Expressive Arts Therapy for Traumatized Children and

Adolescents A Four Phase Model 1st Edition

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First published 2016
by Routledge
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and by Routledge
27 Church Road, Hove, East Sussex BN3 2FA

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2016 Carmen Richardson

The right of Carmen Richardson to be identified as author of this work has been asserted by her in
accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

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Library of Congress Cataloging-in-Publication Data

Richardson, Carmen.
Expressive arts therapy for traumatized children and adolescents : a four-phase model / by
Carmen Richardson. — 1 Edition.
pages cm
Includes bibliographical references and index.
1. Art therapy for children. 2. Psychic trauma in children—Treatment. I. Title.
RJ505.A7R53 2016
618.92′891656—dc23
2015007082

ISBN: 978-0-415-73377-9 (hbk)

ISBN: 978-0-415-73378-6 (pbk)
ISBN: 978-1-315-81785-9 (ebk)

Typeset in Galliard
by Apex CoVantage, LLC
To each child who taught me what it means to do brave therapy
Tell Me, She Said

Tell me, she said:

What is the story you are telling?
What wild song is singing itself through you?

Listen:
In the silence between there is music;
In the spaces between there is story.

It is the song you are living now.

It is the story of the place where you are.
It contains the shapes of these old mountains
The green of the rhododendron leaves,
It is happening right now in your breath,
In the heartbeat still drumming the deeper
rhythm
Beneath your cracking words.

It matters what you did this morning and last

Saturday night and last year,
Not because you are important
But because you are in it and it is still moving,
We are all in this story together.

Listen:
In the silence between there is music;
In the spaces between there is story.

Pay attention:
We are listening each other into being.
Sally Atkins1

NOTE

1. Appalachian Expressive Arts Collective. (2003). Expressive arts therapy: Creative process in art and life.
Boone, NC: Parkway Publishers. Reprinted with permission.
Contents

Foreword xi
William Steele
Preface xiii
Acknowledgments xvii
Introduction xix

PART 1
The Expressive Arts Therapy Way 1

1 Expressive Arts Therapy 3

The Expressive Arts Way 3
The Profession of Expressive Arts Therapy 4
The Shapers of the Field 5
Expressive Arts Therapy: The Prairie Approach 6
References 8

2 The Action of Expressive Arts Therapy 9

An Expressive Arts Therapy Framework 9
The Persona of the Therapist: The Many Hats We Wear 9
Introducing the Arts to Clients 11
Engaging Clients With Their Art 16
The Art of Questions 18
Experiments 19
Artistic Acts of Victory 20
The Voice: Breathing Life Into Words 23
Wise Witness 25
Art Responses 26
When to Use an Art Response 27
Inviting Others to Create an Art Response 29
References 31

PART 2
Trauma and Expressive Arts Therapy 33

3. Children’s Experience of Trauma 35

The Sensory Experience of Trauma: Honoring the Internal World of the Child 35
Trauma and the Brain, Memory, and Body 35
Trauma and the Brain: Wired to Survive 37

vii
viii Contents
Trauma and Memory: The Journey From Implicit to Explicit Memory 39
Trauma and the Body: Nervous System Arousal 41
References 42

4 A Resource-Oriented Lens 44
Resourcing as the Foundation 44
Resources Inherent in the Expressive Arts Process and Product 48
Resource-Oriented Attitude of the Therapist 50
The Ear of the Heart Listening 53
Working With Resources 54
Dumpster Diving: The Therapist’s Healing as a Resource 58
References 61

PART 3
An Expressive Arts Four-Phase Model of Treatment 63

5 Introduction to the Expressive Arts Four-Phase Model 65

Overview of the Four Phases 66
Working With Single-Incident and Multiple Traumas 67
Phase Guidelines and Phase Interventions: Rationale and Process 67
Caregiver Involvement Throughout the Four Phases 67
The Therapy Process Over Time: Beginning, Middle, and End 68
Number of Sessions Required 69
Individual Session Structure: Beginning, Middle, and End 70
Temporal Orientations: Then and Now/Past and Present 72
Working With the Body’s Rhythm 73
Therapist and Caregiver Attunement to the Child 73
Compassionate Listening 74
Structured Flexibility 74
What to Do With the Tangible Art 75
Modifying Interventions 75
Working Intermodally 75
Permission Statements 75
Moving From One Phase to the Next 76
Therapist Handouts for Organizing Assessment and Treatment Information 76
Information Handouts for Clients 80
Readiness to Begin Phase One 81
References 81

