Integrating Expressive Arts and Play Therapy with Children and Adolescents -  - ebook

Integrating Expressive Arts and Play Therapy with Children and Adolescents ebook

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Praise for Integrating Expressive Arts and Play Therapy WithChildren and Adolescents "With this book, Drs. Green and Drewes have filled an importantvoid in the play therapy literature, namely the integration of theexpressive arts in play therapy with children and adolescents. Theyhave assembled the best theorists and practitioners of theexpressive arts and given them an appropriate structure to writetheir chapters. The book is outstanding and provides readers within-depth case studies, detailed methodologies, research findingsand is a useful resource for further training options. I recommendthis book most highly for trainers, practitioners, and graduatestudents." --John Allan, PhD, Professor Emeritus of Counseling Psychology,University of British Columbia, author, Inscapes of the Child'sWorld "Brimming with chapters by 'oracles' from various disciplines,Green and Drewes' guidebook articulates essential competencies forthe cross-disciplinary practice of play therapy and expressive artstherapies. Practical and timely, responsible and readable, it is animportant resource for the mental health community and students whoseek to work creatively with children. A significant contributiontoward bringing professionals and professions together to learnfrom one another." --Barry M. Cohen, MA, ATR-BC, founder, Expressive TherapiesSummit, cofounder, Mid-Atlantic Play Therapy Training Institute Interventions and approaches from the expressive arts andplay therapy disciplines Integrating Expressive Arts and Play Therapy With Children andAdolescents presents techniques and approaches from the expressiveand play therapy disciplines that enable child and adolescentclinicians to augment their therapeutic toolkit within a competent,research-based practice. With contributions representing a "who's who" in the playtherapy and expressive arts therapy worlds, IntegratingExpressive Arts and Play Therapy With Children and Adolescentsis the definitive bridge between expressive arts and play therapycomplementarily utilized with children and adolescents in theirhealing and creative capacities.

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About the Editors

About the Contributors

Chapter 1: The Expressive Arts Therapy Continuum: History and Theory


Media Dimension Variables

Discerning Rationale


Chapter 2: Play Therapy


Rationale for Play Therapy

History and Development

Empirical Support

Procedures and Application


Specialized Training and Resources


Chapter 3: Art Therapy


Art Therapy: Theory


Art Therapy: Process and Procedures

Practical Techniques


Specialized Training and Resources


Chapter 4: Drama Therapy


Drama Therapy: Process and Procedures

Blending Drama/Theatre and Therapy in NADTA

Effects of Attachment and a Nurturing Environment on the Ability to Work and Play

Drama Therapy Techniques

Drama Therapy Techniques With Different Ages


Specialized Training and Resources


Chapter 5: Integrating Play Therapy and Sandplay Therapy


Therapeutic Play

Sandplay in a Play Therapy Setting


Specialized Training and Resources


Chapter 6: Working With Children Using Dance/Movement Therapy


Dance/Movement Therapy: Process and Procedures

Case Studies


Specialized Training and Resources


Chapter 7: Music Therapy


Music Therapy: Process and Procedures

Music Therapy Methods

Practical Techniques for Nonspecialists


Specialized Training and Resources


Chapter 8: The Therapeutic Uses of Photography in Play Therapy


Historical Overview

Photography as a Therapeutic Modality: The Power of the Image

The Importance of the Unconscious

The Range of Processing Visual Metaphors

A Note of Caution

Technological Update

Special Considerations of Confidentiality

Suggestions for Creative Project Directives

Detailed Digital Editing Directions for More Advanced Projects

Case Studies: Clinical and Creative Uses of Photography


Specialized Training and Resources


Chapter 9: Poetry Therapy


Poetry Therapy: Process and Procedures

Practical Techniques and Case Studies


Specialized Trainings and Resources


Chapter 10: Integrating Play and Expressive Art Therapy Into Educational Settings: A Pedagogy for Optimistic Therapists

Introduction to Creative Experiential Learning




CEL Classroom Scenario



Chapter 11: Integrating Play and Expressive Art Therapy Into Small Group Counseling With Preadolescents: A Humanistic Approach


Integrating Play and Expressive Art Therapy Into Small Group Counseling with Preadolescents: Process and Procedures

Practical Application



Chapter 12: Integrating Play and Expressive Art Therapy Into Communities: A Multimodal Approach



School Community Response

Shattered Worldview

Expressive Therapies Haven


Author Index

Subject Index

Cover Design: Andrew Liefer

Comer Image: Kriss Russell/

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Library of Congress Cataloging-in-Publication Data

Integrating expressive arts and play therapy with children and adolescents / [edited by] Eric J. Green and Athena A. Drewes.

1 online resource.

Includes bibliographical references and index.

Description based on print version record and CIP data provided by publisher; resource not viewed.

ISBN 978-1-118-77544-8 (ebk) — ISBN 978-1-118-77561-5 (ebk) — ISBN 978-1-118-52798-6 (pbk)

1. Arts—Therapeutic use. 2. Play therapy. 3. Performing arts—Therapeutic use. 4. Psychotherapy—Practice. I. Green, Eric J., editor of compilation. II. Drewes, Athena A., 1948– editor of compilation.




Eric J. Green

To my young nieces, nephews, and godchildren:

Maddy, Lily, Isabel, Oscar, Katelyn, London, Levi,

Cameron, & Zach. Thank you for teaching Uncle

Eric the true and amazing power of play. I love you!

Athena A. Drewes

To my sons, Scott Richard Bridges and Seth Andrew

Bridges, from whom I draw inspiration and love that sustains

me through all that I do! You are my pride and joy!


Welcome to Integrating Expressive Arts and Play Therapy With Children and Adolescents. The premise of this book began as an idea in October 2010 at the Association for Play Therapy’s Annual Conference in Sacramento, California. Rachel Livsey, Senior Editor at John Wiley, approached me (Green) with an idea. She inquired about my interest in compiling a resource-type book integrating the expressive arts and play therapy frameworks so that clinicians would have ease of access to the ethical considerations and competency implications when developing a multimodal treatment stance.

