Ethical implications of cross-cultural international art therapy

Accepted Manuscript Title: Ethical Implications of Cross-Cultural International Art Therapy Authors: Jordan S. Potash, Heidi Bardot, Catherine Hyland Moon, Michelle Napoli, Angela Lyonsmith, Megan Hamilton PII: DOI: Reference:

S0197-4556(16)30238-6 http://dx.doi.org/doi:10.1016/j.aip.2017.08.005 AIP 1473

To appear in:

The Arts in Psychotherapy

Received date: Revised date: Accepted date:

11-12-2016 17-5-2017 3-8-2017

Please cite this article as: Potash, Jordan S., Bardot, Heidi., Moon, Catherine Hyland., Napoli, Michelle., Lyonsmith, Angela., & Hamilton, Megan., Ethical Implications of Cross-Cultural International Art Therapy.The Arts in Psychotherapy http://dx.doi.org/10.1016/j.aip.2017.08.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Ethics International Art Therapy p. 1 Ethical Implications of Cross-Cultural International Art Therapy Jordan S. Potash, PhD, ATR-BC, REAT, LCAT, LCPAT Art Therapy Program, The George Washington University, Alexandria Graduate Education Center, 1925 Ballenger Avenue, Suite 250, Alexandria, VA 22314, [email protected] Heidi Bardot, MA, ATR-BC, LCPAT Art Therapy Program, The George Washington University, Alexandria Graduate Education Center, 1925 Ballenger Avenue, Suite 250, Alexandria, VA 22314, [email protected] Catherine Hyland Moon, MA, ATR-BC Art Therapy Department, School of the Art Institute of Chicago, 37 S. Wabash, Chicago, IL 60603, [email protected] Michelle Napoli , MA, ATR-BC, LMHC Expressive Arts Therapy Emphasis in Clinical Mental Health Counseling Department, William James College, 1 Wells Ave, Newton, MA 02459, [email protected] Angela Lyonsmith, MAAT, ATR-BC Art Therapy Department, School of the Art Institute of Chicago, Gather, 602 Davis Evanston, IL 60201, [email protected] Megan Hamilton, MA, LPCA Birch Counseling, 3325 Durham-Chapel Hill Blvd, Suite 205, Durham, NC 27707, [email protected] Corresponding Author: Catherine Hyland Moon, MA, ATR-BC Art Therapy Department, School of the Art Institute of Chicago, 37 S. Wabash, Chicago, IL 60603, [email protected] Editor’s Note: This paper was developed from a panel delivered by the authors titled “Conducting CrossCultural Art Therapy Internationally: Ethical Implications” at the American Art Therapy Association Annual Conference in San Antonio, TX on 12 July 2014. Highlights 

nternational art therapy collaborations entail:

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self-reflexivity, decolonizing approach to cultural competence, and supervision

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attention to culturally appropriate studio environment, materials, creative processes 

accountability through long term commitment, and respectful power sharing Abstract

Art therapists are increasingly offering their services in international contexts. Although usually altruistic in nature, unexamined practices can result in detrimental consequences to both the

Ethics International Art Therapy p. 2 travelers and host communities. A consideration of the ethical dilemmas that one might face can better orient art therapists to the many aspects of offering art therapy abroad. Preparation for cross-cultural work in international contexts entails assessing motivations, developing cultural competence, and ensuring sustainable practices. While in country, there are considerations pertaining to art materials, studio space, service delivery, artworks, roles, positions of power, and consent. Throughout the experience, examination of accountability to multiple stakeholders, including through reporting and fund-raising, is crucial. A critical look at the ethics and values involved in providing art therapy internationally can help ensure that art therapists offer global services with integrity. Keywords: international; ethics; art therapy; cultural humility; decolonizing approach Ethical Implications of Cross-Cultural International Art Therapy Due to globalization, increasing numbers of people and organizations have been involved in international volunteer and employment opportunities (Lough, 2013). Among them, a proliferation of art therapists have travelled across international borders to provide disaster response, direct service, paraprofessional training, or university educational programs (i.e. Anderson, 2013; Arrington, 2013; Kapitan, Litell & Torres, 2011; Moon, 2013; Wallingford, Hamilton, Kirschner, Palladino, & Tosatto, 2013). Typically, art therapists from high-income countries (HIC) travel to low or middle-income countries (LMIC) for a limited period of time, motivated by well-meaning but potentially misguided intentions to alleviate suffering, offer technical expertise, or develop cultural competence. Both service recipients and travelers may learn new skills, broaden their perspectives, and widen their professional networks, but travelers may also experience complex ethical questions about cross-cultural international practice.