6 Phase One Guidelines: Understanding the Child’s World 83

Initial Assessment 83
Multiple Treatment Providers/Professionals 84
Process of Assessment Sessions 84
Therapist Response During Assessment Versus Treatment 85
Overview of Assessment Tools 85
Standardized Tests 86
Art Therapy Assessment Tools 87
Expressive Arts–Based Information-Gathering Tools 87
Questionnaires for Information Gathering 97
Readiness to Move to Phase Two 103
References 104
 Contents ix
7 Phase Two Guidelines: Cultivating Safety and Resources 105
Phase Two Expressive Arts Interventions 107
Readiness to Move to Phase Three 119
References 120

8 Phase Three Guidelines: Processing the Trauma 121

Phase Three Expressive Arts Interventions 122
Readiness to Move to Phase Four 144
References 144

9 Phase Four Guidelines: Reclaiming, Reframing,

Repairing, and Reorienting 145
Phase Four Expressive Arts Interventions 146
Readiness to Close Therapy 167

Appendix A. An Expressive Arts Four-Phase Model 169

Checklist of the Main Map 169
Appendix B. Therapist Handouts for Organizing Assessment
and Treatment Information 171
Highlighting Core Issues 171
Feedback Form 172
Tracking Assessment and Treatment 173
Managing Activation—Adolescents 174
Managing Activation—Children 175
Acts of Victory and Mastery 176
Thoughts, Feelings, and Beliefs Checklist 177
Appendix C. Information Handouts for Clients 178
Caregiver Involvement in the Four Phases 178
The Inner World of My Body 180
Appendix D. Phase One: Expressive Arts–Based Information-Gathering Tools 185
Map of My World 185
How Trauma Changed My World 186
My Relationships 187
Amazing Body 1 188
Amazing Body 2 189
My Body and the Trauma 1 190
My Body and the Trauma 2 191
Self-Portraits 1 192
Appendix E. Phase One: Questionnaires for Information Gathering 193
Exploring Art Modalities and Creativity Beliefs 193
Child and Caregiver Trauma History 195
Impact of Trauma on Caregiver 196
Why It Was Hard for Me to Tell 197
Why It Was Hard for My Child to Tell 198
Responsibility Rating Scale (Child) 199
Responsibility Rating Scale (Caregiver) 200
Responsibility for the Trauma 201
Safety Questionnaire 202
Feelings About the Trauma 203
Disclosure Questionnaire 204
x Contents
Disclosure Picture: When I First Told About the Trauma 205
Trauma Self-Statements 206
Reminders of the Trauma 207
Pieces of My Story, Part 1: Remembering 208
Appendix F. Phase Two: Expressive Arts Interventions 209
Pouches, Pockets, Bags, and Boxes 209
Setting My Own Pace: Stop, Slow, Go 210
Learning About Safety 211
Cultivating Hope 212
Building Resources 1 213
Building Resources 2 215
Exploring and Healing Boundaries 217
Labyrinths, Mazes, and Mandalas 218
Learning to Be My Own Best Friend 219
Building Awareness and Resources Through Imagery and Stories 221
Getting a Handle on Tricky Trauma Behaviors 223
Appendix G. Phase Three: Expressive Arts Interventions 226
The Wall 226
Surfing the Waves 227
My Iceberg 228
Tracking Trauma Processing 229
Pieces of My Story, Part 2: Putting It All Together 230
Resource/Trauma Art 231
Time Lines and Road Maps 232
Honor and Transformation 233
My Body, Part 1: What My Body Did at the Time of the Trauma 234
My Body, Part 2: What I Wished My Body Did 235
My Body, Part 3: My Body’s Voice 236
My Body, Part 4: Caregiver and Child Session 237
My Expressive Arts Bravery Story 238
Appendix H. Phase Four: Expressive Arts Interventions 239
Therapy Review: What’s Left to Do 239
My Healing Journey 240
Self-Portraits 2 241
Secrets 242
My Inside/Outside Stories 244
Before Therapy and Now 245
Evidence of Growth 246
Victim–Survivor–Thriver 247
Beyond the Trauma: Action Figure and Doll Making 248
Expressive Arts Review 249
Celebration or Ceremony 250
Appendix I. Questions 251
Appendix J. Further Resources 253
Index 255
Foreword