Little has been written in the literature regarding clinicians seeking to competently integrate the expressive arts into their child play psychotherapy practice. At first, I was ecstatic about the idea. This could be another opportunity for our disciplines to bridge commonalties under the expressive art therapy umbrella, as opposed to us looking at the negatives and the deficits in each other and our training. Sometimes we engage in anxiety-driven, petty turf wars, where unchallenged ideology and rigid doctrine blinds us to the real mission of why we’re here in the first place. At this point, I also instinctively knew this project was going to have a bit of a synergistic element, and so it began. First, I implored Athena Drewes to co-edit the volume with me. We sought out the consult of one of the gurus in the expressive arts field, Barry Cohen, who hosts the annual Expressive Arts Therapy Summit in New York City. This summit is a conference where therapists from all of the expressive arts disciplines from all over the world come together to provide trainings from their respective fields of expertise. This is when the book began to take its shape, focus, and soul.

This guidebook’s overall premise is meant as a practical illustration for child-based mental health clinicians to competently integrate interventions and approaches from the expressive arts and play therapy disciplines. Moreover, we compiled this volume so that clinicians and graduate students in mental health programs can augment their therapeutic toolkit and training within a competent, research-based practice. The second aim of the book is to provide a resource guide and practical textbook for educators in university settings who teach either play therapy or one of the disciplines in the expressive arts that seek to integrate disciplines for holistic care of children, adolescents, and families. We have found that clinicians who are certified in the expressive art therapies are typically unfamiliar with some of the interventions and approaches used in play therapy, and vice versa. Therefore, we hope this book will be a bridge between the expressive art therapies and play, as they are therapeutic modalities utilized with children that are complementary in their healing and creative capacities. Play therapists who utilize techniques from the expressive arts disciplines may benefit from exposure to the diverse and innovative approaches within the expressive arts literature that this book presents.

We hope that, after reading this resource book, child and adolescent mental health clinicians, play therapists and clinical supervisors, graduate students in mental health programs, and university educators will become interested in—or in some cases, maybe even become aware of for the first time—a specific expressive art area(s) and seek training or supervised practice to competently employ it with children. This was our singular passion behind writing this project. Although neither Athena nor I claim to be experts in expressive arts, we are licensed mental health clinicians and Registered Play Therapist-Supervisors (RPT-S) who integrate expressive art therapy interventions into our clinical work with children and families. With this transparency and humility, we sought the originators/creators of the distinct areas of the expressive arts, or the leading U.S. authorities in their respective expressive art therapy modalities, to contribute chapters on the subject matter. The contributors comprise a diverse geographic pool across the United States. By utilizing contributors who are leading scholars from the expressive arts and play therapy disciplines, the book presents a unique crossover appeal to clinicians who have one foot in one of the disciplines and want to plant their foot in the other.

This book consists of two introductory chapters. The first chapter highlights the history and spectrum of the expressive art therapies, by one of the leading gurus in the expressive arts therapy field. The second chapter gives an overview of play therapy and its integration of expressive arts interventions through the lens of four major theories. The book then delves into the major disciplines of the expressive arts as distinct chapters. It covers the wide spectrum of art, drama, sandplay, dance/movement, music, photography, and poetry. The book concludes with three chapters integrating the disciplines, specifically in play therapy treatment, for clinical and educational settings.

All of the chapters focus on explicating the respective expressive art therapy modality in a clear, straightforward manner, along with case examples and applications. The majority of the chapters offer practical techniques that can be safely and ethically applied so that clinicians, students, and educators can use this book as a resource to augment their clinical practice. Each chapter also contains information about becoming credentialed in the respective discipline. A resource appendix appears at the end of each chapter to illustrate the systematic nature of simultaneous curricular and supervised experiential training required with all of the respective expressive art therapy disciplines.

One of the core concerns in writing this book was the attention to and mindfulness required by child-based clinicians of ethical and supervision implications in practicing outside one’s training and scope of practice. This book seeks to address cross-disciplinary core competency issues while offering clinicians practical ways to apply expressive arts techniques to further enhance their treatment modality with children and families. Readers are urged to seek outside supervision regarding use of applications from disciplines beyond their training. Also, this book is by no means a substitute for what constitutes best practices when learning new areas within the field of mental health counseling: formal education/training, supervised practice, and critical reflectivity/therapist-initiated inner work. The significance of engaging in ongoing reflectivity in our archetypal role as the “wounded healer” expands our collective awareness and calls us to be responsible, progressive, and endlessly curious. The childlike puer aeternus calls us to forgo complacent behaviors and to seek new aspects of our field, new paradigms validated by research, and new paths to take that may lead us to understandings of ourselves and our patients that could deepen our work with them.

In conclusion, we hope that readers will find comfort and creativity in this book and that it will enrich their child mental health treatment protocol. Last, we honor the paths already illuminated by those who have paved the way before us in these rich traditions of helping others to self-heal through creative media. May all of our work become more interdisciplinary and inclusive. And may we all contribute to cross-fertilization—where the expressive arts, replete with all of its equally important and numerous disciplines, are accessible and beneficial to those very children who need them the most. Let us now “play on,” and begin the journey of this book.

Eric J. Green

Athena A. Drewes


First and foremost, we’d like to thank our editor, Rachel Livsey, from John Wiley, for believing in this project from the very beginning. Rachel, you were so supportive of this project from its inception that you illuminated the path for it to come to fruition. Thank you for all of your tireless efforts, for your encouragement, for your editorial acumen, and for believing.

We’d also like to thank Eliana Gil, who was consulted very early on and helped the book take shape and focus. Thank you, Eliana, for your selfless contributions behind the scenes that went into helping us envision this book.

Barry M. Cohen, ATR-BC (Expressive Therapies Summit;, you were hugely instrumental in the formation of the content of this book, its focus, and securing the appropriate scholars in their respective disciplines. Thank you for your support and guidance!

We also want to thank all of the contributors of the chapters. It was a humbling experience working with each of you, as you are gurus and legends in your own right. Thank you for your incredible contributions to this volume. Let us all rejoice that we are working together to continue the literature in support of integrative treatment for children and families from the expressive art therapy framework!

And finally, we want to thank all of you, the readers, who support and understand the utility of the expressive arts and the curative power of play therapy to help children and families heal. May this book be a part, however small, in assisting you along the journey in deepening your meaningful and valuable work with children.

