Sample characteristics
The survey response rate was 77% (92/120). Personalized reminders increased the initial response rate from 60% to 77%. Respondents were comprised of board-certified music therapists (61%), board certified or registered art therapists (35%), board certified or registered dance movement therapists (4%) and registered drama therapists (1%), which mirrors the composition of CAT therapists employed by the VHA. Survey responders represented 17 of the 18 VHA regions of the United States. Sample characteristics are outlined in Table 1.
(insert Table 1)
Telehealth Adoption and Characteristics for Creative Arts Therapies
As shown in Table 2, 69 (75.8%) therapists delivered a telehealth CAT session between May 2020-May 2021, and about 74% of those each delivered more than 50 sessions that year. Most therapists (59/69, 85.5%) used VA Video Connect (VVC), the internal VHA platform for delivering telehealth services from the clinician at one location directly to the patient’s home. However, for part of the pandemic other video platforms (e.g., WebEx, Zoom) were temporarily approved and used by therapists. Therapists were asked to provide further explanation for any preferred platforms. Many comments were positive or neutral; however, of the 17 negative comments, 12 (70.5%) were about VVC, primarily related to poor audio quality and limited capability for group therapy sessions. The Zoom platform received the most positive comments citing it produced a better music experience, and could display all Veterans participating in a group.
(insert Table 2. Telehealth usage characteristics)
Technology problems and challenges
Most therapists (65%) reported moderate technology issues that they were able to overcome. Technology issues were often specific to the creative arts discipline with 76.3% (29/38) of music therapists reporting technology problems related to their specific therapy modality compared to 29.6% of art therapists (8/27) (p<0.001).
Technology issues were attributed most often to platform or internet issues (57%) and difficulties from Veterans limited technology skills (45%). As shown in Table 3, therapists’ age was related to training needs (p<.002) and confidence using technology (p<.002). Therapists aged 55 years and over reported the highest need for training and lowest average technology confidence. Therapists with 6-10 years of experience reported the lowest rate of training needs and highest technology confidence, but only technology confidence reached statistical significance.
(insert Table 3. Therapist characteristics and virtual CAT training needs and technology confidence)
Therapists delivered telehealth CAT in outpatient and inpatient settings to a variety of populations, with 81% working with multiple populations. Telehealth CAT was prominently delivered to Veterans with mental health issues (93%) and post-traumatic stress disorder (PTSD) (81%). Therapists also delivered telehealth CAT to Veterans with traumatic brain injury (TBI), pain, geriatric populations, hospice, and surgery or general medicine support. Therapists who had not delivered telehealth sessions differed in their patient populations treated, with 90.9% working with older adult patients (see figure 1). In response to whether there is a need for telehealth CAT delivery, 98% of the therapists said yes, although some listed certain caveats such as only when in-person delivery is not possible (9/91, 9.9%), or only for certain patient populations (12/91, 13.2%).
(insert Figure 1. Patient populations receiving telehealth and in-person CAT)
Thematic results of survey open responses
Thematic analysis from survey open responses revealed therapists’ perceived facilitators, benefits, barriers, and adaptations needed for effective telehealth delivery. Survey themes and exemplar quotes are presented in Table 4.
(insert Table 4. Survey themes and quotes)
Barriers to telehealth delivery
Barriers to telehealth delivery fell under three main themes: technical, space, and rapport. Technical barriers were mentioned by 70% (46/66) of therapists. Video platform limitations were reported to cause a significant decrease in sound quality for synchronous music making. Some Veterans did not have internet access in their home or had outdated digital devices. Equipment that could improve session quality (e.g., better lighting, additional cameras, microphones, and external speakers) was sparse for therapists and not available to most Veterans. Poor internet connectivity or inadequate bandwidth was an issue for therapists and Veterans. Knowledge and skills to navigate changing technology was a barrier for many Veterans, and therapists needed to dedicate session time to teach technology when issues arose.
Another issue mentioned by therapists was that there was less control over safety and privacy due to lack of control over the Veteran’s environment. Dance and movement experiences were limited in range or therapists needed to spend extra time assessing the Veteran’s home environment for adequate space. Not all Veterans had a private space where they could participate in sessions.
Therapists also detailed the difficulty of building rapport through telehealth sessions. The absence of physical presence and the limited ability to see and hear parts of treatment sessions contributed to lack of connection, ability to offer support, and limited information used to gain insight into the therapeutic process.
