Shifting to tele-creative arts therapies during the COVID-19 pandemic: An international study on helpful and challenging factors.

The COVID-19 pandemic has led to an unprecedented shift to online treatment. For the creative arts therapies (CATs) - a healthcare profession that involves the intentional use of the visual art, drama, music, dance, and poetry within a therapeutic relationship - this shift has been highly consequential for practice. This study examined (a) how the COVID-19 pandemic has impacted clinical practice in the CATs, and (b) the features characterizing online practice in an international sample of 1206 creative arts therapists aged 22-86 (92% female). It aimed to identify changes in the use of the arts in therapy, resources that contributed to the delivery of therapy, and the role of therapists' creative self-efficacy in adapting to these changes. Respondents completed close and open-ended questions providing examples of what does and does not work in online practice. The results indicate that creative self-efficacy plays a meaningful role in buffering the impact of therapists' computer comfort on their perceived difference in online clinical practice; confidence in one's abilities positively contributed to their adaptation to online practice. The qualitative analysis yielded four main categories: the challenges of tele-CATs, continuing the therapeutic process through tele-CATs, adaptations for tele-CATs, and future directions. Overall, the results present a timely report on the inevitable transition of the CATs to online practice.

Introduction

On March 11, 2020, the World Health Organization (WHO) officially declared COVID-19 a pandemic with a global impact (WHO, 2020). Containment measures have been enforced in many countries that include social distancing and stay-at-home orders. Mental-health care providers, including creative arts therapies have been required to shift from in-person therapy to remote tele-psychotherapy using telecommunication technologies (Wind, Rijkeboer, Andersson, & Riper, 2020). Given these radical changes worldwide, this international study examined how the COVID-19 pandemic has impacted creative arts therapies’ clinical work and what characterizes their online practice.

The outbreak of COVID-19, together with the enforced quarantines, social isolation measures, and resulting financial hardship, have had a major impact on mental health resulting in rises in depression, anxiety, and post-traumatic stress (Brooks et al., 2020, Palgi et al., 2020, Rajkumar, 2020). Some populations have been more vulnerable such as older adults (Shrira et al., 2020, Yang et al., 2020), pregnant women (Fakari & Simbar, 2020), people with mental illness (Yao et al., 2020; Zhu et al., 2020),people experiencing chronic physical illness (Hacker, Briss, Richardson, Wright, & Petersen, 2021), individuals with intellectual and developmental disabilities including autism (Turk, Landes, Formica, & Goss, 2020), people suffering from domestic abuse and family violence, both of which have increased globally since the enforcement of lockdown measures (Usher, Bhullar, Durkin, Gyamfi, & Jackson, 2020), and frontline healthcare workers (Cabarkapa, Nadjidai, Murgier, & Ng, 2020).

In the face of the pandemic and alongside the need for mental health care providers to continue their work, tele-psychotherapy practice shifted from being peripheral to the main mode of therapy. The emerging literature on the subject indicates that tele-psychotherapy (including psychotherapy via video conferencing or by telephone) is effective in addressing common mental health disorders such as anxiety and mood disorders (Berryhill et al., 2019). Its effectiveness was reported to be comparable to in-person treatment (Poletti et al., 2020). Patients receiving tele-psychotherapy have reported a good working alliance and close contact with the therapist, and perceived treatment to be highly effective (Etzelmueller, Radkovsky, Hannig, Berking, & Ebert, 2018). In addition, evidence from the field of psychotherapy indicates that for some clients, tele-psychotherapy may afford better connections with their therapist and new possibilities for treatment than in-person (Chen et al., 2020). Tele-psychotherapy has also been lauded for its ability to overcome geographic and stigma-related barriers to mental health care. It can increase access by lowering costs to patients in terms of transportation, missed work, and childcare costs, which are the key issues for those who live in rural areas (Tuerk, Keller, & Acierno, 2018). Clear organizational policies supporting tele-psychotherapy and training, such as the ethical guidelines concerning tele-psychology published by the American Psychological Association (2013), encouraged both clients and therapists to use and benefit from this modality (Pierce, Perrin, & McDonald, 2019) provided necessary competencies are met.

However, research also points to several shortcomings to the implementation of tele-psychotherapy in routine care such as the lack of availability of trained and experienced tele-therapists (Tuerk et al., 2018) and technical difficulties that cause video conferencing sessions to break down (Poletti et al., 2020). Studies have noted that clients may be unwilling to engage in tele-psychotherapy (Apolinário-Hagen, Vehreschild, & Alkoudmani, 2017), and that exchanging materials and paperwork between patient and therapist such as self-assessments, worksheets, and psychoeducation materials is complex. Because tele-health programming in health care systems requires careful planning on all levels, lack of collaboration and compatibility can also constitute an obstacle to the seamless implementation of tele-health services (Tuerk et al., 2018, Vis et al., 2018). Studies indicate that one of the main hurdles to integrating tele-psychotherapy as part of routine care practice is the lack of acceptance by the therapists themselves. Concerns have been raised about confidentiality, privacy, and the reliability of technology. This is coupled with beliefs that tele-psychotherapy may be less effective, and that the therapeutic alliance can only be established face-to-face (Berger, 2017, Chen et al., 2020, Schulze et al., 2019, Topooco et al., 2017). Critics have also voiced objections that tele-psychotherapy may limit access to patients’ verbal, non-verbal, and unconscious communications during therapy (Brahnam, 2017). Thus, in the last two decades, tele-psychotherapy has been adopted far more slowly than initially expected by both clients and therapists (Wind et al., 2020). The pandemic forced therapists to cope with all these obstacles overnight and has become a powerful catalyst for the implementation of tele-psychotherapy in all creative arts therapies disciplines.

Tele-creative arts therapies

Creative arts therapies (CATs) are credentialed healthcare professionals who have completed extensive education and clinical training in using the creative and expressive process of active art-making and its outcomes to ameliorate disabilities, illnesses and optimize health and well-being within a therapeutic relationship (Orkibi, 2020). Creative arts therapies work with clients of all ages, with individuals, dyads, families, and groups across a variety of medical, rehabilitative, educational, and community settings. The CATs are especially valuable for clients who have difficulties expressing themselves in words alone (Orkibi, 2020). The CATs consist of the following seven disciplines: art therapy (AT), music therapy (MT), dance movement therapy (DMT), drama therapy (DT), psychodrama (PD), poetry or biblio-therapy (P/BT), and multimodal expressive therapies (EXT). The artistic modalities provide additional means of self-exploration and expression within a therapeutic relationship (Shafir, Orkibi, Baker, Gussak, & Kaimal, 2020) that rely on tangible art materials, music, embodied movement and gestures, and performed or written characters and stories. Thus, the shift to online settings is likely to need profession-specific adaptations to the unique features of CATs practice.

