Expressive Therapies Continuum

Distinctive in its application as a foundational theory in the field of art therapy, this
up-to-date second edition demonstrates how the Expressive Therapies Continuum
provides a framework for the organization of assessment information, the formulation
of treatment goals, and the planning of art therapy interventions.
In addition to the newest research supporting the uses of art in therapy, this volume
offers the latest research in media properties and material interaction, the role of neuro-
science in art therapy, emotion regulation, and assessment with the Expressive Therapies
Continuum. It provides case studies to enliven the information and offers practical sug-
gestions for using art in many and varied therapeutic ways.
Through rich clinical detail and numerous case examples, this book’s easy-to-use
format and effectiveness in teaching history and application make it an essential refer-
ence for practitioners and students alike.

Lisa D. Hinz, PhD, ATR-BC, is an adjunct professor of art therapy at Notre Dame de
Namur University, a consultant to the Residential Lifestyle Medicine program at Adventist
Health Napa Valley Hospital, and in private practice. She is the author of three books on
art therapy.
Expressive Therapies Continuum

A Framework for Using Art in Therapy

Second Edition

Lisa D. Hinz
Second edition published 2020
by Routledge
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been asserted by her in accordance with sections 77 and 78 of the
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First edition published by Routledge 2009
Library of Congress Cataloging-in-Publication Data
Names: Hinz, Lisa D., author.
Title: Expressive therapies continuum : a framework for using art in
therapy / Lisa D. Hinz.
Description: 2nd edition. | New York, NY : Routledge, 2019. |
Includes bibliographical references and index.
Identifiers: LCCN 2019017842 (print) | LCCN 2019018241 (ebook) |
ISBN 9780429299339 (E-book) | ISBN 9781138489714 (hardback) |
ISBN 9780367280420 (pbk.) | ISBN 9780429299339 (ebk)
Subjects: | MESH: Art Therapy—methods | Models, Psychological
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Dedication

The second edition of this book is still affectionately and gratefully

dedicated to Vija Bergs Lusebrink, PhD, ATR, HLM, Professor
Emerita. She carefully read each chapter of this book as it was finished
and offered advice and encouragement; her thoughtful comments
honed my thinking and greatly enriched my work. Vija’s support
sustained me during the eighteen-month-long odyssey of research and
writing that it took to complete this endeavor. She has inspired me,
taught me, encouraged me, challenged me, supported me, questioned
me, and always believed in me. I am proud to have written this book
that honors Vija’s creation, along with Sandra Graves-Alcorn,
The Expressive Therapies Continuum.
Contents

List of Plates xiv

List of Figures xv
List of Tables xvii
Foreword by Vija B. Lusebrink xviii
Preface to the First Edition xx
Preface to the Second Edition xxii

PART I
Historical Perspectives and Foundations 1

1 Overview of the Expressive Therapies Continuum 3

Introduction 3
The Expressive Therapies Continuum at First Glance 4
A Developmental Hierarchy 8
Kinesthetic/Sensory Level 8
Perceptual/Affective Level 8
Cognitive/Symbolic Level 9
Creative Level 10
A Reverse Developmental Hierarchy 10
Using the Expressive Therapies Continuum in Therapy 11
The Expressive Therapies Continuum Components at Work –
The Example of the Scribble Chase 12
The Expressive Therapies Continuum as a Foundational Theory 13
Unifying the Field of Art Therapy 14
The Rest of the Book 14

2 History and Evolution of the Expressive Therapies Continuum 16

Introduction 16
The Grandmother of the Expressive Therapies Continuum: Florence Cane 17
The Mother of Art Therapy: Margaret Naumburg 18
Art as Therapy: Edith Kramer 19
Creating Order out of Chaos: Elinor Ulman 20
The Value of Creative Learning: Viktor Lowenfeld 20
The Phenomenology of Expression: Mala Betensky 20
The Role of Gestalt Art Therapy: Janie Rhyne 21
viii Contents

Representing the World: Jerome Bruner 22

The Developmental Aspects of Image and Thought: Mardi Horowitz 22
Further Elaborations of the Expressive Therapies Continuum 23
Summary 24

3 Media Properties and Material Interaction 26

Introduction 26
The Therapeutic Effects of Media Properties and Task Instructions 26
Media Properties 27
Boundaries, Mediators, and Reflective Distance 31
Task Complexity and Task Structure 31
Novelty 32
Culturally Sensitive Art Materials 33
Unconventional Materials 33
Found Objects 33
Fiber Arts and Textiles 34
Digital Culture 34
Safeguarding Client Welfare When Using Art Materials 36
Summary 36

PART II
Characteristics of the Expressive Therapies Continuum
and its Components 39

4 Kinesthetic Component of the Expressive Therapies Continuum 41

Introduction to the Kinesthetic Component 41
Developmental Hierarchy 42
Embodied Learning and Cognition 43
Therapeutic Functions of the Kinesthetic Component 43
Examples of Kinesthetic Activities 44
Media Experiences that Enhance Kinesthetic Functioning 45
Reflective Distance with the Kinesthetic Component 46
Questions and Discussion that Promote Kinesthetic Functioning 46
Emergent Function of the Kinesthetic Component 46
When Work on the Kinesthetic Component is Indicated 47
Overcoming Blocks to the Use of Kinesthetic Functioning 47
Balancing Overuse of Kinesthetic Information Processing 48
Summary of Therapeutic Goals with the Kinesthetic Component 49
Case Example 50
Summary 54

5 Sensory Component of the Expressive Therapies Continuum 56

Introduction to the Sensory Component 56
Developmental Hierarchy 57
 Contents ix

Embodied Learning and Sensory Stimulation 58

Therapeutic Functions of the Sensory Component 58
Examples of Sensory Experiences 59
Media Experiences that Enhance Sensory Functioning 61
Reflective Distance with the Sensory Component 62
Questions and Discussion that Promote Sensory Information Processing 62
Emergent Function of the Sensory Component 63
When Work with the Sensory Component is Indicated 63
Overcoming Blocks to Sensory Functioning 64
Balancing Excessive Sensory Information Processing 65
Summary of Therapeutic Goals with the Sensory Component 66
Case Example 67
Summary 69

6 Perceptual Component of the Expressive Therapies Continuum 71

Introduction to the Perceptual Component 71
Developmental Hierarchy 72
The Importance of Good Gestalts 74
Therapeutic Functions of the Perceptual Component 74
Examples of Perceptual Experiences 75
Media Experiences that Enhance Perceptual Functioning 77
Reflective Distance with the Perceptual Component 77
Questions and Discussion that Promote Perceptual Information Processing 78
Emergent Function of the Perceptual Component 79
When Work with the Perceptual Component is Indicated 79
Overcoming Blocks to Perceptual Functioning 81
Balancing Excessive Perceptual Functioning 81
Summary of Therapeutic Goals with the Perceptual Component 82
Case Example 83
Summary 88

7 Affective Component of the Expressive Therapies Continuum 90

Introduction to the Affective Component 90
Developmental Hierarchy 91
Therapeutic Functions of the Affective Component 92
Examples of Affective Experiences 92
Media Experiences that Enhance Affective Functioning 93
Reflective Distance with the Affective Component 95
Questions and Discussion that Promote Affective Information Processing 95
Emergent Function of the Affective Component 96
Overcoming Blocks to Affective Information Processing 98
Balancing Overuse of Affective Functioning 100
Summary of Therapeutic Goals with the Affective Component 100
Case Example 100
Summary 104
x Contents

8 Cognitive Component of the Expressive Therapies Continuum 106

Introduction to the Cognitive Component 106
Developmental Hierarchy 106
Embodied Cognition 108
Therapeutic Functions of the Cognitive Component 108
Examples of Cognitive Experiences 110
Media Experiences to Enhance Cognitive Functioning 112
Reflective Distance with the Cognitive Component 112
Questions and Discussion that Promote Cognitive Information Processing 114
Emergent Function of the Cognitive Component 115
Overcoming Blocks to Cognitive Functioning 117
Balancing Overuse of Cognitive Functioning 117
Summary of Therapeutic Goals with the Cognitive Component 118
Case Example 119
Summary 121

9 Symbolic Component of the Expressive Therapies Continuum 123

Introduction to the Symbolic Component 123
Developmental Hierarchy 124
Therapeutic Functions of the Symbolic Component 124
Examples of Symbolic Experiences 125
Media Experiences to Enhance Symbolic Functioning 129
Reflective Distance with the Symbolic Component 130
Questions and Discussion that Promote Symbolic Information Processing 131
Emergent Function of the Symbolic Component 132
Overcoming Blocks to Symbolic Functioning 133
Balancing Overuse of Symbolic Functioning 135
Summary of Therapeutic Goals with the Symbolic Component 136
Case Example 136
Summary 139

