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Expressive Therapies Continuum: Use and Value

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dmontrant leur utilit et valeur)
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Expressive Therapies Continuum: Use and Value

Demonstrated With Case Study (Le continuum
des thrapies par l'expression : tude de cas
dmontrant leur utilit et valeur)
Lisa D. Hinz
To cite this article: Lisa D. Hinz (2015) Expressive Therapies Continuum: Use and Value
Demonstrated With Case Study (Le continuum des thrapies par l'expression : tude de cas
dmontrant leur utilit et valeur), Canadian Art Therapy Association Journal, 28:1-2, 43-50, DOI:
10.1080/08322473.2015.1100581
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CANADIAN ART THERAPY ASSOCIATION JOURNAL

2015, VOL. 28, NOS. 12, 4350
http://dx.doi.org/10.1080/08322473.2015.1100581

Expressive Therapies Continuum: Use and Value Demonstrated With Case Study

rapies par lexpression : e

tude de cas de

montrant leur
(Le continuum des the

et valeur)
utilite
Lisa D. Hinz
ABSTRACT

Downloaded by [Lisa Hinz] at 16:05 18 December 2015

The Expressive Therapies Continuum (ETC) is a theoretical and practical structure to describe the
ways in which clients process information during their interactions with art materials. The means by
which clients use art materials to form images in art therapy are reective of the ways that they
think, feel, and act in their lives, and thus give information about strengths and challenges, starting
points for therapy, and directions and goals for treatment. The ETC offers a method for
conceptualizing how and why particular art interactions can be therapeutic. It provides a framework
for communicating with clients, fellow art therapists and other professional about the therapeutic
uses of art materials and processes.




RESUM
E

Le continuum des th
erapies par lexpression est une structure th

eorique et pratique pour d

ecrire la
fac on dont les clients traitent linformation au cours de leurs interactions avec le mat

eriel dart. En
art th
erapie, les moyens dutilisation de ce mat
eriel par les clients pour former des images re
etent
leurs fac ons de penser, sentir et agir dans leur vie, offrant donc une fen^
etre sur leurs forces et d

es,
les points de d
epart et orientations possibles pour la th

erapie ainsi que les objectifs de traitement.
Le continuum propose une m
ethode pour conceptualiser comment et pourquoi certaines
interactions a travers lart peuvent ^etre th
erapeutiques. Il fournit un cadre pour communiquer avec
les clients, collegues art-th
erapeutes et autres professionnels sur les usages th

erapeutiques du
mat
eriel et des proc
ed
es artistiques.

The Expressive Therapies Continuum (ETC) is a

foundational theory in the eld of art therapy. First
formulated by Kagin and Lusebrink (1978) and further developed by Lusebrink (1990, 1991, 2004), the
ETC offers an explanation about how people interact
with art materials to process information and form
images. The way in which clients interact with various
media in art therapy is hypothesized to parallel the
ways that they process information in other areas of
their lives to reect how clients think, feel, and behave.
The ETC is a transtheoretical organizing system that
provides a language to facilitate communication across
diverse approaches to art therapy. With a common
language, different therapeutic methods and effects
can be easily understood, respected, and shared (Hinz,
2009c). In addition, knowledge of the ETC can promote communication between art therapists and their
clients, as they share a language of therapeutic goals
based on art materials and processes. The art therapist
can help clients appreciate when they need to release

energy and thus help them to request Kinesthetic

work, or when they need relaxation to ask for meditative materials and methods (Hinz, 2009b). Finally,
knowledge of the ETC can foster communication
between art therapists and other professionals.
The Expressive Therapies Continuum is represented schematically in Figure 1. Components on the
left side of the diagram are hypothesized to correspond to left-brain hemisphere functions that are
sequential, language-oriented, and logical. Functions
on the right side correspond to right-brain hemisphere
functions and are described as intuitive, visual-spatial,
emotional, and spiritual. The ETC is a hierarchical
structure that represents a developmental sequence of
image formation and information processing (Lusebrink, 1990).
Processing develops from simple kinesthetic and
sensory activities at the bottom of the diagram, to
sophisticated interactions involving complex thought
processes at the top. The Kinesthetic/Sensory level

