Revisiting the Experience of Art Therapists and Drama Therapists Working in Schools Two Years after the First Lockdown: A Qualitative Pilot

Hofit Edna Mashiah , Susana Pendzik ^*

1. Tel-Hai College, Upper Galilee, Israel

* Correspondence: Susana Pendzik

Academic Editor: Noah Hass-Cohen

Special Issue: Expressive Arts Therapies during and in the Aftermath of the COVID-19 Pandemic

Received: May 25, 2023 | Accepted: July 02, 2023 | Published: July 11, 2023

OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 3, doi:10.21926/obm.icm.2303027

Recommended citation: Mashiah HE, Pendzik S. Revisiting the Experience of Art Therapists and Drama Therapists Working in Schools Two Years after the First Lockdown: A Qualitative Pilot. OBM Integrative and Complementary Medicine 2023; 8(3): 027; doi:10.21926/obm.icm.2303027.

© 2023 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

The Coronavirus pandemic brought many changes in the entire world. It affected social practices and psychological well-being, demanding the implementation of new interventions in many aspects of life, including therapeutic practices [1]. During the first lockdown, treatments that normally took place in person were forced to move online abruptly, without any preparations [2]. This change required therapists to create or maintain therapeutic relationships with their clients in a format that was foreign to therapists and clients alike. The transition to remote treatment changed the therapeutic setting, where the therapist felt they had less control [3]. In addition, all this occurred at a time when the therapists themselves were facing uncertainty in the shadow of the pandemic as much as their clients did: Isolation and loneliness, financial anxieties, and worries concerning their health and the health of family members, were shared by both [4].

In the case of creative arts therapists, this transition required a change in the processes, techniques, and materials that the therapists apply in their work. Creative arts therapy is “an umbrella term used to describe the professions of art therapy, music therapy, dance therapy, drama therapy, poetry therapy, and psychodrama” ([5], p. 527). To some extent, online creative arts therapies had been explored before the pandemic [6,7,8,9,10]. However, the implementation of remote methods was still in its beginning when the outbreak of COVID-19 forced most creative arts therapists to go online [11,12]. This transition affected all the modalities of the creative arts therapies, as this practice is strongly based on actual contact, physical presence, and concrete art materials [13]. In drama therapy and dance-movement therapy, the difficulty of seeing the entire body and the scarcity of sensory experience that could be offered during online sessions were limiting for both clients and therapists, resulting in an experience of distance and two-dimensionality, which made it difficult to properly play [14,15]. In art therapy specifically, the materials available in the treatment room were not necessarily accessible to the client in their homes, thus restricting the possibilities of implementing accurate interventions [16].

This study focuses on art and drama therapists working in schools in Israel. Israel’s educational system is primarily public, and creative arts therapists constitute the main source of therapeutic support, both in the special education system and the regular one [17]. Through a network of Regional Support Centers nationwide, children and youth get free professional therapy through creative arts therapies in Hebrew and Arabic [18,19]. The Ministry of Education is the country's main employer of creative arts therapists. In a recent study, Regev & Snir [20] report that over 3500 creative arts therapists are working within the educational system of Israel.

From mid-March to mid-May 2020 the first lockdown was declared in Israel, and the educational system was moved to the remote format [21]. This affected the regular classes and the therapeutic processes of many children and youth who were in the care of creative arts therapists. Subsequent lockdowns or restrictions were enforced after this. However, the current study focuses on the period of the first lockdown, exploring the implications of this transition for six creative arts therapists working in schools within the educational system. A preliminary study was published in Hebrew [22]. The current paper builds on this data, adding a follow-up interview that illuminates another layer regarding the long-term experiences of creative arts therapists.

2. Method

2.1 Research Purpose

The preliminary study explored how art and drama therapists experienced the transition to remote practice during the first lockdown due to the Coronavirus pandemic. At the beginning of 2023, the authors recontacted the six therapists who participated in the initial research [22], requesting a follow-up study. Five of them responded positively. The purpose of the follow-up was to revisit their feelings and observations concerning the long-term effects of the lockdown on their professional life, and their current positions about the use of the remote platforms.

2.2 Participants

The preliminary research was based on interviews with six creative arts therapists (self-identified as female) that worked in schools – three drama therapists and three art therapists. Their experience in the field at the time of the interview ranged from 6-16 years (see Table 1). Five agreed to be interviewed for the follow-up study (three drama therapists and two art therapists). One art therapist was unavailable for the interview.

Table 1 Interviewees’ data.

2.3 Research Procedure

Semi-structured interviews were used to examine the experiences in the interviewees’ own words [23]. A basic outline of questions was used, which then developed into spontaneous dialogue and in-depth answers [24].

The first interview was carried out at the end of 2020, and covered the therapists' experiences of the first lockdown, including the transition into remote therapy. Questions were asked about the consequences of the Coronavirus pandemic for them in general, and then particularly, on their clinical practice. Specific questions were included about perceived changes in the therapeutic process due to the transition to online therapy (Appendix 1).

The follow-up interview comprised observations regarding the long-term effects of the lockdown on their current clinical practice and professional development. The questions considered the themes that emerged in the first interview to get a retrospective view of this time. In addition, interviewees were asked to describe this period with a metaphor (Appendix 2), in an attempt to gather information about the process more indirectly.

