I have been working in two locations, London and Fuerteventura for the past 5 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 onlineart 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 client’s 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 strategiesand 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.