunities that technology brings for art therapy should be considered alongside limitations and challenges of clinical, pragmatic and ethical nature. The review aims to invite conversations and further research to explore ways in which technology could increase relevance and reach of art therapy without compromising clients' safety and key principles of the profession.

Introduction

The use of digital technology in art therapy is not limited to online communication tools but extends to the application of digital media for the purpose of art making, equally relevant to face-to-face practice. While distance art therapy could potentially widen the reach of therapy to include new groups of clients, expanding the range of therapeutic tools to include digital arts media might extend art therapy toolbox to widen access for those clients who might not otherwise engage in traditional art materials for a variety of reasons.

However, it has been argued that the process of digital media adoption in art therapy is slow ( Carlton, 2014; Choe, 2014) and resistance to digital technology as well as concerns about the use of digital tools for art making in therapy have been reported in literature ( Kuleba, 2008; Klorer, 2009; Potash, 2009). It has been even implied that art therapists themselves may be more conservative and hesitant in their use of digital media than their clients ( McNiff, 1999; Peterson et al., 2005; Carlton, 2014). This cautiousness is stipulated to be informed by a heightened sense of responsibility for clients' safety and wellbeing ( Orr, 2016). Art therapists' own emotional factors and biases were cited to be important barriers to adoption of technology ( Asawa, 2009) while it has been suggested that therapists experience "conflict between the desire to promote art therapy and engage in technology and the desire to remain loyal to the field's origins in traditional methods of communication and art media" ( Asawa, 2009, p. 58).

Aims

In order to identify key topics important for practitioners and areas for further research, we aimed to capture and synthesize available research literature that explores the role of digital technology in the current and future art therapy practice (understood here as within-session work with clients). More specific research questions were:

- How do art therapists use digital technology in their practice?

- What benefits and challenges of using digital technology with clients do they identify?

- How do clients experience art therapy sessions with digital technology elements?

Methodology

Search Strategy

Inclusion/Exclusion Criteria

We opted for broad inclusion criteria to report on all research studies pertaining to the use of digital technology in art therapy and therefore no specific definition of 'digital' was adopted other than how authors describe the focus of their paper(s). Time of publication was not initially considered a selection criterion but on reviewing the papers a decision was made to exclude those that focused on technology no longer relevant to modern practice, which, it was felt, related to articles published before 1999.

Articles were included in the review if they:

- concerned the use of modern (currently relevant) digital technology (DT) in within-session art therapy practice with clients;

- reported outcomes observed through empirical study, regardless of whether these were investigated using quantitative, qualitative, mixed or arts-based methods;

- were available online and in English.

Articles were excluded if they:

- focused exclusively on the use of digital technology for office work, assessment, supervision, training or research;

- were PhD theses, dissertations or books/book chapters;

- were theoretical/opinion papers with no empirical data reported.

Data Extraction

Data were extracted from included papers using a data collection form based on the Template for Intervention Description and Replication (TIDieR; Hoffmann et al., 2014) which helped to record the characteristics of the studies, interventions, outcomes and main findings reported.

Data Synthesis

We followed the recommended process for synthesizing data in an integrative review ( Whittemore and Knafl, 2005) by initially comparing the extracted data item by item, recognizing similarities and groupings, to eventually identifying meaningful categories for studies and interventions included in the review. Each of the papers was read multiple times to generate a mental map of ideas explored across the literature. Iterative process of examining the classified data enabled us to identify themes and relationships which constitute the essence of this synthesis process. Due to expectedly heterogenic character of included studies, attempts at establishing a meaningful classification were at all times guided by the above principles.

Results

Of 474 records identified through database searching and consulting reference lists, 405 were excluded based on title and abstract screening. Full-texts for the remaining 69 records were consulted and 56 were excluded with reasons ( Figure 1). Many of the excluded papers were opinion pieces which did not present empirical outcomes, but were nevertheless helpful in gaining a fuller perspective of the topic and are frequently referred to in the discussion. Selection process resulted in 13 articles included in this review.

Study Characteristics

All of included research was undertaken either in the US (9 studies) or in Canada (4 studies). The studies were varied methodologically, with qualitative (6 studies), quantitative (1 study) and mixed methods (5 studies) paradigms all represented. The studies employed primarily surveys, focus groups, interviews, case studies and prototyping workshops, often following participatory and mixed-method designs, which seems appropriate for early explorations and for highly applied research with direct implications for clinical practice. Art therapists themselves were research participants in the majority of included papers with only three reporting specifically on client experiences ( Darewych et al., 2015; Levy et al., 2018; Spooner et al., 2019). Numbers of participants in qualitative, client-focused and/or workshop-based studies (8 studies) were generally low (ranging from single figures to 25 participants) and numbers of respondents in survey-based studies (4 studies) ranged from 45 to 195. Two papers ( Collie and Čubranić, 1999, 2002) reported on the same research study and are referred to jointly throughout this review (including in tables).

The articles tended to discuss the use of digital technology in art therapy practice in a more general way or focus on one of the two uses of digital technology identified in our initial literature review: the use of online tools for distance art therapy and the use of digital media for art making within therapy sessions. Majority of the survey-based studies which examined directly arts therapists' opinions on the use of digital technology in art therapy were interested in both uses of technology, while workshop-based studies typically focused on either distance delivery or exploration of digital media for art making. There were overlaps and we tried to capture the relationship between the digital technology interest and the categories we eventually decided to group the articles into in Figure 2, which also provides an overview of methodologies and participant groups. The results are presented below in three seemingly separate groups of studies. However, the concepts explored in this research are inevitably intertwined, which is important to note to avoid over-simplifying the nature of opportunities and challenges brought into art therapy realm by the progressing developments in digital technology. Paragraphs below present key messages from the papers grouped in the three categories, except findings pertaining directly to the challenges and benefits of using digital technology within therapy, which will be discussed separately.

General Views on Technology, Online Art Therapy, and Digital Arts Media

Art Therapists' Views and Opinions

Although all studies reported also on the general adoption of technology by art therapists in personal and professional practice including office work, research and training, this review extracted findings pertaining to in-session practice with clients as far as it was possible or to any aspects of digital technology use that directly affect work with clients. Therefore, information on other uses of technology by art therapists, although reported in the cited papers, is not presented here. The general message coming from all included surveys was that art therapists tended to use technology far more often for their own personal practice and for administrative professional tasks than within sessions with clients.

Another survey conducted almost a decade ago moved beyond establishing how art therapists use digital technology to determine their reasons for adopting or rejecting emerging digital tools for therapeutic use with their clients ( Peterson, 2010). A client's response to a form of digital technology was found to be a key factor in art therapists' decision as to whether the technology was an effective therapeutic medium. The respondents agreed that if a medium (including digital media) could safely contribute to a desirable change, then its inclusion in treatment is warranted. Cost was, again, cited as an adoption deterrent, while providing new capabilities for the therapist and the client was an additional adoption factor.