Ethics International Art Therapy p. 3 The art therapy literature about international work seldom addresses the ethics involved. Conducting ethical work outside one’s home country requires continuous examination of crosscultural ramifications of power and privilege. When international work is framed as helping or empowering people, there are often overlooked implicit biases that: a) those requiring help have limited power, b) there is a radical division between “us” and “them,” and c) those with more resources hold exclusive rights to empowerment, wellness, and fulfillment. While most art therapists would deny this colonial logic, research suggests that it may unconsciously hold sway (Watson, 2013). A common assumption is that Western psychology as implicitly more valid, developed, and valuable than folk or ethnic healing systems. In reality, Western psychotherapy is also culturally determined and exists among many other contemporary, relevant psychological healing practices across the globe (Christopher, Wendt, Maracek, & Goodman, 2014; Mills, 2014a; 2014b). To examine some of the ethical implications of conducting art therapy internationally and to identify best practices, we reviewed literature by art therapists and other mental health professionals and critically reflected on our own work. Although we are all based in the United States, collectively we have worked across the globe: Potash in Hong Kong, China; Bardot in India, Lebanon, United Arab Emirates, France, Croatia, South Africa; Moon and Lyonsmith in Kenya, Tanzania; Napoli in Guatemala; Hamilton in Cambodia, Nepal. For this paper, we define international work as contributing art therapy informed knowledge and skills to projects outside one’s country of residence. Visitors are those who engage in such work, and the host community is the international destination where an exchange takes place. For simplicity’s sake, we use the term art therapy in this article, even though a number of us intentionally refer to our international work with alternative terms (for example,

Ethics International Art Therapy p. 4 therapeutic arts or art as therapy). Art therapy often implies a specific Western concept, while these alternative terms encompass a wider array of arts in health and healing practices and demonstrate respect for the profession of art therapy in countries where it is regulated. Ethical Decision Making Many professionals see ethical behavior as a means to guard against liability. Knapp and VandeCreek (2006) stressed, “ethics can be viewed as a voluntary effort to ‘do the right thing,’ motivated by deeply held moral principles” (p. 3). Basing ethical decision making on aspirational or positive values promotes increased context-specific critical thinking, rather than generalized prescriptive principles (Hinz, 2011; Hunt, Schwartz, Sinding & Elit, 2014). The five traditional aspirational values include: autonomy (participants’ right to informed decision making), nonmaleficence (do no harm), beneficence (promote good and wellness), fidelity (honesty and integrity), and justice (fairness in access to resources). The Ethical Principles for Art Therapists (American Art Therapy Association (AATA), 2013) identifies a sixth value of creativity. Depending on the international context, art therapists may find that ethical principles based on Western philosophies and worldviews fail to cover the nuances of their work. These ethical codes emphasize individualism, autonomy, and boundaries between people and thus fall short when applied to cultures oriented toward collectivism, interdependence, and interpersonal connections (Pettifor, Sinclair & Falender, 2014). Given such uncertainty, international health care professionals are prone to moral stress, defined as feelings of “insufficiency, powerlessness, meaninglessness, and frustration,” (Nilsson Sjöberg, Kallenberg, & Larsson, 2011, p. 66). Because most ethical codes fail to address the unique challenges of working internationally (for an exception, see Universal Declaration 2008), it is important for art therapists to adopt a framework that is self-reflexive to mediate among individual, cultural, economic, and political

Ethics International Art Therapy p. 5 realities (Thoburn, Bentley, Ahmad & Jones, 2012). The goal is not mastery of a set of skill set, but rather ongoing critical reflection, cultural humility, and openness to the complex interaction of diverse worldviews. Since real-world examples are a more effective means to hone “good moral ‘reflexes’” than general, abstract principles (Hunt, Schwartz, & Elit, 2012, p. 96), this article provides examples of our first-hand experiences. Our overall aim is to identify potential ethical issues and guiding principles, rather than to address the nuances of each specific situation. Preparation Working internationally begins when one initiates a relationship or accepts an invitation to share professional expertise abroad. While rooted in beneficence, such work also calls to mind the value of fidelity. An overarching consideration pertains to working within one’s area of competence: “Art therapists refrain from using art materials, creative processes, equipment, technology, or therapy practices that are beyond their scope of practice, experience, training, and education” (AATA, Principle 6.2). A common critique of volunteer tourism is that travelers adopt the role of expert when they may not only lack requisite skills and knowledge, but also know little about the communities within which they are working (Guttentag, 2009; Palacios, 2010). Such an approach “raises the specter of neo-colonialism in the tacit assumption that even ignorant Westerners can improve the lot of the people in the [global] South” (Brown & Hall, as cited in Palacios, 2010, p. 863). Posing critical questions is essential. For example, while engaged in a graduate art therapy program’s service learning trip to Cambodia, Hamilton and her fellow participants wanted to ensure their readiness before accepting an invitation to work in an orphanage. They assessed their knowledge regarding the specific organization and the cultural circumstances under which Cambodian orphanages operate. Some questions they considered included: How would accepting the invitation benefit the children, the orphanage, and the