The participants were located using convenience sample [25]: Phone calls or e-mails were sent to art and drama therapists who might be suitable for the study, and their consent to participate was checked. The interviews were conducted after a preliminary telephone conversation or correspondence, in which the study’s aims and expected procedure were explained to the interviewee, and the interview was scheduled. The study was approved by the Ethics Committee of the Chief Scientist at the Ministry of Education of Israel (11362).

2.4 Analysis

For the preliminary study [22], we used the Six-Key Model [26] as an instrument to analyze the emergent themes. This model was created initially as an integrative assessment and intervention tool that enables the mapping of processes in drama therapy and in other creative arts therapies. The model is based on the idea that dramatic reality is at the core of creative arts therapies. Dramatic reality is the concrete materialization of imagination through artistic processes in the here-and-now [27]. Akin to Winnicott’s [28] notion of the potential space, dramatic reality designates the intermediate space between imagination and reality. It gives them an actual form, making it tangible and visible to others – whether as a dramatized character, a drawing, or through other artistic means. By so doing, dramatic reality facilitates a dialogue between content and form in which therapy may occur. Any creative arts therapy session entails a journey into this realm [29]. The Six Keys encompass all the aspects about dramatic reality and its connection with actual life (see Table 2). The 1^st Key looks into the transition back and forth between ordinary and dramatic realities. The 2^nd Key describes the quality and style of the dramatic reality developed in the process. The 3^rd Key comprises the characters and roles that inhabit the process. The 4^th Key provides an overview of the content patterns, such as plot, themes, conflicts, symbols etc. The 5^th Key describes the person’s response or reflections about the dramatic reality created once they return from the journey. The 6^th Key illuminates the unexpressed, unconscious subtext [26].

Table 2 The Six-Key Model.

The model was designed as a drama therapy assessment and therapeutic intervention tool [26,29]. In addition, it has been used as a research tool in situations involving a liminal reality, such as ritual practices or life transitions [22,30,31].

The choice to use the Six-Key Model to analyze the data in the preliminary study was made after the first examination of the interviews [22]. From the initial data, it became clear that the first lockdown had been framed in the interviewees’ minds as separate from the routine: It was experienced as a kind of intermediate space that is both real and different from normal reality. The therapists referred to the first lockdown as a departure from normal life into a reality that is highly infused with subjective feelings – much like dramatic reality. The decision to approach the data using the Six-Key Model allowed us to map out various aspects of the experienced timeframe [22].

The analysis of the follow-up interview did not lend itself to categorization through the Six-Key Model, as it mainly invited a retrospective view of the period. In the Six-Key Model, such a reflective view of the lockdown would be considered a deepening of the 5^th Key. Therefore, we used thematic analysis [32] and Lakoffian metaphor theory [33]. The follow-up interview was based on the findings of the preliminary study. Hence, it was more focused, attempting to cover the central themes that had emerged in the preliminary study and to understand the changes that might have occurred over time. Concurrent with thematic analysis, the researchers read the interview transcripts several times. Recurrent themes were detected, extracted, and clustered. Discrepancies between researchers were discussed until consensus was reached.

The analysis of the metaphors was informed by Lakoff and Johnson’s [34] notion that metaphors permeate our everyday life. In their view, metaphorical thought is embedded in our cognitive understanding, including affective aspects. In this vein, the metaphors used by the practitioners to describe their experiences were regarded as encapsulating a deep perception of their process and their view of it as a positive or a negative experience.

3. Findings

3.1 Summary of the Preliminary Study

This section summarizes the main points encountered in each category or Key in the preliminary study [22]. In general, no differences were found between art therapists and drama therapists. Therefore, we will refer to them indistinctly, except for the specific Keys in which differences appeared (2^nd and 5^th).

3.1.1 First Key: Transition between Realities

In this context, the 1^st Key referred to the transition into the first lockdown, its implications, and its subsequent exit.

Most therapists (four out of six) described the transition to remote therapy as shocking. They elaborated on their attempts to understand how to conduct themselves in the new setting, while searching for appropriate ways to contact the clients. About two weeks into the transition to online therapy, the Passover holiday took place in educational institutions. During the vacations, the therapists reported not maintaining contact with the clients. However, some had wondered about staying in touch even during the holiday, as the online therapeutic setting would have allowed it.

After the vacations, remote therapy became an intensive routine they had to get used to. The lockdown continued for another month, with physical encounters in the schools starting only gradually around mid-May 2020. Five out of the six therapists described a sense of great uncertainty surrounding the physical return. This was elicited, among other things, by the changes in the educational setting: Learning in capsules, the need to isolate those exposed, and the entrance of the Coronavirus as a theme in the therapy room.

Most therapists (five out of six) stated that the pattern of returning to the physical setting differed between clients. In many cases, there was a sense of continuity. Several clients returned to the point where the treatment had stopped before the lockdown. Other clients needed time to re-adapt upon return, acting like at the beginning of the therapeutic process. In some cases, the relationship was never fully restored. A couple of therapists (two out of six) compared the return to physical meetings to coming back from the long summer vacation: "I think children have some kind of rhythm of going in and out of vacations and returning to a routine that is […] something they quite know how to live with, even though it wasn't a normal vacation."