A theme consistent across the presented surveys seems to be the highly ethical and professional approach of art therapists in deciding on the use of technology with clients. The responses seemed consistent in indicating that a degree of familiarity with digital medium is necessary for therapists to implement it in therapy session with clients. Importantly, the clients' response to any novel arts medium is the guiding factor in making decision about a specific technology adoption. Being certain of the benefits for clients seems to be a prerequisite for introducing a specific technology in art therapy sessions. The survey from 2011 revealed that art therapists were increasingly more concerned about ethical and confidentiality issues than 7 years before and that their main reservations about using digital media were linked with uncertainties around ethics ( Orr, 2006, 2012).

Online Art Therapy: Digital Technology Used for Distance Art Therapy Sessions

We identified five research studies (of which one was reported in two articles) that were concerned primarily with application of digital technology solutions to remote art therapy delivery ( Table 3: Collie and Čubranić, 1999, 2002; Collie et al., 2006, 2017; Levy et al., 2018; Spooner et al., 2019). Three of these studies, all from the same Canadian research team, similarly to research discussed above, examined art therapists' opinions through focus groups ( Collie et al., 2006), interviews and participatory designs, including simulated online art therapy interventions ( Collie and Čubranić, 1999, 2002; Collie et al., 2017). The studies were concerned with development of an online art therapy service for people with limited mobility, women with breast cancer and, most recently, young adult cancer patients. Two other studies from one US-based research team examined the experience of veterans participating in a blended (primarily online, with face-to-face initial assessment and re-evaluation) creative arts therapies program via semi-structured interviews and a single case study of an art therapy participant ( Levy et al., 2018; Spooner et al., 2019). Both studies were undertaken as part of a clinical program evaluation and therefore did not follow a fully experimental design. Although pre-post assessments were undertaken, these have not been reported yet.

In two studies ( Collie and Čubranić, 2002; Collie et al., 2017) the participants were also co-researchers, described as art therapists, counselors, educators and people with experience of life-threatening illness (total n = 17), who were invited to take part in simulated online art therapy group sessions. The interventions experienced in the two studies were quite different, one being a group art therapy session in which participants communicated and shared digital images created in real time ( Collie and Čubranić, 2002), while the other included both synchronous and asynchronous elements, allowing participants to take part in live chat-based session and also upload images to a discussion board outside of scheduled session times ( Collie et al., 2017). In both studies participants shared their experience via discussions and follow-up interviews. Another study ( Collie et al., 2006) used focus groups and interviews with similarly diverse participants ( n = 25) to generate clinical and technological guidelines for distance art therapy.

One of the key conclusions coming from the studies was that online group art therapy, being a relatively novel intervention, would require certain adaptations in relation to face-to-face practice ( Spooner et al., 2019), for example development of suitable "social protocols" ( Collie and Čubranić, 1999), refining of communication procedures ( Collie and Čubranić, 2002) and development of "new therapeutic models" ( Collie et al., 2006). These adaptations would need to comply with the legal and ethical guidelines, with new telehealth-related guidance eventually required for art therapy profession and initially adapted from related disciplines such as counseling or psychology ( Spooner et al., 2019).

In their evaluation of a US-based creative arts therapy program for veterans living in rural areas, Levy et al. (2018) reported primarily positive experiences of using an online art therapy service. Participants appreciated the delivery mode and not having to travel long distances to sessions and described the normally expected positive effects of therapy like increased confidence, improved communication and making sense of emotions through self-expression. A case study of a female veteran participating in the program ( Spooner et al., 2019) initially revealed a decrease in perceived quality of life and satisfaction with health, which was attributed by her and her therapist to the actual progress in therapy being made: becoming more aware of emotions and ready to explore more difficult topics to eventually rediscover aspects of herself that were previously lost. These accounts seem to confirm that the therapeutic process can manifest within distance art therapy sessions and therapeutic outcomes can be achieved.

Digital Arts Media: Digital Technology Used for Making Artwork in Art Therapy Sessions

A study examining the experiences of eight adults with developmental disabilities who used digital art making in art therapy sessions ( Darewych et al., 2015), concluded that the participants appreciated the ease of use of the apps tested, which allowed them to create images independently. Those with olfactory and tactile sensitivity preferred the texture-free touchscreen devices to traditional art materials.

Making art in virtual reality, as "a new medium that challenges the traditional laws of the physical world and materials" ( Kaimal et al., 2020, p. 17), was also tried and tested for use in art therapy in a small experiential study. The authors propose that therapeutic change can occur in VR environments and that it relates primarily to the unique qualities of the medium and to the fact that the participant is exposed to new environments of choice and creative opportunities not available in the material world ( Kaimal et al., 2020).

Challenges and Opportunities of Using Digital Technology in Art Therapy Practice

The following section presents findings across the three sets of studies that pertain more specifically to the challenges and opportunities of the use of digital technology in art therapy practice. Although these are grouped into three categories, not dissimilar to the categories of studies presented above, findings are based on contributions from across all papers examined in this review. We found frequent overlaps in aspects of technology discussed within papers, for example it was common for studies generally focusing on digital media to provide insights on remote delivery and vice versa. Not wanting to lose those, we decided to thematically analyze the content of all 13 included articles to identify themes relating to the advantages and disadvantages of technology use in art therapy, pertaining in particular to digital media and technologies and processes enabling remote delivery.

General Concerns About Including Digital Technology in Art Therapy Practice

Cost of equipment

Extra time

The importance of a specialist training for art therapists in the use of digital technology is highlighted across studies ( Collie et al., 2006; Orr, 2006, 2012; Kaimal et al., 2020). It is recognized that skilful and active facilitation, essential for providing appropriate container (safe environment) and ensuring client safety ( Collie et al., 2017; Kaimal et al., 2020), requires extra time for learning ( Orr, 2006). Similarly, more effort and time investment in training might be needed on the client's side, either to adjust to an online mode of therapy ( Spooner et al., 2019) or to a new type of digital arts media ( Kaimal et al., 2020). A concern has been raised about this additional learning potentially impeding the therapeutic process and that extra time might be needed for establishing a therapeutic relationship ( Collie et al., 2006).