Ethics International Art Therapy p. 6 student group? How might it cause harm? Might such a decision perpetuate systemic problems caused by dependence on international volunteers? Might it potentially exploit the children, the organization, or the service-learning participants? Preparing to work internationally mandates weighing intentions against a range of potential outcomes. Assessing Motivations An examination of motivations and intentions is essential to ethical practice. Unexamined attitudes and practices can perpetuate inequality in any cross-cultural situation (Sajnani, 2012; Talwar, 2010), but in international contexts these dynamics can be complicated by competing humanitarian, political, and economic agendas among international providers, host communities, governments, and multinational corporations (Vickers, 2015). Typically, humanitarian aid workers focus only on the perceived benefits of their services related to compassion, moral obligation, and reparation, but fail to take into account the perils of short-term inefficiencies and “a neo-colonial, or imperialist relationship between ‘recipients’ and ‘donors’” (Sumner & Tribe, 2011, p. 790). Such power inequities are present when international workers take on features of the White Savior complex by “rescuing” others who are deemed poor, needy, and powerless (Hughey, 2010; Zeddies & Zsuzsa, 2015). Cole (2012) described a person with this complex as one who values personal emotional experience over justice, “supports brutal policies in the morning, founds charities in the afternoon, and receives awards in the evening” (para. 1). Although many volunteers traveling to LMICs identify as White, it is important to note that White Savior is not an indication of racial identity, but rather a signifier for unexamined power and privilege. Anyone who has the resources to undertake international travel for the purposes of “helping” others is vulnerable to manifesting these characteristics.

Ethics International Art Therapy p. 7 Art making is a particularly useful means for critically examining—and stimulating discussion about—power dynamics, underlying motivations, roles adopted in the cross-cultural encounter, potential impact on the host community, desired personal gains, and the influence of various constituencies on the direction and aims of the work. Visual journaling may be especially helpful for recognizing otherwise unexamined negative, positive, or pseudo positive biases and attitudes (Shannon-Baker, 2015). Moon and Lyonsmith found that participants in programs in Kenya and Tanzania often romanticized the East African lifestyle as much more relaxed than the hectic pace of U.S. living. The participants failed to take into account that the “relaxed lifestyle” has come, in part, from high unemployment and poverty, which, in turn, is related to the long-term effects of colonialism and neoliberal global politics. Trip and project leaders are responsible for ensuring that visitor preparations include educational materials about the historical realities and current impact of imperialism. Denying or remaining ignorant about this influence enables the visitor to encounter locales as unspoiled, authentic, and unchanged. Yet this very perceptual stance replicates the colonized/colonizer relationship by positioning the host culture as an undeveloped site that is a prime target for modernization by foreign influences (Caton & Santos, 2009). Developing a Decolonizing Approach to Cultural Competence Sue and Sue (2016) identified three components of cultural competence as selfawareness, knowledge, and skills. Self-awareness includes examining one’s values, worldviews, beliefs, assumptions, and biases and how they impact cross-cultural relationships. Knowledge entails learning about another’s customs, values, language, and history, as well as how the host’s culture intersects with one’s own culture. Skills pertain to working effectively within the norms and expected practices of the other’s culture. Critiques of cultural competence point to the

Ethics International Art Therapy p. 8 mistaken belief that culture is a static concept that can be mastered and to its lack of a transformative social agenda (Fisher-Borne, Cain, & Martin, 2015). Cultural humility, on the other hand, emphasizes “an interpersonal stance that is other-oriented rather than self-focused, characterized by respect and lack of superiority toward an individual’s cultural background and experience” (Hook, Davis, Owen, Worthington & Utsey, 2013, p. 353). It calls for the mitigation of power imbalances and emphasizes individual and institutional accountability (Fisher-Borne, Cain & Martin, 2015) To instill cultural humility, orientation to a new country ought to include materials that disrupt embedded stereotypes about both people and place. Ideally, before attempting to do work in a foreign country one would learn the local language, conduct an in-depth study of the culture, and live in the locale for an extended period of time. However, the duration of most international work is brief. Further, command of the language, cultural values, and intricacies of intracultural dynamics are unlikely. Calls to deepen social justice pedagogy in art therapy have implications for international applications (Gipson, 2015; Sajnani, Marxen & Zarate, 2017). Preparing to work from a culturally humble, decolonizing framework requires learning about the historical, political, economic, and structural legacies of colonialism and White supremacy. Visitors can seek counter-narratives to dominant myths about the “Other,” and discuss strategies for decentering Western hegemony in favor of acknowledging the legitimacy of indigenous and previously subjugated knowledge and experiences, particularly in relation to ways of understanding health, illness, and healing. Humility, openness to the unfamiliar, and commitment to learning create a basis for developing knowledge of the host community. Establishing Collaborative Relationships

Ethics International Art Therapy p. 9 Establishing collaborative, consultative relationships helps decenter the role of the visiting art therapist and fosters attunement to the host culture’s resources and needs. Consultative relationships establish a basis for privileging local knowledge about cultural beliefs, mental health practices, and art. Local hosts can help ensure cross-cultural sensitivity by providing information about common cultural practices as well as prevalent attitudes toward foreigners. Some strategies to consider when preparing to work internationally include: asking host communities to set meeting agendas, working collaboratively on goals, co-leading training sessions, inviting local people to present on their work, recognizing host and visitors accomplishments, and establishing a budget that includes paying local collaborators for their program development work. Long-term relationships with local collaborators are preferable, as it takes time to establish trust, deepen cross-cultural understanding, and develop shared accountability. Moon recalls the first time her East African colleagues, after discussing and supposedly agreeing with her on a plan for an art project they would carry out with local children, implemented an entirely different plan. Their actions seemed to indicate enhanced trust in their indigenous knowledge as well as in the strength of the collaboration to withstand conflict. Over the years, as trust and understanding have continued to develop, differences of opinion have been more overtly expressed by all involved. The preparation necessary for creating healthy cross-cultural collaborations is not a one-time project, but rather an ongoing commitment. Creating Support and Supervision Structures An additional consideration in preparing for international work is the establishment of ongoing support structures for self-assessment, contextual exploration, and supervisory oversight during and after the visit (Canfield, Low, & Hovestadt, 2009; Hammersley, 2014). Trip leaders