10 Creative Level of the Expressive Therapies Continuum 141

Introduction to the Creative Level 141
Developmental Hierarchy 142
Embodied Creativity 142
Therapeutic Functions of the Creative Level 143
Media and Experiences to Enhance Creative Functioning 144
Reflective Distance with the Creative Level 147
Questions and Discussion that Promote Creative Information Processing 147
Emergent Function of the Creative Level 147
Overcoming Blocks to Creative Functioning 148
Understanding and Supporting Creative Functioning 150
Creativity, Flow, and Post-Traumatic Growth 152
The Creative Transition Areas of the Expressive Therapies Continuum 153
Kinesthetic/Sensory Level 153
 Contents xi

Perceptual/Affective Level 154

Cognitive/Symbolic Level 154
Summary of Therapeutic Goals with the Creative Level 155
Case Example 155
Summary 159

PART III
Assessment and Clinical Applications 161

11 Assessment Within the Structure of the Expressive

Therapies Continuum 163
Introduction to Art-Based Assessment 163
Assessment with the Expressive Therapies Continuum 164
Assessment of Client Functional Level on the Expressive Therapies Continuum 165
Information Gathered from Assessment Tasks 166
Elements of Art-Based Assessment Using the Expressive
Therapies Continuum Framework 167
Preferred Medium 167
Media Properties and Strength of Preference 167
Risk Taking 168
Manner of Interaction with Media 168
Responses to Limits and Boundaries 169
Commitment and Frustration Tolerance 169
Level of Energy 170
Coping Skills 170
Stylistic or Expressive Elements of the Final Art Product 170
Developmental Level 171
Line and Form Quality 171
Use of Space 171
Color Use 172
Neurological Indicators 172
Content and Symbolism 172
Organizing Functions 173
Verbal Communication 177
Quality of Verbal Comments 178
Rate and Volume of Speech 178
Logic Displayed 179
Structure of the Expressive Therapies Continuum Assessment 179
Case Example 181
Summary 182

12 Using the Expressive Therapies Continuum to Structure Therapeutic

Interventions with Individual Clients 183
Introduction to Therapeutic Intervention with the Expressive
Therapies Continuum 183
Formulating Treatment Goals Using the Expressive Therapies Continuum 184
xii Contents

Determining a Starting Place for Art Therapy 184

Establishing a Client–Therapist Partnership 185
Conceptualizing Treatment Guided by the Expressive
Therapies Continuum 186
Initiating Art-Based Treatment 186
Making Planned Therapeutic Changes 187
When to Change Component Processes 188
How to Change Component Processes or Levels 188
Changing Media Properties 188
Not Changing Media 189
Task Complexity and Task Structure 189
Questions and Discussion 191
Negotiating Unplanned Changes 191
Avoiding Non-Therapeutic Movement 192
Facilitating Termination 193
Working Through Therapeutic Obstacles 194
Summary 197

13 Using the Expressive Therapies Continuum to Structure Therapeutic

Interventions with Couples, Families, and Groups 198
Introduction 198
Conducting Group Therapy in the Expressive Therapies
Continuum Framework 199
Kinesthetic/Sensory Level 200
Perceptual/Affective Level 201
Cognitive/Symbolic Level 203
Individualizing Group Art Therapy Using the Expressive
Therapies Continuum 204
Termination of Group Art Therapy 205
The Expressive Therapies Continuum in Couples and Family Therapy 206
Kinesthetic/Sensory Level 207
Perceptual/Affective Level 207
Cognitive/Symbolic Level 210
Creative Level 211
Termination of Couples and Family Therapy 212
Summary 212

14 Aspects of the Therapeutic Relationship and the Expressive

Therapies Continuum 214
Introduction 214
The Therapeutic Alliance 214
The Therapeutic Relationship 215
Treatment Goals 215
Therapeutic Tasks 216
Summary 217
 Contents xiii

Transference and Countertransference and the Expressive Therapies Continuum 217

Transference 217
Countertransference 218
Preferences and Aversions 219
Dealing with Client Resistance: Suggestions from the ETC Framework 220
Cognitive/Symbolic Level 220
Perceptual/Affective Level 221
Kinesthetic/Sensory Level 221
Avoiding Therapeutic Errors 222
Cognitive/Symbolic Level 223
Perceptual/Affective Level 223
Kinesthetic/Sensory Level 224
Summary 224

15 The Intersection of Neuroscience and Art Therapy 225

Introduction to Art Therapy and Neuroscience 225
Neuroscience and the Expressive Therapies Continuum 227
Expressive Therapies Continuum and Large-Scale Brain Networks 230
Introduction 230
Large-Scale Brain Networks in Cognition 230
Central-Executive Network 230
Default Mode Network 231
Salience Network 231
Organization of Large-Scale Brain Networks in Cognition
and Creativity 232
Developmental, Connective, and Compensatory Aspects
of LSBN 233
Case Study 233
Summary 236

Appendix A 237
References 240
Index 271
Plates

1 “Compassion” painting created through digital software on a tablet

2 Art expression with the Affective component: The use of art can aid the expression
of emotion
3 Mood/states mind/states activity demonstrates how emotions with similar
physiological substrates are confused with one another; Anger (top) is
confused with Excitement (bottom)
4 Final image symbolically depicting change in self-image from conduit to container
and movement from Cognitive to Symbolic component
5 Perceptual/Affective interplay demonstrated through finding form
in wet paint
6 Perceptual/Affective interplay demonstrated through finding form in
wet paint
7 Perceptual/Affective Creative Transition Area. Painting from the
inside out and the outside in: experiencing expansion and control
8 Collage of words demonstrates a preference for Cognitive component functioning
9 “Storm in the Night” painting dominated by a looming form, dark colors,
and dynamic outlines demonstrates Affective component functioning
10 Abstract family collage demonstrates enmeshed family relationships
11 “Be Curious” collage shows preference for Cognitive component
functioning
12 Jessica’s self-portrait
13 Jessica’s image of “How I See Myself”
14 Jessica’s image of “How Others See Me”
15 Jessica’s image of “How I Feel Right Now”
16 Jessica’s final image in therapy: “Heart Matters”
Figures

1.1 The Expressive Therapies Continuum (Figure reprinted with

permission of the American Art Therapy Association from Hinz, L. D.
(2008). Walking the line between passion and caution: using the
Expressive Therapies Continuum to avoid therapist errors, Art Therapy,
25(1), 38–40) 5
1.2 Rubin’s vase demonstrates “representational diversity.” A figure can be
viewed in two ways 9
3.1 Media properties from resistive/cognitive to fluid/affective 27
4.1 “The Fight” dot-to-dot drawing shows movement from the Kinesthetic
component to the Perceptual component 51
4.2 “Racecourse stoplights” free drawing showing functioning
with Symbolic component 53
5.1 Sensory exploration drawings: pictures drawn before (left) and
after (right) sensory exploration of pinecones with eyes closed 60
5.2 Dryer lint and devil: sensory experiences evoke affective expression 68
6.1 Schematic drawing. A triangle is a visual shortcut or schema for a skirt 72
6.2 Schematic mermaid. Children who easily master schema branch out
to draw related images 73
6.3 An adolescent girl’s Perceptual representation of her anger being
“let out of the box” 76
6.4/5 Information processing with the Affective component shows that
Affect distorts form 84
6.6 Changing point of view exercise – original image 86
6.7 Changing point of view exercise – close-up view image 86
6.8 Changing point of view exercise – bird’s eye view image 87
7.1 Four primary emotions activity helps discriminate emotions.
Beginning in the upper left and continuing clockwise, the emotions
depicted are: Happy, Anxious, Sad, Angry 97
7.2 Art expression with the Affective component: journaling can help
contain emotional expression 99
7.3 A collage of various emotions 102
7.4 Art expression with the Affective component: free art expression
leading to the realization of the relationship between stress
and physical symptoms 103
xvi Figures

