Art Therapists’ Perceptions, Attitudes, and Experiences of Participation in Research

Abstract The study examined art therapists’ subjective experiences, attitudes, and perceptions when participating in a longitudinal study in the Israeli public education system. Seventy-six reflections written by 38 art therapists on their participation in art therapy research were analyzed. Sixteen therapists also took part in focus groups, 5–7 years after the original study. Findings indicated that despite the time and energy required to take part in the study, the therapists were proud to have made a contribution to research, learned a great deal from participating, and felt that taking part had a positive effect on the course of treatment. They viewed their participation in the research as an empowering and valuable experience for them and for their clients.

Research in the field of art therapy has grown considerably in the last 20 years.This underscores the increased need for cooperation from art therapists and their consent to take part in these studies.A survey on art therapists' attitudes toward research found that some were reluctant to take part in studies due to their insufficient familiarity with the field, concerns about the lack of financial or other compensation for the considerable time they must invest (Betts & Laloge, 2000), fear of undermining the therapeutic process, and the possible infringement of clients' rights (AATA, 2013;Moon & Nolan, 2019).
Clearly, these difficulties are not unique to the art therapy profession.Studies on therapists from other fields have reported similar negative attitudes, concerns, and fears.Psychotherapists expressed a lack of confidence in their therapeutic abilities which they perceived as being under scrutiny, concerns about the impact of the findings on their professional status, and possible criticism and judgments from being observed (Bager-Charleson et al., 2018;McBeath et al., 2019;Taubner et al., 2016).A significant proportion of the participants in some studies felt they lacked enough background in what constitutes research, its phases, and support, training, and accompaniment from the researchers (Bager-Charleson et al., 2019;McBeath et al., 2019;Taubner et al., 2016).
No studies have examined the contribution of participation in research to art therapists.However, psychotherapists have noted that their participation had a significant impact on their way of thinking as therapists, exposed them to new knowledge, promoted their personal and professional development (Thurin et al., 2012), and had a positive impact on their practice (Taubner et al., 2016).Studies have shown that given sufficient time, money, and space (Bager-Charleson et al., 2019;Taubner et al., 2016) as well as accompaniment, training, and support (Abrams & Nolan, 2016;Taubner et al., 2012;Thurin et al., 2012), there can be mutual cooperation between researchers and therapists, which can lead to findings that advance the field.
When participating therapists are invited to share their opinions, reflect and share their perceptions about the therapeutic process in a confidential and nonjudgmental environment, a rich joint research relationship can develop that benefits both the researchers and the participants (Bager-Charleson et al., 2018).Studies have shown that acknowledgment of the creation of a beneficial relationship between the researcher and the therapist can allow for change and innovation, advance the field of research and increase the involvement and participation of other therapists in research (e.g., Halvorsen et al., 2020).The present study examined art therapists' subjective experiences, attitudes, and perceptions with respect to their participation in a longitudinal study on art therapy that took place in the Israeli public education system.

Research Design
The current study is a qualitative study, based on a constructivist worldview.The research focuses on the unique perceptions of the participants and their descriptions of their subjective experiences.This study was approved by the Office of the Chief Scientist at the Ministry of Education (permit #11811) and by the Ethics Committee of the Faculty of Health and Welfare at the University of Haifa (permit #216/21).

Participants
The art therapists in the present study all took part in a longitudinal study (2015)(2016)(2017) that examined the integration of art therapy in the Israeli education system as well as in a research course that accompanied the study.The researchers, who also taught the research course, contacted the art therapists in 2021 to obtain their consent for the present study.Thirty-eight art therapists out of the 46 women (83% agreement) who participated in the original study, consented.Sixteen of the participants also agreed to be part of the focus groups in the second phase.The art therapists in the original study ranged in age from 28 to 61 (SD ¼ 8.89, M ¼ 44.12).Half had seniorities of 5-10 years, and the other half had more than 10 years' seniority.