Eric J. Green

Athena A. Drewes

About the Editors

Eric J. Green, PhD, LPC-S, RPT-S, LMFT, Certified School Counselor (K–12), is Associate Professor of Counseling at the University of North Texas at Dallas and is also a part-time faculty member and coordinates the annual play therapy institute at the Johns Hopkins University in Baltimore, MD. He has more than 50 professional publications related to children’s mental health, including book chapters, magazine submissions, and peer-reviewed journal articles on play therapy and child-related trauma. He is the author of the upcoming book, Handbook of Jungian Play Therapy (Johns Hopkins University Press), as well as the film, “Jungian Play Therapy and Sandplay” (Alexander Street Press). Dr. Green is a frequently invited speaker at Association for Play Therapy (APT) state branch conferences across the U.S. and internationally. In 2013, some of his keynote speaking events included the Hawaii Association for Play Therapy Annual Conference in Honolulu, Hawaii; the Australia Pacific Play Therapy Association’s Annual 2013 Conference in Gold Coast, Queensland, Australia; and the Canada Association for Child and Parent Therapy 2013 Annual Conference in Niagara Falls, Ontario, Canada. Counselors for Social Justice, a division of the American Counseling Association, presented Eric the O’Hana Award in 2007 and the Mary Smith Arnold Anti-Oppression Award in 2013 for his sustained contributions in mental health advocacy for child trauma survivors. He maintains a part-time, private practice in child and family psychotherapy in Dallas, TX. For more information, visit

Athena A. Drewes, PsyD, RPT-S is a licensed child psychologist, certified school psychologist, and Registered Play Therapist and Supervisor. She is Director of Clinical Training and APA-Accredited Doctoral Internship at Astor Services for Children & Families, a large multiservice nonprofit mental health agency in New York. She has over 30 years of clinical experience in working with sexually abused and traumatized children and adolescents in school, outpatient, and inpatient settings. Dr. Drewes has worked over 17 years with therapeutic foster care children in treatment. Her treatment specialization is children with complex trauma, sexual abuse, and/or attachment issues.

She is a former Board of Director of the Association for Play Therapy (2001–2006) and Founder/Past President of the New York Association for Play Therapy (1994–2000) and its newly elected President. She has written extensively about play therapy, with seven edited books, and has been a sought-after invited guest lecturer throughout the U.S., England, Wales, Taiwan, Australia, Ireland, Argentina, Italy, Denmark, Mexico, and Canada on play therapy

About the Contributors

Sinem Akay, MS, MEd, LPC-Intern, is a doctoral candidate at the University of North Texas counseling program with a specialization in play therapy. Sinem received a Fulbright scholarship after pursuing her master’s degree in clinical psychology in Turkey, and moved to the United States for master’s and PhD degrees in counseling. She has advocated for children throughout her education and provided counseling services in the community and schools. Sinem’s primary area of scholarship includes play therapy for children with perfectionism and chronic illnesses. Sinem also served as Student Director for Texas Association for Play Therapy (TAPT) and Secretary for the North Texas Chapter of TAPT.

Jennifer N. Baggerly, PhD, LPC-S, RPT-S, is a professor and the Chair of the Division of Counseling and Human Services at the University of North Texas at Dallas. She is Chair-elect of the Board of Directors of the Association for Play Therapy (APT). Jennifer is a Licensed Professional Counselor Supervisor and a Registered Play Therapist Supervisor. She has provided play therapy for 18 years in schools and community agencies and teaches play therapy on a regular basis. Dr. Baggerly’s multiple research projects and over 50 publications have led to her being recognized as a prominent play therapy expert.

Sue Bratton, PhD, LPC-S, RPT-S is Professor and Director, Center for Play Therapy, University of North Texas. Dr. Bratton is a nationally and internationally known speaker and author with over 65 publications in the area of play therapy and filial therapy, the majority of which are outcome research. Her most recent books are Child Parent Relationship Therapy (CPRT), CPRT Treatment Manual, Child-Centered Play Therapy Research: The Evidence Base, and Integrative Play Therapy. Dr. Bratton is a Past President of the Association for Play Therapy, recipient of the 2007 APT Outstanding Research Award, 2011 CSI Outstanding Supervisor Award, 2013 ACA Best Practice Award, and 2013 AHC Humanistic Educator/Supervisor Award.

Julia Byers, EdD, LMHC, ATR-BC, is currently a professor and Graduate Art Therapy Program Coordinator, co-chair of the Advanced Professional Certificate in Play Therapy, and PhD Senior Advisor in the Interdisciplinary Studies degree at Lesley University, Cambridge, Massachusetts. With over 35 years of clinical practice, university teaching, and administration, Julia has provided Art/Play Expressive Crisis Intervention Counseling in over 18 countries.

Rebecca C. Chalmers, PsyD, MFA, is a published poet, a clinical psychologist practicing in New York City and Brooklyn, and a full-time faculty member at Brooklyn College, City University of New York (CUNY), in the Department of Psychology, where she teaches psychotherapy, psychopathology, and group processes. She specializes in facilitating, and training others to facilitate, Creative Writing Therapy groups and workshops that focus on strengthening mindfulness, preventing clinician burn out, and enhancing creativity.

Jodi Crane, PhD, LPCC, NCC, RPT-S, is Associate Professor in the School of Professional Counseling at Lindsey Wilson College (Kentucky), where she has been teaching for the past 13 years. She received her play therapy training at the University of North Texas. She is the author of chapters in Gary Landreth’s Innovations in Play Therapy and R. Van Fleet and L. Guerney’s Case Studies in Filial Therapy (with Sue Bratton). She is the first recipient of APT’s Research Grant to complete and publish her research in the International Journal of Play Therapy. She serves on the Board of Directors of APT and is a Past President of the Kentucky Association for Play Therapy. In 2010, she received the Terry Fontenot Play Therapy Award for her service to play therapy in Kentucky.

Harriet S. Friedman is on the teaching faculty of the Jung Institute of Los Angeles. She also served at the Jung Institute as director of the Hilde Kirsch Children’s Center, serving both parents and children. Harriet is a founding member of the Sandplay Therapists of America (STA), serving STA as Board Chair and having served on the board for the International Society of Sandplay Therapists. Along with Rie Rogers Mitchell she co-authored the book, Sandplay: Past, Present and Future (Routledge, 1994) and Supervision of Sandplay Therapy (Routledge, 2007). For the last 25 years she has lectured both nationally and internationally on integrating sandplay and Jungian psychology. She has a private practice in West Los Angeles.

