The Exploration of the Experience of Expressive Therapies in a Pediatric Medical Setting in the COVID-19 Pandemic through Arts-Based Research
Intermountain Health; Primary Children's Hospital, 100 Mario Capecchi Dr, Salt Lake City, UT 84113, USA
Academic Editor: Noah Hass-Cohen
Received: March 27, 2023 | Accepted: October 15, 2023 | Published: October 24, 2023
OBM Integrative and Complementary Medicine 2023, Volume 8, Issue 4, doi:10.21926/obm.icm.2304044
Recommended citation: Lahue K, Rivera E, Schmidt S. The Exploration of the Experience of Expressive Therapies in a Pediatric Medical Setting in the COVID-19 Pandemic through Arts-Based Research. OBM Integrative and Complementary Medicine 2023; 8(4): 044; doi:10.21926/obm.icm.2304044.
© 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.
The COVID-19 pandemic uniquely impacted medical facilities, patients, and frontline caregivers. In the pediatric medical setting at Primary Children’s Hospital in Salt Lake City, Utah, things changed drastically overnight in early March 2020. Changes included new personal protective equipment guidelines, visitor restrictions, testing requirements, and staffing changes. The expressive therapies team including Eliana, a music therapist, Sara, a dance/movement therapist, and Katie, a music therapist, were asked to work from home to eliminate infection risk for the pediatric patients. Expressive Therapists had to shift their work with patients to a virtual platform with many complications, learnings, and impacts on the care being delivered. Limited research has been conducted to understand what this experience was like for therapists.
1.1 Purpose and Research Question
This study's purpose was to answer the research question: What was the experience of expressive therapists working in a pediatric hospital setting during the pandemic? The authors sought to describe the experience through this qualitative, art-based design. Many parties may benefit from this study including expressive therapists, therapists of other disciplines who work with pediatric patients and/or in a virtual platform, as well as the patients served by these two groups.
2. Literature Review
2.1 Expressive Therapies
Expressive Therapies, also known as Creative Arts Therapies, can include art therapy, music therapy, and dance/movement therapy [11,12,13]. Much of the work of expressive therapies is done through non-verbal creative expression and processing. Expressive Therapies use creative modalities and interventions to address individualized patient goals within the context of mental health counseling, physical rehabilitation, and health care. Expressive Therapies are an integrative profession that use psychotherapeutic art, movement, and music to promote social, emotional, physical, and cognitive integration of the individual and families . Expressive Therapies are used to improve cognitive and sensory-motor functions, support and foster increased self-esteem and self-awareness, cultivate emotional resilience, promote wellness, enhance social skills, manage stress, and express feelings .
2.2 Expressive Therapies in a Pediatric Setting
Expressive Therapies have been used in the pediatric medical setting for decades to support patients and families with coping, expression, processing, and rehabilitation [2,3,4,5]. When children are hospitalized, they are facing a traumatic event, and subsequently facing difficult emotions, pain and discomfort, stress and anxiety, lack of control and disempowerment . These experiences may be difficult to express and understand with words. Expressive therapies offer an important safe space for children and their families to express their experience through creative means in a developmentally appropriate and normalizing way . Expressive therapists use their creative medium (music, art, or dance/movement) within a therapeutic relationship to promote healthy coping, increase quality of life, decrease pain and agitation, build resiliency, and offer any emotional support needed to hospitalized children and their families [2,5]. Expressive therapies in a pediatric medical setting can bring joy and connection in a time of fear and isolation.
2.3 Expressive Therapies During the COVID-19 Pandemic
In December of 2019, the first cases of a novel coronavirus were detected in Wuhan, Hubei Province in China, with the first recorded case outside of China located in Thailand in the beginning of 2020 . After a series of events involving proposed infection prevention guidelines, investigations into transmission rates, and risk assessments, COVID-19 was characterized as a pandemic level outbreak by the World Health Organization (WHO) March 11th, 2020. This led to many changes across the country and wildly impacted how individuals operated and lived their lives. The pandemic transformed the ways in which many expressive therapists provided services and their overall employment. Survey results indicated a massive shift in music therapy to switch to telehealth services . Many music therapists were aware of the need to maintain social distancing and adapted their services to continue to meet their client’s needs. Art therapists went through a similar change from in person therapy sessions to online platforms . Combining dance/movement therapy (DMT) and psychotherapy techniques to create an online medium, via videos and zoom, helped psychologists in Bejing process their own and their patients’ trauma from the pandemic . Expressive therapists had to evolve to meet the needs of the ever-changing world due to COVID-19.
