Introduction

Castelnuovo, et al have proposed that “telehealth is the use of telecommunications and information technologies to provide access to health information, assessment, diagnosis, intervention, consultation, supervision, education and follow-up programs across geographical distance” (Castelnuovo, et al., 2004, p. 16). And also, “a wide array of telehealth services is currently offered across diverse settings, including hospitals, community mental health centers, long term care facilities, schools, prisons, and rural health centers” (Glueckauf, Pickett, Ketterson, Loomis, & Rozensky, 2003, p. 160) However, As Carlton (2014) noted, the process of digital media adoption in art therapy is slow (Carlton, 2014), as well as “research has been developing relatively slowly and has not yet been systematized” (Zubala, Kennell, & Hackett, 2021, p. 2).

According to McNiff (1999): “art therapy, with its often-limited physical resources and its generally conservative approach to media, has yet to realize the opportunities offered by the digital era” (McNiff, 1999, p. 197). In addition, the advantages provided by cyber space are frequently accompanied by resistance stemming from art therapists’ worries about ethics, privacy, and other specific difficulties of online art therapy session (Zubala & Hackett, 2020), however, practitioners in art therapy who switched to remote delivery have argued that despite its potentially enormous implications for art therapy practice is perhaps not yet sufficiently researched about it (Kapitan, 2011). Thus, art therapists, clinical practitioners, and researchers need to be aware of features and factors of telehealth-based assessments tools and remote delivery including the lack of physical presence, technological issues, and also procedural issues (Luxton, Pruitt, & Osenbach, 2014) to assure optimal and competent of this tool of therapy.

Since the triangular therapeutic relationship, (therapist, the client and the artwork) (Schaverien, 2011) plays the key role process of art therapy, the transformation of this method to the online sessions is not recommended. However, it has been argued that distance delivery can be employed for art therapy practice because of increasing ease of sharing images via online channels and non-reliance on verbal communication, and also “due to dealing with symbols, metaphors and projections, which can manifest irrespective of medium used” (Zubala & Hackett, 2020, p. 2).

Aims

The aim of the current paper is to put the advantages of using digital technology in art therapy in front of its challenges to demonstrate a wide range of features of this space for practitioners and media specialists, (See table 1 for a summary.). As Zubala and Hackett debate “therapists’ willingness to adopt new digital media for therapy only once their benefits for clients and any risks are known” (Zubala & Hackett, 2020, p. 162). It is therefore important to consider academic theory and research in relation to online counselling methods and art therapy via technology approaches to help further our understanding of the possible effectiveness of online art therapies. To approach this target, we seek to address the following questions:

1.What are the benefits of digital world for art therapy according to research so far?

2.What are the challenges and drawbacks of using cyber space in art therapy session?

Methods

As the area which set to explore was relatively unique, the author expected that any published research accounts were likely to include a variety of study designs which tend to draw upon diverse methodologies and beyond qualitative and quantitative paradigms thus we chose an integrative review framework. And also, search string on the following databases: APA PsycInfo, JSTOR and Google Scholar search included the five elements: cyber-therapy, teletherapy, e-therapy, art therapy and digital technology. Finally, we included the articles if they concerned the use of digital technology in art therapy practice with clients which reported outcomes observed through empirical study, regardless of whether these were investigated using quantitative, qualitative, mixed or arts-based methods, but articles were excluded if they were PhD theses, dissertations or book chapters.

Advantages of including digital technology in art therapy session

To stress the general advantage of using Internet-based tools in psychology, according to Castelnuovo (2003) here four main features are reported:

1.The possibility to provide health information and services across geographical distance for underserved population

2.The possibility to increase the quality of health information and services in particular areas or for specific populations.

3.The possibility to ensure a continuous medical and psychological service overall for chronic disabilities reducing the cost of an extended traditional assistance.

4.The growing trend of patients’ preference towards accessing therapy via a home-based computer system. (Glueckauf, Pickett, Ketterson, Loomis, & Rozensky, 2003, p. 162)

However, to explain the accurate benefits of digital technology specifically cyber space in art therapy practice, in this chapter we discus of specific value that relate to the uses of technology in art therapy practice.