Four of six therapists described returning to the tools they had used in the in-person meetings. Some (two out of six) felt a strong need to use what the room can offer, especially what does not exist in remote contact: "I felt that after we returned from the lockdown [...] something in the meeting also asked for the experience, the doing, the contact." Two out of six therapists described that some clients continued to call them on the phone between meetings – even during the holidays. They sensed that the therapeutic boundaries had been broken during the remote therapy period, and that the fact that clients had their personal phone numbers continued to affect them.

3.1.2 2^nd Key: Quality and Style

This Key usually focuses on the aesthetic aspects of the treatment. In the context of this study, these include the quality of the online therapeutic setting, the types of platforms through which the communication was created, and the artistic tools and techniques that the interviewees used in the online treatment.

The transition to remote therapy constituted a drastic change in the therapeutic setting. During the lockdown, the therapists’ work spanned many hours compared to the normal routine. Only with a handful of clients it was possible to establish a regular contact with a stable platform. With the rest, a new coordination of the setting was required every week: "With some clients [weekly coordination] became a regular feature [of the therapy]. [The work] spread out over many hours of the day because the treatments were not possible during normal times [...] It all became much less defined."

Questions arose regarding how the therapists would maintain the therapeutic relationship, due to the existence of different platforms (such as Zoom, video calls, messages, sending and receiving videos from clients, and phone conversations with parents). The platforms on which the relationship was established were chosen in dialogue with the clients. They were often changed over time to make the platform more accurate for the client, to allow a visual dimension, or as a result of the newly acquired courage of the therapists to experiment with platforms that were previously less familiar to them. With very young clients or those who did not respond to remote contact with the therapist, the dominant tool was conversations with the parents.

All the therapists expressed a clear preference for in-person work over any remote alternative. According to them, all the platforms lack the shared space of imagination and the use of the body, a hidden layer that allows the therapist to feel heaviness or intimacy, a gradual entrance into the room, and the possibility of having eye contact. Some therapists (two out of six) described the therapeutic interaction as more verbal.

For the most part (four out of six), the therapists preferred platforms with a visual dimension, as they are the closest to their usual therapy experience. Three out of six therapists described cases in which the screen created new possibilities and opened something in the therapeutic relationship, or in the client's ability to express themselves. They hypothesized that this could be due to the shield that the screen creates, to being near the parents during the therapeutic encounter, or because of the fewer social confrontations at home (compared to the school).

Differences were found between art and drama therapists, regarding the use of tools and techniques. Art therapists described that in the physical therapy room, their interventions are directly linked to art materials, and sometimes to games. Drama therapists referred instead to various artistic and playful tools. They posed that they acted online similarly to what they do in the physical room: Using the interventions that arise from the here and now to get into dramatic reality. They did not describe difficulties finding the appropriate tools for the online setting. Two drama therapists continued working as they were doing in the in-person process, with a modification to the online platform. Two also exploited the possibilities the digital space offers by using it as an as if space (pretending to do things they would like to do).

In contrast, the art therapists reported big differences. One art therapist used digital tools, which she described as “essentially different” from non-digital means. Another reported being more verbal and using fewer tools, such as paper and colors: “I didn't even open the option of creating [a drawing] and showing it to me. Some clients showed me things in their room, artworks they had made in the past [...] but we didn’t do art…” The third one described attempting to use digital media and transfer conventional methods to online therapy, which she said, was less effective: "I can't find my hands and my feet in terms of the tools [...] I can't find the right tools for remote work [...] I have not yet been able to produce in remote therapy [...] something [like] painting and touching the material.”

3.1.3 Third Key: Roles and Characters

This Key refers to the roles and characters that populate the therapeutic process. In this context, it concerns the therapist's roles within the therapeutic relationship and the surrounding environment.

Some of the roles played by the therapists were similar to those in the in-person setting. However, during the lockdown, they took a greater dimension. This was particularly true for roles connected with holding the setting, supporting the parents, gathering information from various sources, and being a team member. New roles were added during this period, which are not typical for therapists. These were mostly related to technical aspects (such as “the learner of platforms”) and influenced the therapists' perception of themselves. In addition, four out of six therapists described a feeling of "juggling between roles" (being simultaneously a therapist and a mother). Despite the difficulty, some reported that in the end, they came out strengthened from the experience.

As the clients were at home during the lockdown, the parents’ full cooperation was necessary to establish contact with the children. As a result, the triangle of client-therapist-parents became more significant than usual. Five out of six therapists experienced situations in which the parents' difficulties, which are often at the root of their clients' experiences, became decisive regarding whether there would be contact or not: “There was a client with whom the link was only through the mothers’ WhatsApp [...] I think that if [she] would have allowed it, he would have talked to me a little on the phone.” The majority reported situations in which the parents maintained the contact with the therapist, either when the children did not agree to go online or because the parents “sucked this time for themselves.”

3.1.4 4^th Key – Content Patterns

This Key refers to the themes, conflicts, and other content patterns that appeared during the described period, both in the treatments themselves and in the context of the online therapeutic setting.

