Digital art therapy

1. Introduction

Version followed: the field as mapped in Malchiodi (ed., 2018) The Handbook of Art Therapy and Digital Technology (publisher description and chapter list only). The concrete procedures below come from published protocols: Darewych, Carlton & Farrugie (2015) for tablet art therapy; Kaimal et al. (2020) and Hacmun, Regev & Salomon (2018) for virtual-reality (VR) art making; the Zubala et al. (2021) review, which reports Collie et al. (2006) and Levy et al. (2018), for remote delivery; BAAT's 2020 online-practice guidance (Huet, Benoit & Nash); and the AATA best-practice paper on storing art.

What it is. Digital art therapy is not one manualised therapy with a founder. It is an umbrella term for art therapy in which digital technology is either (a) the art medium (tablet and touchscreen drawing apps, digital photography and collage, film and animation, VR painting) or (b) the way therapy is delivered (video, chat or image-sharing platforms) [source: Zubala et al. 2021; Malchiodi 2018 description and contents]. The therapeutic frame is ordinary art therapy: client, therapist and artwork in a relationship. The device adds a fourth element, and the review notes that its role in that "therapeutic triangle" is still unclear [source: Zubala et al. 2021].

How change is thought to happen. Change happens through the same image-making, reflection and relationship as in art therapy, with properties of the medium added on top. Authors name these properties:

• No mess and no texture, so people with tactile or smell sensitivities, immune suppression, or limited hand function can make art on their own.
• Undo, erase and save, which lower fear of mistakes and invite play.
• A record of every stage of the work, which can be reviewed later.
• A sense of control and of being protected behind the screen.
• In VR: an immersive, scalable, three-dimensional "potential space" (Winnicott's term) that the client can step inside and see from more than one point of view.

[source: Darewych et al. 2015; Hacmun et al. 2018; Social Work Today 2012 on The Animation Project; Zubala et al. 2021]. The review's overall stance is "cautious openness": technology is treated as added value, not a replacement for traditional materials [source: Zubala et al. 2021].

Professional frame.

• UK: "art therapist" and "art psychotherapist" are titles protected by HCPC registration, which follows an approved master's training. BAAT is the professional body. BAAT expects online practitioners to meet HCPC standards of proficiency and of conduct, performance and ethics, to complete CPD in online practice, and to be supervised by someone competent in online work [source: BAAT 2020].
• USA: AATA is the professional association and the Art Therapy Credentials Board (ATCB) is the credentialing body (ATR, ATR-BC) [source: AATA ethics page; credential requirements are [uncertain]].
• Other psychotherapists: a psychotherapist who is not an art therapist can use simple digital drawing or photo tasks as an adjunct within their own modality and competence. They should not describe this as art therapy, and should not run immersive VR or projective drawing assessment without training and supervision in those methods [synthesis].
• Training gap: training has lagged behind uptake. Orr reports that art therapists' use of technology rose from 19% to 32% between 2004 and 2011 [source: Orr, as reported in Zubala et al. 2021].

2. Framework

There is no published phase model specific to digital art therapy [uncertain]. The structure below puts together the steps the protocols actually use. The overall sequence is [synthesis]; each step is cited.

Session counts and formats reported (these describe study protocols, not prescriptions):

• Tablet: five individual 1-hour sessions about a week apart, in a quiet room [source: Darewych et al. 2015].
• VR: two 1-hour sessions at least a week apart, each with two tasks of about 5 minutes and short breaks [source: Kaimal et al. 2020]. VR sessions of 20–25 minutes [source: Kaimal et al. 2020 via Zubala et al. 2021].
• Video art therapy: 8–10 weekly sessions for rural veterans, with a face-to-face re-evaluation [source: Levy et al. 2018 via Zubala et al. 2021]; 6–8 weekly sessions [source: Spooner et al. 2019 via Zubala et al. 2021].
• Online groups: 2-hour simulated distance groups; synchronous groups, asynchronous image-posting groups, and mixed groups [source: Collie and colleagues via Zubala et al. 2021].
• Group 3D animation: small groups meeting twice a week over several weeks per film, co-led by an art therapist and an animator [source: Social Work Today 2012].