Ethics International Art Therapy p. 10 have an ethical responsibility to ensure regular supervision and consultation. The needs and interests of multiple stakeholders—visiting students, professionals, organizational staff, local participants and collaborators— must be considered. The challenge for trip leaders is to establish an environment wherein local perspectives and agendas are privileged, but mutual learning, raised consciousness, and intercultural inquiry is possible for all. Culture shock, the sense of disorientation people often experience when encountering unfamiliar social conditions or cultural practices, is a normal aspect of traveling or working internationally. Moufakkir (2013) conceptualized culture shock as occurring in seven stages: “interest/curiosity, apathy, annoyance, hostility, acceptance, adaptation, and positive assimilation” (p. 328). Progression through all of these phases typically requires prolonged engagement in a new cultural context, though people on short-term assignments may experience some of them. However, international work does not inevitably leads to culturally sensitive development. Without proper supervision and opportunities for reflection, travelers might interpret and judge their experiences based on the dominant social and cultural perspectives of their home countries, exoticize their cross-cultural encounters, and fail to recognize meaningful changes in their perspectives, motivations, and relationships with other travelers, host community members, and the people they eventually return to in their home country (Bamber, 2015). Supervisory support can be provided through creative means as well as discussion. Bardot (2011) invited her graduate art therapy students to participate in a daily arts-based experience to promote expression, grounding, and reflection in relation to the community service they provided as part of their study trip. The students created an image in response to the day’s events and interactions, engaged in reflective writing, and then shared their art with their fellow

Ethics International Art Therapy p. 11 students. The resulting artwork was then hung in a public space, becoming part of a group art piece. By the end of the trip, each individual had an art journal and the group had an overall record of their collective challenges and learning. Activities such as this help students avoid fragmentation that may come with culture shock, while also exploring their own cultural identity and biases (Bardot, 2011; Tomlinson-Clarke & Clarke, 2010). Service Delivery The emerging field of global mental health has addressed the paucity of mental healthcare in LMICs and taken into account complicating factors, such as stigma, poverty, social inequality, gender discrimination, and environmental injustice (Ngui, Khasakhala, Ndetei, & Roberts, 2010; O’Donnell, 2012). However, global mental health also has been widely criticized for its reliance on Western concepts of mental health and illness, as well as its ethnocentric understandings of social relations and norms related to personhood, privacy, emotional display, children’s development, gender roles, spiritual beliefs, family constellations, etc. (Christopher, et al., 2014; Makhashvili, Tsiskarishvili, & Drožđek, 2010). Likewise, art therapists cannot simply rely on ethnocentric assumptions about the nature of art and its relationship to healing. The conceptual understanding of art therapy and how it is practiced varies from place to place (Karkou, Martinsone, Nazarova & Vaverniece, 2011). Ideally, art therapists are able to switch between an individualistic and a collectivistic lens, as well as between ethnocentric and ethnorelative perspectives (Kapitan, 2015). While art therapists may conceive of the arts as means for self-expression and healing, other project stakeholders may consider the arts to be evidence of achievement, a means for education or activism, or culturally embedded components of spiritual and communal rituals (Huss, Kaufman, Avgar, & Shouker, 2015). The complex dynamics among conceptions of health, art, and therapy within a

Ethics International Art Therapy p. 12 given cultural context will largely determine the nature and scope of art therapy in that locale (Potash, Bardot & Ho, 2012). Building Relationships A prime consideration in international art therapy is how to frame the relationships between cross-cultural partners to ensure sustainability. Art therapists are required to “avoid ambiguity in the therapeutic relationship” (AATA, Principle 1.3) by establishing clear boundaries in relation to beginnings and endings. Unlike art therapy practice undertaken in one’s home country, international work is often characterized by short-term contact, either oneoff or structured through repeated visits with large breaks between. The nature of the relationship between the hosts and visitors should be clearly and collaboratively established, including both what happens while visiting art therapists are in the host country as well as what happens once the visit has ended or between visits. An honest discussion of reasonable objectives, goals, and potential outcomes is essential. Close collaboration with local professionals or community leaders (AATA, Principle 6.4) helps ensure that art therapists provide high quality, site-specific, culturally informed, and locally supported services. To establish the tenor for ongoing international collaborations Moon (2013) suggests honoring the principles of reflexivity (taking into account one’s assumptions and privilege), power sharing (working from the basis of hosts’ and visitors’ mutual expertise), cultural relevance (privileging local perspectives and expertise), and openness (maintaining interest and curiosity while suspending judgment). Engaging in the Work Cross-cultural international art therapy includes: direct service, relief work, training, and consultation/supervision. Direct service refers to visitors providing art therapy to individuals in

