What is the Expressive Therapies Continuum?
The Expressive Therapies Continuum is a framework for making responsive, outcome-informed decisions in client-centered care.
But what does that really mean? What is responsive? What is outcome-informed? What is client-centered?
“What Is the Expressive Therapy Continuum?”
I’ll answer those questions, but first let me introduce myself as someone who studied for two years with the co-creators of this framework. The Expressive Therapies Continuum, or ETC, is sometimes mistakenly referred to as the “Expressive Therapy Continuum”, and apparently Google has seen lots of searches for this slightly off term--that’s where I found the question above!
There are more than one kind of expressive therapy involved. In the world of art therapy, it’s not uncommon for practitioners to forget this and just assume the Expressive Therapies Continuum is about art therapy, but it also concerns dance/movement therapy, drama therapy, and music therapy.
Vija Lusebrink
The framework was developed by art therapy pioneers Vija Lusebrink and Sandra (Kagin) Graves-Alcorn. These two came together via their work at the University of Louisville in the U.S., and each had a research-informed perspective that shaped their understanding.
Levels of Mental Image Formation and Expression
For Dr. Lusebrink’s part, she arrived at the university with a grasp of the physiological basis of the mental image formation process and its corresponding levels of mental image expression. This is pretty wild, considering the research she did was well ahead of the neuroimaging advances of the 21st century!
Vija recognized that different brain states resulted in different kinds of visual expression.
Sandra (Kagin) Graves-Alcorn and Media Dimension Variables
As for Dr. (Kagin) Graves-Alcorn, she arrived at the university with knowledge of the three primary means by which a client’s visual expression could be influenced through therapeutic intervention. She discovered these agents of change—or Media Dimension Variables, as she called them—while doing research for her master’s thesis.
The three Media Dimension Variables are task complexity, task structure, and media properties. Sandra found that strategically adjusting all three on an individualized basis made the difference between client progress vs. lack of progress.
The Expressive Therapies Continuum in Art Therapy
These two great thinkers combined their respective areas of expertise to form the Expressive Therapies Continuum. Because they were both art therapists, the Continuum only got fleshed out in art therapy, but both women envisioned it to be relevant in all the expressive therapies.
The Expressive Therapies Continuum and Therapeutically Induced Shifts
Now let’s get back to “what is the Expressive Therapies Continuum?” Well, in a nutshell, it’s a way to think about and see shifts in a client’s nervous system functioning as they engage with art materials and media experiences.
Integration Within a Client’s Nervous System
A therapist who’s been trained in the Expressive Therapies Continuum has learned how to think about and see the relationship between the interventions they pose to a client and the rationale for creating nervous system shifts via changes in materials and media experiences. Why is this important?
Because therapeutically induced shifts have the goal of creating integration within a client’s nervous system.
Responsiveness
Creating nervous system integration leads us to the issue of “responsiveness”. What is it? It’s the quality of being able to attend to and address a therapy client’s needs with the understanding that these are undergirded by a variety of contextual factors at any given moment.
In short, it’s the opposite of canned or manualized treatment. The Expressive Therapies Continuum is a vehicle for the demonstration of the therapist’s responsiveness in that the therapist is responding in real-time to what they see in the client’s artmaking process, art products, and spontaneous verbalizations about these.
The Expressive Therapies Continuum and Responsiveness
This is different from “directive”-oriented approaches to art therapy in which a prompt or project is given to a client to help them express something. But after the client follows the directive, the therapist doesn’t necessarily know what to do next in regard to clinical decision making.
With the Expressive Therapies Continuum, the client’s visual and verbal output leads to responsive decisions about what to do next—either keeping the client where they’re at in terms of nervous system functioning or supporting them in creating a shift.
Outcome-informed Decisions
An exploration of responsiveness brings us to the topic of “outcome-informed”. What does that mean? Outcome-informed decisions are based on client output. This output is information the therapist uses to make decisions about next steps.
The Expressive Therapies Continuum and Outcome-informed Decisions
A therapist who works within the Expressive Therapies Continuum is actually being guided by the client’s artmaking process, art products, and verbalizations. These are all outcomes. And what are they outcomes of?