Active participants

Several studies have revealed that telehealth causes the shift in the triangular relationship, that reduces the attention on the therapist/patient relationship and emphasizes the attention on the patient/artwork relationship (Schaverien, 2011). Which means participants playing a more active role in their own treatment process and have a greater autonomy within therapy sessions (Zubala, Kennell, & Hackett, 2021), as well as rely more heavily upon verbal descriptions of their artworks, that often leads to improved communication (Levya, et al., 2018). More importantly, it seems that “an art therapist facilitating an online group would generally be more active, expressing in words many things that would be expressed non-verbally in an in-person group” (Collie, et al., 2016, p. 10)

Therapy beyond borders

Not only online health services reduce gaps of quality in treatments between different demographic groups (Glueckauf, Pickett, Ketterson, Loomis, & Rozensky, 2003), but also a number of studies have found that online mode of delivery has the potential to not only bridge geographical distances by expanding access to services (Collie, et al., 2016), as well as, makes art therapy approachable to clients regardless of barriers such mobility disability, stigma (Spooner, et al., 2019) or someone who is feeling emotionally isolate (Collie, et al., 2016). Equally important, it is also observed 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” (Zubala, Kennell, & Hackett, 2021, p. 13).

Multimodal expression environment

A careful study of the literature reveals that, expressive qualities of the digital arts media can be empowering, not only because of providing the freedom of expression environment without the constraints of the physical and material world but also by providing opportunities to create digital art making (Kaimal, et al., 2020), that subsequently can facilitate multimodal expression not limited to images (Collie, et al., 2016). Besides “playfulness of the artmaking process and creative exploration was another positive aspect of engaging with digital arts media noted in the literature” (Zubala, Kennell, & Hackett, 2021, p. 14).

Cathartic pleasure

As Schaper (1968) explained, in one sense “catharsis means purgation, which is sign of getting rid of disturbances by removing their causes. And in the second sense, catharsis is said to mean purification, and this meaning derives from a religious context of cleansing the spirit and sublimating the emotions in order to prepare for or to achieve a state of exaltation” (Schaper, 1968, p. 132). In addition, according to Aristotle’s catharsis theory pleasure through catharsis, is produced by works of art which are well-made tragedies. Catharsis is the telos of tragedy, the end towards which the formal artefact is functionally directed. In Aristotle’s theory catharsis is part the definition of tragedy: “an imitation of an action” with incidents arousing pity and fear, where with to accomplish its catharsis of such emotions (Schaper, 1968, p. 131).

It has been also argued that, clients during the art therapy with technology are eager to demonstrate others what they have done and even “they forget the psychologically revealing nature what they have created and instead became fixated on the immediate cathartic pleasure of having created something “really cool” (Alders, Beck, Allen, & “Basia” Mosinski, 2011, p. 167).

Mess-free, and user-friendly therapeutic relationships with low cost

In general, as observed from prior studies, the rapid development of Internet and new communication technologies and also the widespread presence of “user friendly” computers are having a growing impact on the process of psychology and psychotherapy, and allows more professionals, psychologists and psychotherapists to use the Internet and other technological tools in the field of psychology (Castelnuovo, et al., 2004). Moreover, previous studies have reported that reducing client’s resistance to therapy has been always the main target of therapists that will become possible by the use of technology in therapy with the process of art making (Orr, 2012). In addition to this, some studies found a positive impact of online mode of art therapy on developing therapeutic relationships which can be caused by considering the client’s home environment by the therapist as well (Levya, et al., 2018) and it seems plausible that people could communicate effectively online even when the content of their communication is fraught with affective intensity (Castelnuovo, et al., 2004). Furthermore, there are 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” (Zubala, Kennell, & Hackett, 2021, p. 13). And finally, until recently the considering issue of not including technology in art therapy practice was the cost of equipment, ranging from electronic art tools to the internet access fees however, some practitioner believed that “an Internet-based interaction between a therapist and a patient could avoid a physical contact and saving economical, social and individual costs” (Castelnuovo, et al., 2004, p. 4).

Challenges, drawbacks and concerns of including digital technology in art therapy session

Brenes and et al argued that working in a manner that seems so untraditional seems the main cause of not applying digital sphere in psychotherapy (Brenes, Ingram, & Danhauer, 2011). More importantly, Collie (2017) explained that as another concern, it seems be harder to create a safe emotional container in a cyberspace than in traditional mode (face-to-face), therefore this vulnerability needs to be addressed with skillful facilitation (Collie, et al., 2016). Although, in most cases the difficulties and challenges that arise with telehealth can be solved with some alterations and adjustments, “should be considered before agreeing to work with a client via telehealth” (Levya, et al., 2018, p. 24). In general, some reasons that psychotherapists may perceive online psychotherapy as more difficult include:

1.Lack of nonauditory cues that can limit the psychotherapist’s ability to interpret client experiences, responses, and ambivalence.