Procedure
Brief Description of the Original Study.
The original study in which the participants took place was conducted from 2015 to 2017.At the beginning of the first school year, each therapist was asked to choose one client, whose parents gave their informed consent.The therapists completed a structured diary once a week in which they described the course of the therapeutic session that week.In addition, they filled out closed-ended questionnaires on the therapeutic relationship and the treatment process, either once a week or three times during the year.In the second year of the study, the art therapists were asked to fill in the closed questionnaires, but not the diary.The parents and the child's homeroom teacher filled out questionnaires both years on the child's condition before and after treatment (outcome questionnaires).The children themselves also filled out questionnaires on their condition before and after treatment (outcome questionnaires), and on the therapeutic relationship three times a year (process questionnaires).Art therapy students and an art therapist served as research assistants and reminded the participants which questionnaires to fill out and then helped the clients with their questionnaires, and sent links and reminders to the teachers and parents.
While taking part in the study, the art therapists could take part in a course titled Research in Art Therapy taught by the researchers, which earned them 60 h of training points in the education system and served as the basis for a promotion and a pay raise.As part of an assignment given during the course, the art therapists were asked to write two reflections in which they described their experiences taking part in the study.The first was written about six months after the beginning of the study, and the second upon its completion.The therapists were asked to relate to the search for suitable clients, their relationship with the research assistant, their reactions to filling out the questionnaires and the diary, and how participation in the study affected them as therapists, the development of the therapeutic relationship, and the client.Each reflection was between half a page to a page-and-a-half in length.
Current Study Procedure.
The reflections written during the course that accompanied the original study were analyzed for the purpose of the current study.After analyzing the reflections, an initial summary was sent to the participants.To gain a more in-depth understanding of the experiences of the art therapists who participated in the study over time and the insights that emerged, two focus groups were conducted in 2022.Eight art therapists agreed to take part in each group.At the beginning of the meeting, the findings from the reflections were presented again for those who had not read them, and the participants were asked to comment on these findings as well as provide additional insights, thoughts, and feelings on their participation in the study, and its effect on their clients and the treatment.

Credibility
To achieve triangulation, we used two sources: written reflections and focus groups.For this purpose also, the data analysis was conducted by a research team, as described in the data analysis section.The findings section was sent to the participants before its publication for their approval (Shenton, 2004).

Data Analysis
The Consensual Qualitative Research method (Hill et al., 1997) was used to analyze the art therapists' reflections.The rating team was composed of two art therapy students in a research track and an art therapist who is also a researcher, and who conducted the original study.Each rater first analyzed three reflections and suggested coding domains.In the consensus stage, the team met to cross-check the individual raters' domain choices to reach a common consensus on the domains in the material.Based on these jointly defined domains the team analyzed the rest of the raw material, adjusting the definitions of the domains to new information that emerged from the reflections.Next, the core ideas in each domain were defined by each rater in terms of frequency.A fourth researcher, an art therapist who also conducted the original study, served as an auditor in both stages of the analysis and in discussions to achieve consensus.The analysis of the transcripts of the focus groups was carried out by two researchers: one of the students and one of the experienced researchers, who worked separately and met for discussion until an agreement was reached.This analysis included deductive elements where information that contributed to the themes and core ideas defined in the reflection analysis phase was added to the description of these core ideas.The analysis also included inductive elements that involved searching and locating additional core ideas.
In the description of the findings, the frequencies of mention of the core ideas are expressed as follows: "most of the participants" refers to mentions by 23-37 therapists, "some of the participants" refers to 12-22 therapists, "a few of the participants" refers to 4-11 of the therapists, and "a small number of participants" refers to 1-3 therapists.The information that emerged from the focus groups is presented without reference to frequency, following the fact that in many instances in the discussion the group's voices merged into one voice.