Technical issues

Concerns Related to Online Art Therapy

Confidentiality and safety

Technological limitations

Benefits of Online Art Therapy

Bridging divides/connecting

Research on online art therapy seems to confirm that online mode of delivery has the potential to bridge geographical distances ( Collie and Čubranić, 1999; Collie et al., 2017) and expand access to services otherwise unavailable to clients living in rural and more remote areas ( Collie and Čubranić, 2002; Levy et al., 2018). It also helps make art therapy more accessible to clients regardless of barriers such as stigma or disability ( Spooner et al., 2019), and especially mobility disabilities ( Peterson, 2010). It was also observed that technology might have an equalizing effect in a group therapy setting if it is new to everyone ( Collie et al., 2017) and that the semi-anonymity of an online group might in fact increase a sense of privacy, particularly for those who are worried about being judged by appearance ( Collie and Čubranić, 1999; Collie et al., 2017). Technologies that enable collaborating on a single artwork from different locations or even looking at each other's art on the screen were reported to bring a sense of connection and emotional closeness, as if being in the same place ( Collie et al., 2006, 2017). It was also felt by some that distance delivery promotes community involvement, integration and social engagement by, for example, allowing incorporation of family members into the treatment plan ( Levy et al., 2018; Spooner et al., 2019).

Therapeutic rapport

Empowering

Some papers suggested that using technology for distance therapy can be empowering ( Orr, 2012), allowing the client to take a more active role in their own treatment process and to have a greater autonomy within and outside therapy sessions ( Levy et al., 2018; Spooner et al., 2019). There were also indications that creating art in a home setting might lead to increased engagement in arts processes on a more regular basis and between therapy sessions ( Levy et al., 2018; Spooner et al., 2019).

Best Practice Recommendations for Online Art Therapy

Two papers in particular ( Collie et al., 2006; Levy et al., 2018) attempted to suggest solutions to some of the challenges mentioned above and ways of working which might increase safety and efficacy of online AT practice.

Levy et al. (2018) proposed that in order to address potential technical issues with connectivity, therapists might offer their clients more than one way to connect and agree alternative ways of contact (e.g., by telephone) in case the connection breaks mid-session, to be able to continue any unfinished discussions and/or obtain closure before the end of the session. It was also suggested that interruptions from family could be minimized if the therapist and the client agree in advance how these would be handled, e.g., client could alert therapist when others are present. Instructing clients to be prepared for the session and to call exactly at appointed times was also proposed best practice. To address issues with blurred or unclear image while showing artwork to the webcam, it was recommended that, in case of digital artwork, client might share their screen, and in case of art made with traditional arts media, a digital photograph might be taken and shared with the therapist. Establishing a common vocabulary for describing artwork was another suggestion for improving communication.

Concerns Related to Digital Arts Media

Lack of tactile qualities

An opinion that technology is cold, isolating, and even "dehumanizing" is repeated particularly in the literature published in the previous decade ( Collie et al., 2006; Orr, 2006). These seem to refer primarily to the nonsensory character of digital arts media ( Orr, 2006), the lack of tactile and sensual qualities ( Collie et al., 2006; Orr, 2012; Choe, 2014) or even lack of tangible physical engagement with the medium as in case of making art in virtual reality ( Kaimal et al., 2020). It was suggested that this lack of sensory input might lead to clients disconnecting not only from art materials, but also from their own bodies and social interactions ( Orr, 2012) and that the therapeutic value of working with "traditional" tactile art materials should not be underestimated ( Collie et al., 2006; Orr, 2006). Technology was also cited as potentially overwhelming and distracting from the creative process ( Orr, 2012).

Limited room for expression

Benefits of Digital Arts Media

Freedom of expression

It was suggested across a number of papers that digital arts media can be empowering by possessing expressive qualities not necessarily achievable with traditional physical art materials ( Collie et al., 2006; Orr, 2012). Digital art making, including in virtual reality, was proposed to reduce inhibitions, promote freedom ( Collie and Čubranić, 1999; Darewych et al., 2015; Kaimal et al., 2020), and facilitate multimodal expression not limited to images ( Collie et al., 2006). It was observed that inhibitions were diminished in creating artwork using digital media since there were no expectations of how a digital artwork should look like and it was also speculated if the elusiveness of a computer image might in fact strengthen the therapeutic process ( Collie and Čubranić, 1999). VR environments were found to enhance the freedom of expression without the constraints of the physical world, empower clients with restrictions in their movements and "explore creative opportunities otherwise unavailable in the material world" ( Kaimal et al., 2020). Playfulness of the artmaking process and creative exploration was another positive aspect of engaging with digital arts media noted in the literature ( Collie and Čubranić, 1999; Kaimal et al., 2020).

Digital environment

Discussion

Research to date, although some survey-based, is largely qualitative and heterogeneous, presenting difficulties to any inter-studies comparisons. However, these seeming limitations demonstrate, in fact, the seriousness with which the subject has been approached by art therapy practitioners and researchers. Creative use of diverse methodologies to examine art therapists' views is an essential first step, appropriate for the early stage exploration of how (and indeed, whether) digital technology might be used in art therapy practice. It is appropriate that early investigations are cautious and focused on practitioner's perspective before any new strategies may be implemented in the actual practice with clients. Such approach seems highly ethical and client-focused, as indeed confirmed in this review in the reasons given by art therapists for their reluctance and cautiousness with which they decide on whether to introduce digital technology in art therapy sessions. Impacts on clients are of primary importance and therapists, understandably, are not willing to compromise on client safety in adopting technological solutions not thoroughly tested ( Peterson, 2010; Orr, 2016).

Nevertheless, it is important to highlight that the findings in this review are largely based on art therapists' opinions and attitudes, not necessarily rooted in experience of using technology in practice. Given the common human error of judgment in terms of imagining theoretical concepts in practice, one can only wonder if some of the opinions expressed might have changed following an actual engagement in digital media-based or online practice, particularly if, as suggested ( Asawa, 2009), emotions such as fear and anger might guide art therapist' initial impressions on technology, and, as suggested elsewhere ( Collie et al., 2017), art therapists might be surprised at how quickly they start to feel comfortable with technology that they have had a chance to try out.

In addition to the increased research need, the importance of specialist training for art therapists has been commonly advocated ( Orr, 2006, 2012; Kapitan, 2007; Kuleba, 2008; Carlton, 2014; Kaimal et al., 2016). A call has also been made for development of new ethical guidelines for art therapists, which would provide an appropriate framework, aligned with practice needs and with practical considerations ( Alders et al., 2011; Evans, 2012). This need for robust guidance, which would help ensure client safety and increase therapists' confidence in working with technology, has been highlighted more recently by the changing global health situation (COVID-19 pandemic), in which art therapists found themselves transitioning to online practice with unprecedented speed and often against own preference. It is a striking realization that in a survey conducted only 15 years ago none of the respondents reported that they had conducted online art therapy ( Peterson, 2006). McNiff's prediction from over two decades ago that distance art therapy would grow ( McNiff, 1999) has, however, become reality, if only too suddenly for some.