Ethics International Art Therapy p. 13 the host community. It is imperative to work with local partners to develop context-sensitive and responsive services, and to establish a plan for what will happen when the visiting art therapists leave. Determining clear goals for the work can be accomplished through discussion and artsbased explorations with local community partners, and can lead to co-creating positive, constructive, resiliency-based arts engagement opportunities. In brief cross-cultural work, being embedded in local programs or working from a community studio model is often preferable to initiating clinical work. A studio model provides flexibility and helps to normalize a situation in which ongoing uncertainty is ever-present (Czamanski-Cohen, 2010) and may be more acceptable or useful in a given cultural context (Kalmanowitz & Ho, 2016; Kalmanowitz & Lloyd, 2011). An art psychotherapy approach, in contrast, is potentially harmful if time with participants is inadequate for developing rapport, working on issues, terminating responsibly, and establishing links to other services for follow-up care. Relief work is a specific form of direct service that occurs in the context of trauma following a natural disaster such as earthquakes, floods, or disease, or political violence including war, terrorism, or civil conflict. Such work is particularly challenging when traumatic events are massive, ongoing, and multigenerational. It is important to balance the urgent need for assistance with the ethical responsibility to adequately understand the community’s historical relationship and response to traumatic incidents (Kira, 2010; Makhashvili et al., 2010). Although traumatic incidents are a universal phenomenon, conceptualizing the causes, meanings, consequences, and means of recovering are culturally determined (Marsella, 2010). A Western-based understanding of trauma tends to pathologize and medicalize distress, and participation in mental health services may lead to stigmatization that destabilizes aspects of identity that are key to well-being and resilience (Trivedi, 2014). So-called symptoms are often

Ethics International Art Therapy p. 14 normal, understandable responses to overwhelming situations and effective means of coping (Goodman, 2015). Listening for the ways that local people and communities understand trauma and supporting their indigenous strategies for regaining equilibrium are key to a decolonizing approach to art therapy (Kalmanowitz & Ho, 2016; Miller-Graf, 2016; Stein & Illes, 2015). While theories and practices of trauma specific art therapy in HICs have been addressed (i.e. Chapman, 2014; Klorer, 2017; Malchiodi, 2014), there has been little research on the effectiveness of these approaches in LMICs. General principles of trauma informed care, such as collaboration, focusing on strengths, and emphasizing choice, control, and psychological safety are all consistent with commonly accepted ethical standards for global mental health practice. In addition, the creative arts therapies provide opportunities for connection with cultural traditions and rituals, which can reinforce collective resilience (van Westrhenen, Fritz, Oosthuizen, Lemont, Vermeer, & Kleber, 2017). Inviting survivors to tell their trauma stories, even through indirect art-based expression, may have negative effects. Studies with war-affected adolescents indicated future orientations and avoidance of dwelling on feelings correlated with better mental health outcomes (Wessells, 2017). Treatment involves not only addressing individual trauma, but also providing community-based resources for regenerating collective values, memories, social networks, routines, and self-healing processes. Goals associated with community arts events, spiritual ceremonies, community based care, and social enterprises can help to mobilize resources, support reengagement in daily functioning, and maximize well being (Huss, Kaufman, Avgar, & Shouker, 2015; Makhashvili et al., 2010). To maximize trauma responsiveness and sensitivity, it is important to be judicious in selecting the types of services to offer (Kalmanowitz, 2014). In the immediate aftermath of a

Ethics International Art Therapy p. 15 crisis, service recipients may require structure, order, and safety rather than psychotherapy. Those who are not in immediate danger may benefit from using art for expression, reflection, and meaning-making, while people in situations of ongoing threat may require multiple forms of treatment, such as psychological first aid, psycho-education and affect regulation strategies (Higson-Smith, 2013). A combination of expressive arts and integrated body-mind-spirit approaches has been found to be effective, particularly in helping individuals regulate physiological response, become more open to new information, address numerous losses, promote group cohesion, foster self-care strategies, and improve overall quality of life (Gordon, Staples, He & Atti, 2016; Ho, Potash, Lo & Wong, 2014; Kalmanowitz & Ho, 2016). When Bardot worked with refugees in Lebanon, addressing the multiple layers of trauma and loss required a variety of approaches – community work, art, movement, poetry, and drama. To make this practice sustainable, a collaborative approach included the relief workers, counselors, educators, and social workers, all who were refugees experiencing their own trauma responses. Training refers to visiting art therapists engaging with host collaborators in a reciprocal cross-cultural exchange to learn about therapeutic and healing applications of the arts. In countries that have yet to develop widely available art therapy educational or organizational structures, a focus on paraprofessional training can honor indigenous knowledge, methods, and pioneers of healing art practices while also acknowledging the advanced professionalism of the field in other parts of the world. Lay counselors who have received culturally responsive, context-specific training and supervision have helped fill gaps in LMICs where there is a severe shortage of mental health professionals, and have delivered effective mental health services resulting in symptom reduction (Miller-Graf, 2016; Woods-Jaeger, Kava, Akiba, Lucid, & Dorsey, 2010) and post-traumatic growth (Gregory & Prana, 2013). Nonprofessionals can