2.Distraction, difficulty maintaining attentiveness during the session, and potential for focusing on extraneous tasks.

3.Potential for sessions to become more social or conversational rather than therapeutic.

4.Concerns about ability to establish an effective therapeutic alliance with the client (Brenes, Ingram, & Danhauer, 2011, p. 5).

Technical issues and limitations

Although, Stamm (1988) argued that psychologists do not have to be technology specialists to be competent providers of telehealth services, they will need more technology proficiency, particularly with computers, than has been the norm (Stamm, 1988). Moreover, from one point of view, art therapy sessions are inherently stressful for clients, which can be enhanced when art therapists or clients confront technical issues such as sufficient strength of signal and reliability, “even when using the newest technologies, it is possible to experience issues with connection speed” (Levya, et al., 2018, p. 23) that cause blurred or unclear image and loss in subtle detail while showing artwork to the webcam, through the therapy, which can “diminish the sense of being seen and heard and therefore the sense of connection” (Collie, et al., 2016, p. 9). Thus, as Levya (2018) proposed, therapists might offer their clients more than one way to connect and agree alternative ways of contact in order to address potential technical issues with connectivity. Also from another standpoint, lack of experience of using devices is cited as the key barrier and challenge to engaging in art therapy or tele-therapy sessions (Spooner, et al., 2019), which could cause distress to both clients and therapists.

Ethical challenges

Art therapists face a number of ethical challenges as they employ new media, as Orr (2012) argued that ethical concerns of art therapists are predominant barriers to introducing technology in therapy session (Orr, 2012). Thus “much work is needed to fully understand how technology is being used, with attention to possible misuses and client vulnerabilities” (Alders, Beck, Allen, & “Basia” Mosinski, 2011, p. 167). AATA’s (2011) ethical principles state, “art therapists strive to provide a safe, functional environment and treat clients in an environment that protects privacy and confidentiality” (Section 1.12, p. 3). Also, in order that art therapists maintain client treatment records for a reasonable amount of time, “creates potential vulnerabilities that could decrease trust within the therapeutic relationship and result in a client withholding information” (Alders, Beck, Allen, & “Basia” Mosinski, 2011, p. 168)

Lack of tactile qualities

“Posture, tone, inflection, eye contact and other nonverbal cues can give the therapist a lot of precious information” (Castelnuovo, et al., 2004, p. 5). However, previous studies based on the nonsensory character of digital arts media, have confirmed that technology is cold, isolating, and even dehumanizing as well as the lack of tactile and sensual qualities (Collie, Bottorff, Long, & Conati, 2006) or even lack of tangible physical engagement with the medium have been reported (Kaimal, et al., 2020). Moreover, “some therapeutic scenarios, such as highly experiential setting and approaches that give great importance to the front-end diagnosis step, are strictly related to face-to-face situations and need to be deeply redesigned in case of using an Internet-based medium” (Castelnuovo, et al., 2004, p. 5) Equally important, several studies have revealed that observing art making process directly is not easily achievable in online therapy setting, which cause therapists being unable to view chronological order in which elements are added to the drawing as well as clients’ facial expression (Levya, et al., 2018). Cosequently, “this lack of sensory input might lead to clients disconnecting not only from art materials, but also from their own bodies and social interactions” (Zubala, Kennell, & Hackett, 2021, p. 14). In the same way, computer image might not be an adequate container for emotional material by reason of there are unlimited copy of images (Collie & Čubranić, 1999). Therefore,using computers for art making might put more emphasis on the product than on the artistic process (Collie, Bottorff, Long, & Conati, 2006). That is why for some theorists “the communication over the Internet would be an inadequate replacement for face to face intimacy “ (Castelnuovo, et al., 2004, p. 5)

Crisis Situations

The conducting of a safety and confidatial psychotherapy session to reduce the risk of crises and prevent adverse events, is one of the most crucial point in art therapy practice, which has been concerned in traditional psychotherapy, and psychotherapists have a considerable amount of control over the environment. However, when psychotherapy is conducted via internet, psychotherapists will lose a substantial amount of this control. As a result, clients with low motivation for psychotherapy such as, clients seeking treatment upon pressure from family or friends may receive minimal benefit from online psychotherapy. Moreover, some crises that a psychotherapist may face when conducting obline psychotherapy are suicidal intent, homicidal intent, and worsening symptoms thet they must be handled differently than in a typical face-to – face therapeutic relationship. Thus, online-delivered psychotherapy may not be appropriate for all clients, and may benefit more from a combination of face-to-face and online psychotherapy (Brenes, Ingram, & Danhauer, 2011)