This review has synthesized the challenges and benefits of working with clients online, as reported in literature, and any solutions proposed by the authors. It is clear that distance art therapy differs from the usual face-to-face situation on many levels and requires adaptations on both art therapists' and clients' side. The relatively novel way of working therapeutically demands more effort and time initially (e.g., for learning of procedures and devices), but has the potential to become less burdensome practically in the long term (e.g., saving the need to travel to sessions). More importantly, it demands skilful and perhaps more active facilitation from art therapists in order to create a safe enough container for clients in virtual space ( Collie et al., 2017). It is recognized that this might be harder to achieve in online therapy and compensations might need to be made for the lack of physical presence and limited non-verbal expressions ( Chilton et al., 2009). It has been suggested that semi-anonymity that online contact allows might be both restricting and facilitating for the development of therapeutic relationship and emotional connection ( Collie et al., 2017; Levy et al., 2018). The responsibility for successful outcomes does not lie entirely with art therapists, and clients might similarly be expected to take on a more active role in their own treatment for a distant art therapy to be beneficial. There is a potential for this increased engagement to promote community integration and to feel empowering for the client ( Orr, 2012; Levy et al., 2018; Spooner et al., 2019). The pace of technological advancements also means that certain technical limitations mentioned in the literature may already be overcome, for example observations by some that a computer is not conducive to group therapy ( Kuleba, 2008).

As indicated at the beginning of our work, opportunities and limitations of digital technology in art therapy extend beyond telehealth and remote connectivity. The use of digital arts media presents entirely new challenges for the profession and, arguably, entirely new possibilities with potentially profound impacts on practice. There are polarized opinions and ideas around the therapeutic value and risks of incorporating digital arts media in art therapy sessions.

It has been indicated that digital media provide more security to experiment and offer more freedom of expression due to endless modifications and manipulation of artwork being possible, as well as an option to not leave a trace of one's creative experimentation if one wish ( Canter, 1987; Collie and Čubranić, 1999; McLeod, 1999; Parker-Bell, 1999; Peterson et al., 2005; Edmunds, 2012; Orr, 2016). A notion that making digital art may be less intimidating than working with traditional art materials has been widely discussed in literature ( Weinberg, 1985; Hartwich and Brandecker, 1997; Collie and Čubranić, 1999; McLeod, 1999; Thong, 2007; Evans, 2012; Orr, 2012; Kaimal et al., 2016). However, it is worth noting that the potentially freeing and playful novelty of digital arts media might not have the same effect nowadays and an observation made in 1999 that people feel less self-conscious due to not having expectations about how a digital image should look like ( Collie and Čubranić, 1999) is already likely to be redundant. Similarly, propositions that interaction with digital art making tools gives a sense of mastery and independence ( Canter, 1989; Edmunds, 2012; Orr, 2012) might naturally become less relevant with increased use and familiarity.

Nevertheless, the therapeutic potential of making changes to artwork, recording, sharing and revisiting the process of creation, and allowing both the artwork and the process evolve over time, cannot be underestimated ( Hartwich and Brandecker, 1997; McLeod, 1999; McNiff, 1999; Evans, 2012; Orr, 2016). Interaction between the person and the electronic device used for art making is potentially therapeutically powerful. It has been suggested that artmaking process becomes a mirror of this relationship ( Hartwich and Brandecker, 1997) but also that a computer is simply a mediator in the relationship developing between the client and the therapist ( Orr, 2010) or that it can support and provide a transactional space between them ( Gussak and Nyce, 1999). The role of the machine in the development of the therapeutic process remains unclear and it will be important to investigate how it affects (or fits within?) the triangular relationship between the client, the therapist and the art.

Probably the most prominent accusation against digital art making tools is their "synthetic" nature, lacking sensual and tactile qualities of traditional arts media, often considered therapeutic in themselves ( Kuleba, 2008; Klorer, 2009; Potash, 2009; Carlton, 2014; Orr, 2016; Garner, 2017). Suggestions have been made that this seemingly distant and nontactile nature of digital arts media might result in clients disconnecting not only from sensory experience but also from relationships and the "real world" in the present moment ( Klorer, 2009; Potash, 2009). This perception of the isolating, impersonal and even dehumanizing character of digital technology, as well as coldness associated with computers, have been widely discussed by art therapy researchers and practitioners ( Gussak and Nyce, 1999; McLeod, 1999; Collie and Čubranić, 2002; Collie et al., 2006; Orr, 2006; Kuleba, 2008). However, some have observed that constant technological advances gradually lead to the cold digital media becoming more integrated with human interactions, senses and emotions, in increasingly intuitive and responsive way ( Orr, 2012). Touchscreen sensitivity, for example, allows for pressure to be incorporated in digital art making, mimicking physical art materials, an important quality which was not previously available for art created with a computer mouse, as noted by McNiff two decades ago ( McNiff, 1999). Despite some issues which are unlikely to be resolved, it is probably safe to say that with technology generally becoming more human-oriented we may expect an increasing relevance of digital art making tools for art therapy.

An entirely new art medium which is now available within virtual reality environments presents its own unique concerns and prospects ( Kaimal et al., 2020), including creative opportunities reaching beyond material world, but also risks of further disconnection from the real tactile experience. Here also some of the previously expresses preconceptions might be challenged, for example another observation made by McNiff that "computer art will never replace the three-dimensional presence of the actual thing being made" ( McNiff, 2000, p. 97). It remains debatable of course whether virtual presence is at all comparable to physical experience, but it might be that an opportunity to print out a virtually created artwork using a 3D printer makes the distinction less obvious.

A substantial attention is dedicated in literature to speculation on groups of clients who might benefit most from working with digital arts media. It has been suggested that although this is primarily an individual matter and not necessarily defined by age, contradictory to stereotype ( Asawa, 2009), children and young people might be particularly responsive to digital artmaking ( Alders et al., 2011; Carlton, 2014). Reports on successful practice with hospitalized children highlight the benefit of adaptations enabled by technology to compensate for physical and emotional challenges ( Thong, 2007; Malchiodi and Johnson, 2013). Digital arts media offer a sterile art making environment ( Malchiodi and Johnson, 2013; Orr, 2016) and can be used by patients who might not be able to hold art materials but might be able to interact with space or make art on a tablet device using tiny gestures ( McNiff, 1999; Hallas and Cleaves, 2017). It has been also demonstrated that the previously mentioned lack of sensory input might be therapeutically beneficial for clients with developmental disabilities and those with olfactory and tactile sensitivities ( Darewych et al., 2015). It has been proposed that digital art making tools might be in fact an ideal medium for clients easily overwhelmed by tactile sensations ( Alders et al., 2011), allowing them to sustain a safer and longer art making experience ( Edmunds, 2012).

