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Digital technology is increasingly present in psychotherapy practice worldwide, enabling clients and therapists to connect remotely. This way of improving access to therapy is important for those who might not otherwise be able to benefit from treatment due to living in more remote locations or having disabilities or mobility problems preventing them to attend therapy sessions in person. Despite this general trend of expansion in telehealth provision, to include also psychotherapy services, relatively little is known about its use within art therapy practice (Choe, 2014; Levy et al., 2018). Research in the area focuses primarily on verbal therapies and more specifically on cognitive-behavioral therapy conducted online (Hedman et al., 2012; Saddichha et al., 2014; Vigerland et al., 2016) with some notable examples of work highlighting issues key to psychodynamic psychotherapy (De Bitencourt Machado et al., 2016; Feijó et al., 2018).

Art therapists support clients in engaging in creative processes to improve their psychological wellbeing. Due to incorporating art making within therapy process and the key role of triangular therapeutic relationship between the therapist, the client and the artwork (Schaverien, 2000; Gussak and Rosal, 2016), art therapy practice is arguably more difficult to translate to online situations. However, suggestions have also been made that art therapy is particularly well suited to distance delivery, partially due to increasing ease of sharing images via online channels and non-reliance on verbal communication, and also due to dealing with symbols, metaphors and projections, which can manifest irrespective of medium used (McNiff, 1999; Austin, 2009).

Art therapy profession has not entered the digital world only recently. In fact, it has been critically engaged in often difficult discussions on the risks and potential of digital technology for art therapy practice for over three decades (Weinberg, 1985; Canter, 1987, 1989; Johnson, 1987). Back in 1999 the Art Therapy Journal dedicated a special issue to the links between computer technology and art therapy and has repeated a similar issue a decade later. In 2019, the Journal asked therapists and researchers to consider ways in which professional assumptions can be updated, modernized or reframed to meet contemporary needs.

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

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

The use of digital arts media is unique to art therapy practice and is perhaps not yet sufficiently researched for that reason, despite its potentially enormous implications for art therapy practice (Kapitan, 2009). Lack of in-depth research on digital art making has been cited as a key barrier for practitioners to introduce digital arts media in therapy sessions (Klorer, 2009; Potash, 2009). Similarly, limited guidelines from professional associations and importance of more specific technology-oriented ethical codes for practitioners are frequently highlighted (Kuleba, 2008; Asawa, 2009; Alders et al., 2011; Evans, 2012).

A challenge identified in early stages of discussion on the use of technology in art therapy was the need for increased collaboration between art therapists, designers and developers in order to device technological solutions suitable to art therapy practice (Gussak and Nyce, 1999). Limited attempts to develop art therapy-specific electronic devices to date lacked in-depth input from art therapists at the technical stage and, in consequence, appropriate integration of the established processes of art therapy with technology (e.g., Mihailidis et al., 2010; Mattson, 2015). In effect, art therapists who incorporate digital arts media in their practice elect to use painting apps not necessarily suitable for art therapy practice. There is also an ongoing debate on the tactile nature of art materials being lost if art is made using digital tools and potential impact on clients (Kuleba, 2008; Garner, 2017). A similar discussion concerns the therapeutic relationship and specifically whether it could be recreated in distance therapy (Klorer, 2009; Potash, 2009).

Despite these indicated debates on the usefulness of digital technology for art therapy practice and polarized opinions, some scholars and practitioners have advocated for increased efforts to incorporate digital art-making in the therapy process suggesting rising and permanent role of technology in art therapy (McNiff, 2000; Kapitan, 2007; Thong, 2007). Given the rapidly growing interest in digital technology applications to art therapy practice, research has been developing relatively slowly and has not yet been systematized. Doing so would help paint an inevitably complex picture of how art therapy is currently engaging with digital technology and how it might make the best use of the opportunities it presents and critically address challenges early in the process.

Through our own experiences in research and practice and following some initial literature searches we were aware that the area we set to explore is complex and relatively novel. Thus, we anticipated that any published research accounts were likely to include a variety of study designs, appropriately to the overall exploratory character of research in the area and in line with research in arts therapies in general, which tends to draw upon diverse methodologies and beyond qualitative and quantitative paradigms, to include also arts-based approaches. We chose an integrative review framework as a guide to allow us to undertake a well-rounded but flexible evidence synthesis that would present a breadth of perspectives and combine methodologies without overvaluing specific hierarchies of evidence (Whittemore and Knafl, 2005). Integrative review is an appropriate method at early stages of systematizing knowledge on a developing subject area (Russell, 2005; Souza et al., 2010) and as such was deemed suitable for our exploratory work which aimed to identify central issues in the area, indicate the state of the scientific evidence across diverse methodological paradigms and identify gaps in current research (Russell, 2005).

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

This review set out to provide some understanding of how digital technology is applied with therapeutic intent within art therapy sessions. We were able to answer two of our research questions, describing how art therapists work with digital technology in their practice and discussing the benefits and challenges of both online provision and the use of digital arts media. The perspective we were able to provide is the one of art therapists’ primarily and still little is known about clients’ experiences, attitudes and outcomes (Kapitan, 2009; Edmunds, 2012; Carlton, 2014).

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

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

As suggested previously, the review confirmed that the perception of digital technology in art therapy realm is dominated by ambivalence and tendencies to pull toward and against, which seems an appropriate attitude on encountering something which we do not yet fully understand. Both an increasing interest in the opportunities that digital technology potentially brings, as well as cautiousness around implementation have been apparent in the literature examined. Nevertheless, a common recognition seems to prevail that, given the likely permanency of digital technology in all aspects of our lives, understanding its benefits and potential harm in therapy situations is indeed essential to reduce risks and increase the therapeutic relevance of digital tools (Kapitan, 2007; Asawa, 2009; Orr, 2012; Kaimal et al., 2016).

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

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

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

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

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

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

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

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

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

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

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

Rise in online art therapy practice could be observed on a large scale in the previous months (second trimester of 2020) and new interventions have been developed with impacts already captured in research which was in press at the time of writing of this review (e.g., Gomez Carlier et al., 2020; Newland et al., 2020). It is important that these accounts of sudden changes in practice are recorded and examined for any lessons to be learned for a longer-term approach to how art therapy might contribute to mitigating the psychological impacts of the pandemic, which are likely yet to emerge (Miller and McDonald, 2020; Titov et al., 2020; Wind et al., 2020; Zubala and Hackett, 2020). The research to follow must acknowledge the extraordinary circumstances under which art therapy has adopted online mode of working, often not by choice but due to demands of the situation and clients’ or employers’ expectations. This fact alone and combined with other factors may have huge implications for practice and we hope that these are captured sensitively in forthcoming research.

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

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

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

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

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

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

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

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

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