Expectations and Interest in Contributing Combined With Apprehension.
Most of the art therapists were enthusiastic about participating and the opportunity to make a contribution.In the reflections and later in the focus groups, they mentioned wanting to promote the field of art therapy and their sense of pride in being able to say they had taken part in a study at their workplaces: "I remember feeling great pride … the fact that I would participate and that there would be people who would research and write … to contribute to something that I strongly believe in and want to have in our profession."In their reflections, some therapists described the beginning as a complex experience, since they had concerns about involving their educational framework, writing and documenting the treatment processes, using technological devices, and organizing and sticking to a tight schedule: "I was a little worried about the need to mobilize the support of the entire system: the school principal, parents, children, and teachers." Challenges and Doubts About Choosing a Suitable Client for the Study.
In some of the reflections, the art therapists referred to the challenge of finding a student who would fit the requirements of the study, and whose parents would agree and cooperate.In some of the reflections, the therapists said that they preferred choosing a student who was getting individual sessions because they thought it would be easier for recruitment purposes.Others, who chose a child from group therapy, needed to deal with jealousy: "The other children in the class were angry and offended that I did not choose them and even tried to convince me that they were experts and understand art therapy." The Impact of the Research Instruments and the Writing Process Usefulness of Filling Out the Research Instruments and Their Value in Focusing the Therapeutic Thought Process.
In most of the reflections, as well as in the two focus groups, the therapists said that they experienced filling out the questionnaires and writing the diaries as contributing to a more in-depth, detailed observation of the client.They felt they tuned into their clients more during the treatment and between treatments, gave them more attention, and also gave themselves a moment to remain with the treatment despite their hectic schedules: "focusing with this magnifying glass helped me see things that I believe I would not necessarily have noticed."The participants said that it took time for them to get used to the diary method, its stages, and the structured content, but when they did, they included this technique in their general therapeutic routine, where it functioned at times as an inner supervisor: "When I started thinking about these things … based on the questions, this is how the treatment worked out for me … and I started to think of it that way … it also affected my other treatments." Technical Challenges in Filling Out the Research Instruments.
In their reflections, many therapists mentioned encountering difficulties in filling out the questionnaire.These included meeting the tight schedule required by the study protocol since the lack of time between treatments often forced them to fill out the questionnaires and diaries long after the treatment ended.In some cases, the content was forgotten that they were unable to retrieve: "Filling out the questionnaires every week forced me to work under pressure because it took me almost 2 h.I did the questionnaires at home and sometimes the material was no longer fresh in my mind." The Closed-Ended Questionnaires Were Not Always Perceived as Relevant.
Some of the therapists described in their reflections that the closed-ended questionnaire format restricted their ability to convey what they felt and experienced during the treatment.Some art therapists felt that the questionnaire items were overly specific to certain behaviors that were not applicable to their client.Some therapists felt that the items did not reflect the therapeutic process or the changes associated with it and that they often did not go into detail or missed important issues in the therapeutic system.In their reflections, some therapists stated that they felt that the questionnaire was written with a specific therapeutic approach in mind and that there was no way to respond to the items appropriately when a different treatment or approach was used: "I work with my client (who has anxiety attacks) with a cognitive-behavioral approach.So, the questions were completely irrelevant." The Contribution of the Study to the Clients and the Therapists The Clients Benefited Overall From Participating in the Study.
Many participants reported both in their reflections and in the focus groups that their clients ultimately benefited from their participation in the study, and that a significant therapeutic process took place including improvement in their mental and functional well-being.The continual reflections on the therapeutic process prompted by the research instruments made the therapists ask questions about their clients and notice small changes they might have missed: "I found myself asking myself questions about where he is, and was focused and more alert to the things that were happening." Insights and Contributions Deriving From the Study for the Therapists.
In most of the reflections and in the two focus groups, the therapists described their participation in the study and the training course as contributing and constructive for their professional and therapeutic identity.They cited the knowledge they gained that related to theory, the research techniques they learned about in the course, and ways of collecting data about the treatments.This all contributed to their feeling of pride in their professionalism.In the focus groups, therapists stated that their participation in the study gave them an opportunity to learn and use the therapeutic language and made it accessible to them: "A therapist in the school system does not meet researchers … she sees children and deals with the system … at the end of the day therapists really only open a book if they are truly interested … so it was a real boost." In both focus groups, the therapists Commented on the feeling of empowerment they experienced as a result of participation in the group of art therapists.They related to the group as an inclusive setting that enabled them to get to know, be exposed, share, experience, learn and be part of an influential research group.The experience of the partnership created an anchor and a safe haven for their own therapeutic actions in the school setting by knowing that their actions were backed up in the field: "I felt that I had backing, that I could always turn to and ask for help or brainstorm." Desire to Make a Change, Belief in the Profession, and the Power of Treatment.
In most of the reflections and in the focus groups, the therapists wanted to make a change in the profession and guide it to a better place.They hoped to pass on their experiences to the next generations of art therapists.Participating in the study gave them confidence and a more secure base to establish themselves within their educational frameworks, promoted partnership and teamwork, the therapeutic language, and above all, faith in the profession and in themselves: "I said that I would make art therapists that I supervise stand tall and know that we have value and that there are people who appreciate it." The Relationship Between the Therapists and the Educational Frameworks In Some Cases, the Staff in the Educational Framework Cooperated With the Study.
In some of the reflections, the therapists noted the positive response from their school's educational staff to their taking part in the study.In some reflections, the therapists indicated that cooperation with the teacher and the school counselor made them take a greater interest in the child's condition: "Cooperation on the part of the school principal and the educational team enhanced the treatment.They were ready to help with anything and everything." Participation in the Study at Times Led to Complications in the School Framework.
In their reflections, other therapists noted that their schools had concerns and doubts about the nature of the study, how it would be conducted, and the rights of the children taking part.A few therapists commented in their reflections that they had to ask the educators repeatedly to fill out the questionnaires and felt that some of them did not understand the objectives of the study or had time for it: "Sometimes I had to nag and chase after other teachers and staff members, which was frustrating and oppressive." The Impact of the Relationship Between the Research Assistant and the Therapist, the Client and the Parents Positive Relationships Between the Therapists and the Research Assistant.
In most reflections, the therapists described the collaboration with the research assistant as positive.They emphasized the importance of continuous contact with her and her support, availability, and assistance throughout the study.They also felt that the relationship with the research assistant enriched their work and provided a safe place to express questions and concerns about the research in general and the treatment in particular: "The relationship with her was useful both in terms of the practical side, by sending the weekly link to fill out the questionnaires and on a personal level … she was empathetic and supportive." Cooperation Between the Research Assistant, the Child, and the Parents.
In most reflections, the therapists described the research assistant's relationship with the client's parents as professional and pleasant.They felt that the cooperation between the client and the research assistant was positive: "The child cooperates and is happy to be the focus of the meeting with the research assistant, which unfolded in a pleasant and friendly manner."By contrast, in a few reflections, the therapists described the relationship between the research assistant and the client as posing problems within the therapeutic relationship and as interfering with the privacy of the therapeutic setting.These therapists described situations in which the child resisted sitting with the research assistant and needed the therapist's mediation.In some reflections, the therapists said that they felt that the meetings with the research assistant added another dimension to the treatment that could affect the quality of the relationship or confuse the client: "I think the study injected some confusion into the therapeutic relationship.I experienced the sessions before filling out the questionnaires as different.During these sessions, the children asked questions and looked more stressed." The Importance of the Relationship Between the Therapists and the Parents in the Context of Participation in the Study In most therapists' reflections, they stated that the parents expressed their consent for their child to participate in the study and considered that it enhanced their child's progress in art therapy.Parents mainly took an interest in the treatment their child would receive and were motivated to cooperate in a successful and efficient manner to ensure that participation in the study would benefit their child.The therapists saw this as an opportunity to strengthen their relationship with the families and encourage them to play a more active role in the therapeutic process.Other parents asked for a broad and comprehensive description of the study including details on the procedure before agreeing to allow their children to take part: "More explanations were needed for the parents, I felt that I had to convince them."A few therapists said that in some cases the parents refused and that they had trouble finding clients whose parents would agree and cooperate.