Some art therapy practitioners and researchers have long made a proposition that technology-enhanced therapy, whether in form of online delivery or adoption of digital arts media for art making, may actually be the best form of therapy for certain clients and not a mere substitute for more traditional ways of working ( Collie and Čubranić, 1999; McNiff, 1999; Parker-Bell, 1999; Evans, 2012). Others have pointed out to contradictory beliefs of some art therapy practitioners, focusing more on potential risks and worrying that technology would "remove what art therapy holds sacred, which is the art." ( Asawa, 2009, p. 64). Between the two polarizing perspectives might be most commonly advocated one, that digital technology is not a replacement for traditional arts media or long established ways of working, but rather an added value, a new quality, expanding and not limiting the profession ( McLeod, 1999; McNiff, 1999; Orr, 2006; Choe, 2014).

While flexibility and adaptability have been cited as qualities shared by art therapists that could support them in the predicted continued integration of technology in therapy ( Spooner et al., 2019), a question remains whether art therapy profession would accept technology as a true creative and therapeutic medium ( McNiff, 1999; Peterson, 2006; Austin, 2009). Over three decades ago, it was suggested that the answer might depend on art therapists' innate curiosity as artists to investigate the new medium ( Canter, 1989) and, more recently, that the potential of technology in art therapy is only limited by practitioners' creativity and imagination ( McLeod, 1999; McNiff, 1999; Peterson, 2010). It has been already proposed that art therapy profession, to remain relevant, might need to "move beyond historically validated media" and also to new contexts ( Kapitan, 2007, p. 51).

Future Research

Given the growing interest in digital technology within art therapy world and the current global health crisis (COVID-19 pandemic) which forced therapists to move their practice online, we expect and would welcome a rise in research in the area. While we already have some understanding of art therapists' perspective, more research to explore clients' experiences is clearly needed. This research need must not, however, compromise on clients' safety and ethical ways of working with technology in art therapy sessions and should observe (and help develop) guidelines from professional associations for the discipline ( Zubala and Hackett, 2020). Once new ways of working are established, these need to be reflected in art therapists' education and research could contribute to identifying the needs for training.

Regardless of the mode of delivery, there remains a lot to learn in terms of the emotional and interpersonal implications of digital artmaking for the development of the therapeutic relationship. Previous research encouragingly indicates that therapeutic alliance in verbal psychotherapies can be successfully recreated in an online setting ( Sucala et al., 2012). In art therapy case, however, potential impact of technology is not limited to client-therapist relationship but extends to the essence of the triangular relationship including also the artwork. Understanding the impacts of digital tools on the dynamics of this triangular relationship and their place within it seems fundamental to increasing art therapists' confidence in introducing digital arts media in sessions.

Limitations

This review attempted to capture research findings from diverse literature for a holistic understanding of the topic ( Whittemore and Knafl, 2005) and we recognize that such approach brings some inevitable challenges which we were able to address partially.

Firstly, the heterogeneous character of included studies and breadth of perspectives adopted by the authors meant that the synthesis relied vastly on our own interpretation of the findings due to no specific guidance on such syntheses available. Neither meta-analysis nor meta-synthesis could be performed and instead a method not dissimilar to thematic analysis was employed for identifying key themes often present across the literature examined. It might be that such approach could have missed some of the findings potentially best captured via another methodology. Additionally, inclusion of papers focusing on art therapists' views and opinions mean that findings are based on both the anticipated and the actual practice-based experiences.

Secondly, we acknowledge that PhD theses, dissertations and book chapters were deliberately excluded from the review due to limited resources and also due to expected further complexities arising from an attempt to synthesize insights from these data sources. The searches have, however, identified substantial volume of material on the subject published in books and available as unpublished doctoral theses and masters dissertations and it would have been valuable to examine these also, perhaps in a more narrative type of review or as part of more specific sub-topic explorations. Similarly, only articles presenting empirical findings were included which means that a number of important opinion papers have not been formally a part of this review. Instead, recognizing the contribution of these authors to the overall conversation, we refer to their work in the extended discussion section. We are also aware that strict inclusion criteria meant that some contemporary uses of digital technology in art therapy such as digital photography, computer animation or digital storytelling, are not discussed here. Peer-reviewed papers in these areas seem sparse despite comprehensive practice-based literature available (e.g., Loewenthal, 2013; Malchiodi, 2018). Therefore, while it was not our intention to exclude these widely used techniques, we acknowledge that this review might not be a complete representation of practice, now commonly adopting many other imaginative uses of digital technology.

Thirdly, we chose not to undertake a formal quality assessment of the studies included, which might have enabled a fairer weight to be allocated to findings, currently considered and presented as being of equal value. An informal quality assessment has been, however, included and we decided that a more formal analysis would not match the complexity of the topic and the nature of the very early exploratory studies, meaning that useful insights might be lost with a standardized form of assessment applied. With progress in research in the area and more methodologically coherent groupings of studies possible, we expect that future syntheses would be able to perform more formalized quality assessments, particularly on studies that report on client experiences.

Conclusion

This review offers an integrative synthesis of research undertaken to date on the use of digital technology in art therapy, including both online connectivity allowing distance delivery as well as digital artmaking within therapy sessions. The complex characteristics and methodologies of included papers resulted in diverse findings which were integrated to identify key themes in the growing debate on the role of digital technology in art therapy. Potential benefits and challenges were identified, including impacts on the therapy process and the therapeutic relationship. It may be safely concluded that the use of technology in art therapy presents both immense opportunities and serious risks that need to be considered by practitioners, professional associations, and the clients themselves. It is important that early research in the area strives to examine both in order to help art therapists make an informed choice when deciding on whether to incorporate digital technologies in their practice.

We would like to invite the art therapy community worldwide to expand this conversation and to explore together, safely but with curiosity and openness, the expanse of the digital world which, if nothing else, deserves our consideration of its relationship to art therapy. We propose that we approach this exploration with acknowledgment of its importance for the continued relevance of art therapy ( Kapitan, 2007) but also reflecting that "art therapy is eclectic and not reducible to a single set of algorithms" ( Gussak and Nyce, 1999, p. 194). It might be a demanding but a fascinating journey.

Author Contributions

AZ conceptualized, planned, and undertook the review, analyzed the data, and wrote the first draft of the manuscript. NK and SH revised the work critically and contributed to edits. All authors contributed to and approved the final version of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

AZ would like to thank co-authors, Catriona MacInnes, Simon Reekie, Gill Houlsby, and other art therapists, conversations with whom helped shape the thinking about this research.