To date only a few studies have explored tele-CATs (Sajnani et al., 2019, Spooner et al., 2019), the use of digital resources in CATs or the training of creative art therapists (Beardall et al., 2016, Blanc, 2018, Hacmun et al., 2018, Pilgrim et al., 2020; Sajnani et al., 2020; Wood et al., 2020). For example, remote music therapy with military populations showed that participants responded positively in an online setting, and reported a decrease in pain, anxiety, and depression (Vaudreuil et al., 2020). Online drama therapy with older adults was shown to reduce isolation during COVID-19 (Kordova & Keisari, 2020). Other works have explored the use of digital resources in art therapy, such as virtual reality (Kaimal et al., 2020), or digital resources in drama therapy (Atsmon & Pendzik, 2020). These works point to the therapeutic potential of the tele-CATs as well as necessary considerations such as familiarity with and access to digital tools and environments and specific ethical requirements when working with art materials in the often semi-private space of one’s own home.

In this study, we measured a construct that is widely researched in the creativity research field named creative self-efficacy, which refers to an individual’s self-belief in their ability to be creative when required by a situation (Tierney & Farmer, 2002). Creative self-efficacy is rooted in Bandura (1997) social cognitive theory which posits that strong efficacious beliefs enhance human well-being because people who have high confidence in their capabilities perceive difficulties as challenges to be mastered rather than as threats to be avoided. Accordingly, creative self-efficacy has been conceptualized as a personal factor that contributes not only to creativity outcomes (Karwowski and Barbot, 2016, Qiang et al., 2020) but also to outcomes of health and posttraumatic growth (Orkibi and Ram-Vlasov, 2019, Orkibi, 2021). Therefore, we have examined the role of creative self-efficacy as a personal resource reasoned to be helpful in adapting to changes imposed by the COVID-19 pandemic among creative arts therapies.

The present study

While previous research has looked at various aspects of the pandemic, tele-CATs, and creative self-efficacy, there has been no large-scale research to examine the international impact of COVID-19 on creative arts therapies, including all the different artistic modalities. Thus, the purpose of this study was to examine (a) how the COVID-19 pandemic has impacted creative arts therapies’ clinical practice, and (b) what characterizes their online practice. Specifically, we aimed to identify reasons for changes in practice, any change in the use of the arts in therapy, resources that contributed to this change, and the role of therapists’ creative self-efficacy in adapting to these changes. The survey included open-ended questions intended to provide more detailed examples of what worked and what did not in shifting to online CATs practice. Note that at the outset of the survey it was clarified that “the term online refers here to any distance/ teletherapy by video, telephone or any other platform.”

Method

Procedure

In April-June 2020, during the peak of the initial COVID-19 outbreak in many countries, we sent a link to the survey to creative arts therapies worldwide by means of social media platforms (e.g., Facebook), private and professional email lists, listservs, messaging apps (e.g., WhatsApp), etc. The survey was administered online in Hebrew and English, using the Qualtrics research platform. All quantitative data collected were anonymous to protect the respondents’ privacy. The study was approved by the ethics committees of the three universities involved (UH approval 162/20; NYU IRB-FY2020-4363; LU 19/20-038).

Participants

The initial sample consisted of 1534 individuals who clicked the survey link. Of these, 1330 answered only the first question regarding their gender (92% female); 1325 also reported their age (ranging between 22 and 86, M = 45, SD = 12). Next, 1319 reported their CATs discipline: 32% AT, 24% DT, 14% MT, 11% DMT, 8% PD, 7% EXT, and 4% P/BT. Of the remaining 1271 respondents, 74% held a master’s degree, 9% a bachelor’s degree, 10% a doctoral degree, and 2% a non-academic certificate. Of the 1206 final respondents, the largest group was from Israel (45%), 20% were from the US, 8% from Canada, and the rest from other countries.

Years of practice ranged from 0 (the participant had just graduated) to 63 (M = 12, SD = 9.88). Most therapists (55%) reported that their main client age group was children and adolescents, followed by adults (34%) and older adults (5%). The largest group of therapists (21%) worked with clients with anxiety or depression, followed by mild emotional difficulties (13%), behavioral problems (11%), and developmental problems (11%). Most therapists reported that their main work sector was public (43%), followed by “private and public” (25%), and private (23%). Before the COVID-19 pandemic, the average number of therapy meetings (appointments) per week was 13 (SD = 8.93), and the average number of individual clients per week was 23 (SD = 22.09).

Survey

Each member of the research team reviewed the survey to ensure that the questions were clear and intelligible before they were disseminated. The survey consisted of 40 items and took about 15 min to complete. It consisted of the following subsections:

Socio-demographic and background information, which included gender, age, CATs discipline, years of practice in the discipline since graduation, highest education level, main and additional age groups of clients, main and additional health conditions of clients, work sector, and country of practice.

Personal effect of the COVID-19, which consisted of items assessing stress level, ranging from 1 (not stressed) to 4 (extremely stressed), specific health risks from contracting COVID-19 to self or a close family member (yes/no), self or a close family member testing positive for COVID-19 (yes/no), and a family member currently hospitalized for COVID-19 (yes/no).

Practice-related questions included level of comfort with basic computer use, responses ranging from 1 (very uncomfortable) to 4 (very comfortable), the average number of weekly clients before COVID-19, the number of weekly therapy sessions before COVID-19, the extent to which the typical clinical work before and after COVID-19 involved their art form, with responses ranging from 1 (not at all) to 4 (to a large extent). We also asked respondents to indicate the extent to which their clinical work had been affected by COVID-19, with responses ranging from 1 (seeing all my clients) to 4 (stopped seeing all my clients), a high score indicating a greater negative effect. With respect to the clients whom they were still seeing during COVID-19, the therapists were asked to select from a list the statement that best described their practice (e.g., online, face-to-face, blended, etc.), and to identify the platform used for online therapy. Therapists were asked to select the nature of their online practice and what helped them. They were also asked how different their online practice was from face-to-face practice, with responses ranging from 1 (very much the same) to 4 (very different), and were given the opportunity to provide examples. Therapists who stopped seeing clients were asked to specify the reasons for termination.