All the therapists spoke of maintaining the therapeutic setting and its continuity as the main issue in the described period. Five out of six therapists reported experiencing disconnections with clients for various reasons, including the client's refusal or inability to communicate from remote platforms, and parental presence. The therapists perceived these disconnections as reflecting the therapeutic alliance: “The disconnection was also within the relationship, it was part of this client's story – what happens to him when [someone] disappears from his life, when there is an interruption in the relationship [...] So… the treatment continued, it was part of the therapy."

Four out of six therapists reported a difference between clients regarding the depth of the contents they could reach in the remote setting. Two art therapists felt that it was not possible for most clients to reach deep content. They attributed this to the fact that there was less artwork in the online setting or that the digital art forms allow less depth. Nevertheless, some therapists pointed out that the themes that emerged in the remote setting resembled those that existed in the in-person context: “I was a little surprised that some of the contents that came up were the same. For some reason I expected that school and home would be different, and it wasn't. [...] Children who are frustrated at school remain frustrated at home as well […] albeit by other things.”

All the therapists reported that content related to the client's family increased due to their virtual entry into the clients' homes. Although most of these issues were known to the therapists before, the exposure to the child’s daily life provided an additional layer of understanding or sharpened it: “It was an amazing opportunity to experience the here-and-now of the child and perceive what they experience […] [In some instances] seeing it sharpened things about the relationship [of the child] with the parents or the siblings [...] I knew it from before, but suddenly, seeing it live made it clearer.”

Some interviewees spoke about limitations in the privacy and intimacy that could be achieved with the clients during this period. This made managing the relationship from a distance or engaging in meaningful contents difficult. In addition, some of the interviewees revealed that the remote setting brought up personal disclosures by the therapists in a way that would not have happened in the in-person setting: The clients had access to the therapists’ phones, and in some situations, details of the therapists’ personal lives were revealed during the treatments. For example, a therapist’s child who knocked on the door or interrupted while she was on a Zoom call, exposing the private room of the therapist, etc.

3.1.5 5^th Key – Response to Dramatic Reality

This Key is usually an evaluation or a response to the experience in dramatic reality. In this case, it refers to the perception of the framed period in retrospect. Here too, some differences were found between art therapists and drama therapists.

In general, four out of six therapists felt that it was significant to maintain the continuity of the therapeutic process through remote means. Some asserted that with certain clients the therapeutic alliance was even strengthened. In addition, most therapists reported that the alliance with the parents intensified following the remote therapy period. As contact with the parents was more frequent, a stronger sense of partnership was forged. In contrast, two out of six therapists felt that, for the most part, the relationship with the parents was weakened during this period because the parents themselves were less available or due to the cancellation of a mid-year meeting that would have taken place in regular times.

It is important to note that the return to in-person meetings occurred relatively close to the end of the school year. In addition, many restrictions and regulations were applied (such as a ban on physical contact, the requirement to wear masks, to disinfect objects that have been touched, etc.). Three out of six therapists stated in the interview that it was difficult for them to define what had to do with the period of remote therapy, what with the restrictions of the Coronavirus that stayed in place, and finally, what with the termination that was approaching.

One issue that came up in the 5^th Key is a sense of self-worth, connected with success and failure: All the therapists reported that remote therapy required more effort than in-person therapy, and they were happy to return to the usual treatment. The drama therapists described having mixed feelings: They experienced frustration and doubted the meaning of the remote encounters, as well as feelings of satisfaction, excitement, and enthusiasm, when things went well, and they managed to “breakthrough” the screen. Two described a sense of surprise that things worked on these platforms. Two out of three described that overcoming the difficulties that arose from the challenge generated a feeling of empowerment for them. One reported a fear of dealing with technology at first, and then “patting [herself] on the shoulder” for overcoming the fear. Another drama therapist described a sense of suffocation from mixing the roles of “mother” and “therapist,” which later transformed into a feeling that she had received a great gift by developing the ability to move flexibly between these roles.

In contrast, the art therapists mainly described the frustration that accompanied the period. They reported their feelings through metaphors such as “clipping their wings” and trying to “swim without success in waters of different temperature, color and density.” The three art therapists described moments of feeling successful with specific clients or in connection with the parents, but they did not characterize the period according to these moments.

3.1.6 6^th Key: Meta-Reality

The 6^th Key generally involves unconscious, unexpressed, contents. In this study, it encompasses the subjective dimension of the therapists in the described period: Their feelings and experiences of the events.

For some therapists, the relationship with the parents and families was challenging. For example, one therapist described feeling like an “underdeveloped student” when requiring assistance with technical difficulties from the parents. Another therapist felt uncomfortable with the presence of certain parents in the therapeutic setting. Four out of six therapists said they were required to set their limits when scheduling the remote meetings, as working hours became “fluid.” Four out of six therapists felt they were intruding on the privacy of those staying at home, in situations where the clients were walking around their house, staying near family members, or showing them various parts of the house.

Regarding personal disclosures by the therapists, sometimes it was possible to limit them, while other times, it was out of their control. This issue was also accompanied by feelings of intrusiveness, powerlessness, or discomfort: The period “required a lot of definitions, first of all, with yourself about how flexible you are willing to be, but also with the client […] Part of the ritual was [...] to establish to what extent… I am ready to be seen.”