What I most appreciate about Carmen Richardson’s presentation of this four-phase expressive
arts intervention model is that it is not only a presentation of case studies to support the value
of the model, but also the story of the author and her clients’ journeys on untraveled paths, as
unknowing individuals, never quite sure what they might discover while learning along the way
how best to manage those discoveries, no matter the challenge.
Expressive Arts Therapy for Traumatized Children: A Four-Phase Model represents a consil-
ience of the author’s experiences with action therapies—dance, music, creative writing, poetry,
drawing, play, and art—and her years of training in the use of the arts and varied modalities,
including Inner Relationship Focusing, Sensorimotor Psychotherapy, and Integrative Body
Psychotherapy. Her use of an intermodal approach to treatment establishes her appreciation
for the reality that there is no one intervention that fits every child and the reality that at any
given time, in any one session, children may need several different modalities to communicate
verbally and nonverbally what matters most at that moment in time.
Although rich with creative activities, the author quickly establishes that these are not to be
approached as a “recipe” of activities to pick and choose from, but as strategically placed activities to
support the larger picture of helping children develop the resilience needed to experience posttrau-
matic growth. The structured framework helps to ensure a process that is safe, but it also provides
the flexibility necessary for following the child’s creative processing and use of varied activities at
a pace that is safe and tolerable. Under each intervention/activity we’re given the rationale for its
use and the process for engaging the child in the activity. The author also provides us with several
starting points based upon the number of sessions available. For example, if there are only five ses-
sions available, safety and stabilization, including regulation, become the focus of the intervention.
What is refreshing is that prior to introducing the model, the author spends much needed time
discussing the “persona” of the therapist and the many hats that need to be worn in order to bring
forward aspects and dimensions of the therapist and the therapy to benefit the child. She identifies
six different personas. There is the scientist, who acquires knowledge by observing responses follow-
ing the exploration of different art forms with clients. The explorer has a courageous spirit for going
where he has not been before. The detective is curious minded and allows children to go deeper
into their subjective worlds. The magician is skilled at being playful and creative in her use of varied
modalities. The curious cat is an observer first and only jumps into action when the time is right.
The clown brings the element of laughter to the therapeutic process—a reminder that life is more
than just the “hard stuff.” The model is as much about therapists working within themselves and
their relationships with art as it is about guiding the ways they assist children through the use of art.
The four phases are assessment; cultivating safety and resources; trauma processing; and
reclaiming, reframing, repairing, and reorienting. The assessment phase is not about making
assumptions about children based solely on their behaviors and symptoms, which are often
misleading, but on using action activities and the arts to discover how they are subjectively
experiencing the varied environments that they struggle daily to navigate and survive. The
assessment process guides the practitioner beyond the administering of tools to the processes
xi
xii Foreword
necessary to become deeply curious about how children see themselves, others, and the world
as a result of their traumatic experiences.
Positioning the therapist as “non-knowing” is an excellent beginning, as it demands that
the therapist becomes immediately curious. Hughes (2009) wrote, “When curiosity is directed
toward the child’s experience rather than toward the factual events in his life and when it is
conveyed with both affective and reflective features, the child is likely to go with the therapist
very deeply into his or her life story and experience a co-regulating of emotions related to what
is being explored and the meaning given those events” (p. 169). In essence, curiosity is the cor-
nerstone of empathy, and as such, it is essential for establishing a trauma-informed relationship.
What is so important about Phase Two is that it is not only about helping children ready them-
selves to safely process their trauma, but also to empower them to regulate their reactions to daily
worries, fears, threats, or ongoing trauma that may yet be enduring. In this effort, the author has
masterfully integrated the arts with working with the body as a wise resource. Teaching children to
be attuned to their bodies and to respond to their bodies’ assessments of what is or is not helping
empowers children and develops the resilience needed to process their traumas in the next phase.
The author’s emphasis on the body as a resource took me back to my personal experience with
Dr. Alexander Lowen, the founder of Bioenergetics. My body had tightly locked away the sensa-
tions and memories of earlier traumas that cognitive processes simply could not reach or release.
In one session, Dr. Lowen analyzed my body through its language—body posture, breathing,
movement, rigidity, shape, and so on. He prescribed a series of body positions and activities to
use to release, reveal, and then refocus my view of self and life. That process became the major
turning point in my life. The body holds the key to healing, to regulating unwanted reactions,
and to bringing energy and vitality to one’s life. The author’s incorporation of the use of the body
through developmentally appropriate activities is not only essential for safely processing trauma,
but also for experiencing a renewed confidence about the future. Every child deserves this gift.
One of the primary goals of trauma processing is helping survivors discover, through the
wisdom of their bodies that, despite the many triggers in their environment that can remind
them of their traumatic experiences, they need no longer be trapped or held hostage by those
memories. In Phase Three, activities such as Surfing the Waves, My Iceberg, Pieces of My
Story: Putting It All Together, Time Lines and Road Maps, and Honor and Transformation
help children master their trauma memories by organizing them in meaningful ways. This helps
children put the trauma in the past so they can focus on the future.
Too often, trauma processing becomes the goal of treatment rather than children learning
to flourish as thrivers. In Phase Four, the author has developed a process that prepares children
to go beyond processing the trauma to rediscovering the many parts that make them who they
are and can become. This helps them reclaim what was lost and repair the “who” and “what”
that emerge as important in their efforts to now thrive and reframe the larger picture to reori-
ent themselves to the future.
The final activity is a celebration of the child’s courage, tenacity, trust, creativity, empower-
ment, and mastery. It is designed as a co-celebration because both the therapist and the child have
traveled an amazing journey. It is a journey Carmen Richardson has made safe, creatively inviting,
and empowering for any new or seasoned therapists interested in using expressive interventions
within an intermodal framework to assist traumatized children in their efforts to flourish.