Creative self-efficacy (CSE) questions (Karwowski, 2014), which included items such as “I trust my creative abilities,” were rated on a scale from 1 (strongly disagree) to 5 (strongly agree), a higher mean score indicated higher CSE. This scale has demonstrated good validity and reliability in both its English (Karwowski, 2014) and Hebrew (Orkibi & Ram-Vlasov, 2019) versions.

Four open-ended questions about the effect of the pandemic on clinical practice: “Please give us an example of what works well for you in your online [specified CATs discipline],” “Can you give an example of something that does not translate well from the face-to-face setting to the online [specified CATs discipline]?” “Please detail specific adaptations you have made when moving to online [specified CATs discipline] in relation to the specific / various populations you work with,” and “How do you imagine the response to the current COVID-19 pandemic will change the future of [specified CATs discipline]?”.

Data analysis

Given the descriptive nature of the study, the analysis included descriptive statistics to quantitatively depict and summarize the characteristics of the participants and determine the central tendency and the variability in the data (in view of the missing data and the resulting altered sample sizes, the corrected percentages are reported in the descriptive statistics results). We also computed bivariate correlation and chi-square tests to probe the relationships between variables. According to the data type, we conducted parametric or non-parametric tests to compare different subgroups. The change score (difference score) was calculated by subtracting the variable representing the typical use of the arts in therapy during COVID-19 from that before COVID-19.

We examined the open-ended questions using thematic analysis (Braun & Clarke, 2006). To enhance reliability, two members of the research team conducted an independent analysis of the data, both beginning the analysis with a read-through of the responses to familiarize themselves with the data. An initial set of codes was created for the dataset, which was followed by an examination of the codes to identify broader significant patterns of meaning, i.e., themes. Next, all candidate themes were checked against the dataset and refined if needed. Finally, a detailed analysis of the content of each theme resulted in the definition and final labeling of the themes for the writing up of the results.

Results

Most therapists (60%) indicated they were “very stressed” when asked about their daily stress levels related to COVID-19. Most therapists (58%) also indicated that they, or a close family member, were not at specific health risk for contracting COVID-19%, and 97% indicated they, or a close family member, had not been found positive for COVID-19. Relatedly, 98% indicated they did not have a family member currently hospitalized due to COVID-19. There was a negligible positive correlation between daily stress levels and being at specific health risk from contracting COVID-19 (r = 0.13, p < .001, N = 1196).

Similarly, there was a negligible negative correlation between therapists’ age and their level of comfort with basic computer use (r = −0.21, p < .001, N = 1186), whereas age was not correlated with the impact of COVID-19 on work, use of art in practice during the pandemic, or reports of perceived change in online vs. non-online. There was also a negligible negative correlation between years of practice with feeling comfortable with basic computer use (r = −0.12, p < .001, N = 1187), but not with these same three variables. Age was not correlated with therapists’ CSE. Overall, the correlations between these variables were so small as to be considered negligible (Hinkle, Wiersma, & Jurs, 2003).

Impact of COVID-19 on practice

In terms of the extent to which their clinical work has been impacted by COVID-19, the largest group of therapists (45%) indicated they were still seeing most of their clients, followed by 31% who indicated they had stopped seeing most of their clients. The therapists who had stopped seeing clients were asked to select the reasons for termination from a list. The most frequent reason was (42%) “clients don’t want to meet online,” followed by “other” (22%), “the agency doesn’t approve” (11%), and “the economic situation” (11%) (see the online supplemental material file, Fig. S1).

When asked to indicate how different their online practice was compared to non-online practice, the largest group of therapists (45%) indicated it was “very different” followed by 33% who indicated it was “mostly different,” 18% “mostly the same,” and 1% “very much the same.” Consistently, most therapists (53%) indicated that prior to COVID-19 their typical clinical work involved their art form “to a large extent,” followed by 36% who indicated it only involved their art form “to a moderate extent.” In contrast, when asked to indicate the extent to which their typical online clinical work during the pandemic involved their art form, 42% of those practicing online indicated “to a small extent” followed by 26% who indicated “to a moderate extent.” To further examine these differences, a paired-samples t-test was computed. The results indicated that prior to COVID-19 therapists’ typical clinical work involved their art significantly more (M = 3.41, SD =0.722) than during COVID-19 (M = 2.08, SD = 1.22), t (1106) = 33.44, p < .001, with a large effect size, d = 1.33 (Cohen, 1992). Interestingly, self-reported impact of COVID-19 on one’s work had a negligible negative correlation with use of the arts in online therapy (r = −0.27, p < .001, N = 1104).

Group differences

A multivariate analysis of variance (MANOVA) was computed with CATs discipline as the independent variable. The dependent variables were “impact of COVID-19 on clinical work” and the change score of using the arts in therapy. The analysis revealed a significant main effect for the CATs variable, Wilks’ Lambda= 0.919, F(12,2192)= 7.925, p < .001, ηₚ²= 0.04. As seen in Table 1, the results indicated significant differences between different modalities in “impact of COVID-19 on clinical work” and in the change score, but with small and medium effect sizes, respectively (Cohen, 1992). Regarding impact as a dependent variable, a Tukey post hoc test indicated that MT practice was statistically significantly more impacted by COVID-19 than DT, AT, and EXT. Regarding change (scores) in using the arts in therapy as a dependent variable, significant differences were found between AT and B/PT, DT, PD, EXT. Significant differences were also found between B/PT and DMT, MT, as well as between DMT and DT, PD, EXT. Moreover, significant differences were found between MT and PD, EXT.

Table 1

Means, standard deviations, and MANOVA for differences by CATs discipline on the impact and change variables.

	1. AT		2. B/PT		3. DMT		4. DT		5. MT		6. PD		7. EXT
Variable	M	(SD)	M	(SD)	M	(SD)	M	(SD)	M	(SD)	M	(SD)	M	(SD)	F (6,1097)	ηₚ2	Post hoc difference
Impact	2.37	.05	2.43	.12	2.49	.08	2.41	.05	2.70	.07	2.38	.09	2.16	.10	4.236***	.02	5 > 1,4,7
Change	-1.59	.07	-.57	.18	-1.66	.12	-1.16	.08	-1.52	.10	-.84	.13	-.84	.15	11.948***	.06	1 > 2,6,7
																	3 > 2,4,6,7
																	5 > 2,6,7

In addition, a MANOVA was computed with the work sector as the independent variable and the impact of COVID-19 on clinical work and the change score of using the arts in therapy as dependent variables. The analysis revealed a significant main effect, Wilks’ Lambda= 0.968, F(4,2200)= 8.901, p < .001, ηₚ²= 0.02. As seen in Table 2, there were only significant differences between the work sector for the change score variable, with a small effect size (Cohen, 1992). No significant differences between the main sector of work were found in terms of the impact of COVID-19 on clinical work. A Tukey post hoc test indicated that the change in use of arts in therapy was greater for those working solely in the public sector, compared to those working in the private sector and those working in both sectors.