Sandra Graves-Alcorn, PhD, LPAT, is founder of the Master’s program in Art Therapy and Institute in Expressive Therapies at University of Louisville and a Professor Emeritus at the University of Louisville. Also, she is the Past President of the American Art Therapy Association. Currently, she’s in private practice in LaGrange, Kentucky.

Susan Hadley, PhD, MT-BC, is professor of music therapy at Slippery Rock University, Pennsylvania. Her books include Experiencing Race as a Music Therapist: Personal Narratives (2013), Feminist Perspectives in Music Therapy (2006), and Psychodynamic Music Therapy: Case Studies (2003). She co-edited Therapeutic Uses of Rap and Hip Hop (2012) and Narrative Identities: Psychologists Engaged in Self-Construction (2005) with George Yancy. She has published numerous articles, encyclopedic entries, chapters, and reviews in scholarly journals and academic books. Dr. Hadley serves on the editorial boards of several journals and is co-editor-in-chief of the online journal, Voices: A World Forum for Music Therapy.

Dr. Eleanor Irwin, one of the co-founders of the NADT, is also a Child and Adult Psychoanalyst, a Clinical Psychologist, and a TEP Psychodramatist. In addition to being a Clinical Assistant Professor of Psychiatry at the University of Pittsburgh, she is also a Past President of The Pittsburgh Psychoanalytic Center and serves as the Chair of the Child Analysis Committee. She has made films about Expressive Arts Therapies and has published articles and book chapters about assessment and treatment issues. With Dr. Judith Rubin, she is a co-founder of Expressive Media, Inc., a non-profit organization dedicated to teaching and training in the Expressive Arts Therapies.

Diane Kaufman, MD, is the guiding leader of Creative Arts Healthcare—The University Hospital. She is a Child Psychiatrist and Master Clinician at the Rutgers Health Sciences Campus at Newark. She was honored with the Healthcare Foundation of New Jersey’s Leonard Tow Humanism in Medicine Award (2000) and Lester Z. Lieberman Humanism in Healthcare Award (2011). Dr. Kaufman is a published poet, an expressive arts educational facilitator with expertise in poetry as therapy, and author of Cracking Up and Back Again: Transformation Through Poetry, and the children’s story on trauma and resilience, Bird That Wants to Fly. She presents internationally on arts and healing.

Mariah Meyer LeFeber, MA, LPC, BC-DMT, DTRL, is a dance/movement therapist and licensed professional counselor at the Hancock Center for Dance/Movement Therapy in Madison, Wisconsin. She currently works with a variety of ages and diagnoses, although her work on dance/movement therapy and children with autism has been published several times. In addition to her work as a therapist, Mariah teaches modern dance and organizes a community outreach and education program in the dance department at the University of Wisconsin, Madison. She enjoys performing as a modern dancer and dancing for joy’s sake with her husband and two little girls.

Reina Lombardi, MA, ATR-BC, is an art therapist at Delta Family Counseling in Cape Coral, Florida, and at the Knox Academy in Bonita Springs, Florida. She has 10 years of experience working with children in a variety of residential, clinical, and educational settings. She blends client centered and cognitive-behavioral approaches with the expressive therapies in her work with children. Currently, Mrs. Lombardi serves on the board of the Florida Art Therapy Association and as the Social Media Coordinator for the Expressive Therapies Summit.

Dr. Rie Rogers Mitchell is a professor of educational psychology and counseling at California State University at Northridge, where she serves as clinical director and supervisor at the university’s clinic. Dr. Mitchell has been the recipient of several awards at her university, including the University Distinguished Teaching Award and the Dorsey Award for mentoring students in the Educational Opportunity Program. The American Board of Professional Psychology has also awarded her Diplomate status in Counseling Psychology. Dr. Mitchell is a certified sand play therapist and has taught sand play around the world. She has recently been elected President of the International Society of Sandplay Therapists.

Wendy Rosenberg, M.Ed., has been a special educator working with children of all ages for over 20 years. She has brought her love of poetry and poetry therapy techniques into the classroom as well as into homeless shelters, after-school programs, and bereavement workshops. Ms. Rosenberg was the recipient of a Dodge Foundation teacher scholarship to the Fine Arts Work Center. She is a published poet, an Expressive Arts Educational Facilitator, a Certified Applied Poetry Facilitator, a member of the National Association for Poetry Therapy, and a certified Kaizen-Muse Creativity Coach.

Nicole Steele, MT-BC, is a music therapist at the Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania. She received her undergraduate degree in music therapy from Slippery Rock University, Pennsylvania. She has presented at national and regional music therapy conferences as well as medical conferences including the International Transplant Nursing Society Conference.

Dr. Dalena Dillman Taylor is an assistant professor at the University of Central Florida and a Licensed Professional Counselor-Intern. She has extensive clinical experience with play therapy with children, siblings, and families in agencies and schools. She is passionate about the advancement of the counseling field and works to advocate for both the profession and her individual clients. She served as the North Texas Chapter President of the Texas Association for Play Therapy (2012–2013) and is the recipient of the 2012 SACES Emerging Leader Award.

Professor Robert Wolf is a creative art therapist and psychoanalyst with over 35 years of experience in private practice and clinical supervision. He has been on the graduate faculty of The College of New Rochelle, Pratt Institute, and The Training Institute for the National Psychological Association for Psychoanalysis. He is a former Director of the Institute for Expressive Analysis and a past President of the New York Art Therapy Association. He has published numerous professional articles on art therapy, countertransference, expressive therapy, and phototherapy and his work as a fine art sculptor and photographer have been exhibited internationally.

Chapter 1

The Expressive Arts Therapy Continuum: History and Theory1

Sandra L. Graves-Alcorn and Eric J. Green


What are the expressive therapies, and what important clinical information do they contextualize for the creative practitioner? In my opinion, we become therapists and utilize expressive art therapies to help others make changes in their lives and guide them toward happier and more fulfilling existences. There are many avenues within the therapeutic milieu to achieve this end. Although the theoretical foundations are often similar, the methods of caregiving to our clients change with our training and chosen area of expertise. Becoming an expressive art therapist and play therapist with children requires accumulating an arsenal of diverse, creative strategies to help clients communicate their experiences and feelings in nonverbal, less threatening ways. It also requires competency based on specified training, credentialing, supervised practice, and ongoing professional development.