8.1 “I am powerful” cognitive art experience demonstrating assertiveness 109

8.2 Abstract family collage. Abstract images can create increased reflective
distance and lessen affective involvement in the artistic experience 113
8.3 “Mountain out of a molehill” example of problem-solving collage 116
8.4 Painting by a 10-year-old girl suffering from obsessive-compulsive
disorder shows regression to compulsive behavior with the use of paint 121
9.1 Dream image shows emotional energy pulling client in many directions 127
9.2 Second dream image shows emotional energy contained
within a ball/mandala 128
9.3 Client confronts implicit bias through self-portrait collage 133
9.4 Achromatic, diagrammatic images demonstrate cognitive orientation 137
10.1 Collage facilitates creative problem finding or problem identification 151
10.2 “I of the Storm” movement to the Cognitive/Symbolic level through
establishing a title for the painting 157
10.3 A 3D representation of “I of the Storm” aids in actualizing
creative potential 158
10.4 The 3D representation integrates a new way of seeing the self:
emotional freedom 158
12.1 Extreme emotion causes regression to the scribble stage 190
12.2 “Hero collage” helps contain emotion 190
12.3 Cartooning aids learning of appropriate problem-solving and social skills 195
12.4 “I’m blue.” A perceptual manifestation of feeling often is acceptable
as an initial therapeutic intervention 196
13.1 Graphic perception – husband 208
13.2 Graphic perception – wife 209
15.1 “My Cat” watercolor painting, Jessica’s first image in art therapy 234
Tables

3.1 Complexity and Structure of Task Instructions as Related to Art

Project Outcome 32
4.1 Examples of Kinesthetic Activities and Associated Therapeutic and
Emergent Functions 55
5.1 Examples of Sensory Activities and Associated Therapeutic and Emergent
Functions 70
6.1 Example of Art Assessment Demonstrating Preferred ETC
Component Process 85
6.2 Examples of Perceptual Experiences and Associated Therapeutic
and Emergent Functions 89
7.1 Examples of Affective Experiences and Associated Therapeutic
and Emergent Functions 105
8.1 Examples of Cognitive Experiences and Associated Therapeutic
and Emergent Functions 122
9.1 Symbolic Component Experiences and Associated Therapeutic
and Emergent Functions 140
11.1 ETC Assessment Form 167
11.2 Predominant Characteristics of Visual Expressions on Different
Levels of the Expressive Therapies Continuum 174
11.3 ETC Component Assessment Form 180
11.4 Assessment of Preferred Component of Expressive Therapies
Component by 15-Year-Old Latina Female Client 182
12.1 Using the Framework of the ETC to Identify Therapeutic
Obstacles and Strategies to Overcome Them 195
Foreword

It has been 30 years since the theoretical concept of the Expressive Therapies Continuum
(ETC) was published in Art Psychotherapy in 1978. The ETC synthesizes and summarizes
the essential steps involved in the visual expression, processing of information, and crea-
tive integration with a focus on the different applications of the basic tools specific to
art therapy, namely art media. The ETC incorporates many concepts of art therapy, but
it does not emphasize any specific approach to psychotherapy or art therapy. When this
concept was first presented at the 9th Annual Conference of the American Art Therapy
Association in 1978, some of the audience were questioning how this concept fit within
the existing framework of art therapy, since it introduced a different way of applying art
therapy. The first introduction of ETC may have been too dense and too complex in the
information presented, but the basic elements of ETC were soundly based on knowledge
of the development of mental imagery available at that time. In 1990, I tried to elaborate
on the different levels of the ETC in my book Imagery and Visual Expression in Therapy, but
the text was still judged as too condensed. Over the years, though, the basic concept of
ETC has continued to be supported by increased knowledge in information processing
and brain processes (Lusebrink, 2004).
With her book, The Expressive Therapies Continuum: A Framework for Using Art in
Therapy, Dr. Lisa Hinz provides a much-needed elaboration of ETC, its different levels
of visual expression, and application of art media in individual, group, and family art
therapy. Dr. Hinz combines her knowledge and training as both a clinical psychologist
and art therapist, with many references to current art therapy and clinical psychol-
ogy literature, illustrated with case examples from her own clinical experience. Her
book elaborates on the different levels of ETC and explores in depth their different
clinical applications. In her approach to art therapy, based on the concept of ETC,
Dr. Hinz uses nondirective approach to art expressions in the assessment phase of art
therapy followed by directions to the use of different media on different levels of ETC.
Her case examples illustrate that different clients may start out using different media
on different levels of ETC, depending on their preferences, whereas the explorations
and enhancement of the expressions and information processing on different levels of
ETC can be influenced by a directed change in art media. The strength of Dr. Hinz’s
presentation lies in the clarity of her writing and systematically organized approach to
the applications of each level of ETC. Her approach renders the concept of ETC easily
comprehensible and applicable, elaborated with informative tables at the end of each
chapter. For those readers who may wonder about the diverse strands of knowledge
and approaches to art therapy incorporated into the concept of ETC, Dr. Hinz provides
historical the background information in her Chapter 2.
 Foreword xix

Lastly, but not least, the ETC was conceptualized as reflecting the parts innate spe-
cifically to art therapy, based on the understanding of the underlying principles of the
development of mental imagery, processing of information, and integrative power of
creativity. Certain theoretical approaches to art therapy would seem to be more compat-
ible with some of the levels of ETC than others, but the concept is applicable regardless
of the practitioner’s personal theoretical preference for a specific approach to therapy.
Art expressions are multileveled, and they deserve acknowledgment of the different pro-
cesses involved in their creation. Dr. Hinz has been able to present her own view of the
ETC, honoring the multileveled nature of visual expressions.
Dr. Hinz’s book offers a new and informed look on ETC, including rich resources
from art therapy and clinical psychology literature for practitioners and students alike.

Vija B. Lusebrink, PhD ATR, HLM, Professor Emerita

April 2008, Palo Alto, CA
Preface to the First Edition

As a student in a clinical psychology graduate program in the early 1980s, I was trained
in behavior modification techniques and cognitive behavioral therapy. Learning these
approaches to psychotherapy affected me in two ways. First, the orientation led me to
believe that control of emotions was a worthy goal. From this perspective, I deduced
that I should be able to provide clients orderly formulas with which they could improve
their mood; yet I often felt uncomfortable telling clients what to do. Second, I felt these
approaches frequently left clients wanting more. Many craved not just behavioral change
but a deeper self-understanding.
In addition, behavioral approaches did not seem appropriate for those who were
grieving significant losses. Nor did they appeal to clients who spoke a metaphorical
language – those with visual, symbolic, or poetic orientations to life. As I went through
my schooling, I learned that there was no “objective evidence” for psychoanalytic theo-
ries, but I often wondered, “Could everything that Freud said about the unconscious be
wrong? Does nothing that Jung said about archetypes and symbolism remain relevant?”
I sought out experiences to appease my curiosity and supplement my education. Most
of these experiences were independent readings, but I also found a professor who was
willing to teach projective personality testing.
This interest led me to another professor who had been hired by a local community
to study the psychological effects on children of a toxic chemical spill caused by a train
derailment. The professor chose to assess the children using the human figure draw-
ing and Koppitz’s (1968) scoring for emotional indicators. The children were given two
sheets of paper in random order: one containing a pre-drawn train track and “chemical
spill” and the other containing cross-hatching in no particular pattern. All children drew
two human figures, one on each paper, and served as their own controls. The papers
containing the railroad track and chemical spill elicited human figure drawings with
significantly more emotional indicators than the standard human figure drawing. The
community used the study results to win a class action lawsuit to fund counseling services
for children who had been displaced from their homes and whose lives had been severely
disrupted by the toxic chemical spill (Siegel, Gottfried, & Lowe, 1988).
Like the judges who presided over the lawsuit, I too was convinced of the power of
drawings to help children express pain they could not articulate. Subsequently, I was
ready and willing to supervise an art therapy intern during my first professional position.
The counseling center at the University of Louisville had not previously supervised art
therapy interns because the director had not studied art therapy. However, based on my
past interest in projective drawings, I wanted to find out more about the field.
As I began my supervisory duties, I also was seeing 25–35 clients per week individually
and in groups. I was trying my best to help them shape their behaviors and moods with
 Preface to the First Edition xxi