Table 2

Means, standard deviations, and MANOVA for differences by work sector on the impact and change variables.

	1. Private		2. Public		3. Private & Public
Variable	M	(SD)	M	(SD)	M	(SD)	F (2,1104)	ηₚ2	Post hoc difference
Impact	2.37	.04	2.41	.05	2.52	.05	ns	–	–
Change	-1.03	.08	-1.53	.06	-1.26	.07	13.574***	0.02	2 > 1,3

Note. Estimated marginal means (M) and standard deviations (SD) are presented. N = 1104.

ns = not significant. *p < .05, **p < .01, ***p < .0001

Lastly, a MANOVA was computed with the main age group of the therapists’ clients as the independent variable and impact of COVID-19 on clinical work and the change score of using the arts in therapy as dependent variables. The analysis revealed a significant main effect, Wilks’ Lambda= 0.956, F (4,2200) = 12.428, p < .001, ηₚ²= 0.02, with small effect sizes (Cohen, 1992). As seen in Table 3, significant differences were found between clients' main age group in terms of the impact of COVID-19 on clinical work and the change score. The highest impact was reported by therapists who worked with older adults and, similarly, the greatest change (score) in the use of the arts in therapy.

Table 3

Means, standard deviations, and MANOVA for the differences by clients’ age on the impact and change variables.

	1. Children / adolescents		2. Adults		3. Older adults
Variable	M	(SD)	M	(SD)	M	(SD)	F (2,1101)	ηₚ2	Post hoc difference
Impact	2.50	.03	2.26	.04	2.77	.11	14.869***	.03	2 < 1,3
Change	-1.34	.05	-1.18	.07	-2.20	.17	15.086***	.03	3 > 1,2

Note. Estimated marginal means (M) and standard deviations (SD) are presented. N = 1104.

*p < .05, **p < .01, ***p < .0001

Working online

The largest group of therapists (54%) indicated they generally felt “very comfortable” with basic computer use, followed by 29% who indicated they were “somewhat comfortable.” When asked to identify the platform they use for online therapy, most respondents (69%) indicated they used a platform that includes both audio and video such as “Zoom, Skype, WhatsApp, etc.,” 23% by phone only, 9% “other.”

With respect to the clients they still see during COVID-19, the therapists were asked to select one item from a list that best described their practice. The largest group of therapists (35%) indicated they saw most of their clients online and some not at all, followed by 23% who indicated “I see all of my clients online” (see the online supplemental material file, Fig. S2).

When asked to specify what they based their online CATs practice on, the items on the list that were most frequently chosen were “I mostly make it up, based on my own creativity” (47%), followed by “I read about it” (15%) (see the online supplemental material file, Fig. S3).

When asked to specify what helped them in online CATs practice, the items on the list that were most frequently chosen were “talking with my colleagues” (36%), followed by “reading or watching resources relevant to my practice” (30%), and “online supervision” (16%) (see the online supplemental material file, Fig. S4).

Creative self-efficacy: correlates and moderation

The CSE scores were not normally distributed, as shown by normality tests and a visual examination of the histograms and Q-Q plot graphs. There was a negative skew value (skewness= −1.080, SE =0.076) with the bulk of the values lying to the right of the mean (M = 4.12, =0.588, score ranged 1–5, variance =0.35). For all six CSE items, most therapists (≥ 40%) indicated their CSE was above the midpoint. However, a sample size exceeding 300, as here, an absolute skew value larger than 2 or an absolute kurtosis larger than 7 may be used as reference values for determining substantial non-normality (Kim, 2013). Accordingly, the CSE scores in our sample did not depart substantially from normality. There were negligible positive correlations between therapists' CSE and them feeling comfortable with basic computer use (r s =0.27, p < .001, N = 1031), and between CSE and their self-reported difference in practice in terms of online practice vs. non-online practice (r s = −0.13, p < .001, N = 1031).

An exploratory moderation model was examined with Hayes’ PROCESS macro (v3.4) for SPSS (Hayes, 2018). The model posited CSE as a potential protective factor that would moderate the impact of therapists’ comfort or lack thereof with basic computer use (predictor), on their perceived extent of difference in their online CATs practice compared to non-online practice (outcome). In the first run, years in the CATs profession was entered as a covariant but was removed because it had no significant effect on the outcome variable.

As shown in Table 4, feeling comfortable with basic computer use (henceforth, “computer comfort”) was significantly related to perceived difference in online clinical practice, such that higher comfort predicted less perceived difference in practice. Higher CSE also predicted less perceived difference. The interaction term was also significant, as illustrated in Fig. 1. The interaction was probed by testing the conditional effects of computer comfort at three levels of CSE, one standard deviation below the mean, at the mean, and one standard deviation above the mean. As shown in Table 4, computer comfort was significantly related to perceived difference in practice when CSE was one standard deviation below the mean and when at the mean (p < .001), but not when CSE was one standard deviation above the mean (p = .054, 95% CI: −0.279,.003). The Johnson-Neyman technique was used to identify ranges of values of the moderator (CSE) for which the interaction effect was significant, indicating that the relationship between computer comfort and perceived difference in practice was significant when CSE was less than 4.7, but not significant with higher values of CSE. This result hints that high CSE may buffer the impact of therapists’ computer comfort on their perceived difference in online clinical practice.

Table 4

Therapists’ computer comfort predicting perceived difference in practice moderated by CSE.

	β	p	95% CI
Computer comfort	-1.15	< 0.001	-1.77	-.536
CSE	-0.72	.008	-1.244	-.188
Interactiona	.22	.006	.063	.368
F (3,1028) = 16.03, p < .001, R = 0.21, R2 = .04
Conditional Effect of Computer comfort on Perceived Difference in Practice
CSE	β	p	95% CI
-1SD (3.53)	-0.39	< 0.001	-.509		-0.276
Mean (4.12)	-0.26	< 0.001	-.358		-0.172
+ 1 SD (4.70)	-0.14	.054	-.279		.003

Note. N = 1032. a = interaction of computer comfort with creative self-efficacy (CSE).

CI = confidence intervals.

Fig. 1

CSE as a moderator of the relationship between therapists’ perceived difference in Tele-CAT and their computer comfort.