Traditional talk therapy alone is generally unsuccessful when working with children and adolescents, especially within the developmental context of young childhood (Green, 2010). Play is a child’s work. Toys are their words and play is their language (Landreth, 2012). As an adult, play becomes a necessary balancing act to mitigate typical psychosocial stressors, often bringing out the “natural child” in each of us. Within the venue of play, we find multimedia and multidisciplinary fields. That is not to say that all of the expressive, creative therapies are a form of play therapy, especially given the credentialing and specificity of studies in each professional arena, but for the sake of simplicity and also as a rationale for why we are integrating these fields in this book, I am going to approach integration by highlighting the similarities. I will be explaining the Expressive Therapies Continuum in this chapter as an attempt to lay a foundation of synthesis so all of the therapies can be understood as simply as possible and to formulate a way for the clinician to plan treatment based on integrated theories.

The following definitions of four of the separate disciplines—art therapy, music therapy, drama therapy, and dance therapy—will lead us to what they all have in common and what differences need to be learned in order to be an effective therapist. For the professional standards and criteria, refer to the Specialized Training and Resources section at the end of most chapters for a list of websites and credentialing processes. The information contained in the following four paragraphs was adapted from Expressive Therapy (2013):

Art Therapy, sometimes called creative arts therapy or expressive arts therapy, encourages people to express and understand emotions through artistic expression and through the creative process. Art therapy provides the client-artist with critical insight into emotions, thoughts, and feelings. Key benefits of the art therapy process include: (a) self-discovery, (b) personal fulfillment, (c) empowerment, (d) relaxation and stress relief, and (e) symptom relief and physical rehabilitation.
Music Therapy is one of the expressive therapies consisting of an interpersonal process in which a trained music therapist uses music to help clients improve their psychological functioning, cognitive functioning, motor skills, emotional and affective development, behavior and social skills, and quality of life. Music therapists employ (a) free improvisation, (b) singing, (c) songwriting, (d) listening to and discussing music, and (e) moving to music to achieve treatment goals and objectives. Music therapy is used in some medical hospitals, cancer centers, schools, alcohol and drug recovery programs, psychiatric hospitals, and correctional facilities.
Dance-Movement Therapy (DMT), or Dance Therapy, is the psychotherapeutic use of movement and dance that influences emotional, cognitive, social, and behavioral forms of functioning. As an expressive therapy, DMT assumes that movement and emotion are directly related. The purpose of DMT is to find a healthy balance and sense of wholeness. DMT is practiced in places such as mental health rehabilitation centers, medical and educational settings, nursing homes, day care facilities, and other health promotion programs.
Drama Therapy is the use of theatre techniques to facilitate personal growth and promote mental health. Drama therapy is used in a wide variety of settings, including hospitals, schools, mental health centers, prisons, and businesses. The modern use of dramatic process and theatre as a therapeutic intervention began with Psychodrama. The field has expanded to allow many forms of theatrical interventions as therapy, including role-play, theatre games, group-dynamic games, mime, puppetry, and other improvisational techniques.


In my early pioneering years, I was struck by how expressive arts media had a direct effect on the healing process. So I went about exploring through scientific inquiry and developed what became known as Media Dimension Variables, which later transmuted into the Expressive Therapies Continuum. I will briefly overview my seminal research in the expressive arts field. Next, I will explain how the media from each expressive arts therapy field can have similar characteristics developmentally and how to incorporate this data clinically.

Early on I defined the use of art and craft materials in therapeutic service as an exploitation of media dimension variables (MDV) (Graves, 1969). MDV were those qualities or properties inherent in a given medium and process utilized in a therapeutic or educational context to evaluate and/or elicit a desired response from an individual (Kagin, 1969). The premises on which the concept of MDV were developed were that (a) the reinforcement value of making art is inherently a therapeutic process; (b) all individuals can be creative to some degree; (c) dimensions of art media are discernible and can be classified; and (d) media dimensions can be therapeutically applied.

Creativity elucidates a modification of behavior. Creativity, therefore, is a compilation of unconscious and/or conscious information channeled into some overt action (Kagin, 1969). A type of cause-and-effect relationship transpires when individuals engage in creative processes that are based on an energy source (motivation) and a data retrieval system leading to problem solving. This original concept was, at that time, based on Guilford’s (1965) model for creative performance, which encompassed a need for individuals to experience achievement or self-esteem, a need for expression, and a need for producing order (homeostasis in the organism). This creativity was determined by the efficiency with which an individual was able to bring schemata, or information, out of storage for indirect use in coping with situations. Guilford (1965) further divided memory storage into various classes, one of which was visual-figural data, which we see manifest in graphic expression as line, form, and shading.

Art is generally thought to be a socially acceptable mode of creative performance, which may provide enough satisfaction to channel otherwise destructive and/or antisocial actions into constructive and appropriate channels, as well as alleviate emotional distress. There is an unconscious attempt by an individual when creating art to build schemata. This process increases environmental awareness and heightens self-esteem, thus aiding the efficiency with which schemata are used. Ultimately, art making can be viewed as a perpetuating creative cycle (Kagin, 1969).

The theoretical underpinnings of art therapy in the early years of its professional development were that the projections of unconscious material, aided by the spontaneity of graphic expression, would assist the client to gain awareness and insight into inner conflicts that needed resolution. Little attention was given to the media by which these projections were promoted. I, therefore, began looking at specific properties of art media and attempted to hypothesize general emotional or other behavioral responses.

No attention had been given in the literature to different responses when directions were given or not given on the subject or use of the media, or how difficult and complex a project might be and whether it would therefore be suitable for any one individual or group. I also was looking at the physical properties of media, such as fluidity, malleability, indestructibility, expansiveness, unpredictability, and adaptability. Three generalized variables were delineated: (1) structure, (2) task complexity, and (3) media properties.