3.2 Follow-up Study

As mentioned above, the follow-up study was responded to by five therapists. (One participant from the preliminary study was unavailable). The interviews were conducted about two years after the initial study. The therapists were asked about their feelings and thoughts concerning the Coronavirus pandemic, their use of online or other remote platforms in clinical work, and their current perception of these platforms. In addition, they were asked to illustrate their perceptions of this period with a metaphor. The main themes that emerged concerned career changes, an expanded sense of resilience regarding online practice, and a certain vagueness in their memories about the remaining lockdowns.

All the therapists reported using digital platforms sometimes, predominantly for the non-clinical aspects of their work, such as contact with parents, training, or multi-professional consultations. All except one, said that they do not use the digital platforms for the treatment itself, beyond what was required from them during the lockdown period: “…For the population I work with it, is not so relevant… there was no need. […] I didn't do therapy on Zoom after [the required period]. I don't even remember being forced to use it too much.”

An exception to this is one drama therapist who held sessions on Zoom with a client who had not attended school for a long time: “He wouldn't come to school at all, so it was either that or not therapy; and it […] felt effective: The treatment was significant […] A process happened online….” Nevertheless, like the others, this therapist showed a clear and definite preference for in-person treatments.

Most therapists reported having a greater sense of resilience than they felt during the previous interview. They said that should another event force them to change to a remote setting, they would now feel more prepared to deal with it: “All this uncertainty […] it's a muscle that has been trained. It's […]different now compared to how it was at the beginning.”

However, drama therapists seem more willing to use online platforms should the need arise. They see the online space as a legitimate setting and their descriptions imply that they feel more at ease with it now: “It has become more comfortable […] My feeling was that I don't need to get ‘out of my skin’ to create the space [...] It just felt like another place I’m familiar with, and I also know how to work therapeutically within it. One drama therapist stated: “If there would be now a lockdown, I am not afraid that my treatments will be interrupted [...] I believe and trust that I can do drama therapy remotely.” In contrast, one art therapist sounded more resistant to online therapy: “I just don't believe in it: I don’t think remote therapy works with the children I treat.” The second art therapist expressed ambivalence throughout the interview regarding the use of Zoom, and added: "I cannot say if I know better than before how to use it… I presume that I have acquired some skills..."

All the therapists described significant changes related to their careers: Willingly taking a leave of absence from schools, voluntarily reducing working hours, becoming supervisors, or opening a private practice. The therapists did not know whether these processes were a direct reaction to the events provoked by the pandemic, like a natural response to the existential turning point that it generated. Changes in their personal lives or the professional environment may have also had an impact: “I can’t tell if it's because of the Coronavirus. There was [that] and then […] additional challenging factors [that came up] in the workplace. [The feeling] developed inside me to the point that I needed to make some changes to replenish [my] batteries. […] I think this is part of the Coronavirus period. […] I gave birth, so things got connected […] but it's really linked […] I think the personal and the professional places became connected for me.”

It's worth mentioning that when the therapists talked about the past years, there was a feeling that their memory was vague and unclear: There was confusion regarding what happened, when, and how much time had passed since then. Some specifically referred to this feeling, while others expressed the distortion only between the lines. One therapist described it well: “I'm trying to remember. I think part of what's happening now is that there is a mark around March 2020, when we went into lockdown, and from that moment on, there are about two years that are very vague […] There is something there, after which I have trouble remembering what had exactly happened.”

3.2.1 A Retrospective of the Coronavirus Pandemic in Metaphors

As part of the study, the therapists were asked to illustrate their experience of the first lockdown with a metaphor (including their online work) and use it to describe their feelings during this time and afterward. Although the therapists’ figurative language essentially differs from one another, a common denominator is that most of them describe a transition into a more positive place (see Table 3).

Table 3 Metaphors and resilience.

One art therapist described the lockdown as resembling World War II – a feeling that the world is shaken. “I thought about the fact that in every generation we are destined again to experience some Great Drama in history.” Later, she sensed that although the war continued (so to speak), she no longer felt powerless. Instead, she experienced herself as being “part of the fighting forces.” She said: “I have some control over my reality, which gives me a certain amount of peace [...] Because we are in a profession that was defined as essential, and we succeeded in going out and doing therapy, to be in this doing [mode] protected me." This therapist also described a quiet return to the routine of the treatments after the lockdown was over, noting that a few things have changed for her, such as maintaining greater hygiene in the therapy room or contacting the parents of a child who didn’t show up to the meeting.

Another art therapist illustrated her process with the image of a painted green scribble, “somewhat cute, somewhat vague, and kind of gloomy.” She explained that, at first, it was fresh and invigorating, but later on, the green color degenerated into a rotten green, and the figure looked like a tired monster, not scary, just with no strength. When asked what happens to this image in the future, she said that it’s going to the garbage. This therapist described her frustration from the lockdown period and her fear of dealing with digital platforms. Throughout the interview there was a sense that she wanted to open a new page, which was also reflected in the changes and the choices she had made regarding her career. About her ability to deal with situations where the therapeutic setting is challenged again, she said: “I feel that the Coronavirus [period] has worn me down a lot [...] as if I aged all at once in terms of burnout.”