Qualitative findings

The participants’ responses converged to four shared categories that illuminate features characterizing their online practice: (1) the challenges of tele-CATs, (2) continuing the therapeutic process via tele-CATs, (3) adaptations for tele-CATs, (4) Future directions (see theme map in the online supplemental material file, Figure S5).

Category 1. The challenges of tele-CATs

The therapists reported that the therapeutic environment was challenging given the lack of shared physical space with the client, limited visibility of body language and physical cues, and the curtailment of interpersonal synchrony. The view of the private environments of the client and the therapist may also disturb the sense of the therapeutic setting as protected, and technical issues may lead to a sense of less control over the therapeutic situation. Tele-CATs in a group format were reported as being more challenging. The responses also showed that some clients were uninterested in tele-CATs and for some specific populations tele-CATs were more challenging. The therapists reported that there was less artwork because conducive conditions were not present, which tended to restrict the creative process. Finally, sometimes therapists and clients were preoccupied with COVID-19, which tended to interfere with the therapeutic presence and attunement. For more details, see Table 5.

Table 5

Category 1: the challenges of tele-CATs.

Theme	Sub-theme	Explanation	Illustrative quotes
1. Challenging therapeutic environment	Lack of shared physical space with the client	Lack in shared physical space was experienced as a central issue in tele-CATs practice that challenges support nd physical contact with the client.	“I really miss the shared energy and energy exchange that comes from being in the same space.”“The [lack of the] ability to comfort by touch or give a hug. There is a need in some clients and some situations for physical touch.”
	Limited visibility of body language and physical cues	The unseen body language in the on-line setting effects the therapeutic interaction.	“There is no [direct] eye contact, I cannot see the patient's body language - I can only hear his tone of voice…”“It is difficult to relate to body sensations, gestures, smells.” “The silence doesn't feel as natural or comforting for clients without object constancy (can feel like a micro-abandonment or disconnection).” “Eye contact is uncertain and unclear. The frenetic image of the client reverberates in the space and creates unrest.”
	Less secure environment	Therapist and client situated in their private environments may disrupt the protected therapeutic setting (despite potential benefits- see Table 2).	“I suddenly enter his private space. Sees him in his pajamas. Sees the personal belongings, the bed. You hear Mom's screams; you see Dad's nerves.” “She [the client] is much closer, in fact, to her mother who is in the living room, and therefore more embarrassed to play a role, and it is somewhat less natural, she does it in a hurry as if someone might hear, and quickly leaves [the role].”
	Less control over the situation	Therapists described having less control over the therapeutic situation due to technical issues.	“Transforming the therapist… into a concrete object contained in a digital device [a smartphone] that the client can move from place to place…lack of control over the setting (…the client can disappear, cut off the meeting), technical problems that create communication problems (disconnections, difficulty hearing what is being said).”
	Restrictions on interpersonal synchrony	Interpersonal synchrony is disrupted due to technical delays and pauses	“Everything that requires synchronization [is difficult]: co-playing, co-singing (although I did not give up singing despite the difficulties).” “rhythm work that is powerful for cohesion and synchrony is not possible due to connection delays, etc.”
2. Difficulties in group tele-CATs		Tele-CATs in group format is more challenging	“The responses of the group members are not flowing and spontaneous. There is restraint because the microphones are muted and the fact that we can't turn on and hear them all together.” “We cannot have hand-held circle dances, techniques involving touch, massage…”“[in PD] there is less opportunity for the protagonist to sense the audience [other group members]”. “[in MT] no singing together because of the lag time [auditory delay]”.
3. Challenges of uninterested clients & specific populations		Some clients are uninterested in tele-CATs and for some specific populations it is more challenging.	“Not everyone has the interest or desire to sit in front of a screen.” “Working with hyperactive (children), autistic (spectrum disorder), introverted children who find it difficult to sit in front of the screen face to face”.
4. Limited art making	Limited conditions	Therapists (mostly AT but also for other modalities) indicated they did not have the materials or instruments to create art.	” I don't have the materials I usually use in therapeutic interventions; the language of the materials is my mother tongue and I found myself improvising an invention within the online therapy.” “The client no longer has the experience of entering a studio full of materials and means of expression where he or she can choose what they like.” “Parents do not always agree to the use of certain materials in the home even if it was pre-arranged”.
	Limited creative process	For many, art making was disrupted when shifting to tele-CATs.	“I miss the…space of working together in the sense of my presence when the patient works with materials - it is missing…The sessions don't allow access to 3D work for example sculpture in plaster, clay, paper pulp and all the things that require complex technical organization”.“There is much less opportunity to see the body I have more difficulty suggesting movement activity…in this medium”. A music therapist added: “singing together or music making is difficult due to the platform and asynchronous nature of communication. …”
5. Therapists’ and clients’ distress		Therapists and clients were preoccupied with COVID-19, which hampered their therapeutic presence and attunement	“[I] feel a huge load and a little anxiety myself, so I do not take enough time to be creative with the patients.” “Most clients and counselors are currently troubled with day-to-day reality and anxiety that is elicited in them. [for example] I have seen that young adults who are preoccupied with caring for children who are at home are not available therapy for themselves.”

Category 2. Continuing the therapeutic process via tele-CATs

For many therapists, the most valuable aspect of tele-CATs was its ability to maintain the therapeutic process and relationships despite physical distance. In contrast, others reported that although tele-CATs maintained the client-therapist relationship during lockdown, it did not allow for an effective therapeutic process. In addition, for some clients tele-CATs allowed new issues and processes to emerge in the therapeutic process, whereas for others the tele-CATs enhanced psychological growth. Screen sharing and the ability to share things from the home environment facilitated a sense of closeness while being physically distanced. To support the creative process, therapists reported they used digital resources, worked with materials that clients had at home, and some even delivered arts materials ahead of time to their clients. Finally, various artistic methods have been found to be effective and suitable for working in the online format. These methods are presented as part of this category. For more details, see Table 6.

Table 6

Category 2: continuing the therapeutic process through tele-CATs.