Media whose properties were soft, aqueous, malleable, and easy to manipulate, such as finger paint, soft clay, polymer acrylics, and so on, were in the fluid range. Resistive materials were defined as hard, brittle, slightly pliable to nonmalleable, and difficult to manipulate, such as hard or highly gorged clay, metal, wood, poster boards, heavier papers, pencils, and so on. A project was considered of high complexity when three or more sequential steps were required for completion, not to include simple repetition of a single process (such as pounding a nail), or of low complexity if the project required only one or two steps.

The difference between the structured and unstructured projects was primarily one of direction. The unstructured goals for completion were left up to the individual, and the instructions were simple (e.g., “Paint anything you wish,” “Put the metal on the board in any design you like”). The structured task was presented in a manner designed to leave little, if any, choice in the results of manipulating the materials. Specific directions on how to use the materials resulted in what would be achieved.

The following MDV examples survived not only my thesis study, but also continued on to become part of the curriculum of the Art Therapy Master’s degree at the University of Louisville and then an integral and defining element in the Expressive Therapies Continuum (ETC). It is therefore important to understand these combinations and concepts. When I taught the Methodology lab, I required students to use index cards and a portfolio to dissect each intervention into the MDV, ETC, description of materials used, the procedure and directions for each project, its rationale targeting specific populations or areas of concern to the therapeutic process, and personal reflections as the project affected the student.

Here are some examples from the original projects of my study, which questioned whether different media variables affected verbal communication. Each project was first demonstrated to each participant. The demonstration may or may not be necessary, depending on the person doing the project and the rationale for using it. I am including the instructions and description of materials because it is important that the best media you can afford is used. Many experiences fail for lack of quality media or specificity of instructions. For the sake of space and to remain focused on this chapter’s aim, I am including only three of the variables (Potter’s Wheel Pot, Mosaic, and Cut and Paste).

Potter’s Wheel Pot: HCSF (High-Complexity Structured Fluid)

Materials included a half-pound of Amaco terra cotta clay, a pan of water, clay sponges, and an electric potter’s wheel with a knee treadle. Throwing a pot generally requires a great deal of skill and craftsmanship. However, a reasonable facsimile (clay has roundness and a hole in the middle) is satisfactory. A round ball of white stoneware clay was given to the participant and placed in the center of the wheel’s turntable. The therapist formed the original ball to ensure some measure of success. The midpoint was to be found by the participant and corrected until accurate. The therapist then assisted the individual in putting pressure with both hands to the top of the clay mound and pushing it down to enable adherence to the metallic turntable. The wheel was then turned and pushed to top speed, at which time the participant applied pressure to the clay from each side, squeezing in slightly with both palms held rigid and steady in an attempt to establish the center of the clay in the exact center of the wheel. Once the clay was centered as close as possible, both thumbs were placed on center top of the mound and quickly pushed straight down to begin the opening process. The hands are then placed on each side to finish the pot.

Mosaic: HCSR (High-Complexity Structured Resistive)

Material included 30 one-inch-square enameled ceramic tiles (10 red, 10 black, 10 yellow), one pair of tile cutters, an 8-ounce bottle of Elmer’s Glue, a 5-inch-by-5-inch piece of pressed board, and a No. 2 drawing pencil. The instructions were to quickly draw lines that would divide the board into at least three areas and thus create a simple design. To color in the design, the tiles were to be glued onto the board in any desired area, and written into the chosen spaces as “R” (red), “B” (black), or “Y” (yellow). The tiles could be broken into smaller pieces by the cutter to enable filling in a smaller area.

Cut and Paste: LCSR (Low-Complexity Structured Resistive)

Materials included one red 22-inch-by-24-inch piece of medium-weight construction paper, on which were drawn in pencil 20 amorphic curvilinear forms; one pair of 5-inch steel teachers’ scissors; one 22-inch-by-24-inch piece of white Bristol board (two-ply poster board), on which identical forms to the above were outlined with pencil; and one 8-ounce bottle of Elmer’s glue. The participants were required simply to cut out the forms on the red paper and glue them onto the appropriate matched form drawn on the white paper.

Verbalizations were considered important in art therapy at that time, as they would lead to insight and problem solving. There was no significant difference between or among the variables as they related to the type of verbalization I was testing. New research in the area of neuroscience now can explain the relationship between talking and making art, or, more specifically, using the art for memory reinforcement and accuracy, and shows that the nonverbal act of drawing about an event has a much greater retention value than talking about an event (Bruck & Melnyk, 2000). However, in 1969, I was focusing on eliciting verbalizations as a measure of success with the combinations of the variables, complexity, structure, and media properties. It was a start.

I was able to develop a course of study that included all of my theoretical background and experiences, as well as promoted the efficacy of both art as therapy and art psychotherapy. In fact, I saw this well-worn argument by other professionals as a continuum of interventions, which allowed flexibility and included a wide range of populations who could benefit from our services. In the early 1970s, I founded the Institute of Expressive Therapies, with the intent to include music, dance, drama, and poetry into the curriculum. This was the beginning of observing the commonalities among the disciplines, rather than the differences. My colleague, Vija Lusebrink, joined the faculty, and together we researched the interrelationships among the various expressive therapies.

We found a commonality first in developmental theory. The well-known work of Viktor Lowenfeld (1952) in the field of art education had long been one of the foundations on which the MDV was founded. Because the field of art therapy was fixing “deviating” behaviors, then what was the “normal” or expected and acceptable behavior in the arts arena? To recognize deviations, you must know the developmental norms. Although other researchers wrote about the development of children’s graphic expression, I was especially taken with Lowenfeld (1952) and Piaget (1962, 1969). When the stages were placed side by side, they explained each other coherently. The development of schema in particular was of common importance as a pattern of thinking that built upon itself and manifest in drawing behaviors, play behaviors, and development of symbolic language.

Following Piaget’s (1962) developmental sequence with use of various arts media, properties, structure (control), and complexity (cognitive understanding), we begin with sensorimotor play, which translated into the Kinesthetic/Sensory level of the continuum. Babies practice play, repeating motions over and over until the action becomes embedded into a form of its own cognition. The Perceptual/Affective level then begins as motion becomes form and touch or other sensory experiences effects feelings. These feelings do not yet have a verbal language, but they begin to serve the function for which they were biologically created. Anger makes change in the immediate present; sadness slows down the body and mind and processes loss; fear alerts us to danger; and happiness or joy balances all of the other experiences and gives motivation for growth. As form begins to develop further into signs, a meaning becomes attached to the action that created the form. Then the Cognitive/Symbolic level is attained.