The therapist’s previous decision! Client outcomes inform therapist decisions, which in turn influence the next round of client outcomes. It’s like a conversation; there’s a back-and-forth exchange between client and therapist that is seamless and entirely focused on keeping the client moving toward their goals, and the encompassing system this interaction takes place in is unique for each client, just as a conversation would be.
Client-centered Care
The quality of uniqueness is important for understanding “client-centered”. Client-centered care puts the client at the center of therapeutic efforts rather than on the receiving end, where they often wind up being cast in a passive role and decisions are made for them and about them but rarely by them.
Client-centered Care and the Expressive Therapies Continuum
Client-centered care respects that each client is unique. As such, there isn’t a one-size-fits-all approach. When a therapist provides services within the framework of the Expressive Therapies Continuum, clients are allowed to express their individuality through a path to integration that is specific to themselves; a therapist who’s been trained in Expressive Therapies Continuum assessment is able to detect a starting point for treatment that corresponds to each client’s preferred or dominant nervous system information processing style.
Treatment begins at that starting point, and through a responsive, outcome-informed approach, the therapist supports the client as the client gradually demonstrates readiness for experiencing other kinds of nervous system input.
The Expressive Therapies Continuum Diagram
The different kinds of nervous system input are called Kinesthetic, Sensory, Perceptual, Affective, Cognitive, and Symbolic. The relationships among these are mapped out in the diagram at the top of this article, but it’s important to note that they’re arranged according to the horizontal levels of mental image formation and expression discerned by Vija Lusebrink.
What about Sandra (Kagin) Graves-Alcorn’s contribution of Media Dimension Variables? Those three are the agents of change that get adjusted to generate movement on the vertical axis of the diagram, or the Creative Dimension.
A Framework for Making Responsive, Outcome-informed Decisions in Client-centered Care
And that’s the Expressive Therapies Continuum, more or less! At least, it’s how I condense what I learned in a two-year training program into a blog article. 😉
Expressive Therapies Continuum Supervision and Other Services
Are you interested in learning more about the Expressive Therapies Continuum? I offer live webinars and supervision opportunities to professionals in the expressive therapies. Contact me for further information, and please let me know if you need customized services that are tailored to your specific area of concern.
The Expressive Therapies Continuum and Art Therapy for Anxiety and Depression
I also have an online private practice providing Expressive Therapies Continuum-based art therapy for anxiety and depression in Texas, Indiana, and Arizona. I’m happy to accept referrals for adults who want responsive, outcome-informed, client-centered care!
References:
Hinz, L. D. (2008). Walking the line between passion and caution in art therapy: Using the Expressive Therapies Continuum to avoid therapist errors. Art Therapy: Journal of the American Art Therapy Association, 25(1), 38-40.
Hinz, L. D. (2020). Expressive Therapies Continuum: A framework for using art in therapy (2nd ed.). Routledge.
Hinz, L. D., VanMeter, M. L., & Lusebrink, V. B. (2022). Development of the Expressive Therapies Continuum: The lifework of Vija B. Lusebrink, PhD, ATR-BC, HLM. Art Therapy: Journal of the American Art Therapy Association, 39(4), 219-222.
Proctor, S. L., & Herschman, P. L. (2015). Client-directed outcome-informed work: An overview. The New School Psychology Bulletin, 12(1), 24-35.
Stiles, W. B., & Horvath, A. O. (2017). Appropriate responsiveness as a contribution to therapist effects. In L. G. Castonguay and C. E. Hill, How and why are some therapists better than others? Understanding therapist effects (pp. 71-84). American Psychological Association
VanMeter, M. L., & Hinz, L. D. (2024). A deeper dive into the Expressive Therapies Continuum; Structure, function, and the creative dimension. Art Therapy: Journal of the American Art Therapy Association, 41(2), 107-110.
Woodbury, M. G., & Kuhnke, J. L. (2014). Evidence-based practice vs. evidence-informed practice: What’s the difference? Wound Care Canada, 12(1), 18-21.