Theme	Sub-theme	Explanation	Illustrative quotes
1. Continuity of the therapeutic process and relationships		The most valuable aspect of tele-CATs during the pandemic was the ability to maintain the therapeutic process and relationships despite social isolation. Other therapists reported that although being able to maintain the client-therapist relationship during the lockdowns, it did not allow for a therapeutic process.	“There was a kind of adjustment period [to the online] and most of the time we continued from the same point and even used the same tools and games.”“I have been able to continue with client rituals and styles of working from before COVID-19. The clients seem able to continue with the therapeutic relationship.”In contrast, “to me, this is not therapy, just a kind of keeping in touch…”
2. Enhancement of the therapy		Tele-CATs allowed for new issues to emerge in the therapeutic process for some clients, for others the tele-CATs enhanced transformation.	“Sometimes there is more intimacy and situations that could not have happened at the clinic - like taking me on my mobile under the blanket.” “I got to know my client’s living environment, I got to know his world at home, and to have a more intensive and positive relationship with the parents.” “A seven-year-old client played role-play games in my clinic - where he was the king, and I was the maid… In the Zoom session during the COVID outbreak, we continued this role-playing game …with the costumes and accessories in the [the client’s] home. The roles have changed - I am the queen and he is the knight… the entrance and exit from the dramatic reality is much clearer to him in the Zoom world - something in the frame and setting are better organized and even the change in the ability to say goodbye at the end of the meeting… before COVID we did not say goodbye.”
3. Facilitating closeness while physically distanced	Using the shared screen to support the shared experience.	The shared screen video helped to maintain a shared and creative experience.	“You can share visual images/ music /anything else that can be displayed on the screen, so the clients can illustrate their experience.”
	Sharing things from the home environment.	Sharing things from the environment can bridge the gap between the physical distance and the separate spaces.	“Some children are happy to share the works they have made at home, including showing their home and favorite objects.” “I [therapist] show the room and their folder that is waiting for them with their artwork.”
4. Supporting the creative process	Using digital resources to make art.	Therapists used varied digital resources to support art making in the session.	“. I have tried to embrace the technologies available to me such as screen sharing… to watch YouTube videos… or cartoons about emotions. I feel that this online art therapy experience has helped me to embrace using other technologies my sessions -- which I see as a benefit now and in the future for my practice.” “We agreed to use Network Games …and Power Point that were never included in my tools.” “We use the screen as a kind of “theater” where you can disappear and show only certain parts of the body, only hands, show only puppets, play with it.” “taking advantage of digital features such as a virtual Zoom background to enhance the esthetic experience.”
	Working with materials that clients have at home	Art making relies on materials the clients have at home rather than those in the therapist’s clinics/studios.	“Inviting the clients to use tools and objects from their personal environment and possessions.”
	Preparing in advance for the creative process	Some therapists delivered arts materials ahead of time to their clients.	“I facilitated a collage work for a 102-year-old client, who created this way in the pre-Corona period, she continued relying on my guidance to choose from the pictures and magazines I made sure to send to her home.” “I videod myself explaining how to make salt dough to make play dough…I sent it and asked the client to prepare it in advance.”
5. Choosing applicable artistic method	Creating & sharing visual art	Therapists from all modalities (but mostly AT), reported their clients made visual art in various ways: a) drawing together on the whiteboard or other applications for shared drawing; b) making art separately in the client’s own location during the session; c) making art between sessions and then sharing and discussing it in the session; d) creating videos with the clients; e) sharing ready-made visual materials such as images from the internet. Therapists also used projective cards, objects available at home, and videos through YouTube or other applications.
	Embodying enactive work	Therapists from all modalities (but mostly DMT, DT, and PD) reported using embodied enactive work. These included authentic movement, expression of embodied images, free style dancing and improvisation, mirroring or imitation of movements, mindfulness, and awareness of somatic experiences, breathing and relaxation exercises, embodied games (e.g., hide and seek) and role play, improvisation, puppetry, sculptures, and pantomime (mostly by DT and PD).
	Playing and imagining	Therapists from all modalities reported using play therapy including board games and questions games, children's imaginary play, associative games, virtual games, exploring and sharing of metaphors, guided imagination.
	Sharing music	Therapists from all modalities reported sharing music and songs during the sessions. A few therapists sang with their clients and recorded music during sessions.
	Reciting/ reading/ creating stories, poetry, and texts	Therapists from all modalities (but mostly B/PT, AT, and DT) used storytelling and the reading of short texts and poetry. The therapists used creative writing including stories, intuitive writing, poetry writing, the six-part story method, and diaries.

Category 3. Adaptations for tele-CATs

Some respondents reported that the shift to tele-CATs caused changes in the setting (session duration, frequency, and payment rates), while others maintained the pre-pandemic setting. Other adaptations to tele-CATs that were mentioned included greater involvement of the parents when working with children, closer contact with clients between sessions, changes in the group setting from a larger to a smaller group or to an individual format, and the need to redefine therapeutic goals. In addition, the responses indicated there were adjustments in therapists’ roles and that sometimes the therapists had to change their core art discipline. For more details, see Table 7.

Table 7

Category 3: adaptations for tele-CATs.

Theme	Sub-theme	Explanation	Illustrating quotes
1. Changing the setting		Some therapists altered session duration, frequency, and payment rates, while others maintained the pre-pandemic setting.	“I [ had to shorten sessions just a bit with clients who are non-verbal, but generally still find that even 20–30 min check-ins are very helpful for the continuity of the therapeutic connection.”“I moved all my clients’ sessions to the evening (after my girls go to bed)”. “Quite a few clients asked for a discount, mainly because they had lost their jobs or a significant portion of it.” In contrast, “The sessions take place at the same time and duration” or “Really no change in the price of the session - it requires even more investment, adjustment, concentration. By charging less, you are implying that the Zoom session is less effective, and that's not the case.”
2. Greater parental involvement		Increase in parental involvement to engage the child in therapy, and more frequent parental guidance.	“With young children on the [autistic] spectrum … the presence of a parent [is needed to] mediate and contain them throughout the session.”“Instead of seeing the child for an hour, I would usually see the child for 1/2 h and then the parent/parents for 1/2 h…”
3. Keeping contact between sessions		Staying in touch with clients between sessions.	“There was a feeling that some of the children needed more than once a week during this period and I allowed them to send me messages and photos of their artwork via WhatsApp.”“Sending a letter or art product to the client via the parent's phone and/or a client’s creative response sent as a photo from the parent's phone.”
4. Adapta-tion in the group format		Change from a larger to a smaller group or to individual format.	“Children who came to me as a dyad or threesome and were not suitable for a group online because they are too young or the depth of the connection between the children - moved on to a personal relationship with me.” “My usual group of 6 has been reduced to 3 at a time.”
5. Redefining therapeutic goals		Occasionally therapeutic goals were redefined, and many indicated greater emphasis on supportive work.	“Previously, the goals were for one-on-one processing of emotions relating to cancer diagnoses. Currently, the goals are providing shared positive social experiences, reducing isolation and improving mood.” “The majority of the therapeutic work has become supportive as opposed to explorative.”
6. Adjusting therapist’s role	Accepting the shift to tele-CATs therapy	Therapist needed to accept the shift to tele-CATs to engage their clients	“Adjustments had to be made in myself to ‘attract’ clients to return to online treatment.” “Mostly it does not work when the therapist is not willing to go out of his or her usual work style. It requires flexibility and creativity.”
	Technological learning and adjustments	Therapists who have not used tele-CATs before had to learn and adjust to tele-CATs	“A lot of time is spent learning the new tool and looking for creative options.” “I had to learn a lot!!! To use the video applications.”
	More verbal communication to compensate for unobserved non-verbal cues	Tele-CATs require greater talking in order to compensate for the lack of body language.	“Sessions have become more heavily talk based, after switching to the online platform”.
	More active in the session	Therapists needed to be more active in tele-CATs	“I had to adapt my energy and bring more into the sessions… I feel as though online drama therapy is more draining on me, requires more effort.”
	More directive in the session	Therapists had to be more directive and that art making is more structured	“I have also noticed I have to be more specific with directions and prompts, and more directive overall because I am not in the room.” “More specific movement/dance exercises.”
	Increased therapist exposure	Online setting involves more of therapists’ personal space	“I am in my own home alone with my children, so it forces me to reveal more of myself more than I would like to …” “A fundamental change was giving my phone number to clients so that we could meet online, which brought about a dramatic change in the boundaries of care.”
7. Changing one’s CATs discipline		Many indicted changing their core discipline	An art therapist said: “My ability to observe processes and products has to transform into observing without the sensory dimension of working with material.” Some of the therapists indicated that they use other modalities in the sessions: “I play games much more than doing visual art”. A music therapist said: “I use stories instead of music and playing instruments”.