One drama therapist explained her process with a metaphor of “blindness” or a feeling of not being able to see well. She described a transformation from not seeing to understanding that she was not blind, but that she needed adjustments: "Like… [when] doing an eye test with an ophthalmologist, and [the doctor] adjusts your lenses and asks, ‘how do you see now… better, or worse?’” This therapist described being in shock at the beginning of the lockdown, a feeling gradually replaced by a sense that she was more at ease with the digital platform. Today she has reached a point where she feels more comfortable and safer to work from it.

Another drama therapist represented the beginning of the Coronavirus pandemic as a helium balloon inside a closed box, which resembles the image of the Zoom square. There was “an overwhelming feeling of distress and something closed.” The balloon “has its own movement, its desire to go up…” Over time, an opening appears in the box: The string is still attached, but it has lengthened, and now the balloon can leave the box and come back to it: "[It] has greater freedom of movement for exploration.” She envisioned the box as foldable in the future: “One can really choose to use this box as one wishes – to enter or to get out." This therapist described a feeling that the Zoom platform, which she was required to use during the lockdown, became another space from which she could enter and exit freely. “If during the first lockdown there was some kind of ‘cut’ [...] and it seemed that we would remain in the Zoom forever [...], suddenly, there is another space here that you can enter when necessary and leave it. We have learned to live with it.”

A third drama therapist chose the image of a turtle to represent the first lockdown: “I really like turtles: they’re slow, you can do everything slowly, you don't have to rush, there's nowhere to run [...] I also managed to get inside my house, go inside myself.” In contrast, she described a fast rabbit to represent the style of living that is constantly in the race of life. Today, she sees herself somewhere between the turtle and the rabbit, in a middle point, that is, in balance. Regarding the online platforms, she commented that, in the past, she felt tension and anxiety when she was unable to handle the tool perfectly and “exposed her weaknesses.” Today she describes a state of balance in this sense as well: “The anxiety decreased, and with it, the pleasure increased. [...] I managed to release myself from [the anxiety].”

4. Discussion

This section will refer to the similarities and differences between art and drama therapists, building from the preliminary study [22] into the follow-up interview.

The therapists characterized the beginning of this period as a shock, as they searched for appropriate ways to establish remote contact with the clients and maintain the therapeutic relationship from a distance. All the therapists agreed that during the Passover holiday there was a disconnection. This temporary detachment perhaps allowed for an incubation interval – a break in the activity dedicated to solving a problem [35]. This break may facilitate the process of problem-solving upon returning to it, thus improving performance. The therapists reported that the remote setting became more of a fact after the Passover break. A greater sense of intensity and pressure was generated due to the expectations posed by the educational system and the realization that there is no prospect of an end to the lockdown in the short run.

The therapists’ concern about how the therapeutic setting could be sustained at a distance is expressed in the breadth and depth of the 2^nd Key. Many references were found there concerning the quality of the therapeutic setting, the selection of the appropriate platform, and the choice of tools. These concerns about the setting also reverberated in the 3^rd Key (roles and characters) and in 4^th Key (content patterns). As a result of the qualitative change to remote therapy, some of the roles played by the therapists during this period were unique (learning to use the online platforms or taking on roles that are not primarily related to the treatment). In the 4^th Key, many contents entered the therapeutic process connected to the remote setting.

Creative arts therapies tend to attribute an added value to the concrete aspects of the therapy room [36,37]. Studies about the physical room in creative arts therapies have shown that space is considered a factor that influences the quality of the treatment [38,39,40]. Some approaches hold that while the therapist is the mental container of the treatment, the room itself constitutes the physical container [41]. The importance given to the physical space may to some extent account for the therapists’ preoccupation with the concrete setting of the treatment during the first lockdown. In this period, the familiar space was replaced by a new, and foreign, virtual space [14], whereas the intimate space of home became public and exposed [42].

The contents elicited by the entrance into the clients' homes were mentioned by all the interviewees as a significant feature of the described period and are also consistent with other studies [13,16]. Although the realities observed were familiar to the therapists, in many instances, witnessing them live provided another dimension of understanding. Yet, most therapists reported feeling that they were invading the privacy of the client's home. This was emphasized because, in child therapy, especially when the parents are involved, the door that closes the treatment room leaves a parent behind, allowing at the same time an opportunity to reveal the child's inner world [43]. Therefore, it is unsurprising that the 6^th Key (the place of the unexpressed, unconscious contents) activated many feelings around this issue: The door that was not closed left the parents’ voices in the background, reverberating both in the children's and the therapists’ heads.

Similarly, the privacy and personal disclosure of the therapists came up as an issue in the 6^th Key. Holding the treatments from their homes was very significant for some therapists, both in terms of how to organize the space, and regarding the appropriateness of what the client sees (exposure of children, personal spaces). The topic of self-disclosure by therapists has been discussed in the literature [44], offering various views. Such exposure may positively or negatively affect clients and therapists, and each choice encompasses ethical considerations [45]. However, in the period described, due to the very situation, the exposure of the therapists’ personal lives was made without a choice [42]. The fact that some therapists had a more negative view of their exposure, while for others, this was less significant, reflects what is found in the literature around the issue of self-exposure [46].