The stages of Graphic Development may be aligned with Piaget’s (1962) development of schema—or a pattern of thinking on which we all build throughout a lifetime. Lowenfeld (1952) also described schema as a visual pattern of rules resulting from early scribble behavior, to making concentric movements, to attaining control enough to create form and name it. The scribble stage occurs generally when the child is able to hold an instrument without eating it and purposely put marks on paper (or whatever background may be selected or available). This can begin anywhere from age 12 months to 18 months and is random in nature. When longitudinal scribbling begins, around age 2, the back-and-forth repetition of practice play assumes a purpose, and experimentation into circular motion occurs. When these motions are mastered, around age 3, the form is purposely constructed. The pencil or crayon is lifted off the page and replaced, allowing for other forms to be produced. With more practice and more schema development, these forms become named, and the cephalopod (body/head configuration) is born. This occurs at approximately age 4, and the ability to draw a human figure begins. In the preschematic stage (ages 4 to approximately 6), much practice and change takes place. The forms do not yet have a set pattern and are randomly placed on the page. When a schema develops (about age 7), then the child has a definite manner in which an object or person is drawn and follows his or her own rules for such drawing. As cognition grows and flourishes, so do the drawings. When an experience is important to the child, a schema deviation takes place to allow for the significance of the experience. Realism is then attempted as the child attempts to draw what he or she sees, not just from internal structure of rules, but also from an external awareness that he or she is trying to translate. Realism begins around age 9, which is also the age when most people arrest further development of drawing spontaneously.

How do media enhance or inhibit this development process? Returning to the media properties ranging from fluid to resistive materials, it is by process of entrainment, resonance, and isomorphism that the media affects the motion and the amount of physical, mental, or emotional energy needed to use it. A LCUF (Low-Complexity Unstructured Fluid) project such as finger painting is basically a Kinesthetic/Sensory experience, where the physical properties of the finger paint are given primary emphasis. If one resonates with the fluidity of the finger paint on the wet paper, the experience should elicit a fluid, fairly unrestricted response, much like you would expect from a 3-year-old. Assuming a normal, healthy, unrestricted response, the 3-year-old will play with the paint joyfully and develop a rhythm to create form. What are the other developmental tasks of the 3-year-old? Would these still be valuable in the adult world? Of course, otherwise we would not be using them as therapeutic treatment toward some specified goal! What does it mean if the individual does not like to touch the finger paint, or get dirty, or feels silly, out of control, and so forth? As educated and intuitive therapists, we should know the answers to these questions. Would you purposely give an experience that you knew would create resistance? Maybe. Under what circumstances and why? My point is that we must anticipate the reaction to each variable along each continuum or we are at best floundering and, at worst, doing harm to our clients. Think now of other arts and play forms: movement and dance, sound and music, sandplay, and drama. They follow the same development on the continuum.

If isomorphism takes place and the individual becomes attuned to the media, with a clear understanding of the structure (direction), then some emotional response should be elicited. If we go back to the function of emotions, where anger is used to make change, fear to alert to danger, and so on, we begin to see how and why individuals react to the media dimensions and levels of the ETC the way they do. There is an additional factor, a reinforcement value of experiencing the steps and completion of the project that must also be considered. Does the person respond to fluid materials in a resistive manner? Do resistive materials frustrate and make the person angry? How does the person use the anger to make a change? Are the directions given facilitating the functional use of emotions or causing anxiety or fear? What is alerting the individual to a danger signal? Is the project too complicated? Are the materials outside of the personal boundaries of comfort due to temperament, environment, or past experiences? What was the rationale for giving the project, and was the anticipated outcome achieved? If not, why? These questions form the basics of a therapeutic design using the MDV and ETC.

Actions and Metaphors

Materials elicit and absorb action and reaction, enhancing awareness of the mind–body connection. When materials are fluid, they may be described, as in the case of finger paint, as sliding, slippery, sticky, slick, smoothing, petting, runny, smearing, and so on. The sensation may be described as soft, gooey, pasty, tacky, and even yucky. Each of these reactions may be explored for background information or directed toward problem solving or insight, depending on the level of the ETC with which you are working. Fluid materials generally elicit a loose, flowing response, especially when there is no mediator between material and hand (such as a brush or scraper). When you observe the approach to the materials, even before the action is taken, you assess something about the person. Is the usage without hesitation and spontaneous, or more calculated and cautious? Does this relate to temperament or conditioning or both? Look for the metaphors.

When Gestalt Art Therapy was introduced by Janie Rhyne (1996), she approached the process as the self and asked her clients to give the experience a voice, preceding a description of materials, line, form, color, and space with “I am.” Although this may work well with late teens or adults by using verbal language to describe the project, it is still a viable theory as a nonverbal form of communication between the media (foreground) and the background on which the media is manipulated. Is the child soothing, smearing, sliding, or did the media elicit slapping, dotting, poking, or testing? If the intent of using a LCUF project with finger paint was to regress or release, did it work? If not, why? These are questions for the therapist to be able to answer.

Boundaries and Cognition

Fluid materials are contained; otherwise, they would be all over the place. One way to place a medium on the continuum is to determine what kind of container it needs and how much needs to be contained. Using the finger paints again, note that when an amount is placed on the paper, it stays where it is placed—not so with tempera paint or inks. Boundaries are either inherent in the materials or must be made by the participant. Internal controls may also be observed. How much paint is put or poured onto the background material? Selection of fluidity or restiveness may speak to the need for, lack of, or too much boundary. Control is another variable that is directly kin to boundary. Persons with few boundaries may also lack control or, conversely, be demonstrating a need for such. Let’s go to the other end of the continuum for an example. A High-Complexity Structured Resistive experience usually is found on the Cognitive/Symbolic level, where intellectualization, control, and even obsessive-compulsive needs may be demonstrated. Let’s look at the example of an HCSR experience, the mosaic.