Expressive therapies had to adapt to the shifting landscape of clinical care to meet the needs of COVID-19. The pandemic had a significant impact on mental health and created adverse situations for children and adults as school closures and lockdowns led to less social interactions and impacted access to support systems . During the pandemic there was a rise in anxiety, depression, fear, suicidal ideation, symptoms of PTSD, sleep loss, and drug and alcohol use. Increased amounts of stress were related to parents needing to find childcare, worry over quarantined friends and family, potential hospitalizations, and the likelihood of death. Children and adolescents were at risk of abuse and neglect as they lost access to people in their lives that might have been able to recognize and report mistreatment .
During the pandemic, expressive therapists worked to creatively address these issues and explore how art, music, and movement could support the issues created by COVID-19. One study found significant reduction in hyperactivity in arts-based groups conducted with children during the pandemic . Another study sought to uncover how listening to a specific music playlist could promote positive feelings in children during the time of the pandemic and found that 81.2% of children in the study reported feeling happier and less distressed post music listening . Similarly, a study found music therapy to improve sleep and decrease disrupted sleep in children who had developmental needs and experienced disruptions in their therapy routines due to COVID-19 . Serlin and Zhou  found that their dance/movement therapy video using movement as expression, created for psychologists and their patients during the pandemic, positively impacted both groups. Psychologists felt validated and supported with their own burnout and fear, while patients felt strengthened and supported to allow space for their bodies and emotions . Expressive therapies helped meet the psychosocial needs of the community during the pandemic by sharing information, prompting creative self-expression, promoting increased family connections, building relationships and connectedness, addressing and processing trauma, increasing coping strategies, and building resilience .
2.4 Expressive Therapies at Primary Children’s Hospital During the COVID-19 Pandemic
The pediatric setting encountered obstacles during the pandemic that needed to be navigated through various creative means. One survey study found that the COVID-19 crisis led to delays in seeking medical treatment which caused more unnecessary inpatient stays and missed opportunities to diagnose diseases early on . In addition, several other themes related to the negative impacts of visitation restrictions were found, such as, cases where younger siblings were not permitted to be with family at end-of-life, mothers unable to deliver breast milk to the NICU, difficulty with virtual care, the inability to adequately perform physical examinations, and challenges providing care with patients experiencing acute mental health needs .
Telehealth became the widely used solution to social distancing and included many advantages and disadvantages. Telehealth has been defined as “the delivery and facilitation of health and health-related services including medical care, provider and patient education, health information services, and self-care via telecommunications and digital communication technologies” . Many pediatric settings resorted to leaning heavily on telehealth, the expressive therapies team at Primary Children’s Hospital in Salt Lake City, Utah being one of them. The expressive therapies team at Primary Children’s worked from home for 10 weeks, and then worked under a hybrid model, working some days remotely and some days on site for another 15 months afterward. Other changes that were required of the expressive therapies team during this period were increased personal protective equipment requirements, enhanced guidelines on equipment use and cleaning protocols, and decreased ability to see patients on certain precaution levels.
Goicoechea and Lahue  discussed the difficulties associated with working virtually at Primary Children’s Hospital, including impaired awareness and loss of control over the environment. Creating the environment is key for an expressive therapist to provide a successful interaction. For example, one patient lost balance while moving to music and became injured, requiring medical attention, which displays the challenges of not being present in the room to limit risks inherent to the environment. Another barrier in this study was limited access to technologies and supplies . Pediatric patients were not always accompanied by an adult, therefore did not have the means to support a virtual session. Primary Children’s expressive therapies team relied on other staff members who were on site, to distribute technology and supplies needed to conduct a session. This protocol was used during the work from home mandate, to varying degrees of success, and included challenges with holding the iPad used to facilitate the virtual session, not having the capability to explore and use materials given to them for the therapy session, and challenges in maintaining attention through the virtual platform . Telehealth proved to be a tenacious challenge during COVID-19, requiring constant adaptation and creative problem solving.