Category 4. Future directions

The responses revealed that therapists expected that tele-CATs would make CATs more accessible. However, many answered that there is no substitute for an in-person session. The respondents expressed feeling uncertain about the future. The therapists predict a rise in the need to provide mental health services to treat trauma, depression, stress and other conditions prompted by the pandemic. The therapists also predicted that the pandemic would increase the need for hygienic measures such as the use of masks, sterile materials, physical distancing, etc. when returning to in person CATs. Finally, the therapists pointed to the need to develop methods suited to tele-CATs and suggested sharing knowledge to enhance theory and practice, in particular by developing training and ethical guidelines. For more details, see Table 8.

Table 8

Category 4: future directions.

Theme	Sub-theme	Explanation	Illustrating quotes
1. CATs and tele-CATs will be more accessible		Expectation that tele-CATs will make CATs more accessible	“It may lead me and others to more online therapy in the future. In the past, it seemed inappropriate and impossible to me but today I see that this therapy can be good and effective sometimes”
2. No substitute for an in-person session		Many want to return to the preferred in-person format	“There is no substitute for a face-to-face meeting, in a closed and containing room, with adapted equipment, with peace and intimacy. I do not see other possibilities for of meaningful therapy for young children or special education children.”
3. Unforesee-able future		Many did not know how to answer this question, viewed the future as unknown.	“I have no idea.” “I cannot imagine the future.” “I am really stuck in total uncertainty about everything.”
4. CATs will focus more on the consequences of the pandemic		Therapists predicted more work on the consequences of the pandemic such as trauma, stress, depression.	“We need to be more trauma informed - lockdown and complex bereavement are going to have a long-term impact.” “Art therapists will grapple with the collective trauma for years to come.”
5. Greater caution		The pandemic will increase the need for hygienic measures in session	“Things will get back on track, with the addition of face masks and maybe alcohol gel.” “Perhaps sterilizing the materials with the client will become part of the therapy ritual.”
6. Developing tele-CATs	The creativity of the therapists in developing the Tele-CATs	Further development of tele-CATs depends to a great extent on the therapist’s flexibility and creativity.	“I personally believe that this particular moment is teaching us to work on our creativity and our flexibility.”“I think this will demonstrate that we need to be flexible and responsive to change but also how we can see clients in a variety of ways.; ”We’ll find other ways of doing psychodrama and maybe create new techniques. Our method will evolve !”
	Sharing knowledge to develop theory and practices for tele-CATs	Emphasize the need to develop theories, methods and techniques through practice, research, and international collaborations.	“I also hope that more remote visual art therapy techniques will become routine (and such projects will be funded) and allow access to remote therapies.” “Many sub-communities of dramatherapy should come together to think creatively about their more specific circumstances.”
	Develop Training	A need to develop specific tele-CATs training.	“I think universities will start offering specific training on ways to provide online therapy as well as tools that can be used in this format.” “Emphasis should be placed on courses and training that provide tools for dealing with crisis situations and simply for the purpose of remote treatment / training.”
	Developing ethical guidelines for tele-CATs	A need to develop specific ethical guidelines for tele-CATs.	“I hope that AATA will formulate clear guidelines for therapists with regard to safety in client care to allow us to better advocate for ourselves during any future events in our organizations.” “I’m thinking more about the ethics and the informed consent process and privacy issues- need to attend to these issues more.”

To summarize, the qualitative findings described the main challenges of tele-CATs during COVID-19 breakout, as well as its opportunities to continue the therapeutic process despite the social distancing. The findings also present the adaptations therapists did to maintain the creative process and therapeutic relationship in the on-line setting. Finally, future directions are presented for both CATs and tele-CATs.

Discussion

Tele-psychotherapy in general attracted substantial interest already before the COVID-19 pandemic (APA, 2013; Berryhill et al., 2019; Poletti et al., 2020). The literature has also addressed the integration of technology and digital resources in CATs (Atsmon & Pendzik, 2020). But apart from a few studies, research on the practice of CAT online is scarce (Baker and Krout, 2009, Sajnani, 2020), which is understandable given the reliance of CAT on tangible, embodied, and shared artistic materials and processes. In view of the global switch to online interaction, the present study aimed to provide a timely report on the use of tele-CATs in the first months after the outbreak of COVID-19.