In practice, an open-ended art therapy course is the usual frame, with digital media used for some or all sessions as a choice alongside traditional materials [synthesis].

3. Guiding principles

• Cautious openness [source: Zubala et al. 2021]. Offer digital media where they add something specific; do not adopt them for novelty.
• Fit the medium to the client [source: Hacmun et al. 2018; Choe 2014 via Zubala]. Check sensory needs, motor needs, risk profile and digital fluency before choosing; VR's "suitability and extent" must match the client so they are not overwhelmed.
• Client choice and a mix of media [source: Collie et al. 2006 via Zubala]. Let clients choose how they communicate and what they make with; keep traditional materials available.
• Process over product [source: Zubala et al. 2021, which names the risk that product is emphasised over process]. Attend to how the image was made (strokes, erasures, hesitations); do not just admire the polished result.
• Therapist proficiency first [source: Kaimal et al. 2020; BAAT 2020]. Know the device, app and platform well before using them with a client, so your attention stays on the person.
• Independence and empowerment [source: Darewych et al. 2015]. Set up tools so the client can work unaided; for example, digital colour needs no mixing and no scissors.
• Secure handling of images [source: BAAT 2020; AATA storing art; Darewych et al. 2015]. Treat digital artwork as clinical data: password-protected folders, encrypted transfer, a stated purpose and period for keeping it, and the client informed when copies are kept.
• Make the remote frame safe [source: BAAT 2020; Levy et al. 2018 and Collie et al. 2006 via Zubala]. Agree beforehand: a private space, a backup way to connect, how interruptions will be handled, an emergency plan, and local support.
• Work within competence [source: BAAT 2020]. Do not try to treat every problem online; refer to face-to-face care when remote work is not safe.
• Augment, don't replace [source: Hacmun et al. 2018; McNiff 2000 quoted in Zubala]. Digital work complements physical materials; do not abandon traditional media.
• No diagnosis from images [synthesis, consistent with the Domain VIII rules]. Digital versions of projective tasks such as House-Tree-Person are invitations to talk, not tests, unless a validated scoring manual is used as published.
• Mind the risk groups [source: Choe 2014 via Zubala]. People with internet addiction, psychosis or OCD may be harmed by digital media; people with tactile trauma or immune suppression may especially benefit.

4. Intervention inventory

The inventory has three groups: (A) setting up and framing; (B) tablet and touchscreen art making, using the Darewych et al. (2015) protocol; (C) VR art making, remote delivery, group digital projects, and documentation. Example language is illustrative unless it is quoted and cited.

A1. Assessing suitability and getting consent for digital work

• Purpose / when: Before any digital or online art therapy, to decide whether it fits and to get informed consent [source: BAAT 2020; AATA storing art].
• Steps:
  1. At intake, ask about the client's access to devices, privacy at home, bandwidth, digital confidence, and feelings about screens.
  2. Screen for risk groups and contraindications. Possible harm from digital media: internet or gaming addiction, psychosis (screen content may be woven into delusions), and OCD (endless undo and perfecting) [source: Choe 2014 via Zubala; the mechanisms in brackets are synthesis]. For VR, also screen for seizures, head injury and motion sickness [source: Kaimal et al. 2020 exclusions].
  3. Explain when online therapy may be unsuitable, and its limits, risks and benefits [source: BAAT 2020].
  4. Get individual written consent that states the online risks. Cover how images are sent and stored, how long they are kept, who sees them (supervisor, MDT), and when confidentiality may be breached [source: BAAT 2020; AATA principles 4.1.a and 4.7 as cited in the storing-art paper].
  5. For children: check that the platform's minimum age is met. BAAT names WhatsApp 16+, Skype/Gmail 13+, Zoom by consent age. Get parental consent, then the child's own assent [source: BAAT 2020; the assent step is synthesis].
• Example language (illustrative): "We can use the tablet, paper, or both. Before we start, here's where your pictures are saved, who can see them, and how long I keep them."
• Watch for: A client who agrees to digital work only to please you, or who seems relieved to avoid physical materials in a way that looks like avoidance. Record what was agreed.