Benefits of telehealth have also been highlighted. For example, Goicoechea  shared his work with a patient and reflected on how he offered increased space during the virtual session both clinically and musically, gaining increased engagement and participation from the patient. Having a screen between the patient and music therapist during virtual sessions appeared to provide a sense of safety and normalcy. Awareness of the drawbacks and benefits of telehealth helped expressive therapists utilize it in creative ways to provide the most effective care for patients during COVID-19.
While the literature suggests benefits and difficulties of providing services during the time of COVID-19, there is limited written understanding of what the experience was like for expressive therapists. Gaddy et al.  discussed how COVID-19 impacted the levels of hope and perceived stress in many music therapists, finding that most of the survey respondents reported feeling hopeful throughout the pandemic while experiencing moderate amounts of stress. Additionally, this survey found that music therapists viewed the pandemic as a source of growth, adaptability, and resilience. Continued research is needed to further explore the experience of expressive therapists during the pandemic.
An arts-based research model was used to understand the experience of expressive therapies in a pediatric medical setting during the COVID-19 pandemic. Within the arts-based research model, the techniques of authentic movement model of witnessing and art therapy witness model were drawn from for the purposes of this study.
Arts-based research is an innovative research approach that surfaced in the 1980s within the field of social work . There are many different definitions of arts-based research, however the definition that we feel applies best to this study comes from McNiff :
Arts-based research can be defined as the systematic use of the artistic process, the actual making of artistic expressions in all the different forms of the arts, as a primary way of understanding and examining experience by both researchers and the people that they involve in their studies (p.29).
The significance of this type of research is that it is often a way to gather information that is otherwise unobtainable . Also, due to this work's flexible nature, it tends to reach a more broad and diverse audience.
3.2 Authentic Movement Model of Witnessing and Art Therapy Witness Model
Dance Movement Therapy, Art Therapy, and Music Therapy provide opportunities for artistic expression through individual movement, art making, and music. Art Therapy and Dance Movement modalities employ a method of movement and art reflection that involves the act of witnessing another person during their artistic expression [8,10]. In Dance Movement Therapy, authentic movement is described as the process by which one person moves in a designated space with their eyes closed, tuning in to their inner experience, while a second person observes or witnesses the movement without judgement. McLeod describes the process of authentic movement as the relationship between mover and focused witness . Mcleod goes on to discuss authentic movement as a non-verbal communication between mover and witness in which the person moving tunes in to their inner felt sense and the witness is there to observe and reflect what they witnessed as the mover engaged in their movement. The mover and witnesser share and process their experience through reflected observation statements . In Art Therapy, the process of witnessing was best utilized by Pat Allen, an art therapist who created the open studio process in which art makers create art, while a witness observes their artistic expression. The open studio process is founded on the elements of intention, attention to art making, and witness through writing and reading . Pat Allen described the essence of the open art process as a therapeutic relationship formed through everyone’s connection to their individual creative process, art making, and community expression rather than having a direct or indirect goal of doing therapy as a group.
Creating and witnessing allows both parties to be fully present in the artistic reflection of an individual person’s experience without judgement and with openness to the process and outcomes . There is an openness and risk that comes with this experience of engaging in one’s own art expression and reflection and requires both parties to trust the unseen experience.
Written consent was obtained by all parents of those that were written about in the case studies and pseudonyms were used in adherence to protected health information regulations.
Trustworthiness and Bracketing Peer debriefing and bracketing was used to help reduce bias, add validity, and identify any potential misinterpretations. Specifically, authors utilized reflexive journaling during and after the process to identify preconceptions and generalizations throughout the research stages .
4. Data Collection and Analysis
Authors first identified specific patients they had worked with during the COVID-19 pandemic and wrote a case study reflecting on their time together. Next, case studies were read aloud one at a time, allowing for art-based processing. Art-based processing included visual mediums, movement, and instrumental music in response to case studies. Eliana utilized visual mediums, Katie utilized instrumental music, and Sara utilized movement. After art-based processing, authors verbally reflected back what they witnessed and experienced without analyzing the response . The witnessing was recorded and transcribed for data collection by the authors. Authors collectively analyzed transcriptions utilizing Braun and Clarke’s  phases of thematic analysis. The authors read aloud the transcriptions and identified recurring words, phrases, and ideas. After gathering these initial recurring sentiments, the authors further grouped them into themes.