cognitive behavioral therapies. I wanted to provide formulas and answers for my clients,
but often felt such answers fell short of meeting clients’ needs or were rejected outright.
Meanwhile, I was witnessing, while observing and supervising the art therapy intern, how
images often held truths that clients provided for themselves. Their own image answers were
not rejected, but rather regarded with reverence as they revealed the clients’ own inner
wisdom. Images provided a vehicle for the metaphorical language that appealed to so
many. Images helped clients understand, express, contain, and soothe emotions. Images
also could be used behaviorally or cognitively, and they could aid in tracking client growth
and progress in therapy.
Images provided a way to address clients for whom the behavioral approach fell short.
I watched with growing respect as the intern provided various media and experiences
that regularly gave her clients the emotional, cognitive, or behavioral information they
needed. How did she know what to do and when? Each experience, different from the
one before it, seemed to provide and evoke what the client required from therapy at
the time. From my observations, I was impressed with the flexibility and power of art
therapy, but I knew that there was so much more that I needed to learn. I wanted to
know how and when to use certain media, how to decide what experiences would be
beneficial, and the best ways to approach clients using art. I joined an art therapy group
in which I experienced firsthand the healing power of art. I enrolled in the University
of Louisville graduate art therapy program. There I had the privilege of being taught by
Vija Lusebrink and Sandra Kagin Graves, the two creators of the Expressive Therapies
Continuum (Kagin and Lusebrink, 1978a, 1978b).
The Expressive Therapies Continuum provided an organizing structure for the art
therapy information that previously had seemed so powerful and mysterious to me. It
gave form to my thoughts and feelings about this new mode of therapy I was learning. The
Expressive Therapies Continuum helped explain how art media could be used in so many
ways – from behavioral to symbolic, affective to cognitive. It provided a framework for
approaching the what, when, and why of what to do in art therapy. From the perspective
of the Expressive Therapies Continuum, I had a method of assessing client preferences
and needs, as well as determining directions for therapy. I had a structure, but I did not
have to impose it on anyone; clients provided their own answers through their creative
experiences and images. This approach to therapy felt informed and respectful. I did
not have to be the expert with all of the answers. I knew that the clients held the answers
to their questions and challenges and that art gave them a vehicle for uncovering them.
It is my desire that this book about the Expressive Therapies Continuum will honor its
creators, as well as integrate, expand, and enrich the body of knowledge already available
on the subject. Dr. Lusebrink’s book Imagery and Visual Expression in Therapy has been
out of print for several years. I have long thought that the concepts of the ETC needed
to be presented in a new format to emphasize to readers that there is an effective way to
structure the sometimes confusing, but always powerful ways in which art media and expe-
riences can heal. Embrace the Expressive Therapies Continuum just as you “embrace the
mystery” of art and its symbols (Moon, 1992). Trust the ETC just as you “trust the process”
of creating art (McNiff, 1998).
Preface to the Second Edition

I had been thinking about updating this book for a year or so when the editorial staff
at the Routledge/Taylor Francis Group contacted me about it. Ten years seemed like
a good interval for publishing a second edition: a decade’s worth of new research must
be considered for its impact on the theory of the Expressive Therapies Continuum. In
writing this second edition, I had to ask myself, is there more support and/or greater
challenges for the model? Enough time had elapsed for people to implement the the-
oretical framework and contact me with questions and concerns; those needed to be
included in further writing about the Expressive Therapies Continuum. The book has
been augmented with three new chapters that consider the past and the foundations of
the field (media and material interactions), the importance of the immediate therapeutic
concerns (the therapeutic relationship), and the future of the field (the integration of art
therapy and neuroscience).
This new edition updates the research support confirming the usefulness of this
foundational theory for using art in therapy. Since the publication of the first edition of
this book in 2009, the educational standards for accredited art therapy programs were
updated and specifically mention the ETC as one example of a necessary category of
information to be mastered by aspiring art therapists. Under Content Area C: Materials and
Techniques of Art Therapy Practice, one area of essential knowledge in which competency
must be obtained is defined as, “Describe theory of specific properties and effects of art
processes and materials informed by current research such as (the) Expressive Therapies
Continuum” (American Art Therapy Association, 2017, p. 16). This is remarkable rec-
ognition for a theory that was denigrated when it was first published and presented 40
years ago (see original Foreword to this book). Drs. Graves-Alcorn (formerly Kagin) and
Lusebrink were ahead of their time, but it seems that the profession of art therapy has
caught up and now can appreciate the ETC as a foundational theory.
The new edition of this book contains an expanded history of the Expressive Therapies
Continuum in Chapter 2 which helps define the numerous and varied influences that
Kagin and Lusebrink (1978a) considered and incorporated in their broad theory of the
ways in which art media and task instructions (Media Dimension Variables) affect the
process of art therapy. Chapter 3 is new to the second edition and emphasizes media
and material interaction as the tools of our trade. This chapter is meant to bring added
attention to Media Dimension Variables as the elements of art therapy practice that we
can manipulate in research to help determine which art materials and task instructions
work best for what types of clients, under what circumstances (Hinz, 2016b). Based on
clinical experiences and many research studies, art therapists know that art therapy is an
effective treatment for many disorders and a powerful tool for enhancing quality of life
(Hinz, 2016a). It is now time to refine art therapy methods to answer vital questions
about these powerful interventions.
 Preface to the Second Edition xxiii

Chapters 4 through 10 have been updated to include recent evidence for the effective-
ness of each Expressive Therapies Continuum component in eliciting the therapeutic
and emergent functions attributed to them. Also new in these chapters is information
about embodied cognition and embodied learning and the ability of art therapy to
enlist these powerful physical attributes to enhance the therapeutic experience. This
content area reinforces the fact that the ETC components are not separate information
processing activities that operate in isolation from one another, but complementary
processes that are inclusive and progressive. Chapter 11 was revised to include new
information about ETC assessment and refers readers to new forms to record and con-
sider assessment results.
Chapters 12 and 13 cover material related to using the theoretical model of the
Expressive Therapies Continuum to guide treatment efforts for individuals, couples, fam-
ilies, and groups. These chapters have been updated with the latest art therapy research
supporting the powerful treatments considered. Chapter 14 is new to this edition of
the book and addresses one of the concerns that I have encountered when conducting
presentations about the ETC. Around the world art therapy students, practitioners, and
professors have asked me to address the therapeutic relationship and the ETC. Therefore,
a second edition of this book would not be complete without a comprehensive answer to
the question of how the therapeutic relationship is considered in this theoretical model.
Finally, the new chapter on neuroscience and the ETC speaks to the future of this frame-
work and the field of art therapy. The field will always be rooted in the art media and
art processes, but we will continue to learn more about the ways that creative expression
changes the brain through collaborative efforts in the field of neuroscience.
Part I

Historical Perspectives and

Foundations
Chapter 1

Overview of the Expressive

Therapies Continuum

Introduction
Every therapist who uses art in therapy faces decisions when working with clients simi-
lar to those of an artist facing a blank canvas or an unformed lump of clay. These are
questions such as: How do I begin – how do I break into that inviting yet intimidating
untouched surface? What direction shall I take – how can I make the best possible use of
time and resources? And, how do I decide when the process is complete? There are no
hard and fast rules in art or in art therapy, and no easy answers to these and other ques-
tions. This book demonstrates that the model of the Expressive Therapies Continuum
(ETC) can provide a framework for addressing these and other difficult therapeutic
decisions. Just as the muse inspires the artist but does not dictate, the ETC animates and
directs, but does not command or require a specific course of treatment. The organizing
structure of the ETC is underscored by an understanding that working with the complex
nature of the human psyche requires great latitude for individual differences.
The art therapy literature demonstrates that various media and methods work effec-
tively with a variety of clients, whether they present in similar or different ways. For
instance, Cox and Price (1990) in their twelve-step approach to working with substance
use disorder used tempera paint on paper to break down resistance and help clients rec-
ognize their powerlessness. The authors chose to work with paint because it is difficult
to control, and they wanted the art experience to reflect the concept of unmanageability
from the first step of the Alcoholics Anonymous twelve-step recovery program. In a less
emotional and more cognitive approach to the disorder, Horay (2006) used collage and
oil pastels to help clients evaluate the pros and cons of their current situation, determine
feeling states, and plan a future course of action. Feen-Calligan (1995) used art therapy
in an addiction recovery program to help participants experience the spiritual aspects
of their journey. The author described using drawing with the eyes closed, drawing
with the non-dominant hand, and translating physical gestures in the air into drawings
on paper. Feen-Calligan used these experiences to help clients give up notions of how
images should look and instead allow the healing images to come intuitively from within.
Each practitioner mentioned above was using art in therapy to help clients with similar
presenting problems. However, the different media and approaches evoked decidedly
different therapeutic experiences.
Answering the question of how to decide the appropriate media for clients and under
what circumstances their use will be therapeutic has been one crucial aspect involved in
defining the field of art therapy (Junge, 2016; Malchiodi, 2012c; Wadeson, 2010). Wadeson
stated that students often ask to be taught a list of specific techniques. She explained that
what is more desirable than isolated descriptions of techniques is a theoretical framework
4 Historical Perspectives and Foundations

from which to select appropriate materials and methods. Ulman (1975a) added that not
only is a theoretical foundation necessary, but also that it should be so well ingrained
that it can inform the “lightning quick decisions” that characterize therapeutic work. The
model of the Expressive Therapies Continuum, developed by Kagin (now Graves-Alcorn)
and Lusebrink (1978a, 1978b) and further elaborated by Lusebrink (1990, 1991b, 2004,
2010, 2014, 2016; Lusebrink, Mārtinsone, & Dzilna-Šilova, 2013) provides such a frame-
work; it explains the therapeutic dimensions of various expressive experiences and the
restorative power of creativity. This is a theoretical and practical guide, which provides
a way to answer questions about what media to use, under what circumstances, and with
which particular clients. In addition, because the ETC has a comprehensible visual struc-
ture, which is presented in Figure 1.1; it can easily be internalized by visually-oriented
practitioners to provide needed guidance for moment-to-moment therapeutic decisions.