In general, the cooperation of the parents is known to be a decisive factor in the success or failure of therapeutic work with children [47]. However, some studies have found that when the treatment occurs in the school, the parent's sense of responsibility and involvement is reduced [48]. According to the interviewees, the role of the parents became extremely significant in the remote therapy setting. The fact that the clients were at home meant that the parents functioned literally as a connecting (or disconnecting) link between clients and therapists. Most of the interviewees felt that the alliance with the parents was strengthened following the remote therapy period, and these findings are corroborated by similar studies [13,16].

As mentioned above, this study found many similarities between drama therapists and art therapists concerning the sudden transition to the online space and the return to the in-person setting (1^st Key). Similarities were found in the role category (3^rd Key), in the contents that appeared in the sessions (4^th Key), and in the subjective experiences of the therapists (6^th Key). However, some differences are worth mentioning, particularly in the 2^nd (quality and style) and 5^th (response) Keys.

Differences between drama and art therapists were reported in the context of adapting to the digital space. The art therapists described that they rely primarily on art materials for interventions in face-to-face practice. Therefore, the transition to digital practice was more complex and challenging for them. Although they could (and did) use digital art, this was only partially satisfactory. In contrast, drama therapists described using various techniques in their in-person practice, relying primarily on imagination (as everything in the room can lead to dramatic reality). Therefore, they found it less difficult to discover suitable ways to play in the online setting.

While all the creative arts therapies share similar features, each modality’s uniqueness is predominantly a function of the art medium used. According to Frohne-Hagemann [49], music relates more to the dimension of time, while the movement has at its core spatial relationships. Both of these differ from visual arts, in that they are presentational forms, whereas in visual art, people find themselves “face to face with the world” (p.171). Art therapy works with creating tangible symbols that have an actual existence in the world [39]. At the same time, drama therapy can also rely on non-objects, on the invisible play of body and imagination [27]. Drama, like movement, is presentational and embodied. These inherent differences inform the 2^nd Key, constituting a qualitative feature of the modality. As they searched for appropriate art tools, the sudden transition to online practice and their reliance on concrete art materials may account for the art therapists' stronger sense of short falling. In contrast, drama therapists’ fundamental reliance on imagination came to their help, as they searched for possible roads into dramatic reality.

It is also possible that these differences are reflected in the feelings of success or failure the therapists experienced concerning their self-esteem and professional effectiveness (5^th Key). While drama therapists reported mixed feelings about their experiences during the lockdown period, art therapists defined it as accompanied mainly by frustration (although there were specific situations in which they felt positive).

The follow-up interviews (about two years after the preliminary study) reveal that all the therapists consider the in-person setting more effective and meaningful than the remote platforms. As a direct consequence, none have resorted to online as a permanent tool, as long as face-to-face treatment is available. However, they continue to use remote means for the needs surrounding the treatment (teamwork, meetings with parents, etc.). Interestingly, the reference to the tools they acquired for using online platforms was barely mentioned in the follow-up interviews, even when the therapists were asked about it directly. This subject had been often cited in connection with the transition to remote work in the preliminary study [22]. From their answers we gather that this is a distant topic, which they did not continue to pursue – at least not for clinical practice. It seems that the confidence to use digital platforms and the belief that it is possible to hold therapeutic sessions through them, is higher among drama therapists, consistent with the therapists' reports in the preliminary study mentioned above [22].

Looking more broadly at a sense of resilience developed for dealing with similar situations in the future, all but one of the therapists reported a strengthened sense of resilience. The metaphors evoked by the therapists also illustrate this tendency to describe the first lockdown period: All contained an unequivocally positive direction, except one therapist – the one who described that her sense of resilience did not increase, but on the contrary, she felt worn out. It seems that this therapist experienced the Coronavirus pandemic as very distressing over time.

According to Lakoff & Johnson [34], metaphors are conceptual structures that allow us to understand experiences by juxtaposing one kind of experience to another, thus “creating coherence by virtue of imposing gestalts that are structured by natural dimensions of experience” (p.235). The term conceptual here implies not only a mental layer, but also sensory and affective aspects. Furthermore, metaphors encapsulate complex experiences and inform our way of acting upon our understanding [33].

The metaphors chosen by the therapists to illustrate the first lockdown period and the transition to remote treatment come from different and varied semantic fields. The drama therapists seem to describe a search for balance: a helium balloon trapped in a box and looking for a way to find more freedom, adjusting the eyeglasses to have a better view, and the balance between the turtle and the rabbit. All these metaphors describe a positive movement: From challenge or difficulty to successful coping. The image evoked by one of the art therapists also reflects a movement from being in a dangerous or scary situation (WWII), to acquiring a coping tool (taking an active role in the fighting forces.) The image suggested by the second art therapist depicts an opposite movement: a scribble that gradually becomes more threatening, and then, just tired and weak.