There are three components to the authors findings: the written case studies, the art reflections, and the themes derived from the transcriptions.
5.1 Case Studies
Kayla was a 14 year old girl who was awaiting both heart and kidney transplants due to congenital heart defects and kidney failure. In infancy, she was diagnosed with anomalous left coronary artery from the pulmonary artery (ALCAPA) post orthotopic heart transplant (OHT) and developed cardiac allograft vasculopathy (CAV). Kayla had a heart transplant before the age of 2 and experienced mixed rejection. This caused diastolic heart failure requiring milrinone, a drug to support the heart muscle and blood vessels. When Kayla was 13 years old, she experienced a PEA (pulseless electrical activity) arrest and needed ECMO (extracorporeal membrane oxygenation) level care. Post ECMO and PEA arrest, she experienced renal failure requiring dialysis throughout the week.
Eliana, a music therapist, met Kayla in October of 2018 when she was 12 years old, almost a year before her PEA arrest. She was initially apprehensive to verbally engage with Eliana but warmed up over a couple sessions. In the second session together, Kayla engaged in some instrumental improvisation, and Eliana sang about how she disliked the hospital, which helped gain her trust and build rapport. Improvisation quickly became the preferred experience together and Kayla eagerly engaged in experimenting with various instruments. Kayla went through several different seasons during the music therapy sessions together, which were impacted by not only her medical evolution, but the state of her world as well.
Season of: Exploration. During this time, Kayla and Eliana were getting to know each other and forming a relationship. Kayla would readily engage in instrumental improvisations. Later, she would become more comfortable singing and sharing preferred music with Eliana. In one session, all the songs Kayla chose and sang along with had themes of strength and internal power. Kayla was focused on staying positive while being treated at the hospital. In a later session, Kayla engaged in a songwriting experience and filled in the line “I just want to see you be:”, with “brave” and “strong”. Her improvisations became more dynamic as she experimented with various volumes, rhythms, tempos, and patterns. She also began to explore giving and responding to musical cues. Kayla used music therapy sessions as a time to explore and express herself and stated it was her “favorite” therapy.
Season of: Support. After over a year of sessions together, Kayla had her PEA arrest. She was put on ECMO level of support for 6 days, after going through more than an hour of CPR. Afterwards, she experienced renal failure and required almost a full week of dialysis regularly. Eliana stopped by her room several weeks later to find the same bright face as before. They had a few music therapy sessions where Kayla was engaged in improvisations, singing, smiling, laughing, and moving to the music. Over time, Kayla began to appear more reserved with a flatter affect. She responded less to questions and prompts and started shrugging or using gestures to indicate her needs. The sessions started to become more receptive where Kayla would choose songs nonverbally and would listen without playing instruments. Sometimes her energy would drop and she would listen to music with her eyes closed while holding Eliana’s hand. Kayla persistently had a flat affect, but there would be moments during a game or funny conversation that she would laugh and smile. Eliana’s focus during this time was more on supporting Kayla in the moment. It didn’t matter whether that was making a pie for the holidays, playing guessing games, or listening to recorded music together.
Season of: Letting Go. Covid hit in March of 2020 and completely changed how Kayla and Eliana interacted. The pandemic pushed Eliana to be creative in how to facilitate music therapy with Kayla while working from home. Calling to check in proved to be ineffective as it was often missed or went unanswered, so Eliana came up with other ways to interact with and support Kayla from afar. Eliana created several music videos using live voice and guitar, which Kayla frequently requested and were sent to her through email. Kayla and Eliana also had the chance to virtually meet one of her favorite musicians through a program in response to the pandemic. When Eliana was onsite, the music therapy sessions continued to be more receptive in nature, with Kayla’s energy low and her affect flattened. In the last session with Kayla, she greeted Eliana with a blank expression, had low energy, and engaged minimally in conversation. Before Eliana left, Kayla gave Eliana a personalized wristband with her name and motto printed on it. The session ended and Kayla died a few days later. Eliana is grateful for the memories she has of their time together, for the keepsakes Kayla left behind, and that in the end Kayla was surrounded by the ones she loved.