The Expressive Therapies Continuum at First Glance

The Expressive Therapies Continuum represents a means to classify how clients inter-
act with art media or other experiential activities in order to process information and
form images (Kagin & Lusebrink, 1978b; Lusebrink, 1990, 2016). The ETC organizes
media interactions into a developmental sequence of information processing and image
formation from simple to complex. Image formation and information processing are
categorized in a hierarchical fashion from simple kinesthetic experiences at one end to
complex symbolic images at the other. The ETC is arranged in four levels of increasingly
complex processing. The first three levels are bipolar or complementary, as shown in
Figure 1.1. The two components on each of these first three bipolar levels represent two
ends of a continuum of information processing. The extreme ends of each level represent
possible pathological variations in visual expression on that level (Lusebrink, 2016). The
fourth level, the Creative level, can occur with any single component or level of the ETC
where it represents optimal functioning, or can represent the integration of functioning
of all components. Thus, a single and simple experiential activity has the power to be a
creative experience or may involve the combination of diverse experiences. Although it
is situated at the “top” of the ETC, reaching the Creative level is not the goal of or the
termination point in art therapy. Art therapists hope that their clients have creative and
enriching experiences during the majority of their art therapy sessions.
Starting at the bottom of Figure 1.1, information processing begins at the prever-
bal level with kinesthetic and sensory experiences, and thus is called the Kinesthetic/
Sensory Level (capital letters are used throughout the book to distinguish the Kinesthetic
and Sensory components of the ETC from other uses of the words). Information gath-
ered through these channels does not require words; it is rhythmic, tactile, and sensual.
Developmentally, this is the first way in which babies process information. Infants up to
the age of eighteen months take in information through their senses and receive feed-
back about their behavior predominately through their own movement, but also through
internal and external sensations. For this reason, experiences on the Kinesthetic/Sensory
level of the ETC are indispensable in therapeutic work with children. Children need to
physically manipulate and handle materials in order to form internal images of them
(Lusebrink, 1991a). The Kinesthetic/Sensory level of the ETC represents the simplest
form of information processing.
Moving up the developmental hierarchy, information processing and image formation
occur on the Perceptual/Affective Level. Information processing may or may not need
words at this level. It is beginning to take form or be absorbed in the creation of formed
 Overview of the ETC 5

Creative (Level)

(Left Hemisphere Brain Functions) (Right Hemisphere Brain Functions)

|

Cognitive < - - - - - - - - - - - - - - - - - - - - > Symbolic (Level)

(Component) (Component)
|

Perceptual < - - - - - - - - - - - - - - - - - - - > Affective (Level)

(Component) (Component)
|

Kinesthetic < - - - - - - - - - - - - - - - - - - - - > Sensory (Level)

(Component) (Component)

Figure 1.1 T
 he Expressive Therapies Continuum (Figure reprinted with permission of the American
Art Therapy Association from Hinz, L. D. (2008). Walking the line between passion and
caution: using the Expressive Therapies Continuum to avoid therapist errors, Art Therapy,
25(1), 38–40)

images on the Perceptual pole. Perceptually influenced images and expressions typically
are characterized by careful attention to the formal elements of visual expression. On the
Affective end of this level, information processing can be emotional and raw, expressed
in an image through vibrant colors without regard to form.
At the third level of the ETC, the functions represented are Cognitive and Symbolic.
Information processed on the Cognitive/Symbolic level of the ETC is complex and
sophisticated; it requires planning, cognitive action, and intuitive recognition. Verbal
input is often, but not always, required to gather meaning about the complex cognitive
operations or the multidimensional symbols involved on this level.
6 Historical Perspectives and Foundations

Although ETC components and levels are conceptualized and presented here as dis-
crete functions, it is at times difficult to provide pure experiences with one component.
Increasingly complex functioning at higher levels of the ETC often emerges from a cre-
ative endeavor and is referred to in this model as the emergent function (Lusebrink,
1990). The emergent function of each ETC component will be discussed in detail in later
chapters. In addition, experiences on lower levels of the ETC inform and are incorpo-
rated into experiences on higher levels.
The component processes represented on the left and right sides of the Expressive
Therapies Continuum can be seen as parallel with functioning and information process-
ing differences in the two hemispheres of the brain (Lusebrink, 2004, 2016). The left
hemisphere deals with information in an organized, sequential, and linear fashion. Verbal
information also is processed in the left hemisphere; it is where logical thought and the
labeling and categorizing of information occurs (Cozolino, 2017; McGilchrist, 2009).
The Kinesthetic, Perceptual, and Cognitive components representing the left-side of the
ETC are hypothesized as being involved with information processing predominately in
the left hemisphere. Similarly, the dimensions of the ETC represented on the right-side
of Figure 1.1 – the Sensory, Affective, and Symbolic components – can be viewed as repre-
senting processes occurring predominately in the right hemisphere of the brain. The right
hemisphere is where the majority of emotional and conceptual information is processed
and where spiritual connections are made (Edwards, 2012; Riley, 2004). Creative experi-
ences have the potential to integrate information from both hemispheres of the brain (Jung
et al., 2013; Riley, 2004; McNamee, 2004). The Creative level of the ETC is believed to
have an integrative function (Lusebrink, 1990).
Jill Bolte Taylor (2006) provided a profoundly personal explanation of the distinct func-
tions of the two hemispheres of the brain. Dr. Taylor is a neuroanatomist who suffered a
stroke that rendered the left-side of her brain nonfunctional. With only the right hemi-
sphere operating, the author said she experienced herself as at one with the world – awash
in sensations – emotional, expansive, and mute. The left hemisphere is the part of the
brain that holds language, organizes activity, and gives instructions. Dr. Taylor is a stained
glass artist, and she used the creative process as one integrative aspect in her rehabilitation
following the stroke. Through creative action, left and right hemisphere functions found
congruent and harmonious expression.
As was stated above, the Creative level of the Expressive Therapies Continuum can
exist at any or all of the levels. For example, finger-paint can be used in a soothing, sen-
sory manner to help an individual establish an inner sense of calm. With just the right
amounts of movement and sensation involved, this simple experience is a creative one;
an individual can bring forth something new (a relaxed state) as the result of the sensual
use of finger-paints. A sense of calm can be created without the formation of an external
image; the media experience itself can induce serenity.
Additionally, a creative experience could combine elements from all levels of the
Expressive Therapies Continuum. The same interaction with finger-paint might begin
as a simple sensory experience as described above and evolve into something integrative
and richly creative. As the fingers move paint around the paper, white lines are pro-
duced which allow forms to emerge from the background color. From an activity using
the Kinesthetic/Sensory level, an experience on the Perceptual dimension evolves when
forms are perceived. Further, the Symbolic component is engaged when a perceived form
takes on special meaning and a personal symbol is produced. In this instance, all levels of
the ETC are represented in one creative experience. This co-existence will be explained
in more detail when the Creative level of the ETC is discussed in Chapter 10.
 Overview of the ETC 7