WILLIAM STEELE, PSYD, MSW

Founder, The National
Institute for Trauma and Loss
in Children (TLC)

REFERENCE

Hughes, R. (2009). Attachment focused treatment for children. In M. Kerman (Ed.), Clinical pearls of
wisdom (pp. 169–181). New York: W. W. Norton.
Preface

TURTLE STORY

It was an early morning run on a beach in Mexico. There in front of me was a wee turtle strug-
gling on her back. I stopped running and, in a moment of panic, thought, “What do I do?”
In my body, I noticed such a strong pull to protect this vulnerable little creature. My instinct
was to try to put her in the water. In the next moment, a woman wandered by and said, “Oh
you found one!” She went on to inform me that there was a protection program for the local
turtles. She told me that the best practice was to first wet your hands, then rub them with sand,
and then to take the turtle to the security guard at the hotel. The hotel staff then pass them on
to the protection program, which releases the turtles at night when they have the best chance
for survival. During the day, the struggling infant turtles are vulnerable to the hungry birds
circling above.
The following morning began with another encounter with a baby turtle flailing on its back.
That morning, there was no question. I knew what to do. As I rubbed sand on my wet hands
and picked it up, another woman went by and said that she had tried to put the turtle back in
the water but it kept being washed back on the beach by the waves, stating, “I thought I had
left it for dead.” Equipped with new knowledge of the right thing to do, I eagerly shared, “You
begin by wetting your hands in the water. . . .”
That morning, I began to recognize a familiarity in the strong pull in my body, the desire and
natural instinct to protect, because it is a similar experience I follow every day when I engage in
therapeutic work with clients. This is why I do what I do. Doing this work is not a job; rather, it
is a calling from somewhere deep inside my body that invites me to follow the impulse in me to
journey with others in a therapeutic way. It is a full body, mind, and heart calling.

FOUR THINGS

These vulnerable turtles taught me four things about my work with trauma: knowing the
“right thing” to do (being trauma informed) can increase confidence and passion when help-
ing others; passing this information on to colleagues and clients can empower others; the body
is a powerful informer, and the impulse in the body is a great guide; and being open to unex-
pected teachers enriches our learning and widens our field of knowledge.

WHY THIS BOOK WAS WRITTEN

Having worked in the fields of social work, art therapy, and expressive arts therapy for 28 years,
I felt a need for a more guided approach to working with the creative arts and trauma. I had
many resources that offered creative arts interventions, but few offered guidelines on how to