Ethics International Art Therapy p. 16 provide supportive listening, information, help with accessing services, strategies for self-care and wellness, and communal arts opportunities that foster social integration and collective empowerment (Wessells, 2017). One possible approach to paraprofessional therapeutic arts training is to identify universal aspects of art making, such as materials, themes, and interpretation, in order to determine how these aspects are understood and implemented within local therapeutic arts practices (Kalmanowitz & Potash, 2010). Built into this way of working is an acceptance of the art therapist’s impermanence in the community and the desire to help the host community achieve self-sufficiency (Moon, 2013). Co-teaching and collaborating with local providers helps ensure cultural competence and relevance. In addition to direct service and training, art therapists frequently offer consultation and supervision services to support existing programs. Consultation involves offering one’s views or expert opinions about program development, implementation, and evaluation, whereas supervision is offered to support, assist with problem-solving, and encourage ongoing learning in those previously trained. When working in the Sichuan province of China following an earthquake, Potash joined a team of creative arts therapists, one of who remained in the host community for a year following the initial training to offer guidance (Ho, et. al, 2012). Other members returned at regular intervals to provide supervision to teachers striving to incorporate expressive arts into their classrooms. Local constituents should be consulted when determining the type of art therapy offered and the potential long-term effects of foreign interventions. As a first step in exploring the development of therapeutic art programs for vulnerable children in East Africa, Moon visited art centers, mental health treatment programs, and other social service sites in Arusha, Tanzania to

Ethics International Art Therapy p. 17 talk with social workers, teachers, principals, artists, and other professionals who could inform her about the support structures already in place, the ways problems and potential solutions were locally understood, the capacity of community caregivers, and the role the arts played in relation to health and healing. These consultations resulted in shifting the proposed plan from building an art therapy center in Arusha to supporting the work of artists and other cultural workers in multiple sites across Tanzania and Kenya. The focus of the program since that time has been to identify and support indigenous therapeutic arts programs. The potential for harm in international projects should be critically evaluated both prior to their undertaking and throughout their implementation, given the art therapist’s outsider status and ambiguous responsibility to the local community. Conceivable harmful impacts include: performing work for free that undermines the local labor market, promoting dependency by ignoring local expertise and reinforcing the myth of Western superiority, performing services the community does not desire or need, offering services by unskilled or culturally uninformed volunteers who do unsatisfactory work and/or interfere with the progress of a project, doing work in hospitals or schools that would be prohibited in one’s home country (Guttentag, 2009), providing mental health services without sufficient follow-up, and offering art materials or processes that create interest and desire among host community members but that are not locally accessible once the project has been completed. Fair Trade Learning principles offer a set of ethical guidelines that may help art therapists avoid such harmful practices. These principles are relevant not only for study trips, but also for any global exchange “that prioritizes reciprocity in relationships through cooperative, crosscultural participation in learning, service, and civil society efforts” (Hartman, Paris & BlancheCohen, 2014, p. 109). Core priorities include “economic equity, equal partnership, mutual

Ethics International Art Therapy p. 18 learning, cooperative and positive social change, transparency, and sustainability” (p.110). The intent of the principles is to foster balanced benefits among visiting volunteers, sponsoring organizations, and host communities. Managing Art Materials, Products, and Studio Providing art materials, offering a reliable art studio, and maintaining the integrity of the resulting artwork are all integral to the work of art therapy and prompt ethical considerations. A culturally competent approach to art materials involves investigating the traditional arts practices and available art materials in the host community. When working with an ethnic minority group in China, Potash and Kalmanowitz (2012) discovered that even though Western art materials were readily available, cultural tradition dictated the nature of their use. For example, experimentation with drawing and sculpture did not necessarily extend to paint, which was used in more prescribed and conventional ways. Although the choice of art materials is often framed within therapeutic intentions, this choice also carries with it economic, relational, and environmental considerations (Hartman, Paris & Blanche-Cohen, 2014; Moon, 2010). Bringing materials from one’s home country may fulfill needs or desires of the host community and may also function as an expression of culturally appropriate gift giving. On the other hand, doing so can foster dependence, prevent recognition of local resources, and undercut income for local art material suppliers. Additionally, the question of sustainability is raised when materials are not locally available. When working in Guatemala, Napoli and her fellow service providers aimed to identify local, sustainable, accessible, and culturally respectful materials for community arts engagements. They incorporated the procurement of art supplies into the cross-cultural training experience by having visiting art therapy students shop for materials in local markets, relying on a budget that was