Baylee is a 7-year-old girl who was diagnosed with neuroblastoma in June of 2020 when she was 4 years old. Throughout her cancer journey she underwent chemotherapy, surgical mass resection, and 2 autologous bone marrow transplants. Baylee was hospitalized more than 150 days during her 2-year cancer journey as well as made more than 50 outpatient visits. She spent many holidays in the hospital during the heaviest COVID restrictions. Baylee has two younger siblings that were never able to be in the hospital with her. Her mom and her dad traded on and off days to be with Baylee in the hospital while the other worked or took care of her siblings. Baylee took advantage of all the hospital services, including music therapy.
Referral and Assessment. Baylee was referred for expressive therapies when she started chemotherapy. Her initial chemotherapy stays were short and because the expressive therapies staff was still working part remotely, Katie missed her on most of her early admissions. It wasn’t until September 2020 that Katie was able to have an initial session with Baylee. Baylee took no time to warm up to Katie or the idea of music therapy. Baylee immediately took the instruments, began exploring them and spontaneously sang lyrics about anything and everything from “Halloween” to “being brave”. Her mom quickly picked up her phone during the session and filmed Baylee as she sang. Her mom became tearful throughout, clearly moved by this outlet for her daughter. From this moment on in her cancer journey, music therapy was involved in every admission. However, because of the limited time Katie was in the hospital due to COVID-19 restrictions, Katie was only able to see Baylee on the days that she was on site. Katie gave Baylee instruments to play in her room while they were apart.
Baylee quickly learned that during music therapy she got to direct everything and everyone. This often looked like telling everyone which instruments to play, when to start and stop, and even how to praise her after a song.
Sophie’s Place. During her initial stays, Baylee was well enough to come to the music therapy space in the hospital for sessions, Sophie’s Place. This became a highlight for her in the hospital. There were even more things and people she could control and direct as well as more opportunities to create musical masterpieces. She loved singing in the microphone about all kinds of things from “rainbows” to “family” to “being together”. Whether it was her mom or dad present during the sessions, they would always video record Baylee on their phone. It was during this phase that Katie became aware that Baylee’s mom is a musician. She played some piano and ukulele and in Sophie’s Place enjoyed picking up some of the instruments and noodling around herself. Katie could tell she was getting a lot out of the experience as well and wanted to play more. Katie encouraged her to take a ukulele to her room to play while inpatient and this became a standard for her whenever they were in the hospital.
Bedside Treatment. After some time, Baylee became more ill and more immunocompromised. This meant she had to stay on the unit and music therapy sessions primarily took place at the bedside. Baylee continued to benefit from the sessions in her room where she continued to improvise songs. One particular session that stands out is one in which she started to pretend the instruments were food, specifically a “soup,” and sang about “stirring the pot”. Katie and Baylee ended up recording this song and singing it for many sessions throughout their time together. While it seemed like a silly song that was meaningless, to Katie it represented Baylee’s innocence throughout this journey. More specifically, she was seeking normal childhood experiences of playing pretend that she was missing out on because she was in the hospital and because she was isolated in a pandemic. She did seek this play experience out through music therapy.
Another session that sticks out to was on Halloween when Baylee was not only in the hospital but was NPO unable to enjoy any candy. Different than the usual pre-COVID-19 Halloween celebrations in the hospital, this year staff brought treats by kids’ rooms while they stayed in their costume at the doorway. Katie remembers Baylee sitting in her doorway dressed up as a Disney princess being frustrated on this day for a number of reasons. Katie spent a long time in her room singing princess songs trying to make this day special for her.
As Baylee was going through her bone marrow transplants, the final stages of her treatment, she became increasingly ill, and the music therapy sessions became more receptive. This looked like Baylee asking for her favorite songs while she closed her eyes and tried to relax in her bed. It was clear that she understood how music was helping her.
Finishing Treatment. As Baylee finished her treatment and was starting to recover and feel better, she had a difficult time saying goodbye to her caregivers at the hospital. Baylee had made incredible connections at the hospital, and she made it abundantly clear that she did not want to leave. As sad as everyone felt for Baylee, Katie remembers telling the team of people that worked with her “this is a sign of a job well done.” Katie cannot help but think that this difficult transition had a lot to do with the role that the staff played for Baylee in her treatment in a time of isolation because of COVID-19. Katie felt as though the staff filled the gap she was experiencing being away from her family and friends.
William was diagnosed with Acute Myeloid Leukemia (AML) at 16 months old. Due to the chemotherapy for his AML, William developed chronic renal failure requiring dialysis three times a week.