Discussion
The present study examined the experiences, perceptions, and attitudes of art therapists who participated in a longitudinal study of the education system.While the reflections provided targeted information in real-time, such as details about technical difficulties or dealing with challenges, content from the focus groups further validated and reinforced the value and meaning of the experience as first expressed in the reflections, with the additional perspective of time.Most of the therapists stated that their prime motivation for taking part in the original study was to contribute to the research field of art therapy.Their interest and willingness most likely also stemmed from the increase in scholarly interest in research in the field of art therapy, which reflects the growing professionalization and academicization of this field of therapy (Abbing et al., 2018;Regev & Cohen-Yatziv, 2018).Some art therapists nevertheless raised concerns about their ability to find the time to take part in the study.Their heavy workload with multiple assignments in different schools (Snir et al., 2018) in conditions that are not always professionally adapted to their work (Elkayam et al., 2020;Raubach Kaspy et al., 2022), and the thought of taking on more responsibilities and the need to meet deadlines (Betts & Laloge, 2000), caused understandable concern.This underscores the need for appropriate compensation, as was done here through course credits.
Despite the workload, most of the art therapists judged the experience to be positive.The participants cited learning about studies and theories, experiencing the research procedure first-hand, discovering the writing and documentation processes, and in-depth observations of the processes occurring in treatment as playing a significant role in shaping their professional identity.These comments are consistent with findings on psychotherapists who reported deriving professional value from taking part in research (Taubner et al., 2016;Thurin et al., 2012).The participants in the focus groups said that they still considered their participation as having been a significant experience several years later and that they felt that being in the study impacted their development and the shaping of their identity as therapists who apply the principles they learned in the study in their therapeutic work in the field to this day.Writing the diary helped them conceptualize their therapeutic thinking as therapists and became a main documentation instrument that they still use.The value of keeping a diary coincides with findings in psychotherapy research (Coxen et al., 2021).Taking personal notes as a way of development and change has been recognized in other contexts (e.g., Faccio et al., 2019).It constitutes yet another gain and benefits that the therapists derived from their participation in research.
The therapists were also appreciative of the training course.Most of the therapists described the course as a beneficial experience that they remember well.The course provided a containing research environment with opportunities for learning, exposure, experiences, and a better understanding of research and treatment procedures, which had an empowering effect.Previous studies have emphasized the importance of scaffolding therapists who take part in studies through a training or learning group as a way to create a positive, supportive, and nurturing experience (Taubner et al., 2012), and as a way to establish a relationship of partnership, trust, and confidence between the researchers and the therapists, enhanced by listening and mutual openness to learning in a way that ultimately benefits both participants and researchers (Abrams & Nolan, 2016;Thurin et al., 2012).Note that the training course also earned the participants points from the Ministry of Education, which ultimately translated into a pay raise, which further contributed to the experience of mutual giving, and encouraged participation in itself.
The findings suggest that the art therapists perceived the experience of participating in the study as beneficial not only to them but also to their clients.Although certain therapists had initial concerns that were shared by some parents and by members of the staff with respect to possible infringements of the students' rights because of the presence of outsiders in the treatment room, greater familiarity with the research process allayed these fears.Concerns over ethical violations when art therapy takes place within the school system (Moon & Nolan, 2019) was addressed here by enforcing strict guidelines on data collection, the use of anonymous identification numbers, and the emphasis throughout the training course on the importance of preserving confidentiality and anonymity.The ongoing contact with the educational staff prompted the therapists to take more interest in the emotional state of their clients.These relationships fostered more joint thinking about these clients and may have contributed to the success of the therapeutic process (Robinson, 2020).
One major problem that emerged from the findings is related to the use of structured questionnaires adapted from psychotherapy research.Some therapists indicated that the self-report closed-end questionnaires did not adequately capture the therapeutic process in art therapy.This points to the need for developing specific evaluation and measurement tools for the content world of art therapy (Kapitan, 2017).
During the original study, in response to these comments, open-ended questions were added to the diary reports, and a questionnaire was developed and included three months later that better reflected the functions of art in art therapy (Regev & Snir, 2021).Future work should recognize the importance of ongoing dialogue with the therapists in the study in a way that enriches both the participants and the research.