A2. Choosing and setting up devices and apps

• Purpose / when: Before the first art-making session, so the tools fit the client and the frame stays secure [source: Darewych et al. 2015; Choe 2014 via Zubala].
• Steps:
  1. Prefer a large screen. The authors recommend a 19–23" all-in-one touchscreen; participants preferred a 13.3" laptop to a 7" tablet.
  2. Set the screen upright like an easel and have a printer in the room for immediate printing.
  3. Use password-protected folders and save files under ID numbers, not names.
  4. Offer round-tip, brush and point styluses.
  5. Choose apps that are simple, easy to use and responsive. Choe's ideal list also includes therapist control, separate secure folders, recording of the process, and mixed media. No single app does everything.
  6. Check that the visuals and audio suit the client's age. Few simple apps have adult-appropriate design.
  7. Apps used by Darewych et al.: ArtRage, Crayola Art Studio, Fresh Paint, Coloring Mandalas, Sand Draw and Zen Brush; plus Sticker Tales, PuzzleTouch, Number Link and GS Kids! Shapes N Colors. The current availability of these apps is [uncertain].
• Watch for: Devices that cannot print or that lack secure folders (an issue with the Android tablet in the study). Fragile screens with clients who handle equipment roughly. Notifications or other apps that break the frame: turn them off, or use a dedicated device [synthesis].

A3. Trial or orientation session

• Purpose / when: Before therapy proper. It checks comfort with the device, interest in the apps, and the ability to apply gentle stylus pressure [source: Darewych et al. 2015].
• Steps:
  1. Demonstrate draw, colour, erase, undo and save.
  2. Let the client play with no task.
  3. Note which apps hold their interest.
  4. Practise saving and printing; these were skills participants valued.
  5. Stop if the client is frustrated or uninterested, and offer traditional materials instead [synthesis].
• Example language (illustrative): "There's no right way to do this. Try a few brushes and see what each one does. This arrow takes back anything you don't want."
• Watch for: Growing independence with the device, which in the study increased across sessions. Distress at accidental marks.

A4. Session structure: warm-up, art task, closure with a feeling chart

• Purpose / when: Every session, to give predictable containment [source: Darewych et al. 2015].
• Steps:
  1. Open with a feeling chart; the client points to or names how they feel.
  2. Warm-up.
  3. The art task (B1–B6).
  4. Closure. Ask two reflective questions (what you liked, and what was challenging), then repeat the feeling chart.
  5. Keep sensory grounding objects within reach. The study used a Slinky, a squishy tube and plastic animal figures.
  6. Offer music as an option and let the client choose whether to have it.
• Example language (illustrative): "What did you like about making this today? What was hard?"
• Watch for: Change between the opening and closing feeling chart. Music can interfere for clients with auditory-processing difficulties; one participant preferred silence. Keep music at a comfortable volume [synthesis].

A5. Post-making reflection questions

• Purpose / when: After any digital artwork, to move from making to meaning [source: Kaimal et al. 2020; Darewych et al. 2015].
• Steps:
  1. Give a re-orientation pause; this is essential after a VR headset comes off.
  2. Ask what it was like to make the artwork.
  3. Ask what the artwork shows or represents.
  4. Where useful, replay the saved process or zoom into details together [source: Hacmun et al. 2018 on saving and replay; the joint viewing is synthesis].
• Example language (illustrative): "What was it like to make that? If the picture could speak, what would it say?"
• Watch for: Talk that stays on technical features ("this brush is cool"). Gently bring it back to experience and meaning [synthesis].

B1. Digital scribble drawing

• Purpose / when: A warm-up and an opener for projection. It was session 1 in the tablet protocol, and the scribble-based task in the VR study was "adapted from art therapy practice" [source: Darewych et al. 2015; Kaimal et al. 2020].
• Steps:
  1. Invite a free, loose scribble on a blank canvas.
  2. Ask the client to turn the canvas and look for shapes or images in the scribble.
  3. Ask them to develop what they find with colour.
  4. Title it and talk about it.
• Example language (illustrative): "Let the stylus wander without planning. Now turn it around. Do you see anything hiding in the lines?"
• Watch for: Engagement and spontaneity. For example, one participant turned a blue scribble into a black cat [source: Darewych et al. 2015]. Hesitant clients can use undo freely to lower the stakes.