Extra time

Although, “technology makes the attainment of social skills more linear and less time dependent” (Alders, Beck, Allen, & “Basia” Mosinski, 2011, p. 166) and also digital technologies provide the opportunities for both clients and therapists to have conducted therapeutic sessions at the same time with any distance, it is recognized that to provide a dynamic therapeutic environment extra time might be needed (Spooner, et al., 2019). Moreover, “a concern has been raised about this additional learning potentially impeding the therapeutic process and that extra time might be needed to establish a therapeutic relationship and also healing effect of physical presence would be lost” (Collie, Bottorff, Long, & Conati, 2006, p. 856). As well as therapists should be aware of the physical risks that may result from prolonged work on computers.

Conclusion

This paper was undertaken with the purpose of providing the clear picture of positive and negative consequences and features of applying cyber sphere and technology in art therapy. In summary, literature reviews have indicated that although cyber-therapy will offer art therapy services across geographical distance for all and specific population and psychological assistance overall for chronic disabilities, the need of technology proficiency more than norm for both clients and art therapists has limited the access of therapy for some individuals. On the other hand, insecure character of online sphere and potential ethical issues could also decrease trust within therapeutic relationship, it may however be noted that reducing client’s resistance to therapy will become possible by employing user-friendly media technologies and home-based therapy process, moreover, participants of online art therapy will be more active and autonomous in their treatment sessions, despite the fact that providing a dynamic art therapeutic environment needs extra time.

Table 1. Pros and cons of using digital world in art therapy practice in summery.

Equally importantly, the findings of the present study provide evidence that cyberspace as a multimodal expression environment by offering the possibility of creating digital arts will provide the freedom of expression for clients, however, there has been discussion about losing the control of conducting online psychotherapy sessions in crisis like suicidal or homicidal intent that they must be handled differently than the typical mode, besides, the lack of tangible physical engagement with online media has been reported that lead to clients disconnecting from art materials and social interaction. In addition, a careful study of the literature reveals that online art therapy has the potential to focus on extraneous tasks as well as become more social then therapeutic, even though, it should be noted that clients during the online art therapy have become fixated on the immediate cathartic pleasure of creating.

Finally, we found that generally there seemed to be quite polarized opinions about the use of online technology in psychotherapy, with majority in favor of distance art therapy in which argued that the nature of online counselling enhances and expands opportunities to connect people, rather than being just an alternative or substitute for face-to-face interaction, however, some researchers also expressing concerns about the antitherapeutic character of technology.

References

Alders, A., Beck, L., Allen, P., & “Basia” Mosinski, B. (2011, 12 21). Technology in Art Therapy: Ethical Challenges. Journal of the American Art Therapy Association, 28(4), 165–170. Retrieved from http://dx.doi.org/10.1080/07421656.2011.622683

Brenes, G., Ingram, C., & Danhauer, S. (2011). Benefits and challenges of conducting psychotherapy by telephone. Professional Psychology: Research and Practice, 42(6), 543–549. doi:10.1037/a0026135

Carlton, N. (2014, 02). Digital culture and art therapy. The Arts in Psychotherapy, 41(1), 41–45. Retrieved from https://doi.org/10.1016/j.aip.2013.11.006

Castelnuovo, G., Buselli, C., Ferrari, R., Gaggioli, A., Mantovani, F., Molinari, E., . . . Riva, G. (2004). New tools in cybertherapy: the VEPSY Web Site. Studies in Health Technology and Informatics, 99, 15–35. doi:10.3233/978–1-60750–943–1-15

Choe, S. (2014). An exploration of the qualities and features of art apps for art therapy. The Arts in Psychotherapy, 41(2), 145–154. Retrieved from https://doi.org/10.1016/j.aip.2014.01.002

Collie, K., & Čubranić, D. (1999). An Art Therapy Solution to a Telehealth Problem. Journal of the American Art Therapy Association, 16(4), 186–193. Retrieved from https://doi.org/10.1080/07421656.1999.10129481

Collie, K., Bottorff, J., Long, B., & Conati, C. (2006, 02 26). Distance art groups for women with breast cancer: guidelines and recommendations. Support Care Cancer, 14, 849–858. doi:10.1007/s00520–005–0012–7