The results indicate that during the first series of lockdowns worldwide, over half of the therapists in our sample shifted to seeing most of their clients online, and a quarter of the sample moved entirely to working online, and saw all their clients on digital platforms. These results point to the scope of the phenomenon and to the fact that many creative arts therapies were called upon to engage in their clinical practice over digital platforms as a result of lockdown orders. Note that before the pandemic only a few participants had experience with online therapy: most had no previous knowledge of online therapy or experience with it, and conducted online practice for the first time in response to COVID-19. Technological literacy has been identified in previous psychotherapy (APA, 2013) and tele-CATs literature (Wood, 2020) as necessary to effective care through this medium. The lack of specific training in online psychotherapy or tele-CATs was considered a key drawback by participants, consistent with concerns regarding the absence of adequate education reported in the general literature on tele-psychotherapy and tele-CATs (Chen et al., 2020, Pilgrim et al., 2020, Sajnani et al., 2019, Tuerk et al., 2018).

Consistent with previous studies, respondents indicated that the benefits of tele-CATs were that it could overcome issues related to geographic and social distance and facilitate access for participants burdened by stigma. For some clients, the online setting also enhanced the therapeutic process, but as others in both general psychotherapy and the CATs have noted (Wood et al., 2020), digital communication had its own set of technical issues (Poletti et al., 2020). Among the examples cited were the relative instability of the Internet connection and difficulties in exchanging materials related to paper-and-pencil psychological assessments (Vis et al., 2018).

Similar difficulties were noted by the participants in the present study, but the results also shed light on issues specific to creative arts therapies. What differentiates creative arts therapies from other psychotherapists, and even defines them, is the use of art as a central part of their practice (Shafir et al., 2020). More than half of our international sample indicated that they used art “to a large extent” in their practice before the COVID-19 pandemic, and almost half of the sample reported they used art only to a small extent when they shifted to tele-CATs in the wake of the pandemic.

When examining the differences between the modalities, the results show that the online use of music in therapy was the most challenging, in particular playing music together in synchrony. Furthermore, it was found that the shift to tele-therapy had the most negative effect on MT from the point of view of the decline in the number of clients, possibly because of the difficulty in facilitating music-making online. Therapists from all modalities reported using the visual / plastic arts (painting, drawing, sculpting, etc.), possibly because the work is often executed individually rather than in groups, and it does not involve the challenge of communicating sound and movement through the online platform.

The results indicate that the creative arts therapies needed to adjust their practice with special attention to the various arts forms and to the way they were used. This included the art materials (using materials that are available in the client’s homes), using digital resources to make art, and even adopting techniques of a different CAT discipline than the one that was usually practiced by the therapist.

The effect of the switch to tele-CAT was manifest especially when working with older adults, in the decline in the number of clients and in the use of the art in therapy. This was due perhaps to the difficulties some older adults experience when adapting new technologies (Kordova & Keisari, 2020). Another notable result indicated that therapists working in the public sector reported a higher negative change in the use of art than did those in the private sector. Adapting the use of arts to digital media may demand versatility of means, materials, and technology, all of which may have been less available in the public sector than in the private sector.

The mental (cognitive) acceptance of the idea of tele-therapy is a vital step in the adjustment, as was described by participants, and it resonates with the tele-psychotherapy literature (Chen et al., 2020, Schulze et al., 2019). Resistance to change may be one of the main barriers to practicing online. In the first few months after the outbreak of the pandemic, creative arts therapies made several key changes in their practice, which included limiting the use of art, changing the way art was used, and for some, using a different art form. Some therapists, however, reported less of a change in their practice than others. Age and number of years of experience were not found to correlate with change or adjustment to online practice, but creative self-efficacy stands out as an important factor that can buffer the effect of therapists’ computer comfort (or lack thereof) on the perceived difference in online clinical practice. This suggests that therapists’ belief in their creative abilities serves as a protective factor against the negative effect of therapists’ deficient computer skills and the need to adjust to the changes that were forced upon them.

Beyond the practical and technological barriers, the demand for a rapid shift to online practice required flexibility and the ability to generate not only new but also adaptive and useful solutions for the situation; hence, to demonstrate creative adaptability (Orkibi, 2021). For example, the results show that therapists were engaged in making adjustments, including developing and learning new technology and digital tools to create art, finding new solutions to generate artistic work, being more active and directive, and using more verbal communication to compensate for the drop in non-verbal communication. Thus, creative adaptability may be considered as an important buffer for adjustment to the new situation.

Limitation and future directions

Some potential limitations of the study should be noted. The study was conducted in the first months of the first outbreak of the pandemic, and it is likely that the ongoing adjustment process may have changed since then. Future studies that focus on the use of tele-CATs at a later time, or that tracks longitudinal data, could help capture the dynamics of adjustment and development over time that are likely to occur. Another limitation is that the CATs disciplines were not equally represented in the sample. Future studies should aim for a more balanced distribution of the disciplines. Relatedly, the sample used in this study is not a representative sample of the field worldwide and the Israeli creative arts therapies are overrepresented.

The current study was designed to provide a broadly based description of all the different artistic modalities of CATs. As noted, CATs clinicians from different disciplines may face different challenges stemming from the characteristics of the various art forms (Orkibi, 2018). Future work should explore the strengths and weaknesses of each of the artistic modalities separately, to better define their unique challenges and required adaptations.

The survey we used in this study relied on self-report data, therefore the possibility of social desirability bias cannot be ruled out. Future studies can triangulate data from therapists with that of supervisors and clients to enhance the reliability of the findings.

The results call for further consideration of specific ethical guidelines for tele-CATs. The participants noted that tele-therapy takes place in the clients’ private homes, where they may have been hampered by lack of privacy and online digital security issues. Creating art may result in further privacy issues, such as having to engage in a loud dramatic scene in the presence of family members, keeping the artistic products private, and more. Therefore, tele-therapy in general, and CATs in particular calls for further ethical deliberation.

Conclusion

This study was based on a survey that was widely circulated at the beginning of the COVID-19 pandemic to creative arts therapies to gauge the effect of the shift to online practice. It offers insight into the use of tele-health in CATs and highlights the strengths and concerns that arise in the online therapy space. The switch to online practice generated mixed responses. Many participants stated that they saw the move as an opportunity that could make CATs more accessible in conditions of social or geographic distancing. At the same time, others stated that they wanted to return to the much preferred in-person format. Tele-arts therapy is a new practice for most therapists, and most participants called explicitly for training for tele-CATs, in particular for developing theories, methods, and techniques through research and international collaborations.

The COVID-19 pandemic causes many difficulties for countries and people worldwide, but the crisis can be an opportunity for change and growth. COVID-19 forced many creative arts therapies to make a sudden shift to working online. What will the day after look like? Will tele-CATs continue to grow and develop, or rather return to being mostly a face-to-face practice? How many therapists will adopt online practices as part of their work, and how many will resist the change? Irrespective of the answers to these questions, the present study should help practitioners in making better informed choices in the future.