Color versions of one or more of the gures in the article can be found online at www.tandfonline.com/ucat.
2015 Canadian Art Therapy Association

Downloaded by [Lisa Hinz] at 16:05 18 December 2015

44

L. D. HINZ

reects the way that infants and toddlers process

information through motion and sensation. Information gathered through these channels does not require
words; it is characterized predominately by movement. In addition, it is rhythmic, tactile, and sensual.
Progressing up the developmental hierarchy, information processing and image formation on the Perceptual/Affective level may or may not need words. It
can be emotional and without form on the Affective
side of the level or be characterized by the creation of
precisely formed images on the opposite side. The
functions represented on the Cognitive/Symbolic level
of the ETC are complex and sophisticated. They
require higher level cognitive functioning and intricate, multilayered symbols (Hinz, 2009a; Kagin &
Lusebrink, 1978; Lusebrink, 1990). Each level and
component will be discussed in more depth below.
The components on each level are related in an
inverted-U shaped relationship. As information processing on one component increases, it at rst amplies
functioning on the opposite side to an optimal point,
then decreases it and can eventually block opposite
component functioning. A well-functioning individual
is able to gather and process information on all levels
and with all components of the ETC in a dynamic balance. Individuals presenting for art therapy show
blocked, overused, or disconnected components. The
goal of art therapy guided by the ETC is to help clients
gain access to information processing with all components. Although the word hierarchical is used to
describe the ETC, no particular component or level is
seen as more or less valuable; all are important and
each component of the ETC possesses a healing function and an emergent function that can be used therapeutically (Hinz, 2009a; Lusebrink, 1990, 2004). The
ETC components are discussed separately in this article; however, due to the nature of art media and individual differences in response to art materials and
processes, it is difcult for the art therapist to provide
pure experiences with a single component.

Kinesthetic/Sensory level
The Kinesthetic/Sensory level of the ETC provides
experiences through vigorous movement and various
sensory activities. Because the focus is on action or sensation, art media may simply serve as facilitators of
action such as tearing, tapping, or touching (Hinz,
2009a; Lusebrink, 1990). On the Kinesthetic side of this

level, motor movement is emphasized. Some healing

functions of movement are the release of energy and
tension, muscle relaxation, and self-soothing through
rhythm and movement. In addition, an emphasis on
movement can help clients break through physical and
psychological numbing (Badenoch, 2008). A wide
range of experiences through art are supported through
movement-focused art therapy. Vigorous art activity
with the Kinesthetic component can give clients the
opportunity to let go of inhibitions and control, or can
allow clients to experience alternating inhibition and
disinhibition: consciously experimenting with acting
out through art and regaining control of behavior. In
addition, recent neurological research has shown that
the motor and affective aspects accompanying the acts
of drawing and sculpting can produce a state of relaxation (Belkofer, Van Hecke, & Konopka, 2014; Kruk,
Aravich, Deaver, & deBeus, 2014).
The Sensory component refers to the tactile and
haptic senses or any other sensation experienced while
interacting with art media. The healing functions of
Sensory work include discovering, valuing, and
expressing inner sensations, as well as increasing tolerance for internal and external sensation (Hinz, 2009a;
Lusebrink, 1990). Clients also can learn to manage
internal sensation by externalizing it through the use
of art, or to manage external sensation by channeling
it through art making (Chapman, 2014). In addition,
Sensory experiences can lead to reduced dependence
on poor coping skills such as substance use to provide
or manage sensation (Hinz, 2009b). It can support
self-soothing through the use of sensation, and
increase life enrichment through helping clients value
and savor sensation (Hinz, 2015). Stimulating sensory-based art therapy can aid sensory integration
(Chapman, 2014; Hinz, 2009a).
Due to the inverse relationship between the two
components, as movement becomes more active and
energetic (K increases), the ability to discriminate ne
sensations is naturally reduced (S decreases). Alternatively, as involvement with sensation becomes the
focus of art therapy (S increases), movement slows
down and eventually stops (K decreases). Examples of
Kinesthetic work include forceful work with hard clay
or other resistive materials, scribbles on large paper,
vigorous tearing of paper and other experiences where
movement is the predominant activity. Sensory activities include nger painting and blending pastels with
ngers, working with soft, wet clay, and textile work.