In the more complex experiences, several steps have to be considered both separately and collectively. The materials listed for the mosaic are tiles, which are very resistive and contained. They have no malleability unless quite a bit of force is exerted to break them into pieces, or the project is designed to have all of the tiles the same, and then placing becomes the focus. If the client needs to be able to perform action on the materials in an assertive, yet controlled manner, then a mediator is introduced to facilitate control (the hammer), and the tiles are placed on a surface that will absorb the action. If the appropriate amount of pressure is exerted, the tiles will break where they fissure. If too much force is used, the tiles may be smashed to dust or such tiny particles that using them for the mosaic will be very difficult. What is the metaphor here? How does the individual approach a task or problem?

In the case of a child, teaching the limits is important, and then the choice to adhere or not is made. This is actually true of the adult as well. In complex tasks, teaching allows for a sense of mastery. If the individual has never encountered the materials or process before, then a directive such as, “Do anything you wish,” which is totally unstructured, will probably raise the anxiety level. However, the purpose of the structure is to give the guidelines and boundaries for the experience, tending to yield the results that have the highest reinforcement value. Hence, each directive is given with each phase of the project.

In the beginning, it is good to go over all of the instructions so the individual may begin to image a finished product, but using each step in a therapeutic manner is very important. Go back to pounding the tiles. Pounding is, as are all actions on materials, metaphorical. Does your client pound, bang, crash, smash, peck, or only touch the hammer to the tile? What step is next? Depending on whether you have required a design before beginning or allowing for the materials and person to dictate the design is another therapeutic decision. Cognitive development comes into play at this point, as well as the rationale for using this project in the first place. What do you wish to emphasize? Usually the HCSR project is very specified, allowing the client to follow clear directives. Deciding how to create the design with the tiles is an excellent interactive tool.

Your assistance as a therapist should fit the needs of the individual. If discriminate learning is a goal for a child, then sorting the tiles according to size needs to be the next step. If the person has developed beyond the schematic/realistic stage, then creating design (which can lead to homeostasis and another metaphor regarding balance and integration) would probably be a good choice. What is design? The term needs to be understood by the client, so ask him or her, “How do you want to plan where to put your tiles?” The response should dictate your reaction. If the individual says, “I want to make a landscape,” then the next question is, “What kind of landscape and what do you want in it?” There is safety in rules, permitting clients to feel comforted by structure. If the response is more vague, such as, “I want to make a pretty design,” then ask the person if he or she already has one in mind, and ask that it be drawn on a separate piece of paper. Following the principle of isomorphism, I like to help the client create space that yields design. I often take a piece of paper and ask the client to use straight lines and curvy lines to divide the paper into three parts, using the lines from one edge of the paper to another. Not only are you helping to divide and assess the space being used, but you are creating boundaries and teaching esthetic balance.

Symbolic Representation and Interpretations

Going back to the developmental cognitive continuum, the ETC begins with the database of knowledge that is conscious and reaches toward the symbolic meaning of configurations. It is very important to integrate all of the levels when wandering into the symbolic territory. The unconscious manifests itself from basic temperament (instinct) to formal operations into latent memories, conflicts, or universal experiences, which yield transformation of body, mind, and spirit. Whether you are working with a young child who uses play to liquidate or compensate for experiences, or a highly talented, intelligent adult who is open to various interpretations of line, form, object, and color, symbolism is the most obtuse or apparent form of communication!

As a child’s play is his work (Green, 2010) and an adult’s work needs to have an element of play, the meaning and meaningfulness is the healing. Acceptance of the spiritual—that there is significance in the universe and that each person’s life is significant and has meaning and purpose—tends to be an awareness that is the end goal in any therapeutic endeavor. Every form of psychotherapy ultimately resounds in a sense of comfort, peacefulness, hope, and a desire to continue living a better life, resulting in the resilience necessary for adaptation. For a child, this is a developmental process, and we hope we have aligned the development to reach its greatest potential. For the teen who is transitioning hormonally and socially, our interventions and connections will foster hope about the adult world and entering into a career path. In early adulthood, and throughout the lifespan development, each milestone that must be achieved and integrated is part of our therapeutic design. When there is a major change in the path and grief is the result of losses, the tools of the creative arts therapist and the concepts of the ETC help establish the resilience needed.


The choice of materials or projects should rest with the client. A range of fluid to resistive media needs to be available but not overwhelming. I have a set of markers, crayons, oil pastels, and colored pencils in one section of the art table. Tempera or acrylic paints and various sized brushes, along with the newer contained painting tools (no use of brush required), sit next to plates and bowls for mixing as well as cups for water and paper towels. A variety of papers is also available, in different sizes, colors, textures, and so on. Glue and scissors are placed next to wires and string or yarn. Modeling clays and plasticene are set alongside tools for sculpting. My sandtray is on the floor next to the art table, with containers of action figures, animals, people, soldiers, dinosaurs, and so on easily available for sandplay. In a nearby closet are large bins of craft materials, found objects, toys, dolls, stuffed animals, puppets, drums, balls, and more. In a different section of the room are playhouses and a kitchen set. In the adjacent room is a game table, comfortable sofa, and a desk. My “cozy corner” has an electric fireplace, overstuffed chairs, throws, and a large ottoman, which also serves as a toy/object box. The two rooms are actually arranged according to the ETC, with open space for kinesthetic and sensory activities, as well as contained spaces for perceptual/affective to cognitive symbolic activities. The materials range from fluid to resistive on a large table, but they are not cluttered together. Other furniture fulfills the needs for family space, couples facing each other, or privacy. The environment must be conducive to accessing materials, experiences, and atmosphere at all levels and appropriate for different ages.

Begin where your client begins. During evaluation when selection of materials is made, note the levels of the ETC and the variables of the media. Most people are not well-versed in the use of arts media, so a certain amount of awareness induction and teaching needs to take place. I almost always introduce art experiences in terms of emotional metaphors and function. I demonstrate how good it feels if I am angry to pound on the drum or clay. If sadness is predominant, I can soothe with clay, paint, or rhythm. When I want to feel safe and am afraid, I may build a structure with blocks to protect me, or hug the dolls, or even sift through the sand. Through the expressive therapies, we are helping to create a different language, a different perspective and identity. We build on strengths and growth, resilience, and a positive attitude. Art is science, and science is interwoven into our spirit and psyche. We mirror integration, and we meet ourselves through our creations.


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