The two components forming each level of the Expressive Therapies Continuum
have been described as having a curvilinear relationship in the form of an inverted-U
(Lusebrink, 1991b). Lusebrink explained this curvilinear relationship by stating that
opposite components of each level at first enhance the functioning of one another. When
both components of an ETC level are contributing optimally to an experience, expressive
functioning is most favorable. Lusebrink has termed this “creative transition functioning”
occurring in the Creative Transition Area (Lusebrink, 2016). In the Creative Transition
Area, functioning is optimized by the combined and interactive influences of both types
of input. For example, when both Kinesthetic and Sensory input guide an experience,
work in the Creative Transition Area is characterized by dynamic Kinesthetic expression
with concurrent Sensory feedback or sensuous involvement propelled by movement such
as the finger-paint example above.
The bipolar nature of each ETC level means that as information processing increases
with one component of the level, it necessarily decreases and eventually blocks function-
ing with the opposite component. In the Creative Transition Area of the Perceptual/
Affective Level, a moderate amount of emotional investment will imbue a perceived form
or a created image with vitality – emotions bring forms to life. However, persons who are
overly emotional have been described as being “caught up in emotion” and “unable to
see clearly.” These common expressions describe the bipolar nature of the Perceptual/
Affective level of the ETC. As emotional involvement increases past an optimal level,
involvement with form (ability to see clearly) decreases and images become indistinct
and formless.
On the other hand, the process of using formal art elements such as shape, size,
direction, and implied movement requires visual representation, but little emotion.
At first, emotional involvement might provide the needed motivation to begin to use
this visual language. However, as affective involvement increases, perceptual process-
ing abilities decrease and eventually become blocked. The same relationship is true
for each bipolar level of the ETC. As involvement with one function increases, process-
ing with the opposing function is at first enhanced, then decreased, and ultimately is
blocked. Later chapters of this book explore using the bipolar nature of each ETC level
to therapeutic advantage.
Each component of the Expressive Therapies Continuum has unique and definitive
therapeutic functions (Kagin & Lusebrink, 1978b; Lusebrink, 1990, 1991b, 2010, 2016).
The therapeutic functions are explained as the activities that are distinctly beneficial
about each component process. According to Lusebrink (1991b), the therapeutic dimen-
sion “denotes optimum intrapersonal functioning on the particular level” (p. 395).
Specific emergent functions (Kagin & Lusebrink, 1978b; Lusebrink, 1990) also are
characteristic of each component of the Expressive Therapies Continuum. The emergent
functions are the processes that arise from work with a particular component. Emergent
functions are believed to potentiate more complex processing of information and/or
images, and often suggest or provoke movement to a higher level of functioning within
the ETC. As was mentioned earlier, the fact that one type of functioning might evoke a
higher-level process can complicate the prescription of “pure” expressive experiences.
However, projecting the progress of emergent functions, along with knowledge of thera-
peutic functions, helps guide art therapists in providing the most effective therapeutic
experience for each individual. The emergence of a higher level of functioning helps
clients experience a more integrated sense of self, which can be therapeutic (Lusebrink,
1991b; Pike, 2014). The therapeutic and emergent functions of each component of the
ETC will be discussed fully in subsequent chapters.
8 Historical Perspectives and Foundations

A Developmental Hierarchy

Kinesthetic/Sensory Level
Infants and toddlers process information through sensation and movement. Indeed,
this has been called the sensorimotor stage of cognitive development (Piaget, 1969).
Feedback loops support learning through the senses and through repetitive movement.
If art activities are engaged in at this stage, the medium is used for its sensual aspects, or as
a passive facilitator of kinesthetic action. For example, a 2-year-old happily bangs a piece
of paper with a marker and, after pounding for a few minutes, probably notices that the
marker left an image; but the focus of the activity was on the kinesthetic action rather than
on the product or image.
A toddler using finger-paints usually is much more interested in the sensory experience
of daubing, spreading, and smearing the smooth paint than in making an image with it.
Similar kinesthetic and sensory experiences are accessed through the developmentally
lowest level of the Expressive Therapies Continuum, the Kinesthetic/Sensory level. It is
important for people of all ages to have access to kinesthetic and sensory information,
as this type of input forms the basis of many experiences, and thus greatly influences the
understanding of emotion and the development of memory (Damasio, 1994; Feldman
Barrett, 2017; Kontra, Goldin-Meadow, & Beilock, 2012; Lusebrink, 2004).
Between the ages of 3 and 4 years, the scribbling characteristic of toddler art gives way
to form. Preschool-aged children begin to draw concentric scribbles. These repetitive
round forms become differentiated from one another and eventually become identi-
fied and named (Kellogg, 1970; Lowenfeld & Brittain, 1987). Mastering form is essential
because children use art to inform those around them about their world and their feel-
ings. Drawings are the natural language of children; they are one of the universal ways
that children express emotions (Lowenfeld, 1952). Next, during the schematic stage of
graphic development from ages 7 to 9 years, form is vital to children’s drawings. Children
develop visual schemas which function like blueprints or plans for drawings and conse-
quently for communication. Deviations from usual schemas by omissions or elaborations
demonstrate the positive or negative emotional significance of a subject (Kellogg, 1970;
Lowenfeld & Brittain, 1987; Picard & Lebaz, 2010; Thomas & Silk, 1990).

Perceptual/Affective Level
The Perceptual/Affective level is the second level of the Expressive Therapies Continuum,
corresponding to the schematic stage of graphic development in which children are
learning about the world and the forms around them. Children’s drawings are infused
with emotions that give them characteristic qualities and personal meanings. Certain chil-
dren find drawing is a significant way to explain and contain their impulses and emotions.
Individual perceptions of reality are neurologically based, culturally influenced, and dif-
ferent from other individuals’ perceptions. Figure ground drawings such as the Rubin’s
vase shown in Figure 1.2 illustrate what Siegel and Hartzell (2003) have called “represen-
tational diversity” or the ability to perceive reality in diverse manners. In the case of this
drawing, reality can be either two profiles or a single vase.
In order to have fulfilling relationships, it is helpful for people to understand the
concept of representational diversity and to be open to new perceptual experiences.
Art therapy experiences on the Perceptual/Affective level of the Expressive Therapies
Continuum can be designed to broaden clients’ perspectives and increase their ability
to see another person’s point of view through a new visual language. Perceptually-based
 Overview of the ETC 9

Figure 1.2 Rubin’s vase demonstrates “representational diversity.” A figure can be viewed in two ways

experiences can be one method of promoting effective interpersonal communication and

satisfying relationships. The vital role of Perceptual activities in couples and family ther-
apy will be explained in Chapter 13. In addition, everyone should understand and have
access to information about their emotional states. Emotions are used in decision-making,
memory functioning, and in motivating behavior (Damasio, 1994; Ekman, 2007; Feldman
Barrett, 2017; Greenberg, 2012; Plutchik, 2003). Experiences on the Perceptual/Affective
level can help clients identify emotions, facilitate discrimination among emotional states,
and assist in the appropriate expression of emotions.

Cognitive/Symbolic Level
The Cognitive/Symbolic level of the Expressive Therapies Continuum is the most devel-
opmentally sophisticated. It corresponds to adolescence and the development of formal
operational thought (Piaget, 1969). This means adolescents can process information out-
side of their own personal experience. Events no longer have to occur in the adolescents’
personal lives to have meaning for them. Young people increasingly are capable of delay-
ing impulses long enough to plan a course of action, think it through, and then execute
the action. This skill continues to develop throughout adolescence and into the early 20s
(Siegel & Hartzell, 2003). With an increased ability to control impulses and delay grati-
fication, more complex behaviors are available. Art images and processes can become
more complex as well. Images in the teen years often are infused with subtle humor,
irony, or sarcasm (Lowenfeld & Brittain, 1987). Because adolescents are able to think
outside their own experience, and their thoughts have achieved a new level of complex-
ity, they are able to use symbols to represent feelings, thoughts, and events.
Potentially, everyone can benefit from the ability to understand and use symbolic
thought. Symbols provide access to intuitive functions and serve as reminders that
10 Historical Perspectives and Foundations

experiences are not entirely conscious and fully understood. Art therapy experiences
with the Symbolic component of the Expressive Therapies Continuum can aid clients
in accessing the wisdom of their bodies or the wisdom of the world, neither of which
speak in words. Symbol use can allow clients to maintain a healthy sense of mystery in
their lives. The opposite pole of this level is represented by Cognitive information pro-
cessing. Cognitive thought is essential for analytical and sequential operations. It allows
people to plan and carry out complex functions as well as to make decisions and solve
problems. Input from the Cognitive component of the ETC provides reality feedback
in all areas of information processing.

