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

To appear in: The Arts in Psychotherapy

Received date: 11-12-2016

Revised date: 17-5-2017
Accepted date: 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

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 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, jpotash@gwu.edu
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, hbardot@gwu.edu
Catherine Hyland Moon, MA, ATR-BC
Art Therapy Department, School of the Art Institute of Chicago, 37 S. Wabash, Chicago, IL
60603, cmoon@saic.edu
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, michelle_harris01@williamjames.edu
Angela Lyonsmith, MAAT, ATR-BC
Art Therapy Department, School of the Art Institute of Chicago, Gather, 602 Davis
Evanston, IL 60201, alyonsmith@gmail.com
Megan Hamilton, MA, LPCA
Birch Counseling, 3325 Durham-Chapel Hill Blvd, Suite 205, Durham, NC 27707,
meg.hamilton@birchcounselingdurham.com
Corresponding Author:
Catherine Hyland Moon, MA, ATR-BC
Art Therapy Department, School of the Art Institute of Chicago, 37 S. Wabash, Chicago, IL
60603, cmoon@saic.edu
Editor’s Note:
This paper was developed from a panel delivered by the authors titled “Conducting Cross-
Cultural 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:

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

 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 cross-

cultural 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), non-

maleficence (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 self-

awareness, 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 de-

centering 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 one-

off 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 arts-

based 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, cross-

cultural participation in learning, service, and civil society efforts” (Hartman, Paris & Blanche-

Cohen, 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, multi-

faceted, 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
 Ethics International Art Therapy p. 26

The authors would like to acknowledge the many collaborators involved in the programs

and projects discussed within this article.

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