Ethics International Art Therapy p. 19 comparable with what would commonly be available to local community members. Art therapists may also rely on found objects and natural materials (Kalmanowitz & Lloyd, 2011). Even when sourced locally, art therapists should note the cultural meanings ascribed to potential art materials. In Guatemala, Napoli and her colleagues found markers, crayons, paper, paint, and colored pencils to be too expensive and not easily accessible in rural villages. Items from the market such as incense, corn, and beans were only appropriate for use in Mayan ceremonies and religious practices. After consultation with local community members, visiting art therapists learned to use regional raw materials such as wood, thin plant fibers, corn husks, local dyes, sawdust, weaving threads, and wax candles. In some countries, the use of art materials for non-utilitarian purposes is called into question because it implies an economic privilege that is incompatible with local needs and resources. Whether materials are local or foreign, traditional or unconventional, art therapists must also determine if there is adequate infrastructure for cleaning and disposal of art materials’ byproducts or excess. In areas with limited water supplies or waste management systems, many art materials may present environmental hazards (Moon, 2010). It is also important to be mindful of conserving resources by working with local collaborators to repurpose unused materials. Incorporating art modalities such as drama and movement, which do not rely on tangible materials, is a potential solution to a lack of material resources. Ethically, art therapists are obligated “to provide a safe, functional environment in which to offer art therapy services,” one that allows for privacy and confidentiality (AATA, Principle 1.8). The concept of private space implies a position of privilege that is embedded within individualistic societies. Not only may such spaces be unavailable, but they also may be undesirable in communities in which collective art practice is the norm.

Ethics International Art Therapy p. 20 Art therapists are expected to store and retain client “artwork, photographs or digital images” (AATA, Principle 4.7). Underlying this ethical principle are individualistic, capitalist values related to ownership, permanence, and storage. In international contexts, it is important to consider what will happen to the art produced and who will ultimately take ownership of it. In some contexts, there may be little expectation, desire, or opportunity to store finished artworks. For example, Lyonsmith and Moon recognized that it would be impractical to expect families in the Kibera slum of Nairobi to store art products in their homes, as the tiny dwellings were set up to prioritize basic needs such as sleeping and cooking food. In such situations, when individual and collective decisions at the local level determine what happens to the art, both ethical principles and respectful cross-cultural relationships are upheld. Developing Art Therapy Directives and Interpreting Artwork Art therapy, as informed by Western psychological constructs, places emphasis on using art for personal insight, self-expression, and problem solving. In international settings, it is important for art therapists to consider the burden such emphases may place on participants. Art pieces that represent the harsh realities of life may cause stress for families and the community. Efforts to understand local metaphors, idioms, and subject matter increase the likelihood that directives will be context-sensitive and that possible interpretations of artwork will be more closely aligned with the intentions of the maker. The Western-based assessment, “Draw a Person in the Rain,” is assumed to relate to stress, but this interpretation is dependent on an individual’s experience of rain (Graves, Jones & Kaplan, 2013). In an arid climate, rain can signify blessings (Potash & Doby-Copeland, 2011). Longstanding art therapy interpretations that equate psychological pain with drawing characteristics, or seemingly innocuous directives such as drawing one’s feelings, creating body outlines, or designing mandalas (Anderson, 2013;

Ethics International Art Therapy p. 21 Arrington, 2013; Chu, 2010; Liebmann, 2013) should be examined for cultural biases, values, and taboos. Art therapists can integrate cross-cultural symbol associations, culturally specific meanings, and social-political contexts in order to arrive at context sensitive interpretations that maintain host community narratives and consider the social construction of meaning (Huss, 2016; Huss, Nuttman-Shwartze & Altman, 2012),. Acquiring Consent and Authorization When possible, art therapists should secure written consent from participants in educational or therapeutic programs and their authorizations for documenting and photographing sessions and artwork. Written documents should be in the language of the local community. Informed consent for workshops, arts based projects, and trainings are intended to ensure that participants are fully aware of the identity of the professional or group involved, the intentions of the facilitator(s), the duration of the project, the aims of the program, and the benefits and outcomes they should expect as a result of participating. Local participants should also be made aware of whether they are working with students or professionals and of any benefits (financial, academic credit, etc.) the travelers will receive for facilitating or participating in a program. Authorizations for taking photographs of program participants and/or their artwork should explicitly state the purposes for which the photos will be used (documentation, publication, research, presentation, advertising, fund-raising, etc.). When circumstances allow, provisions can be made for photographs to be offered to the local community for their own use. If it is the tradition of the community, or if literacy is a problem, then verbal consent and authorization may suffice. In such circumstances, permission may be gained from recognized community leaders or by community consensus and documented by audio recording or by witnesses from the host community (Tindana, Kass, & Akweongo, 2006).