William was referred to Dance/Movement Therapy services in February of 2020 for developmental stimulation. Sara first met William, his baby brother, and his parents during a family walk around the cancer unit. Sara’s first official session with William occurred via online meeting, as Sara was working remotely due to the COVID-19 pandemic. Due to side effects from the chemotherapy, William was often sleeping and did not feel well enough to do a virtual session. Sara stayed in regular contact with William’s mom, Amber to continue offering sessions for when William was feeling better.
In late April, the Music Therapy Intern and Sara were finally able to have a virtual session with William and Amber. At the start of the session, Amber was unsure how William was going to do, since he wasn’t feeling well and Sara, the intern, and William were still getting to know each other. William started out sitting on his mom’s lap and keeping a watch on Sara and the intern out of the side of his eyes. Using music and movement, Sara and the intern could engage with William, and he began to move his head side to side while bouncing his leg to the music the intern was playing as Sara mirrored his movement. As William moved to the music and Sara moved with him, Sara saw a change in his affect and mood as he smiled and waved his arms and hands. Amber’s affect improved as she moved to the music with William and they smiled and laughed together.
In June of 2020, William received a Bone Marrow Transplant (BMT). Two weeks after his BMT, William experienced respiratory distress due to severe mucositis, resulting in a transfer to the Pediatric Intensive Care Unit (PICU) for higher care. Still working from home, Sara checked in with Amber daily to see how William was feeling and offered therapeutic ideas for how Amber could remain connected to and engaged with William while he was intubated and sedated. These ideas included light touch through gentle arm, hand, leg, and feet squeezing. Sara also offered the idea of using rhythmic tapping on his arm, torso, hands, legs, or feet to his favorite songs. Sara was able to return to the hospital, in-person, during William’s second week in the PICU. Amber reported that she had been using rhythmic tapping and that William had responded well to it and that it helped her feel connected to William. William was sedated for several weeks, and Sara continued to check-in with his family, discussing their love for travel and places they had visited and planned to visit in the future.
In the initial stages of William coming out of sedation and intubation, the dance/movement therapy sessions consisted of eye contact and listening to preferred songs, as reported by his parents and songs William enjoyed dancing to before his intubation and sedation. During the sessions, Sara would engage in light tapping to the music on his arms, hands, and feet to preferred music. His shoulders would drop from his ears, he would release the tension he held in his body when Sara first entered the room, and they would engage in extended eye contact. One of the most memorable sessions was a co-treat with Physical Therapy. Sara provided preferred music on the iPad and engaged William in movement that supported the PT goals of standing and reaching using boom whackers and stuffed animals. As William’s physical health improved, Sara and William worked on fine motor skills by peeling stickers and placing them on his face and body because he thought that was funny. William would engage in small dancing movements to preferred songs and Sara would mirror his movements. After three months in the PICU, William had an up-swing in his physical symptoms and was stabilized enough to return to the non-intensive care unit. William’s Mom expressed feeling afraid that William would not remain stable enough to stay on the floor and excitement that he would continue to recover and get closer to going home. William remained stable and on the medical floor for one week before returning to the PICU. William’s return to the PICU was a result of increase respiratory distress caused by Veno-occlusive disorder and he was sedated and intubated until he passed away a few weeks later. My final sessions with William before his decline, hold a special place in Sara’s memory.
5.2 Art Reflections
5.2.1 Eliana’s Art Reflection (Figure 1)
Figure 1 Art.
5.2.2 Sara’s Dance/Movement Reflection (Figure 2)
Figure 2 Dance.
5.2.3 Katie’s Music Reflection (Figure 3)
Figure 3 Music.
Various themes regarding the experience of expressive therapies at a pediatric medical setting in the COVID-19 pandemic were derived from the transcriptions of the witnessing process. Some interpretation of the language used to describe the art was required (e.g. loud/soft = big/small etc.) There were six themes mentioned in all three authors’ witnessing: Extremes, Space, Back and Forth, Together, Exploration, and Unknown. There were an additional four themes mentioned in two authors’ witnessing: Sections or Boundaries, Intentionality, Moments, and Memories.