Creative Level
As was mentioned above, the Creative level of the Expressive Therapies Continuum may
exist at any or in all levels and often serves an integrative function. Many authors have
discussed the importance of the creative experience. Jung (1964) stated that all persons
show a tendency to grow toward wholeness, bringing to light their uniqueness and indi-
viduality. For Jung, this tendency was best displayed by the creation of a mandala. The
mandala is a circular drawing representing the self, wholeness of the personality, balance,
and a desire for harmony (Jung, 1972). According to Johnson (1990), creative experi-
ences can destroy a “false self” developed in response to shame and can reinforce an
authentic sense of self.
In all types of creative experiences, the artist feels deep satisfaction and moments of
intense joy, which Rollo May (1975) defined as “the emotion that goes with heightened
consciousness, the mood that accompanies the experience of actualizing one’s own
potentialities” (p. 45). Access to creative input allows people to feel the joy that infuses
original, imaginative experiences. Creative involvement itself can be therapeutic without
cognitive overlay or symbolic interpretation (Lusebrink, 2004; Pike, 2014).

A Reverse Developmental Hierarchy

Interestingly, a reverse developmental process can be seen in the art products created by
the devolving or degenerating brain (Ahmed & Miller, 2003). As the disease progresses,
patients with Alzheimer’s disease or schizophrenia show a reverse developmental hier-
archy through the levels of the Expressive Therapies Continuum (Bonoti et al., 2015;
Forsythe, Williams, & Reilly, 2017; Grady, 2006; Killick, 1997; Stewart, 2006; van Buren
et al., 2013; Wald, 1984; Zaidel, 2005). Patients start out with abilities expressed on the
Cognitive/Symbolic level of functioning. They are capable of thinking through sophisti-
cated projects and using learned skills in order to render symbolically rich and complex
art products. As the disease progresses, patient abilities regress to the creation of images
characteristic of the Perceptual/Affective level with what seems to be alternating struggles
to emphasize form with the expression of attendant affect. Finally, the last stages of the
diseases seem to be characterized by Kinesthetic/Sensory activity with notable fragmenta-
tion of images, scribbling, and no true achievement of formal representation. Ahmed and
Miller (2003) reported that patients with Alzheimer’s disease experience an unremitting
loss of “visuoconstructive” ability. They seem aware that their spatial abilities are deterio-
rating but do not know how to change them (Grady, 2006; Zaidel, 2005).
An example of this devolution of ability characterizes the late work of Willem de
Kooning, who suffered from Alzheimer’s disease in the last years of his life (Bogousslavsky,
2005; Stewart, 2006). The artist’s work at first was characterized by the complexity of
 Overview of the ETC 11

design, colors, and materials demonstrating work on the Cognitive/Symbolic level of the
Expressive Therapies Continuum. With the first impact of the disease, de Kooning’s work
seemed to become overly involved with the Perceptual component. It has been called
emotionally flat and cartoon-like, with an emphasis on outlining of the figures and a
limited color palette (Bogousslavsky, 2005). In the last stages, de Kooning’s work has
been described as simplistic and impoverished, “a regression to the scribbling stage with
random marks on paper” (Stewart, 2006, p. 58).

Using the Expressive Therapies Continuum in Therapy

A well-functioning individual is able to process information on all levels and with all com-
ponents or functions of the Expressive Therapies Continuum. Each function provides
unique input with which the individual can make informed decisions and life choices
(Lusebrink, 1990). There is anecdotal evidence that processing information with one
component of the ETC enhances processing in other realms. Work in one artistic area
enhances another to infuse the whole creative spirit (Friedman, 2007; Goldberg, 1997;
Haynes, 2003). Natalie Rogers (1999) coined the term “creative connection” to empha-
size her observations that “one art form stimulates and fosters creativity in another art
form and links all of the arts to our essential nature” (p. 115).
Donald Friedman (2007) compiled an impressive volume of profiles of 200 well-known
authors who also created visual art, and their explanations as to how engaging in painting
or drawing complimented their written art. Writer Natalie Goldberg (1997) discovered
what a profoundly enhancing effect painting had on her writing when she stopped paint-
ing, in order to devote her full attention to writing. She described her time without
painting as being among her least productive writing years. The painting had a synergistic
effect on her writing that enlivened the written word and energized the writing process.
Goldberg explained, “When I cut out painting, I cut off that underground stream of
mayhem, joy, nonsense, absurdity. Without painting, sludge gathered at the mouth of
the river and eventually clogged any flow” (p. 60). Some creative arts therapists would go
so far as to say that enlightened individuals seek out diverse experiences representing all
components of the ETC in order to enjoy the flow, the self-actualizing properties of the
creative process (Capacchione, 2001; Lusebrink, 1990; Malchiodi, 2002; McNiff, 1998).
However, most individuals seeking therapy would not consider themselves function-
ing optimally, but rather as experiencing problems with living. The Expressive Therapies
Continuum helps therapists conceptualize these problems in at least two ways. Problems
can occur when people are blocked from receiving or processing information with
one or more components of the ETC. Difficulties also can arise when individuals dem-
onstrate strong preferences to process information exclusively with one component.
When information processing strategies are limited by being blocked or overused in
a restricted manner, decision-making skills are impaired and life choices often are too
narrowly defined.
The Expressive Therapies Continuum can be used to assess clients’ preferred and
blocked levels of information processing and to prescribe desired therapeutic experi-
ences. The structure of the ETC can help creative arts therapists assess both their clients’
favored components and significant obstacles to optimal functioning. This assessment
information is gathered through evaluating media preferences and styles of interac-
tion with the media, as well as graphic indicators and expressive elements from final art
products. Further, therapists can use information from the ETC to guide clients through
experiences designed to eliminate impediments to effectively using any component, or
12 Historical Perspectives and Foundations

to reducing overdependence, causing rigid functioning. Clients’ social and occupational

functioning can be improved by removing obstacles, and increasing flexibility in the ways
information is processed, and decisions are made.

The Expressive Therapies Continuum Components

at Work – The Example of the Scribble Chase
The scribble chase is an expressive exercise involving only one type of media but including
activity on all levels of the Expressive Therapies Continuum. This experience can be per-
formed individually or in groups (Lusebrink, 1990; Malchiodi, 2012c). When performed
individually, watercolor markers and a large sheet of paper are used. Client and therapist
choose different colored markers, and as the therapist begins drawing a line; the client is
encouraged to “chase” the line with his or her marker. Malchiodi (2012c) explained that
a reluctant client could be drawn into this experience by following a line provided by the
therapist. This part of the “scribble chase” is a purely Kinesthetic experience. During this
Kinesthetic activity, there is no thought as to what the lines might look like or what they
might represent. After the paper is covered with lines, the client is asked to find images in
the scribble and make a picture out of them using markers. By finding images in the lines,
the client enters the Perceptual component of the ETC. Finally, the client is asked to tell
a story about the picture or talk about what the picture means. Putting a story together
requires engaging the Cognitive dimension, and finding personal meaning or a personal
symbol demonstrates functioning with the Symbolic component of the ETC. The integra-
tion of functioning on all levels is one kind of Creative experience.
The scribble chase may be performed in a group of four persons, with two dyads taking
turns leading the chase with markers on separate sheets of paper. This unstructured
movement is the Kinesthetic component of the experience. In the next step, each par-
ticipant selects and outlines five forms or objects from their scribble pictures. When
forms are found, the Perceptual component is engaged. The members of the dyads then
share their perceived images with each other, and the Perceptual dimension moves to
the Cognitive component of the Expressive Therapies Continuum as verbal explana-
tions are provided. Each dyad then selects five objects from the original ten objects.
Two dyads form a group of four and select five forms among them from all of the forms
presented. Negotiation is required in this step because five is an odd number and will
now allow the easy selection of one form from each individual. This negotiation again
engages the Cognitive component. Finally, the group of four uses markers to create a
mural on a 3’ x 5’ sheet of white paper using their chosen five forms or elaborations of
them. The final product is a Creative expression, often on the Symbolic level.
The example of the scribble chase experience demonstrates how the power of the
Expressive Therapies Continuum can aid therapists in comprehending and prescribing
a wide range of appropriate therapeutic experiences. Essential for a complete under-
standing of the ETC is an appreciation of the Perceptual/Affective level as a bridge
between the Cognitive/Symbolic level above it, and the Kinesthetic/Sensory level below
it (V.B. Lusebrink, personal communication, March 3, 2008). If unchecked, activity
on the Kinesthetic/Sensory level has the potential to remain caught up in repetitive
movement and formless sensation, while Cognitive/Symbolic processing could become
characterized by intellectualization and artifice. Activity on the Perceptual/Affective
level can provide the needed constraints to bridge functioning between the ETC levels.
Perceptual/Affective experiences formulate action into an image, and thus set the stage
for contemplation and personalization of meaning.
 Overview of the ETC 13