Given the barriers mentioned and their anticipation that telehealth CAT will continue in some format, many therapists expressed the need for better equipment, technology support and relevant hands-on training to improve the telehealth CAT experience.
Therapist adaptations to CAT
Most therapists (85.5%) who delivered telehealth CAT, adapted or created new interventions for delivery. For example, therapists relied more on verbal communication, needed to plan more, and shifted from shared synchronous experiences to asynchronous experiences. Adaptations and modifications occurred in how they shared materials with Veterans, the individual CAT experiences, and overall expectations regarding process and outcomes.
Session planning for telehealth CAT occurred earlier than for in-person sessions so that art supplies, instruments, or drama props could be mailed in advance. Therapists who could not mail supplies relied on resources in the Veterans’ environment, such as making instruments or props from household items. Without the ability to provide hands-on modeling, there was more reliance on verbal instructions.
Art therapists noted the limited camera view during telehealth sessions and how that altered art-making, increased verbal communication, and necessitated more independent work time for the Veteran. Virtual platforms were not designed for shared music making, thus the quality and opportunity for music interactions was negatively affected. Therapists needed to adapt experiences so only one person was heard at a time or group playing occurred with microphones muted, meaning individuals could see that they were playing with the group but could only hear themselves. Music therapists added more receptive interventions, which had fewer challenges than active ones but still needed modification, for example providing guidance before or after rather than during the music.
Therapists altered their expectations of session content and depth of work. Goals were modified to be more supportive and focused on self-care to meet Veterans’ needs during the pandemic. Treatment goals also shifted due to concerns about safety when engaging in issue-oriented work. Therapists felt that certain advanced CAT methods (e.g., Guided Imagery and Music, Authentic Movement) required greater presence and therapeutic support not possible over telehealth. One therapist shared, “There is less opportunity for experiential interventions that promote in-session catharsis, for example, I am unable to provide the option for Veterans to "make a mess" in a safe space and have the therapeutic outcome of letting go, destroying something or engaging with messiness/chaos, and working through the aftermath. This has considerably adjusted the scope of my art therapy interventions.” [survey 6, art therapist]
When possible, therapists adapted equipment to improve telehealth delivery. Music therapists added audio interfaces to improve sound and art therapists added cameras and lighting to improve visual range and quality. Software resources that enhanced visuals or enabled song sharing improved the quality of the online experience and provided tools that were not possible in person. Additional equipment and software were often dependent on resources provided by clinic/hospital administration. Therapists stated that CAT delivery was easier when internet bandwidth was adequate, and space was provided for conducting telehealth sessions. VHA facilities have limited office space. For some therapists, the option to work remotely meant they had a dedicated quiet home office where they could deliver sessions to more Veteran patients.
Benefits
More than two-thirds (68.7%) of therapists stated that they were able to provide services to more Veterans. Access improved because transportation barriers (lack of car, parking difficulties) were removed. Veterans could access services despite debilitating conditions that prevented them from leaving home, and they could continue care throughout the COVID-19 pandemic. Reach was improved when, through telehealth, CAT could be expanded to areas where facilities did not have CAT therapists, or into rural areas removed from VA Medical Centers. Veterans who preferred telehealth CAT cited scheduling convenience, especially for younger Veterans working or in school.
Veterans reported to therapists that they appreciated staying connected during the pandemic and attending sessions from home, especially those who had social anxiety. These were issues of convenience and therapeutic benefits. Veterans attending sessions from home provided a context of social and family environment that helped build rapport during sessions.
“I enjoy, as a therapist, having a window into their lives in a different way- you really have the opportunity to see them in their own space, see them interacting with the space around them, in a way you would never have the ability to if they were coming into the medical center for appointments.” (survey 41, dance/movement therapist)
Therapists reported their time was used more efficiently because they did not need to set up equipment or session rooms. Some therapists gained time previously spent traveling between VHA facilities, which added flexibility with scheduling. Being pushed outside their comfort zone was cited as an opportunity for clinician growth by several therapists. The addition of screen sharing and software led to exploration of new content such as virtual museum visits and symphony concerts.
Music therapists created music playlists in the moment with Veterans or used music recording software to compose songs together. Art therapists accessed tutorial videos to provide instructions in real time or used inherent artistic skills to create visually rich slides.