5.3.1 Theme 1: Extremes
All three transcriptions discussed the aspects of extremes. This theme was mentioned sixty-four times within the three transcriptions, almost double any of the other themes. Within the movement medium, this was observed as things like “small movements” and “increasingly bigger and faster” as well as “small steps”. In response to the movement medium, one transcription read “I saw you moving in a way that was expanding and taking up a lot of space and then coming back to your body”. Within the art medium this was observed as things like “bright colors” and “long strokes and tiny strokes”, additionally the color choices of yellow and black. In response to the art medium, one transcription read “I see you filling in with a very dark color leaving small space of bright at the end.” Within this music medium, this was observed as things like “using more force”, “slowing down”, and “really, really fast”. In response to the music medium, one transcription read “I see you explore bringing your left hand all the way down to the other end of the piano while staying at the high end.” In addition to these more obvious examples of extremes, some mentions of emotions were included in this theme such as “joy” and “sad”, or “lively” and “somber”.
5.3.2 Theme 2: Space
All three transcriptions discussed the aspects of space. This theme was mentioned thirty-six times within the three transcriptions. One transcription read, “I felt like it was very important to me to like fill the space and to, as much as I could, like not leave any empty spaces.” Another transcription read, “I see you taking up a lot of space, opening up, palms to the sky.” All three transcriptions used the word “space” several times. Additionally, within the movement medium, this was observed as “deep breaths”. Within the art medium this was observed as “fill up the page”. Within this music medium, this was observed as “resting”, “pause”, and “stillness”.
5.3.3 Theme 3: Back-and-Forth
All three transcriptions described a back-and-forth process. Overall, this theme was mentioned thirty-two times within the three transcriptions. One transcription read, “I feel myself and I feel my body trying to process and recreate what that felt like going forward and backward and forward and backward”. The words “back and forth” were used verbatim or something very similar within the transcriptions. Within the movement medium, this was observed as “rock side to side”, “push forward”, and “returning back”. Within the music medium, this was observed as “ebbing and flowing”.
5.3.4 Theme 4: Together
All three transcriptions discussed togetherness. This theme was mentioned twenty-six times within the three transcriptions. One transcription read, “I feel a lot of joy and a lot of play and I feel a togetherness.” In addition to the word “together”, within the movement medium, this was observed as “both sides of your body” and “one hand and the other hand and then both hands”. Within the art medium this was observed as things like “layering”, “blending”, and “adding”. Within the music medium, this was observed as “using both hands” and “supportive rhythms”.
5.3.5 Theme 5: Open/Explore
All three transcriptions described openness and exploration. This theme was mentioned twenty-six times within the three transcriptions. One transcription read, “I started checking in with myself and I felt myself trying to be open to how I wanted to explore the journey.” In addition to the words “open” and “explore”, within the movement medium, this was observed as “extend your arms wide” and “palms up” as well as “embracing”. Within the art medium this was observed as things like “discovering” and “expanding”, and “movement”. Within the music medium, this was observed as “becoming” and “stretching”.
5.3.6 Theme 6: Unknown
All three transcriptions discussed the unknown. This theme was mentioned ten times within the three transcriptions. One transcription read “I feel myself getting like faster and more energy and almost like out of control, not sure, like where I’m gonna land or what’s gonna happen next”. While the word “unknown” was only used one time, in addition to the aforementioned quote, other words that were used within this theme were “dissonance”, “resistance”, “hesitation”, and “chaos”.
5.4 Additional Themes Present
Four additional themes were present in two witnessing transcriptions: Sections/Boundaries, Intentionality, Moments, and Memories. Two transcriptions discussed sections and boundaries. This theme was mentioned fifteen times. The word “sections” as well as “boundary” were used. Additionally, words like “shift” and “transition” were used. One transcription read, “I see you creating a clear line or boundary, or section.” Two transcriptions discussed intentionality. This theme was mentioned ten times. In addition to the word “Intentional”, “deliberately” and “distinctly” were also used. In response to the art medium, one transcription read, “I see you very intentionally choosing bright colors. I see you very deliberately and intentionally coloring the entire sections.” Two transcriptions used the word “moments”. This word was used twelve times. Two transcriptions mentioned memories. This theme was mentioned four times. In addition to the word “memories”, the words “images” and “imagining” were used. One transcription read, “I saw a lot of images while playing and memories.” Another read, “those memories line on through the movement and the process.”