B2. House-Tree-Person from basic shapes

• Purpose / when: Session 2 of the tablet protocol; a structured, familiar drawing for clients who need simple building blocks [source: Darewych et al. 2015].
• Steps:
  1. Using shape tools or freehand, the client draws a house, a tree and a person.
  2. They may add colour and detail.
  3. Invite a story about the scene.
• Example language (illustrative): "Can you make a house, a tree and a person? Use squares, triangles and circles if that's easier."
• Watch for: HTP is a projective drawing. In the source it was a directive, not a scored test. Do not read diagnostic signs, abuse indicators or personality from it, and digital drawing changes line quality and pressure in ways that are not normed [synthesis; norms for digital HTP are [uncertain]].

B3. Digital mandala

• Purpose / when: A calming, structured task for clients who find a blank canvas daunting. It was session 3 of the tablet protocol [source: Darewych et al. 2015].
• Steps:
  1. The client chooses a patterned mandala template in a colouring app.
  2. They fill it with colours of their choice.
  3. Talk about the colour choices and how it felt.
• Example language (illustrative): "Choose a pattern that appeals to you and colour it however you like."
• Watch for: Settling and focus. Mandala symbolism is a theory belonging to particular traditions (e.g. Jungian); attribute it as such and don't present it as fact [synthesis per house rules].

B4. Free drawing (e.g. Sand Draw)

• Purpose / when: An open expressive choice. It was session 4 of the tablet protocol, and Sand Draw was among the most favoured apps [source: Darewych et al. 2015].
• Steps:
  1. Open the app.
  2. Invite any image at all.
  3. Let the client lead.
  4. Reflect at the end.
• Example language (illustrative): "Today it's completely up to you what you make."
• Watch for: Sand Draw-style apps can wash images away. Some clients find this impermanence freeing; others find it distressing. Ask before saving or clearing [synthesis].

B5. "Favourite kind of day"

• Purpose / when: A positive, life-experience directive. It was session 5 of the tablet protocol [source: Darewych et al. 2015].
• Steps:
  1. Invite a picture of your favourite kind of day.
  2. Explore its details, such as who, where and what you eat.
  3. Link it to resources and to goals.
• Example language (illustrative): "Draw what your favourite kind of day looks like."
• Watch for: Concrete, meaningful detail. One participant drew a breakfast egg with ketchup. These details can open conversation about routines and wishes.

B6. Creative-activity apps (puzzles, stickers, shapes)

• Purpose / when: To build concentration, memory and problem-solving, and as an easy way in for clients with developmental disabilities [source: Darewych et al. 2015].
• Steps:
  1. Offer PuzzleTouch-type puzzles, number-linking games or sticker-story apps as a warm-up or as an alternative task.
  2. Use sticker stories to build a narrative.
• Watch for: Games can take over from art making. Use them for a set time, then return to image work [synthesis].

B7. Using digital-medium features therapeutically (undo, layers, save, print)

• Purpose / when: With perfectionistic, anxious or motor-impaired clients, and to build independence [source: Darewych et al. 2015; Orr 2012 and Collie et al. 2006 via Zubala].
• Steps:
  1. Show the client that marks can be undone.
  2. Let them work without help with colour-mixing or cutting.
  3. Teach saving and printing so they own the product.
  4. Print on request; this can include a canvas print for exhibition, with consent.
• Example language: a participant said "This is fun. I can do this by myself!" [source: Darewych et al. 2015, verbatim participant quote].
• Watch for: Endless undo used to avoid committing to an image (see section 5).