CANADIAN ART THERAPY ASSOCIATION JOURNAL

When working with the Kinesthetic/Sensory level, the

art process often is more important than the art product. In fact, people frequently leave art products
behind or throw them away (Snir & Regev, 2013). The
emergent functions of the Kinesthetic/Sensory level
are the perception of form and/or the awareness and
experience of emotion.

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Perceptual/Affective level
The Perceptual/Affective level represents the interaction between awareness and use of formal art elements
on the (P) side and the experience of emotions on the
(A) side. Fluid media and bright or intense colors
evoke Affective functioning (Ichiki & Hinz, 2015;
Lusebrink, 1990).
As involvement with emotion increases (A), the
ability to use the formal art elements to organize
images (P) decreases. On the other hand, involvement
with form (P increases) can reduce the experience of
emotion (A decreases). Healing functions of the Affective component relate to understanding the purpose
and function of emotions. Working with the Affective
component can increase clients ability to identify and
discriminate among emotions. It also will aid clients
in expressing and soothing emotions appropriately
through art making and other creative endeavors.
The Perceptual component focuses on the formal
or structural qualities of images such as dening
boundaries, differentiating form, and striving to
achieve an appropriate representation of an internal
or external experience (Lusebrink, 1990). Work with
the Perceptual component emphasizes that the organization of stimuli and the formation of good gestalts
are healing. Other healing qualities of this work
include the increased internal organization that comes
from focusing on formal art elements (line, shape, and
pattern): perceiving order out of the chaos of emotions
often ooding the therapy-seeking person. Perceptual
work also aids in the clarication of relations between
parts of a problem, the development of relational
diversity, or the ability to take another persons perspective, and the reduction of stress through the focus
on formal art elements (Babouchkina & Robbins,
2015; Bell & Robbins, 2007; Curry & Kasser, 2005;
Drake, Coleman, & Winner, 2011).
Form gives structure to or can contain emotion as is
seen when stress and anxiety are reduced by coloring
mandalas (Babouchkina & Robbins, 2015; Bell &

45

Robbins, 2007; Curry & Kasser, 2005; Drake et al.,

2011). Alternatively, involvement with affect causes
form to become less important in the nished image;
art can be used as a splurge of emotion.
What can emerge from work with the Perceptual/
Affective level is clarity of thought about emotions,
symbol formation, greater self-awareness, and
empathic self-understanding. Affective art directives
include depicting four primary emotions and painting
a feeling. Examples of Perceptual activities include
representational drawing from life, contour drawings,
or nding form in a scribble.

Cognitive/Symbolic level
Work on the Cognitive/Symbolic component is the
most sophisticated type of information processing,
encompassing abstract and anticipatory operations
with images, symbol formation, and the corresponding verbalizations describing these multifaceted experiences (Lusebrink, 1990). When form
takes on personal or universal meaning, the Symbolic component is accessed. This component
focuses on intuitive concept formation and the
symbolic expression of meaning. Abstract painting,
sponge painting, and blot painting often produce
ambiguous forms that allow for the creation of
symbols. The healing function of the Symbolic
component is the ability to understand and prot
from personal and universal symbolic meaning.
Symbol mastery can support psychological growth
through the consolidation and deepening of personal meaning through understanding universal
symbols and themes. Additional benets include
learning to live with ambiguity and increasing clients ability to nd meaning in suffering.
The healing functions of the Cognitive component
are those that support greater executive functioning.
Cognitive activities can increase planning and problem-solving abilities, support decision-making skills,
promote cause and effect thinking, and improve delay
of gratication. Cognitive art therapy also teaches and
reinforces cognitive restructuring (Steele & Kuban,
2012). The planning abilities required for complex art
tasks evoke cognitive processes.
Collage is a classic cognitive art therapy intervention. Collage requires the selection, preparation,
arrangement, and xing of images to produce a personally meaningful product. Completing this multistep