The themes discovered in the authors’ witnessing process respond to the research question: what was the experience of expressive therapies in a pediatric medical setting during the COVID-19 Pandemic? There is limited literature that explores the experiences of expressive therapists during COVID-19, which is why this study, and the themes found, felt significant to the authors. In the literature review, some of the author’s findings aligned with experiences outlined in other research during COVID-19. The authors relate to the Gaddy et al.  findings that music therapists reported levels of hope and stress during the pandemic, however, hope and stress did not arise as main themes from the transcriptions in this study.
The theme of Space was explored by Goicoechea and Lahue  as they shared their experience working with a patient in an environment they had no control over. Diskin et al.  also had a connection to the theme of Space as well as Sections/Boundaries by commenting on the negative effects of visitor restrictions due to social distancing efforts in hospitals. In the Diskin et al.  study, the theme of Togetherness was illustrated in many cases where younger siblings were unable to be physically present in the room of loved ones at end-of-life.
Goicoechea  also discussed having to increase the amount of space he offered in a session when interacting virtually. Goicoechea and Lahue  referenced the theme of Unknown while discussing the challenges of working virtually and not knowing what resources would be available to patients. Many expressive therapists experienced, in some way, the theme of Open/Explore and Intentionality by changing how they presented their care and coming up with creative solutions. For example, Gaddy et al.  conducted a study demonstrating a massive shift in the way music therapists presented their services. Serlin and Zhou  exhibited this theme with their work combining dance/movement therapy and psychotherapy to create videos to address the needs of their patients. Le Vu  commented on the influx of psychosocial needs that COVID-19 brought which ties into the theme of Extremes. Situations like school closures, quarantine, and social distancing arose, which had never happened before and presented as a stark contrast to what expressive therapists had been accustomed to. More research is needed to generalize the themes found in this study to other expressive therapists' experience. Potential future research could be increasing the understanding of the experience of expressive therapists in the pandemic across settings and populations and increasing the understanding of the experience of expressive therapies in the pandemic from the patient perspective.
The impact of expressive therapies in a pediatric hospital setting during the COVID-19 pandemic and the shift to a virtual platform for patient care encouraged growth and creativity in assessing how to best support patients and families in person and virtually. Expressive therapists in this setting encountered advantages when using telehealth such as increased engagement and increased space for processing as well as challenges when using telehealth including lack of being on site to prevent potential accidents, and lack of necessary tools to conduct a successful session. Through this method of discovery, the authors have gained greater insight into our own experience as expressive therapists in a pediatric medical setting and acknowledging the impact of COVID-19 on our work as clinicians and individuals. In addition to 6 discovered themes in this study, a key takeaway from the data collection has been reconnecting with the value of expressive therapies in facilitating emotional expression and the insight individuals gain through creative reflection. Participating in art-based reflection stood as a reminder of the experience our patients have when using the expressive therapy modalities to identify emotions, thoughts, and experiences during the pandemic and beyond.
8. Clinical Implications
This study adds to the current literature describing the work of expressive therapists during the pandemic by describing the experience of the therapists in more detail and validating the experience of the therapists working during this time. Upon reflection, the authors understand that using their clinical modality, the arts, provided a deeper insight into the experience of being an expressive therapist during the COVID-19 pandemic. The findings of this study provide an outline for expressive therapists to utilize as a reflection tool in unprecedented clinical circumstances. Additionally, this process could be used as a supervision and/or self-supervision exercise. The authors acknowledge that this process is fluid and has the capacity to grow and evolve to meet the needs of both new and experienced expressive therapists in a variety of clinical settings.
9. Limitations: Strengths and Weaknesses
It is important to note the limitations of this study. The small sample size of three therapists make these results difficult to generalize to the experience of all therapists working in the pediatric medical setting during the COVID-19 pandemic. Additionally, the authors have a dual role as participants, potentially creating bias in the results. Due to the length of time since the experience of the pandemic, the self-reported reflections are more relevant.
Eliana Rivera contributed the literature review and discussion. Sara Schmidt contributed the methods and summary. Katie Lahue contributed the abstract and data collection and analysis. Each author contributed a case study and art-based processing of the case study. Each author engaged in witnessing process [8,10] and transcription. Additionally, the authors collectively engaged in the thematic analysis process. All other sections were written collaboratively between all authors.
The authors have declared that no competing interests exist.
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