References

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Art Therapy in the Digital World: An Integrative Review of Current Practice and Future Directions

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BackgroundPsychotherapy interventions increasingly utilize digital technologies to improve access to therapy and its acceptability. Opportunities that digital technology potentially creates for art therapy reach beyond increased access to include new possibilities of adaptation and extension of therapy tool box.

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Technology in Art Therapy: Ethical Challenges

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Technology in Art Therapy: Ethical Challenges

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As technology advances, art therapy practices are adapting to the demands of a new cultural climate. Art therapists face a number of ethical challenges as they interact with increasingly diverse p...

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The Art and Practice of Providing On-line Art Therapy to Children during the Covid-19 School Shutdown of 2020

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The Art and Practice of Providing On-line Art Therapy to Children during the Covid-19 School Shutdown of 2020

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online therapy with children during covid-19

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IPad engAGE is an arts project, which aims to inspire digital, creative engagement through the use of iPads, through Person Centred Planning. The artists featured on this page either live in the community or in a residential setting. Each artist has explored a theme that has engaged them personally,…

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British Association of Art Therapists, Code of ethics...

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The British Association Of Art Therapists

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We have issued this Code of Ethics with the aim of providing its members with the fundamental principles, standards and guidelines for good practice. This is to support them in their work, as well as to inform and protect members of the public using their services.

Art therapy is a form of psychotherapy that uses visual art media as its primary mode of communication. It involves the use of visual and tactile media as a means of self-expression. Art therapists and art psychotherapists (both titles are protected by law and either may be used by HCPC registered Art Therapists / Psychotherapists) aim to enable clients both to discover an outlet for often complex and confusing emotions that cannot always be expressed verbally, and to foster self- awareness and growth. Practitioners have evolved distinct ways of working according to their specialism. They work in a clinical context where aspects of health, ill health, difficulties and impairments are a great part of what the client brings to the art therapy sessions. In this context and as registered health professionals, art therapists and art psychotherapists are expected to exercise clinical judgement as a means of practising safely and effectively.

The British Association of Art Therapists ('BAAT') has issued this Code of Ethics and the supporting Principles of Professional Practice and Guidelines with the aim of providing Members of the BAAT ('Members') with the fundamental principles, standards and guidelines for good practice. This is to support them in their work, as well as to inform and protect Members of the public using their services.

Art therapy is a statutorily regulated profession and in the United Kingdom only those persons who are appropriately qualified and registered by the Health and Care Professions Council ('HCPC') and may legally describe themselves art therapists or art psychotherapists. These two titles are both protected by the HCPC and may be used inter-changeably by individual Members as they describe the same practice. Full Membership of the Association is only open to registered art therapists and art psychotherapists. Other professionals and Members of the public may join as Associate Members and are not bound by this Code of Ethics.

Throughout their professional life Members must:

maintain their registration by the HCPC;

adhere to this Code of Ethics and the Principles of Professional Practice and Guidelines for Members;

undertake supervision in accordance with supervision guidelines;

hold personal professional indemnity insurance (PII) as stated in the EU directive 2011/24/EU if this is not provided by an employer's vicarious responsibility insurance.

undertake continuing professional development ('CPD') as required by both the BAAT and the HCPC.

The BAAT Code of Ethics should be read in conjunction with Standards of Proficiency and of Ethics and Professional Conduct from its Statutory Regulator, the Health and Care Professions Council ( ).

1. Membership

1.1 Only those who are registered by the HCPC in the Arts Therapy Part of the Register and entitled to use the title registered art therapist or registered art psychotherapist are eligible for full Membership of the Association.

1.2 Membership of the BAAT may be terminated in respect of any Member who:
(i) contravenes this Code of Ethics;
(ii) is convicted of a crime which has a bearing on their fitness their practise;
(iii) has their registration suspended or revoked by the HCPC or are similarly disciplined by another health care regulatory body; or
(iv) is expelled from or disciplined by another professional organisation.

2. General principles

2.1 Members should seek to establish the highest ethical standards and should regard the therapeutic interests of their clients as paramount.

2.2 Members should practise lawfully, safely, effectively, accountably and fairly.

2.3 Members should only treat and advise on cases in which they are competent, as determined by their education, training and experience. This principle is summarised in the proposition that a Member has a 'scope of practice' at any particular point in their career.

2.4 Members should be culturally competent. Cultural competence is a set of congruent behaviours, attitudes and policies that enable Members to work effectively in cross-cultural situations.

2.5 Members should acknowledge and incorporate into their professional work:
(i) the importance of culture, and variations within cultures;
(ii) the assessment of cross-cultural relations;
(iii) cultural differences in visual symbols and imagery;
(iv) vigilance towards the dynamics that result from cultural differences;
(v) the expansion of cultural knowledge and the adaptation of services to meet differing cultural needs.

2.6 Members should establish if other professionals have a duty of care towards their clients and encourage clients, or their carers to seek the advice of a qualified doctor or psychiatrist for their medical welfare.

2.7 Members should assist clients in understanding their options in making their own decisions,and will respect the choices they make.

3. Professional competence and integrity

3.1 Members must maintain high standards of professional competence and integrity as set out by the HCPC Standards of Proficiency.

3.2 Members must keep informed and up to date with developments in their field, through educational activities, clinical experience and CPD. The learning schemes that Members undertake as part of their CPD must have the objective of maintaining and developing their professional competence.3.3 Members must:
(i) keep themselves informed about current thinking and clinical developments which are related to their practice;
(ii) Keep themselves informed about current research evidence that should inform their practice and aim to provide evidence-based practice.
(ii) make use of any financial or other support provided by their employer to develop their professional skills through attending in-service training programmes, lectures, conferences or workshops. Ideally, they should also keep in contact with fellow professionals through regional or special interest groups of the BAAT and through regular professional updates both in print and on the BAAT website.

3.4 Members must, so far as practicable, inform themselves of any other treatment being undertaken by their client, and make appropriate clinical decisions according to the context and the client's needs.

3.5 Members must exercise care when making public their professional recommendations and opinions through testimony or other public statements and recognise their potential to influence and alter the lives of others.

3.6 Members must not distort or misuse their clinical and research findings.

4. Supervision

Members must monitor their own professional competence through clinical supervision in accordance with the Association's supervision guidelines and clinical supervisors should apply to be accredited by the Association.

5. Accepting clients

Members should, where appropriate, seek a written referral for a client from the appropriate agent. Clients who self-refer should be asked to provide a written request for art therapy after the initial contact. Members must retain the right not to accept certain clients following their assessment.

6. Assessment

6.1 Members must develop and use assessment methods which help them understand and serve the needs of their clients. Such assessment methods should only be used within the context of a defined professional relationship.

6.2 Members should use only those assessment methods in which they have competence through appropriate training and supervised experience.