C1. Immersive VR art making (e.g. Tilt Brush)

• Purpose / when: To offer embodied, three-dimensional, playful image-making in an environment the client customises. It may suit younger and digitally fluent clients [source: Hacmun et al. 2018]. It is an addition to classical art therapy, not a replacement.
• Steps (following Kaimal et al. 2020 where stated):
  1. Screen first. Exclude people with a history of seizures or head trauma, and anyone unable to wear a headset. Ask about motion sickness [source: Kaimal; the motion-sickness question is synthesis].
  2. Clear enough floor space to prevent collisions.
  3. Begin seated; allow standing later if wanted.
  4. Orient the client to the headset, controllers, art tools and environment.
  5. Start with short tasks of about 5 minutes each, with breaks of under 5 minutes between them.
  6. Allow more time over sessions as the client learns the tools.
  7. After the headset comes off, allow a few minutes to re-orient before talking or completing any measures.
  8. Then ask the reflection questions (A5).
  9. Save the work and record it as video, so it can be revisited and continued in later sessions [source: Hacmun et al. 2018].
• Options within VR [source: Hacmun et al. 2018]:
  • Rescale the work, from tiny to room-sized.
  • Walk around it like a sculpture, or step inside it.
  • Use "un-real" properties: objects suspended in mid-air, properties that change over time.
  • Change the background, from a plain colour to a personal photograph.
• Example language (illustrative): "Stay seated for now. Hold up the brush hand and try a stroke in the air in front of you. You can walk around it later if you want."
• Watch for:
  • Learning-curve frustration, which eased by the second session.
  • Headache, the weight of the headset, overheating, and tiredness from viewing large drawings.
  • Dizziness and nausea: one participant withdrew because of them [source: Kaimal et al. 2020].
  • Overwhelm ("overflow") from the infinite canvas and immersion [source: Hacmun et al. 2018].
  • You lose eye contact and most facial expression. Narrate and check in verbally [the check-in is synthesis].
  • The research protocol diffused fragrance into the room as a study condition. That was a research variable, not established practice. If you use scent at all, screen for allergies [source: Kaimal et al. 2020; the caution is synthesis].
  • Disinfect headsets and face pads between clients [synthesis; not addressed in the sources].

C2. Point-of-view switching in VR (first-person / third-person)

• Purpose / when: Hacmun et al. suggest the therapist (and the client) can view the work from the creator's own point of view or from outside. They propose this may support empathy and mentalisation. This is a proposal in a perspective paper, not a tested technique [source: Hacmun et al. 2018; [uncertain] as to clinical effect].
• Steps (synthesis built on the paper):
  1. After the client has made a scene, invite them to step out and look at it from outside.
  2. Ask what they notice from each position.
  3. If you can view the work through a shared view or headset, say aloud which perspective you are using.
• Example language (illustrative): "Step back and look at it as if someone else made it. What do you see from out here that you couldn't see inside?"
• Watch for: Dissociative or depersonalised clients, for whom a shift in perspective may be destabilising. Use grounding and keep shifts brief [synthesis]. The authors link this to the Gestalt empty-chair technique but do not propose using that technique in VR.

C3. Remote synchronous art therapy by video

• Purpose / when: For clients who are rural, have limited mobility, or are held back by stigma, and whenever face-to-face work is not possible [source: Zubala et al. 2021; BAAT 2020].
• Steps:
  1. Agree the platform and switch on its security settings. Have a backup channel, such as a phone number [source: BAAT 2020; Levy et al. 2018 via Zubala].
  2. Ask the client to log in on time, from a private space they have prepared [source: Levy via Zubala; Collie via Zubala].
  3. Agree beforehand how interruptions will be handled.
  4. Record the client's location and mobile number at each session, and have an emergency plan [source: BAAT 2020].
  5. For digital work, use screen sharing. For physical work, the client photographs the artwork and sends it, which also helps when webcam image quality is poor [source: Levy et al. 2018; Spooner via Zubala].
  6. Build a shared vocabulary for describing artwork, because you cannot see texture or the making process clearly [source: Levy via Zubala].
  7. Transfer images securely, for example by encrypted email to a secure drive. For children, take screenshots rather than have images saved on a parent's device [source: BAAT 2020].
  8. If the connection drops, call back and send a follow-up email [source: BAAT 2020].
• Example language (illustrative): "Before we start: if we lose the connection, I'll ring your mobile straight away. Is the door closed and are you OK to talk?"
• Watch for: Facilitation online may need to be more active [source: Zubala et al. 2021]. Ask the client to describe what they are doing, since you may not see the drawing process or their face. Concerning material visible in the home, which may trigger safeguarding [source: Zubala].