Atsmon et al. [14] use the metaphor of “forced or involuntary migration” to illustrate the experience of drama therapists as they moved into digital territory [50]. They propose four positions to characterize their emotional grappling with the situation: resistance, anxiety, adjustment, and fluency. The positions are not fixed, but dynamic and fluid (even within the same person), and they also illustrate the ambivalent emotional dynamics observed in involuntary migration processes. These ideas resonate with the current study regarding the metaphorical language employed by the therapists to depict their experiences of the described period. Despite the oscillation between resistance, anxiety, adjustment, and fluency, most therapists have acquired some fluency. This fluency does not suffice for them to migrate completely online, but they seem more ready and comfortable to visit the online territory. Furthermore, after two years, most of the metaphors evoked by the therapists point to a brighter future, in which the online setting can be used as needed.

The follow-up interview reinforces the preliminary study’s suggestion that the first lockdown in particular, and the Coronavirus pandemic in general, were experienced by creative arts therapists as a liminal space [22]. It’s noticeable that their memory was foggy in trying to remember details from the previous years, and the facts were dim, as if all these years had merged into a single unit. According to Turner [51] limen means threshold and is characterized by confusion and ambiguity. Van Gennep [52] pointed out that all rites of passage involve a liminal phase in which the initiand is separated from normal life and stripped from their known identity. The passage through this period seems to have redefined the therapists’ identity to a certain extent: They have undergone career changes since the previous interview. The metaphors chosen, and the follow-up interview’s overall tone revealed that each therapist was transformed. Some have reduced their job hours at the school in favor of opening a private practice. Others have been promoted to supervisor at the school, etc. Working schedule changes that reflect a more balanced lifestyle or long-awaited decisions about leaving a less gratifying workplace came to fruition. The therapists couldn’t link the professional changes to a single reason, but referred to the lockdown and the switch to online treatment as one of several factors that might have influenced it. In sum, it is impossible to know whether these changes would have occurred without the pandemic, but the fact that all the therapists underwent professional changes speaks for itself.

5. Conclusions

This study followed the transition to remote therapy of art and drama therapists working in schools during the first lockdown due to the Coronavirus pandemic in Israel. Many of the aspects the therapists described were similar and related to the new therapeutic setting and their initial difficulties adapting to it. They described the entrance into the lockdown as a shock, the Passover vacations as an incubation time, and the return to intensive remote work as a challenging experience, of which most of them emerged strengthened. The main differences between art therapists and drama therapists were connected to their adaptation to working remotely, primarily regarding the use of materials: Drama therapists found it easier to transition to online treatment. Art therapists found it harder to operate without art materials. These differences appear to be connected to the particulars of each art modality: Drama therapy relies on imagination to access dramatic reality, whereas art therapy relies on specific art materials, which were not necessarily available in the clients' homes. These differences may have affected to a certain extent how each modality processed their feelings of this period, in terms of success or frustration, and the overall openness of the therapists for using online platforms in the future.

By organizing the data through the Six-Key Model [26] it was possible to see that the transition to online platforms affected all aspects of the clinical practice. Most of these were similarly experienced by the therapists. Among others: The gradual process of entering a remote relationship and returning to a precarious face-to-face (or rather mask-to-mask) setting (1^st Key). The significance of the setting change in terms of possible interventions (2^nd Key). The expansion of the functional roles of the therapist, the shift of the roles within the client-therapist-parent triangle, and the juggling between personal and therapeutic roles (3^rd Key). The contents elicited in face-to-face treatment and those about the remote setting (4^th Key). The meaning of maintaining the therapeutic alliance and the sense of self-worth and efficacy (5^th Key). The blurring of boundaries and self-exposure (6^th Key) [22].

Adding the retrospective dimension of the follow-up interview reinforced these findings, illuminating the therapists’ experience of the period as a liminal phase in which time was perceived as distorted and their known identity was blurred. Most therapists emerged from this liminal stage with a sense of resilience. This feeling was also reflected in the metaphors they chose in order to describe their experience of this time, and in the positive movement that these images depicted: From blindness to seeing, from being trapped in a box to finding some freedom, from being in a war to taking an active part in the fighting, and finally, to find balance between rushing and slowing down. Only one therapist did not report developing resilience but was left a sense of burnout from the experience. Accordingly, her image exhibited a negative movement. Finally, concurrently with what would happen in transition rites, all the therapists experienced substantial changes in their careers: Some opened private practices, others started supervision groups, and/or made necessary adjustments to their working arrangements.

Finally, we would like to refer to the limitations of this study, which was based on a convenience sample – a method with relatively low external validity, and also dealt with children and youth within the educational system in general, without reference to a more specific psychological diagnosis. The fact that one of the art therapists did not participate in the follow-up study weakens the creation of a rounder comparison between both interviews. It prevents a symmetric contrast between art and drama therapists concerning the metaphor question. In addition, both researchers are drama therapists and may know this field more closely.

Acknowledgments

We thank the drama therapists and art therapists who agreed to take part in this study.

Author Contributions

Hofit Edna Mashiah did the interviews, the transcription, the analysis of the data and contributed to the writing of the paper. Susana Pendzik contributed to conceptualize the research, data analysis, and writing of the paper.

Funding

Self-funding.

Competing Interests

The authors have declared that no competing interests exist.

Additional Materials

The following additional materials are uploaded at the page of this paper.

1. Appendix 1: First Interview Outline.

2. Appendix 2: Follow-Up Interview Outline.