7. Informed consent

7.1 Members should obtain informed consent prior to the start of treatment which must be recorded in their clinical notes. Information should be given both verbally and in written form. If a client has difficulty understanding the language or procedures used, Members should arrange for appropriate support to be provided to the client, such as the assistance of a qualified interpreter or signer.

7.2 Information about treatment should include:
* Clear description of the art therapy intervention
* Potential benefits for client
* Potential risks for client (e.g.: "Sometimes people find they feel a little worse at the start of therapy" or "Occasionally, children starting therapy may at first display some increase of disruptive behaviour or feelings."
* Possible alternatives to art therapy where NICE guidelines may suggest interventions specific to conditions (e.g. CBT for mild anxiety and depression).

7.3 Members must consider any factors which may influence the effectiveness of therapeutic practice, including assessment and the reporting of its results, such as culture, race, gender, sexual orientation, age, religion, education, and disability.

8. Accountability and consistency of care

8.1 Members should be clear about their accountability in relation to the treatment of clients and must take reasonable steps to be aware of the current law, and changes to the law, which may affect their practice.

8.2 Members must provide as much consistency of care as possible for their clients, be assertive in their efforts to maintain contact with them during the course of therapy and make every effort to prepare the client for the ending of the therapy. Where circumstances mean that therapy has to end prematurely, Members must make reasonable efforts to help the client find alternative sources of help, within the limitations of the context of the clinical settings.

8.3 Members must keep up-to-date with research evidence defining best clinical approach and apply this knowledge to their practice. Members should also be aware of research evidence on approaches harmful for specific conditions and endure that they do not use these.

9. Clinical Judgement

9.1 Members must take appropriate steps to ensure that their judgement is not impaired, that they do not exploit clients and that that they act in the client's best interest. Members should not practise while under the influence of alcohol or drugs, or if their physical or mental state might affect their ability to practise.

9.2 Members must seek appropriate professional help for any personal problems or conflicts that may impair or affect their work performance or clinical judgement.

10. Confidentiality

10.1 Confidentiality is not an absolute concept. Art Therapists have a professional duty of care to their clients which must override confidentiality, especially if there are concerns about the safeguarding and wellbeing of clients

10.2 Whilst information obtained from clients in conversation or through their artistic expression must be treated respectfully and professionally, confidentiality id held within a treatment team and not by any one individual, including the art therapist. This fact should be made clear to clients.

10.3 Furthermore, disclosure or sharing of information may be necessary. The client may request it. Importantly the law requires that art therapists disclose information in circumstances, where the safety of the client, the therapist, those caring for the client, or the public would be threatened by non-disclosure. In such cases disclosure must be made in the manner which best protects the client's interests.

10.4 The circumstances in which Members must apply the above principles include:
(i) within the framework of the multidisciplinary team;
(ii) within the employer's terms and conditions;
(iii) within the bounds of multi-agency good practice for the safeguarding of children and vulnerable adults;
(iv) within private practice;
(v) within the client-therapist relationship.

11. Clients who are minors

11.1 Whenever possible, Members should communicate with and involve parents/guardians and carers in planning and review meetings as this supports the process of therapy for the child or young person (CYP).

11.2 Members must, so far as possible, seek to preserve the confidentiality of minor clients and refrain from disclosing information to the parent, guardian or carer of a minor client which might adversely affect the treatment of the minor client, or place them at further risk. This does not mean that there should be no communication with parents / carers (see 11.1)

11.3 Members must take appropriate action if they believe that a young person is in danger, and must by law follow child Safeguarding policies.

12. Dual Relationships

12.1 Members should always maintain the therapist-client relationship on a professional basis. A Member should not engage in a dual relationship with clients. A dual relationship occurs when a Member and client engage in a separate and/or distinct relationship from that of therapy. Some examples of dual relationship are:
(i) engaging in a close personal relationship with a client;
(ii) engaging in sexual intimacy with a client;
(iii) borrowing money from a client;
(iv) employing a client;
(v) engaging in a business venture with a client.

12.2 Members must ensure that any relationship they have with the client after therapy terminates is not exploitative.

12.3 Members who are supervisors, training instructors or personal tutors of a student should not engage in a dual personal relationship with that student, either concurrent with, or for at least two years following termination of, the professional relationship.

12.4 At the start of a therapeutic relationship, a Member must agree a clear contract with the client or with the client's parent, legal guardian, or carer, as appropriate. The contract should state the expected start date of therapy, the approximate length of therapy, the agreed frequency of the sessions, and the boundaries of the therapeutic relationship (e.g. any limits to confidentiality).

13. Practice Environment

13.1 Members must treat clients in an environment which protects privacy and confidentiality and provides a safe and functional place in which to offer art therapy services, including:
(i) proper heating and ventilation;
(ii) adequate lighting;
(iii) access to a water supply;
(iv) furniture which conforms to relevant health and safety standards;
(v) knowledge of hazards or toxicity of art materials and the effort needed to safeguard the health of clients;
(vi) storage space for clients' artwork.

14. Records

14.1 Members must record the client's attendance for therapy. Material produced during the art therapy session should be named, dated, and ideally safely stored throughout the therapeutic relationship. In general, the client's art expressions should be kept within the therapeutic relationship and the disposal of such artwork should be negotiated with the client. Art therapists may advise to keep art works within the therapeutic space for the duration of the therapy. However, clients' requests to take art work home should also be considered on an individual basis as should requests for it to be seen publicly. Ultimately the ownership of the artwork remains with the client, as does the manner of its use and disposal. If storage space is at a premium, photographic, digitally or video recorded images may be used an alternative record of the client's art expression.

14.2 Members must ensure that they follow the policy guidelines laid down by their employer with regard to the retention of written or computer-generated client treatment records.

15. Reproduction and Exhibition of Clients' Artwork

15.1 Members should always seek to obtain permission before publishing or using a client's artwork publicly. Although a distinction is sometimes made between publication or exhibition to a public audience and to a limited audience or forum comprised of fellow health professionals, the BAAT recommends that wherever possible, art therapists should inform clients or their legal guardian of the intended use of their private material and obtain their consent.

15.2 Members who wish to use verbal dialogue, pictorial or written products from art therapy sessions for the purposes of research, education, publication or exhibition should:
(i) seek the informed written consent, wherever possible prior to the start of therapy, of the client or the client's legal guardian or carer; and
(ii) clearly inform the client, legal guardian or carer about how the material will be used.
(iii) whenever possible, seek client's views, feedback or participation in the above processes.

15.3 Members must, where ever possible, obtain written consent from the client, legal guardian or carer before a client or client's art work is photographed, recorded digitally, video-taped, audio-recorded, or otherwise duplicated for the purpose of public display and exhibition.