C4. Online group art therapy: synchronous, asynchronous and mixed

• Purpose / when: To create connectedness ("togetherness") among isolated people, such as clients with cancer in rural areas in the Collie studies [source: Collie et al. via Zubala et al. 2021].
• Steps:
  1. Prefer closed groups.
  2. Let members choose among a mix of channels: live video or chat, and discussion-board image posting between sessions.
  3. Set ground rules on privacy and on not sharing others' images.
  4. Encrypt transmissions and store posted art safely.
  5. Make sure every member has immediate local support.
  6. Train facilitators in distance work. [source: best-practice propositions of Collie et al. 2006 as reported in Zubala et al. 2021]
• Example language (illustrative): "Post your image when it feels ready. When you respond to someone else's, say what you notice rather than what it means."
• Watch for: Semi-anonymity can lower worry about appearance and judgement, but it also allows inappropriate online behaviour. Moderate actively.

C5. Group 3D computer-animation project (The Animation Project model)

• Purpose / when: For adolescents and young adults, including court-involved youth. The approach uses the planning and delayed gratification that animation demands, gives a sense of control behind the screen, and offers marketable skills [source: Social Work Today 2012; Kavitski & Austin chapter in Malchiodi 2018, title only].
• Steps:
  1. Run a small group co-led by an art therapist and an animator.
  2. Set ground rules: no gratuitous violence, no abuse, no ridiculing of particular groups or people.
  3. The group brainstorms story ideas drawn from members' own experience. The therapist steers towards the real issues behind the fiction; in one group, zombie stories led to fears about internships.
  4. Post a production schedule on the wall.
  5. Build skills with a simple asset, such as modelling a house.
  6. Divide roles, such as character design and scene setting, and build the assets over several weeks.
  7. Screen the finished film to an outside audience, with consent. The software reported was 3D Studio Max, alongside a Photoshop class [source: Social Work Today 2012].
• Example language (illustrative): "What would your character be scared of? Has anyone here ever felt like that?"
• Watch for: The project turning into a technical class with no therapeutic processing. Keep reflective time in each session [synthesis]. Screenings need consent from everyone shown or credited, and young people should not be identifiable without proper consent [synthesis].

C6. Documenting and storing digital artwork

• Purpose / when: Throughout therapy and at its end. Images are part of the clinical record [source: AATA storing art; BAAT 2020].
• Steps:
  1. Tell the client whenever copies or digital images are kept in the record (AATA principle 4.1.a), and agree how the art is stored and for how long (4.7).
  2. When photographing physical art: keep the camera visible, let the client arrange the work as they want it documented, include a slip with initials and date for filing, and store the images under data-protection protocols (Atkins 2007, cited in the AATA paper).
  3. Keep a secure digital folder with a stated reason for keeping each image.
  4. In the UK, register with the ICO, follow BAAT's GDPR guidance, and check that your indemnity cover includes online and cross-border work [source: BAAT 2020].
• Watch for: Cloud storage means the provider controls the servers [source: BAAT 2020, citing the ICO]. Specific retention periods follow local law; none were given in the sources [uncertain].

C7. Approaches named in the Malchiodi (2018) Handbook (not drawn on)

The following chapter topics exist, but their procedures are not described here [uncertain]:

• Photo-art therapy (Kopytin), which a review says extends the range of collage activities
• Therapeutic filmmaking (J. L. Johnson)
• Digital storytelling and narrative therapy (Grey & Young)
• "There's an app for that" (Malchiodi)
• Virtual reality art therapy (Lohrius & Malchiodi)
• Digital art therapy with children in medical settings (Kometiani)
• Expressive remix therapy with adolescents (Jameson)
• "The One Project", therapeutic photography with adults (Evans)
• Dibaajimowin, digitised oral stories (Johnson-Fuller & Warson)
• Group art therapy and telemedicine (Jones, Rahman & Robson)
• Digital devices for adults with autism (Darewych)
• Computational art therapy assessment (Seong-in Kim)
• A telehealth primer (Walls)

Read those chapters before using these methods. Dibaajimowin concerns Indigenous oral stories: follow the community's own authority over the stories and do not adopt them as a technique [synthesis per house rules].