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46

L. D. HINZ

process calls for complex thought processes. Often

words are included in collage, which heightens the
cognitive aspects of the activity. The Cognitive component emphasizes left-hemisphere thought that is
slow, deliberate, and effortful.
Symbolic thought is more focused in the right hemisphere: quick and intuitive. When one is engaged in
effortful, explicit thought (C increases), it is not likely
that quick ashes of insight will occur (S decreases)
and vice versa (Kahneman, 2011). Mask making and
self-portraiture are examples of Symbolic art interventions. The emergent function of Symbolic work is the
acceptance of previously disowned or shadow parts of
the self that play a role in personal discomfort. What
can emerge from work with the Cognitive component
is the ability to generalize from one tangible experience
to othersto abstract beyond the current situation.

Creative level
Creative activity emphasizes synthesis or putting it all
together, and the self-actualizing forces of the ego and
the self (Lusebrink, 1990). A Creative experience may
take place on any level of the ETC or encompass functioning from all levels. Any medium can be used in a
creative way. The healing function of the Creative level
has been dened as inventive and resourceful interactions with the environment leading to creative selfactualizing experiences (Lusebrink, 1990). Frequently,
through Creative activity, the clients experience aha

Figure 1. The Expressive Therapies Continuum.

moments of self-realization or ah moments of perfect

expression (Hinz, 2012). What can emerge from the
Creative level is an experience of ow that requires
problem solving, goal adjusting, challenge and mastery
(Chilton, 2013; Lee, 2013). Flow experiences are characterized by focused attention, an altered sense of time,
moments of peak joy, and long-lasting periods of wellbeing (Csikszentmihalyi, 1998). It is hypothesized that
work that evokes the Creative level also can positively
increase clients therapeutic experiences, and promote
growth in areas related to symptoms and underlying
causes of previous trauma (Lee, 2013; Lusebrink &
Hinz, in press).

Therapeutic uses of ETC

Knowledge of the ETC allows art therapists to develop
a starting place for therapy, treatment goals, and pathways for change (Lusebrink, 2010). Preferred ETC
component use can be determined through an assessment phase in the rst art therapy sessions allowing
clients free access to art materials and tasks. The rst
images in art therapy will reveal clients ETC component use through media choices, expressive style, and
content (Hinz, 2009a; Lusebrink, 2010). These revelations will point to the clients strengths and areas that
need support. Work in the rst art therapy sessions
will expose overused, underused, blocked, or disconnected components.

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CANADIAN ART THERAPY ASSOCIATION JOURNAL

It is important to begin treatment with the clients

preferred component of the ETC. The thoughtful
choice of materials and methods matching the clients
strengths demonstrates understanding and respect; it
lessens the clients resistance to unfamiliar processes
and increases the likelihood of therapeutic success
(Hinz, 2009a). Results of a free art assessment provide
information about therapeutic direction for optimal
results.
Therapeutic movement can proceed in a top-down
direction as clients who are overly cerebral are invited
to gain greater access to emotion, change typical perceptions, or value the wisdom of the body. A bottomup therapeutic approach can help overly active or
emotional clients gain more cognitive control over
their feelings or behavior. Additionally, movement
could be in a horizontal direction as the use of any
opposing component process encourages decreased
functioning on the opposite side. The following case
study will demonstrate that art therapy guided by the
ETC begins where the client is comfortable and proceeds with the gradual introduction of new media,
directives, and discussion to gently reduce overused
functions and/or increase underused or blocked ones.

Case study
The following case is based on a real person who graciously gave her written consent to have the details of
her case and her artwork used for this purpose; her
name and identifying information have been changed
to protect her identity. The client, Ashley, was a single
Caucasian female, 26 years old. Ashley was a patient
in an addictions treatment program. She was referred
by her parents after a second drunk driving charge in
three years. Her rst image in art therapy (see Figure 2)

Figure 2. First image in art therapy: Collage with one added

element.