Practical Implications
The findings, and the therapists' overall positive experience, should encourage more therapists to agree to take part in the research.Most therapists felt that the study contributed to treatment, and in no way detracted from it.Findings show that opportunities for professional development while making a contribution to the field of art therapy support participation in art therapy studies.In light of the findings, we recommend that researchers create a joint study group for participants that will serve as a supportive space, and be available to provide guidance and explanations regarding all aspects of participation in the research.The findings emphasize the importance of a continuous and supportive relationship with the participating therapists, as was done here through the training course.

Limitations
This study took place in the specific context of the Israeli education system.Follow-up studies in other work settings are clearly important.As often happens in research, consent was not complete; 17% of participants in the original study chose not to participate in the follow-up study, and their views remain unknown.In addition, the focus group was held several years after the end of the study, which made it difficult at times for some participants to recall their experiences.Future research should examine the experiences of the participants more proximally.

Conclusion
Despite understandable concerns about their work overload and the possibility of interfering negatively with treatment, the art therapists viewed their participation in research as an empowering and valuable experience, for them and for their clients.To be experienced as such, researchers need to scaffold the therapists, provide explanations, and maintain continuous dialogue throughout the study.

Sharon
Snir is a faculty member in the Art Therapy MA Program at Tel-Hai College, Tel-Hai, Israel.Shoval Ben-Simon is a graduate student in the School of Creative Arts Therapies at University of Haifa, Haifa, Israel.Dafna Regev is the head of the art therapy program in the School of Creative Arts Therapies at University of Haifa, Haifa, Israel.Atara Ben-Haim is a graduate student in the School of Creative Arts Therapies at University of Haifa, Haifa, Israel.Correspondence concerning this article should be addressed to the first author at sharonsnir@telhai.ac.il ß 2023 The Author(s).Published with license by Taylor & Francis Group, LLC This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.