The transitional aspect of the Perceptual/Affective level is exemplified in the process

of symbol formation. According to Piaget (as cited in Lusebrink, 1990), symbols have
both figurative and operational elements. Formulating the figurative aspect of symbols
requires functioning with the Perceptual component, and the operational aspect involves
the Kinesthetic component. The term symbol is used in this context to mean a mental
representation, and thus applies also to the Cognitive component, with reference to the
thought and memory necessary to bring about the mental picture. Similarly, the Affective
component forms a transition between the Sensory component and the Symbolic com-
ponent. Sensations give rise to affect, which fuels the personal meaning and significance
of symbolic images.
Working with visual expressions in therapy often involves the elucidation and work-
ing through of symbolic images, which will be discussed in the chapter on the Symbolic
component. Briefly, however, working on the Perceptual/Affective level often provides
clarity when differentiating symbolic images and cognitive concepts into their constituent
parts. Personal symbols have figurative and affective components that can be rediscov-
ered in the therapeutic process, thus leading to the meaning of the symbolic images and
expressions, and to the affective charges contained in the symbols. The figurative aspects of
symbolic images can be explored kinesthetically using a Gestalt approach.

The Expressive Therapies Continuum as a Foundational Theory

The field of art therapy is supported by foundational theories and a growing body of
literature demonstrating its power as a unique health service profession (Junge, 2016;
Potash, Mann, Martinez, Roach, & Wallace, 2016; Rubin, 2005). The Expressive Therapies
Continuum can be considered one such foundational theory. As was demonstrated in this
introductory chapter, the ETC is a theoretical and practical guide that describes and rep-
resents the ways in which people interact with various art media or experiential activities
to process information and form images. The ETC attempts to explain the therapeu-
tic dimensions of various expressive experiences and the restorative power of creativity.
Knowledge of the ETC and implementation of its principles can distinguish trained art
therapists from other health service professionals who use art media in counseling ses-
sions. The ETC helps clarify art therapy as not merely a modality of verbal psychotherapy,
but a unique discipline in its own right with a theoretical framework that can guide the
use of art media and expressive experiences.
According to Lusebrink in the Foreword to this book, when the Expressive Therapies
Continuum was first presented to the art therapy community at the Ninth Annual
Conference of the American Art Therapy Association (Kagin & Lusebrink, 1978a,
1978b), the response was one of uncertainty. Because it involved a revolutionary way of
applying art therapy principles, many audience members questioned how the theory
of the ETC related to established conceptualizations of art therapy. However, in the
40 years since its initial presentation, the ETC has been widely discussed in the art
therapy literature (Malchiodi, 2012b), formed the basis of research studies into the
power of art therapy (Haeyen, Kleijberg, & Hinz, 2017; Nan & Ho, 2017), and has been
adopted by graduate art therapy training programs as a unifying theory. The Expressive
Therapies Continuum represents a common language for art therapists having diverse
theoretical backgrounds. It provides guiding principles that aid in the recognition and
discussion of the therapeutic properties of expressive activities and creative experi-
ences. The ETC has the potential to unite art therapists and provide a solid platform
upon which the profession of art therapy can continue to grow. Art therapists of varied
14 Historical Perspectives and Foundations

theoretical orientations can acknowledge the therapeutic and emergent functions of

different expressive experiences (Hinz, 2009b).

Unifying the Field of Art Therapy

Historically in the field of art therapy, there has been a division between art therapists
who define themselves as artists and those who define themselves as clinicians. For more
than 40 years, this has been known as the “artist as therapist” versus “art psychotherapist”
debate (Junge, 2016). The artist as therapist camp has been criticized by their detractors
as not being grounded in science. The art psychotherapists have been viewed as too clini-
cal and as disregarding their roots in all elements of art: art education, art history, and art
making. Among art therapists, there still is resistance to making art therapy too clinical
(e.g., Allen, 1992). The Expressive Therapies Continuum is not an attempt to make art
therapy more clinical or to follow a clinical or medical model in approaching clients and
their treatment. On the contrary, the ETC provides a common theoretical foundation
based on qualities of art media, expressive styles, and creative activities. It has been my
experience, both as a therapist and as an educator, that knowledge and application of the
principles of the ETC facilitates therapist understanding of client needs, effectively guides
the selection of therapeutic experiences, and can promote understanding and communi-
cation among expressive therapists. In addition, it is a positively focused, strengths-based
approach to art therapy. The ETC helps therapists determine client strengths and use
them as a starting point for therapy.
The Expressive Therapies Continuum provides unifying principles that demonstrate
the uniqueness of art therapists, among other types of mental health professionals. A well-
meaning therapist who uses art in psychotherapy might use the same media and directive
ineffectively with all clients. Training in the ETC model, as will be explained throughout
this book, explains why one media or one therapeutic experience cannot be adequate to
meet the needs of all clients. For example, McNamee (2004) reported some success but
more client resistance as she tried to employ scribble drawings with the majority of her
clients. In fact, research has shown that sometimes art making can exacerbate painful
medical conditions such as migraine headache (Vick & Sexton-Radek, 2005). The ETC
can serve as a guide for choosing optimal therapeutic strategies.

The Rest of the Book

The next chapter reveals the historical roots of the Expressive Therapies Continuum as it
applies to the field of art therapy. The ETC is a systems-oriented approach to the expres-
sive arts therapies, and Lusebrink (1991b) has described how the ETC can be applied
to music, dance, and drama therapy as well as to art therapy. The focus of this book,
however, will be on the application of the ETC within art therapy. Also, in Chapter 2,
the contributions of several pioneering art therapists to the field are described, and their
influences on the field of art therapy and the ETC examined. Chapter 3 is new to this edi-
tion of the book and is devoted to media properties and the various ways in which diverse
media and Media Dimension Variables (Kagin & Lusebrink, 1978a) affect the therapeutic
process. The chapter ends with important safety information regarding media use. In
addition, Chapter 3 suggests directions for future research into media properties and
material interaction.
Chapters 4 through 10 explore more deeply each component of the Expressive
Therapies Continuum. Examples of activities to stimulate information processing with
 Overview of the ETC 15

each component of the ETC are provided. Media and methods for use in specific compo-
nent processes are examined, and the relative reflective distance evoked by working with
the components is described. The therapeutic and emergent functions of each level are
explained, and their therapeutic uses explored. Finally, Chapters 4 through 10 provide
case examples that demonstrate treatment guided by the particular component of the
ETC under discussion.
Chapter 11, “Assessment within the Structure of the Expressive Therapies Continuum,”
demonstrates how the ETC centers art therapy assessment on its roots in art and focuses
on how clients create rather than on the product created. The chapter outlines the basic
types of information gathered in an initial series of art sessions, including preferred
medium, method of interaction with media, stylistic elements from final art products, and
verbal communication. Chapter 11 also discusses ways to employ the information derived
from ETC assessment in the formulation of treatment goals. A case example presented at
the end of the chapter integrates and summarizes the material on assessment.
The use of the Expressive Therapies Continuum as a framework for organizing thera-
peutic sessions with individual clients is discussed in Chapter 12. This chapter aids the
reader in understanding how assessment information can be used to gauge where to
begin in therapy and how and when to change therapeutic focus. The chapter contains
an exploration of the ETC as a framework for building a successful client–therapist part-
nership in the formulation of treatment goals and the implementation of effective art
therapy. Chapter 12 also describes how the ETC can be used to structure the positive
termination of art therapy. Chapter 13 delineates particular advantages when using the
Expressive Therapies Continuum as a framework for the use of art therapy with groups of
clients, and with couples, and families.
Finally, Chapters 14 and 15 are new to the second edition of this book. Chapter 14 was
created to address aspects of the therapeutic relationship within the ETC framework.
After a general discussion of the way that the therapeutic relationship is considered
within this theory, it also details transference and countertransference issues unique
to the ETC and dealing with client resistances to treatment. This chapter also high-
lights the ways in which the structure of the ETC can help art therapists avoid errors in
treatment. Chapter 15 presents information on the integration of neuroscience and art
therapy, highlighting the great strides that have taken place in recent years to under-
stand brain structures and functions underlying art therapy.

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