15.4 No verbal dialogue, pictorial or written excerpts from art therapy sessions should be used without the specific permission of the client, apart from when these are used for clinical supervision.

15.5 Members should never seek to profit financially from the sale of art expressions produced in the therapeutic relationship.

16. Responsibilities to students and supervisees

16.1 Members who act as teachers, supervisors and researchers must present accurate information and maintain high standards of scholarship in their continuing education.

16.2 Members in a supervisory relationship with students or other Members must not also engage in a formal therapeutic relationship with them.

16.3 Members who act as supervisors are responsible for maintaining the quality of their supervision skills and must obtain consultation or supervision for their work as supervisors whenever appropriate.

17. Research governance

17.1 As stipulated by the employing institution, e.g. University and/or NHS Trust, research governance is a part of Clinical Governance and as such, the same ethical principles, protocols and processes will apply to all research art therapists.

17.2 Research art therapists must respect the dignity and protect the welfare of participants in research.

17.3 Research art therapists must abide by the laws, regulations, ethics and professional standards governing the conduct of research and publication appropriate to their circumstances and as laid out by their academic organisations or employers.

17.4 Information obtained by a student/clinician about a research participant during the course of an investigation must be held or stored confidentially and any personally identifying information should be anonymised before submission or publication of findings.

18. Responsibility to the Profession

18.1 Members must respect the rights and responsibilities of professional colleagues.

18.2 Members should seek to assist and be involved in developing or changing laws and regulations relating to the field of art therapy where to do so is in the public interest.

19. Financial Arrangements

19.1 Facts should be presented truthfully to clients, third party payers, and supervisees regarding services rendered and the charges.

19.2 Members in private practice must make financial arrangements with clients, their agents, and supervisees that are clear, easily understood and conform to accepted professional practices.

19.3 Members must not offer or accept payment for referrals.

19.4 Members in private practice must disclose their fees at the commencement of service and give reasonable notice of any changes in fees.

20. Advertising

20.1 Members must engage in appropriate informational activities which enable the public to make informed choices in relation to professional services.

20.2 Members must accurately represent their professional competence, education, training and experience.

20.3 Members must ensure that all advertisements and publications, whether in directories, business cards, newspapers or conveyed on radio or television or by electronic media are formulated accurately to convey their services to the public so that clients can make an informed decision about therapy.

20.4 Members must not use any description which is likely to mislead the public about their identity or status and must not hold themselves out as being partners or associates of an organisation if they are not.

20.5 Members must not use any professional identification (such as a business card, office sign, letterhead, internet website or telephone or directory listing) if it includes a statement or claim that is false, fraudulent, misleading or deceptive. A statement is false, fraudulent, misleading or deceptive if it: -
(i) fails to state any material fact necessary to keep the statement from being misleading;
(ii) is intended to, or is likely to, create an unjustified expectation; or
(iii) contains a material misrepresentation of fact.

20.6 Members must correct, whenever possible, false, misleading or inaccurate information and representations made by others concerning the Member's qualifications and services.

20.7 Members must ensure that the qualifications of persons in their employment are represented in a manner that is not false, misleading, or deceptive.

20.8 Members must only represent themselves as specialising within a specific area of art therapy if they have undertaken further education, training, or experience which would enable them to practice in that speciality area.

20.9 Members who practise privately may advertise their services. However, advertising should be limited to a statement of name, address, qualifications and type of therapy offered and such statements should be descriptive and not evaluative.

20.10 Members must adhere to professional rather than commercial standards in advertising their services. They must notify related professions and referring agencies of their practice and should promote and facilitate public awareness and understanding of the profession with dignity and discretion.

20.11 Members must follow the BAAT guidelines on use of logo and only use the affiliate full BAAT Member logo and not the corporate BAAT logo on all documentation and advertising. Members must also follow the HCPC guidelines in relation to the use of the HCPC logo for that purpose.

21. Termination of services

21.1 On terminating a therapeutic relationship, Members should consider writing a discharge/transfer summary that includes a record of the client's response to treatment and any recommendations for future treatment.

21.2 Wherever possible, Members should terminate art therapy services in agreement with the client and in a planned manner and must do so when therapy is no longer helpful or appropriate. When it is not possible to discuss termination of therapy with the client, others close to the client, such as a parent, carer, guardian or case manager should ideally be involved.

22. Caseload

22.1 Members will increasingly face challenges in the workplace as conditions change but, so far as possible should negotiate their caseload based on what they were employed to do, local circumstances and safe practice.

22.2 Members should seek to negotiate adequate time for preparation, record keeping, administration, clinical and managerial supervision, meetings and case conferences.

23. Private practice

23.1 Members must comply with the General Data Protection Act 2018. Members in private practice who intend to hold information about clients on their home computer are advised to register with the relevant National Data Protection Authority (currently the Information Commissioners Office, ICO)

23.2 Members who wish to be listed in the BAAT approved list of private practitioners must:
(i) have completed two years full time post-qualifying clinical work or four years part-time of supervised practice or equivalent number of hours
(ii) submit an application for private practice (PP) status to the Association's Membership Group.

23.3 Members in private practice must confine their practice within the limits of their training. Members must neither claim nor imply professional qualifications beyond those they hold and are responsible for avoiding and correcting any misrepresentation of those qualifications.

23.4 Members in private practice should ensure that they obtain the client's permission to contact the client's General Practitioner, who is responsible for the client's medical welfare, and partner, carer or next of kin should it be necessary to do so. Where the client does not give permission, Members should ensure that this is specifically noted in their client's records and should make a decision on whether to accept the client for private practice on a case-by-case basis.

23.5 Members in private practice should ensure they have made living will arrangements to inform clients, in the case of the therapists' incapacity or death.

23.6 Members in private practice must have adequate professional indemnity insurance and where necessary ensure that public liability insurance is also in place.

24. Referral and acceptance in private practice

24.1 Members in private practice must, on accepting a client, explain to the client their:
(i) fee;
(ii) method of payment;
(iii) session times
(iv) notification of holidays
(v) notice of cancellation
(vi) boundaries
(vii) information relating to the limits of confidentiality; and
(viii) duty as a therapist to report infringements against minors or violent risk to others.

25. Treatment and planning in private practice

25.1 Members who work in private practice must make art therapy plans that:
(i) seek to attain and maintain the client's optimum level of functioning and quality of life;
(ii) delineate the type, frequency and duration of art therapy;
(iii) set goals that, wherever possible, are formulated with the client's understanding and permission and reflect the client's current needs and strengths; and
(iv) allow for review, modification and revision.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, and recording or otherwise, without the prior permission of the British Association of Art Therapists.
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Code of ethics - The British Association Of Art Therapists

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