Ethics International Art Therapy p. 22 Accountability Art therapists’ accountability to multiple stakeholders can cause conflicts of interest due to the diverse agendas at play and the range of political, economic, and social capitol held by the stakeholders. Accountability in international work is demonstrated by fulfilling original agreements for service delivery and allocation of funds. Ideally, members of the host community are the ones who determine if project goals have been satisfactorily achieved. Honoring Stakeholders Throughout the international work experience, including pre-travel planning, in-country activities, and post-travel follow-up, art therapists are accountable to various groups of people who each have their own stake in the project. Art therapists have the ethical responsibilities of refraining from exploitation and being truthful in representing services and fees (AATA, Principles 11.2 and 11.4). Because expectations may vary widely among stakeholder groups and individuals, it is important to clarify program costs, goals, objectives, and anticipated outcomes. Being as clear and transparent as possible helps ensure that all stakeholders are treated with fairness, respect, and integrity. Stakeholders include local participants, foreign visitors, and sponsoring organizations from the host community and/or the visitors’ home country. Local collaborators might expect to gain skills and knowledge, increase financial support, gain local legitimacy through U.S.-based institutions, or develop or deepen international friendships and professional relationships. Art therapists who organize trips are accountable to visiting students and professionals whose expectations might include any of the following: being educated, providing direct service, sharing their knowledge and skills with other professionals or trainees, acquiring souvenirs or

Ethics International Art Therapy p. 23 mementos, taking part in cultural experiences, and making long-lasting connections with people from the host community. Trip organizers also might be accountable to educational institutions or non-profit organizations that sponsor and/or fund the trips, as well as organizations on the ground in the host country. These entities may have a range of expectations, such as trip documentation, program reports or evaluations, budget management, advancement of an organizational mission, revenue production, problem solving, fundraising, and research. Beyond project stakeholders, art therapists working internationally are accountable to the profession of art therapy, to represent it accurately and uphold its ethical principles. Further, there is a responsibility to represent one’s country well, as every international encounter is an opportunity for cross-cultural exchange. Evaluating and Reporting Accurate reporting to organizational stakeholders may require formal evaluation and documentation procedures. Culturally appropriate processes are most likely when visitors collaborate with stakeholders from the host community to identify the goals of the project, to create a set of program evaluation questions, and to revise evaluation procedures as needed. Aside from traditional reporting strategies, arts-based research methods can be embedded in evaluation methods to ensure that community voices retain a central position (Huss, Kaufman, Avgar & Shouker, 2015). Hamilton and her colleagues in Cambodia worked with community partner agencies to develop a survey and end-of-project evaluation for project participants, local collaborators, and visitors. Even with this collaborative approach, there remained questions as to whether or not a survey was the most appropriate way to get feedback about the work. It became clear that the surveys overlooked cultural nuances and influential factors that would likely skew the data. The

Ethics International Art Therapy p. 24 feedback collected from various stakeholders has been used to make program adjustments, including developing more culturally appropriate evaluation measures. In follow-up reports, art therapists involved in international work are responsible for ensuring that anecdotes and images about the work are presented respectfully and fairly. Because such representations are not value neutral, they should be carefully analyzed prior to use. Analysis helps to reveal potential underlying dominant narratives and media stereotypes that essentialize host cultures as inherently different, exotic, unchanged over time, or inferior and that perpetuate historical and structural power inequities. Images and discourses that serve to entrench binary stereotypes about people in need (passive, disadvantaged, exoticized, backward, victimized) and people who are needed (agentic, advantaged, normative, progressive, heroic) have no place in reporting on or promoting projects, whether through formal accounts or through informal sharing via casual in-person contacts or social media. Fair, honest, and respectful representation occurs when host communities and cultures are presented as complex, multifaceted, evolving, dynamic, and globally interconnected (Caton & Santos, 2009). Acquiring Funding The costs of traveling abroad can be high, which leads many to seek funding for travel expenses and remuneration for services delivered through institutional grants or private donations. It is common practice to show photographs or describe anecdotes aimed at enhancing the viewer’s emotional response as a means of raising funds. Unfortunately, products of art therapy are sometimes used for this purpose, flattening complex narratives into marketable images and stories of suffering, victimization, and helplessness (Edmondson, 2005). Not only are art therapists ethically obligated to obtain permission to discuss projects and show photographs of participants and artwork but, also, as noted above, photographs and stories should

Ethics International Art Therapy p. 25 be presented in a way that is honest and that does not exploit or sensationalize participants or unduly influence potential funders. Selling participants’ artwork needs to be done with considerable caution, taking into account whether the art was made for the purposes of selling or for therapeutic expression. Profit-sharing arrangements should be carefully discussed with the host communities and potential funders made aware of how their monies will be used, whether for direct programming, art supplies, incidentals, training, or travel Conclusion In this paper, we propose ethical considerations and guidelines for providing art therapy services internationally. Preparing for travel allows for increased self-awareness, development of cultural knowledge, and consideration of how one will be perceived as an international worker. When delivering services, art therapists carefully determine the kind of work needed and how to best support the host community while honoring art therapy values and practices. Accountability to multiple stakeholders through honest collaboration, reporting, and fundraising is crucial. As the field of art therapy expands and international collaboration becomes increasingly accessible and commonplace, it is crucial that art therapists develop ethically grounded and intentionally focused cross-cultural practices. There are inherent tensions between the roles of expert and collaborator, as well as between adherence to home and host community values. Rather than providing universal best practices, ethical guidelines reinforce the need for continuous critical thinking to ensure that art therapy is delivered with the utmost integrity. Acknowledgements

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