Collie, K., Hankinson, S. P., Norton, M., Dunlop, C., Mooney, M., Miller, G., & Giese-Davis, J. (2016, 02 24). Online art therapy groups for young adults with cancer. An International Journal for Research, Policy and Practice, 9(1), 1–13. Retrieved from https://doi.org/10.1080/17533015.2015.1121882

Ethical principles for art therapists. (2011). Retrieved from American Art Therapy Association: http://www.americanarttherapyassociation.org/upload/ethicalprinciples.pdf

Glueckauf, R., Pickett, T., Ketterson, T., Loomis, J., & Rozensky, R. (2003). Preparation for the delivery of telehealth services: A self-study framework for expansion of practice. Professional Psychology: Research and Practice, 34(2), 159–163. Retrieved from https://doi.org/10.1037/0735–7028.34.2.159

Haywood, S., & Grant, B. (2022, 07 05). Reimagining art therapy for the digitally-mediated world: a Hexagonal Relationship. International Journal of Art Therapy, 1–8. Retrieved from https://doi.org/10.1080/17454832.2022.2084124

Kaimal, G., Carroll-Haskins, K., Berberian, M., Dougherty, A., Carlton, N., & Ramakrishnan, A. (2020). Virtual Reality in Art Therapy: A Pilot Qualitative Study of the Novel Medium and Implications for Practice. Journal of the American Art Therapy Association, 37(1). Retrieved from https://doi.org/10.1080/07421656.2019.1659662

Kapitan, L. (2011, 04 22). Introduction to the Special Issue on Art Therapy’s Response to Techno-Digital Culture. Journal of the American Art Therapy Association, 26, 50–51. Retrieved from https://doi.org/10.1080/07421656.2009.10129737

Levya, C., Spoonerc, H., Leec, J., Sonked, J., Myerse, K., & Snowc, E. (2018, 02). Telehealth-based creative arts therapy: Transforming mental health and rehabilitation care for rural veterans. The Arts in Psychotherapy, 57, 20–26. Retrieved from https://doi.org/10.1016/J.AIP.2017.08.010

Luxton, D., Pruitt, L., & Osenbach, J. (2014). Best practices for remote psychological assessment via telehealth technologies. Professional Psychology: Research and Practice, 45(1), 27–35. Retrieved from https://doi.org/10.1037/a0034547

McNiff, S. (1999). The Virtual Art Therapy Studio. Journal of the American Art Therapy Association, 16(4), 197–200. Retrieved from https://doi.org/10.1080/07421656.1999.10129484

Orr, P. (2012, 04 12). Technology use in art therapy practice: 2004 and 2011 comparison. 39(4), 234–238. Retrieved from https://doi.org/10.1016/j.aip.2012.03.010

Schaper, E. (1968). Aristotle’s Catharsis and Aesthetic Pleasure. The Philosophical Quarterly, 18, 131–143. Retrieved from https://www.jstor.org/stable/2217511

Schaverien, J. (2011). The triangular relationship and the aesthetic countertransference in analytical art psychotherapy. In M. Gerry, The changing shape of art therapy : new developments in theory and practice (pp. 55–83). London: Jessica Kingsley Publishers.

Snyder, K. (2021, 02 01). The digital art therapy frame: creating a ‘magic circle’ in teletherapy. International Journal of Art Therapy, 104–110. Retrieved from https://doi.org/10.1080/17454832.2020.1871389

Spooner, H., Lee, J., Langston, D., Sonke, J., Myers, K., & Levy, C. (2019). Using distance technology to deliver the creative arts therapies to veterans: Case studies in art, dance/movement and music therapy. The Arts in Psychotherapy, 62, 12–18. Retrieved from https://doi.org/10.1016/j.aip.2018.11.012

Stamm, H. (1988). Clinical applications of telehealth in mental health care. Professional Psychology: Research and Practice, 29(6), 536–542. Retrieved from https://doi.org/10.1037/0735–7028.29.6.536

Zubala, A., & Hackett, S. (2020, 12 15). Online art therapy practice and client safety: a UK-wide survey in times of COVID-19. International Journal of Art Therapy, 25(4), 161–171. Retrieved from https://www.tandfonline.com/doi/full/10.1080/17454832.2020.1845221

Zubala, A., Kennell, N., & Hackett, S. (2021, 04 08). Art Therapy in the Digital World: An Integrative Review of Current Practice and Future Directions. Frontiers in Psychology. Retrieved from https://doi.org/10.3389/fpsyg.2021.600070