47

Figure 3. Collage with one image and one word.

was a collage in which Ashley added the gure of a

hand made out of tissue paper to an existing magazine
picture. She explained that the hand exemplied that
she felt controlled by alcohol and that her life was
unmanageable. Ashleys second work (not pictured)
was a collage in which she again combined two
images. She placed a baby on top of a temple and said
that she believed that this collage represented her
infant spirituality, which needed care in order to grow
and support her in recovery. The third image was the
collage shown in Figure 3 in which the client used one
word and one image to communicate her commitment to personal growth and healing. In examining
the rst three images created in art therapythe use
of collage, words, and symbolsit appeared that Ashley favored the Cognitive/Symbolic level. In addition,
she used high arousal colors in each of the images,
which hinted at hidden emotions needing expression.
The starting point for art therapy was the C/S level,
and Ashley continued to create collages that reected
the 12 steps. At the same time, Ashley was taught the
structure of the ETC and basic media properties. The
art therapist discussed therapeutic goals and directions

48

L. D. HINZ

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Figure 5. Expression of feeling.

Figure 4. Representational self-portrait.

with Ashley, and she agreed that movement to the

Affective component would encourage greater access
to emotions.
The client stated that in her strictly religious family
of origin, people did not express emotions and therefore she was wary to do so. However, Ashley chose a
uid medium to create a watercolor mandala. After
she completed the image (not pictured) Ashley
described it not as expressing emotion but as a symbolic self-portrait. She explained that she was sunny
on the outside; no one would guess that I had a problem, but dark on the inside, close to the core. She
added that she wanted to believe that she was fundamentally good, so the actual core of her was yellow,
not black. The client chose chalk pastels for her next
image and created the representational self-portrait
pictured in Figure 4. Having completed the image,

Ashley indicated that there was something that she

was feeling, but that she did not know what it was or
how to express it. The therapist talked with Ashley
about experimenting with color, reducing the use of
form, believing that this would help evoke emotion. It
is possible that the use of vigorous Kinesthetic work
might have had a similar effect, but in order to keep
the therapeutic process nonthreatening, it was decided
to stay close to the ETC level where Ashley was comfortable (C/S). Oil pastels require somewhat more
effort to use and blend than chalk pastels; the therapist
recommended the use of this slightly resistive media
oil pastelsto evoke increased emotional responding.
The client was asked to experiment with color
without regard to form on a 12 by 18 inch paper.
After a brief introduction to the medium, she took
approximately 30 minutes to ll the entire paper
shown in Figure 5, drawing and redrawing various
spaces with progressively darker colors. Ashley began
to shed tears halfway through this image. She disclosed that her image reminded her of feelings and
facts about an abortion she had during her rst year at
university.
Ashley talked about how lonely and depressed she
felt at the time, sure that she could not tell her religious parents about her pregnancy. She said that she
felt coerced to have the abortion by her boyfriend, the
dormitory residence advisor, and even the abortion
clinic staff. Ashley described feeling shame, guilt, and
more depression afterward. She reported that she
began drinking alcohol as a way to not experience

CANADIAN ART THERAPY ASSOCIATION JOURNAL

these emotions. The art therapist continued to urge

Ashley to experiment with oil pastels and other richly
colored media, and to discuss whatever topics came
up as a result. In this manner, Ashley processed many
feelings about her past abortion and perceived abandonment. She gained much greater access to her emotions. In addition, Ashley learned that she could use
art at any time to aid emotion regulation.

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Conclusions
The ETC is a model that helps clarify how clients process information to form images during interactions
with art materials. The ETC proposes a model that
frames a practical way of working with clients in art
therapy. Using a clients preferred component of the
ETC as a starting place in therapy is a respectful way
to help clients feel understood and valued, and it
reduces time spent in trial and error trying to determine an effective intervention (Hinz, 2009a). The
ETC provides a framework for communicating with
art therapists and other professionals about client
interactions in art therapy. Additionally, it can aid clients in discussing their needs in therapy. Teaching clients about media properties and how they function to
release or contain emotion, to further cognitive or
symbolic processing, or to help with energy release
and body awareness makes clients active partners in
their art therapy (Hinz, 2009b).

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