5. Handling problems

• Technical failure: dropped call, frozen app, poor image [source: BAAT 2020; Levy et al. 2018 and Spooner et al. 2019 via Zubala et al. 2021].
  • Agree the reconnection plan in advance. If it fails, phone or email to reschedule.
  • If the image is poor, ask the client to photograph the artwork and send it.
  • With a vulnerable client, treat an unexpected disconnection as a possible risk event: call back at once and follow up.
• Accidental erasure or lost work [source: Darewych et al. 2015].
  • Two participants erased work when a palm touched the screen. Teach undo early, use palm-rejection settings or a drawing glove, and auto-save [the glove and settings are synthesis].
  • Acknowledge the frustration and the loss before fixing it [synthesis].
• Learning-curve frustration or "I can't do technology" [source: Kaimal et al. 2020; Zubala et al. 2021].
  • Clients need time to adjust. Give trial sessions (A3), keep tool sets small, and lengthen sessions as competence grows.
  • Always offer traditional media as a choice.
• Resistance to digital media; the medium feels "cold" [source: Zubala et al. 2021, reporting the critiques].
  • Digital art can feel cold, isolating and dehumanising, and small screens and mouse movement may "tame emotions".
  • Ask what is missing for the client. Mix media: a physical drawing photographed and reworked digitally, or the reverse [synthesis]. Return to clay or paint when the client needs touch, mess or force.
• Emotion too big for the screen; the image cannot contain it [source: Zubala et al. 2021].
  • Move to large physical materials or a bigger screen.
  • Name it: "This looks like it needs more room than the tablet gives" (illustrative).
• Overwhelm or overflow in VR [source: Hacmun et al. 2018; Kaimal et al. 2020].
  • Pause and take the headset off. Re-orient with feet on the floor, naming the room, and a sip of water [the grounding steps are synthesis].
  • Shorten tasks, switch to a plain background and a smaller working scale, or go back to 2D.
• Cybersickness: nausea, dizziness, headache, overheating [source: Kaimal et al. 2020; Hacmun et al. 2018].
  • Stop at once. Keep the client seated and allow recovery time before they leave.
  • Do not resume in that session. Reconsider VR for this client.
  • Make clear to the client that withdrawing is fine; one study participant withdrew [source: Kaimal].
• Perfectionism and endless undo; product over process [source: Zubala et al. 2021 for the product-over-process risk; the OCD risk is from Choe via Zubala].
  • Agree limits, such as a time box or "no undo for the next five minutes".
  • Turn to the process ("what made you erase that?"), and reflect on the urge to perfect [synthesis].
  • With OCD, consider whether digital media feed the compulsion and switch medium [synthesis].
• Clients at risk from screen-based work [source: Choe 2014 via Zubala].
  • For internet or gaming addiction, psychosis or OCD, weigh the risks first. Prefer traditional media, or use devices only in session, on a dedicated device, without internet access [the methods are synthesis].
• The home frame breaks down: interruptions, no private space, family members in the room, concerning material on view [source: Zubala et al. 2021; Levy via Zubala; BAAT 2020].
  • Agree the interruption plan in advance. Help the client create a private space; use headphones or a code word for "I can't talk freely" [synthesis].
  • If you see something concerning in the home, follow safeguarding procedures.
  • Return to face-to-face work if safety cannot be secured.
• Risk or crisis during remote work [source: BAAT 2020].
  • Have to hand: the client's location, mobile number, next-of-kin and local help.
  • Red-flag responses can include GP or hospital referral or an ambulance, plus urgent discussion with the MDT and your supervisor.
  • Assess suicide and self-harm risk by your service's standard protocol, as you would face to face [synthesis].
• Children and young people [source: BAAT 2020; the rest is synthesis].
  • Platform age limits apply. Follow an e-safety framework and NSPCC e-safeguarding guidance. Take screenshots rather than have images stored on a parent's device. You remain responsible for children's images and portfolios.
  • Consider dyadic work with parent and child together.
  • Add the young person's own assent. Agree session-length limits that suit their age, and decide what parents will and will not see.
  • Mandatory reporting duties apply exactly as in person.
• Image privacy breach, or a client posting therapy art online [source: BAAT 2020 for the risk; the responses are synthesis].
  • Nothing online is fully secure, and BAAT notes that internet information is "recorded forever".
  • If the breach is on your side: contain it, inform the client, and follow data-protection breach reporting (in the UK, ICO rules).
  • If the client posts their own work: explore with them what it means to share it, and protect other group members' images.
• Ruptures linked to the technology: the client feels unseen because you watched the screen, or you missed the making process [synthesis].
  • Name it, repair it, and ask the client to narrate as they work.
  • Put the device down during the reflection.
• Therapist under-confidence [source: Zubala & Hackett 2020; BAAT 2020].
  • Get specialist CPD and supervision from someone experienced in online and digital practice before offering it.
• Physical safety [sources as marked].
  • VR: clear space, a seated start, screening for seizures and head injury [source: Kaimal et al. 2020]; hygiene of face pads [synthesis].
  • Touchscreens are fragile: secure cables and mounts [source: Darewych et al. 2015 on fragility; the steps are synthesis].
  • Keep music and headphone volume moderate [synthesis].
  • Digital media are mess-free and can be cleaned, which helps immunocompromised or hospitalised patients [source: Malchiodi via Zubala; Choe via Zubala]. Clean devices between users [synthesis].
  • Touch: helping a client by guiding the stylus hand-over-hand needs explicit consent and an easy way to say no; offer an adaptive stylus or larger targets first [synthesis].
• Projective over-interpretation [synthesis].
  • Digital HTP, mandala or scribble images are not diagnostic of abuse or disorder. No norms for digital versions of these tasks were found [uncertain].
  • Record what the client says about the image, not your inferences.