xiii
xiv Preface
incorporate the creative arts in an overall framework to trauma work with children. This book
was written in an effort to provide an expressive arts structured approach to trauma treatment
with children.
Providing safe trauma treatment means we are trauma informed. This book is embedded
in trauma-informed practices. As in the turtle story, when we know what to do, we can help
others with more confidence. Being trauma informed helps guide us as therapists to know how
to provide the best interventions for clients with increased assuredness. Whether we are part
of a larger organization or are in private practice, we can provide trauma-informed care. Being
trauma informed means understanding the impact of trauma experiences on the brain, mem-
ory, and body. It means being guided and educated on current literature to provide structured,
sensory-based interventions. It also means understanding best practices for our particular cli-
ent population. Educating our therapist selves by being trauma informed is one of the most
empowering things we can do in our practice and to pass that learning on to our clients and
colleagues. This learning can help keep our passion alive in the work.
This book was also written to contribute to the literature by providing therapists with a way
of working with children that included the wisdom of the body. For me, there has always been
a knowing that the body has an essential role in treating injuries of the heart, mind, and body.
While talking is a part of the process, I believed that somehow the body needed to be included
in this work. I just didn’t know how. My first in-depth body psychotherapy training experience
was a 4-year journey learning Integrative Body Psychotherapy (IBP). Core elements of body,
breath, and boundary exercises provided me with a framework in which to understand how to
incorporate the body in the therapy experience.
My training in art therapy and then in expressive arts therapy contributed to understand-
ing the body’s role in therapy. These creative arts experiences are body-born experiences, and
every impulse to write the story, paint the image, or speak the poem has origins from deep
within. We smell, taste, touch, see, and hear through the body. These sensory experiences are
central to expressive arts therapy and key to healing trauma in the body. My training with the
National Institute for Trauma and Loss in Children (TLC) provided a critical foundation for
my work with the sensory experience of trauma and the need to provide sensory interventions
to children.
Inner Relationship Focusing training has been pivotal in teaching me about mindfulness,
patience, and the deep practice of learning to listen to the different parts of myself and then
my clients. Focusing has been a great guide to the inner terrain of sensations and allowing the
inner body experiences time to form and become known.
My most recent training in Sensorimotor Psychotherapy for trauma treatment has given
me further language to explain what I often witness when working with the expressive arts,
children, and trauma. It has expanded the process of how to work, in a sensory way, with the
body and trauma. It has also shaped how I choose to incorporate the creative arts in trauma
treatment. Each training I have taken has been a following of my own impulse within, which
comes from the same impulse to want to protect the turtle, work as a therapist, expand my
learning, provide responsible treatment, and, above all, to do the right thing.

UNEXPECTED TEACHERS

As a therapist with prior trauma, I have often silently considered my personal healing journey
to be a gift, a resource, to what I bring to the therapeutic relationship. Yet, there was always
something seemingly taboo about discussing this topic with colleagues. It is as though we must
somehow separate from, bracket out that experience, and be neutral and somewhat distant from
our personal stories. Yet, inside my own body, I knew that this experience is what brings a certain
depth of understanding of personal suffering that cannot be learned in books or school. Even if
we do not have significant traumas in our lives, the fact of being human on this earth brings us our
 Preface xv
fair share of grief and loss. These personal experiences and stories are what bridge our lives to
the lives of our clients. In this way, we can sit with others with a shared knowing of the trials
we face on this journey. We are not so different. It does not mean we get tangled up in unclear
boundaries or that we feel as though we know our client because we have “been there.” In fact,
our own stories and experiences can tell us that we need to listen first and listen last, and that we
are attentive and nonjudgmental. It is how we listen, the way we are with others, the dropping
into safe, silent spaces with others. We create a safe enough space for this child to bring forward
her unique story so that we may come to see, from her point of view, how she has been shaped
by her story.
Through training at TLC, my understanding about resilience and posttraumatic growth
(PTG), in particular, deepened. I began to identify that what I was doing now, in my everyday
life, with passion, was an act of PTG. It was because of my own trauma as a child and youth that
I have a clear vision of moving toward working with young people. It was choosing to live in
a connected way and my desire to give back and to walk alongside those who also experienced
body, heart, and mind injuries as young people. While I did not have the resources to support
me as a young person, it was as a young adult that I found a way to heal and truly transform
my own traumas so that I was able to be with and offer clear presence to others. I love this
gift. I would have it no other way. This book was born from posttraumatic growth. My own
experience of trauma has, in many ways, been an unexpected teacher.
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Acknowledgments

I have a Grateful Heart for . . .

The little ones (and not-so-little ones) who have offered opportunities to help me cultivate
a deeper knowing and understanding of how to be present, to listen, and to learn what worked
and what didn’t.
Teri Brannen Gallagher for singing “You Gotta Have Pep” whenever I needed that little
push of encouragement to keep moving forward, giving perspective when I lost it, and being
available to review the work as needed.
Lori Boyko for your helpful feedback, your very caring and tender heart, and our focusing
partnership that nourishes me.
Lenore Mulvaney for our shared journey of doing our best, your encouragements to keep
believing, and, most important, your playfulness and laughter. You inspire always.
Dan Pasley for your daily ear of the heart listening. Your feedback and support were
invaluable.
Ralph, my precious husband, for your infinite presence, steadfastness, and constant, gentle
care and taking care of “everything else.” And I do mean everything else. You are my rock.

xvii