Sources

Sources:

• The Handbook of Art Therapy and Digital Technology (JKP product page)
• The Handbook of Art Therapy and Digital Technology: catalogue contents (ECU Library)
• Zubala, Kennell & Hackett (2021) Art therapy in the digital world: an integrative review (Frontiers in Psychology PDF)
• Hacmun, Regev & Salomon (2018) The Principles of Art Therapy in Virtual Reality (Frontiers in Psychology PDF)
• Kaimal et al. (2020) VR art-making study (Frontiers in Psychology PDF)
• Darewych, Carlton & Farrugie (2015) Digital technology use in art therapy with adults with developmental disabilities (JoDD PDF)
• Huet, Benoit & Nash (2020) Developing online art therapy: guidance on ethical, legal and practice issues (BAAT Newsbriefing)
• AATA Ethics page
• AATA Ethics Committee: Storing Art Created in Art Therapy (best-practice paper)
• Zubala & Hackett (2020) Online art therapy practice and client safety (Newcastle eprints record)
• Social Work Today (2012) on The Animation Project
• Garner (2016) Digital Art Therapy: Material, Methods, and Applications (Kennesaw record; description only)

Further reading (not drawn on): the AATA Ethical Principles for Art Therapists PDF. The principle numbers above are as cited in the storing-art paper.

Books and papers cited (most via the sources):

• Malchiodi, C. A. (Ed.) (2018). The Handbook of Art Therapy and Digital Technology. Jessica Kingsley.
• Garner, R. L. (Ed.) (2016). Digital Art Therapy: Material, Methods, and Applications. Jessica Kingsley.
• Choe, N. S. (2014); Collie, K. et al. (2006, 2017); Levy, C. E. et al. (2018); Spooner, H. et al. (2019); Orr, P. (2012); Atkins, S. (2007); Hartsell, B. (2006); McNiff, S. (2000). These are cited as reported in Zubala et al. (2021) or in the AATA paper; the originals are not drawn on.