A Deeper Dive into the Expressive Therapies Continuum: Structure, Function, and the Creative Dimension

Abstract

This viewpoint conveys insights about the Expressive Therapies Continuum (ETC) from the perspective of two students who trained under ETC co-creators Vija Lusebrink and Sandra (Kagin) Graves-Alcorn. The structure of the ETC is based on relationships among various kinds of information processing, and the function of the ETC is to provide integrative treatment through the modification of task complexity, task structure, and media properties, collectively known as Media Dimension Variables (MDV). Adjusting MDV potentiates activation of the Creative Dimension, where client-specific interventions serve to balance overused, underused, and blocked information processing patterns. ETC-based assessment determines the starting point for ETC-based treatment; a client’s artmaking behavior, art products, and verbalizations are then used to ascertain subsequent steps in art therapy.

Keywords:

• Art therapy
• Expressive Therapies Continuum
• ETC
• Media Dimension Variables
• MDV

The Expressive Therapies Continuum (ETC) emerged as a joint effort that combined Dr. Sandra Kagin’s construct of Media Dimension Variables (MDV) (Kagin, 1969) with Dr. Vija Lusebrink’s longstanding interest in the underpinnings of mental image formation processes and the shift between nonconsciousness and consciousness (Hinz, VanMeter et al., 2022). Foundational literature for the development of the ETC included scholarly works about convergent principles in cognitive psychology and art education (Lusebrink et al., 2013). The model that emerged from Lusebrink and Kagin’s combined endeavors was relatively brain-based for its time and took a meta view of different art therapy approaches, illustrating the compatibility of art as therapy and art psychotherapy. Lusebrink and Kagin published an article about the ETC in 1978 and introduced the ETC at the annual conference of the American Art Therapy Association the same year. The presentation was not considered a success; audience members had difficulty understanding how this complex model related to their work and demonstrated little interest in it (Hinz, 2020).

Despite the less than enthusiastic reception of the ETC, Lusebrink and Kagin (subsequently Graves-Alcorn) continued teaching it to their students at the University of Louisville and refined their ideas as the years passed, expanding it into an outcome-informed framework. The model ultimately became the backbone of the graduate art therapy program at the university and was integrated into nearly all courses. Students were provided with a scaffolded learning experience that exposed them to the nuances of the ETC via didactic, experiential, and clinical means. This gave them a strong framework for assessment, treatment planning, intervention, progress monitoring, and case conceptualization within one outcome-informed system that relies on client responses to agents of change for guiding clinical decision making on an individualized basis (Hinz, VanMeter et al., 2022). Students learned not only the structural framework of the ETC, but also the therapeutic function of MDV to create horizontal and vertical movement within the pantheoretical framework via resonance, isomorphism, and entrainment in a manner that privileges each individual client’s information processing patterns.

The art therapy community lost both co-creators of the Expressive Therapies Continuum in less than a nine-month span. Sandra Graves-Alcorn died on September 16, 2021, at the age of 78, and Vija Lusebrink died on June 12, 2022, at the age of 97. Both demonstrated interest in the theory and a desire to disseminate information about it until their deaths. As former students of theirs, we wrote this viewpoint article to encourage a deep dive into the ETC and to clarify some of the nuances and complexities of the structure and function of the ETC, the Creative dimension, and how to best utilize this pantheoretical theory. Having close relationships with Sandra and Vija might have allowed us some insights into the theory that others did not have the opportunity to develop, and we decided to share our insights and our passion for this responsive, individualized treatment model in the hope that art therapists will be inspired to seek further information about the ETC.

Structure and Function

Many people are familiar with the ETC and will recognize that it delineates not only how the mental image formation process evolves, but also how Media Dimension Variables (MDV), which are modifiable aspects of the art therapy experience, can be used as agents of change to influence the art therapy process. Lusebrink (1990) conceptualized the diagram shown in Figure 1 to represent this complex system. The diagram depicts the relationships among different types of information processing and the integrative aspects of creative intervention that respects these relationships.

Figure 1. The Original Expressive Therapies Continuum Diagram

The K/S (Kinesthetic/Sensory) level is about physical information processing, the P/A (Perceptual/Affective) level concerns emotional information processing, and the C/Sy (Cognitive/Symbolic) level focuses on intellectual information processing (Graves-Alcorn & Fricker, 2013). Components on the left side of the ETC schematic (K, P, and C) are thought to be externally directed while components on the right side of the schematic (S, A, and Sy) are internally oriented (Hinz, 2020). The phenomenon of emergent functioning, in which information processing tends to organize in increasingly complex ways, is indicated as the left side of the schematic flows from Kinesthetic to Perceptual to Cognitive functioning, and as the right side flows from Sensory to Affective to Symbolic functioning. The Creative level, represented as Cr in the schematic, serves as a horizontal bridge between opposing components, balancing attentiveness to outer reality and attunement to internal experience on any given level. It can also be described as a vertical bridge for promoting emergent functioning as well as therapeutic downshifting to focus on the healing function of a particular level (Hinz, 2020). The Cr level signifies the integrative potential of individualized interventions that rely on agents of change to create movement within and among ETC levels. As defined by Kagin (1969), these agents of change, or MDV, are identified as task complexity, task structure, and media properties.

Creative Dimension

Kagin and Lusebrink conceptualized the Creative level as the interventive aspect of the ETC, where Kagin’s MDV (1969) are enlisted to initiate therapeutic shifts among and within the horizonal levels (Hinz, VanMeter et al., 2022). The MDV impact one another and serve as agents of change; they can be used to identify the core underpinnings of any intervention. Although the ETC has potential application for all the expressive therapies (Duhovska et al., 2018; Graves-Alcorn & Green, 2014; Hinz, VanMeter et al., 2022; Kagin & Lusebrink, 1978; Lusebrink, 1991; Lusebrink et al., 2013; Mārtinsone et al., 2013), MDV have not yet been examined in light of the other expressive therapies, though it stands to reason that task complexity and task structure likely play a role in treatment across all disciplines. Only the MDV of media properties (the fluid to resistive continuum) seems like it would require effortful translation into the other expressive therapies. A next step in the development of the ETC model could be to invite collaboration with colleagues and to develop the concept of MDV with other expressive modes.

The Creative level of the ETC is brought to life throughout the therapeutic process by adjusting the three MDV of task complexity, task structure, and media properties to suit individual client needs and promote integrative information processing among the six ETC components. The topic of creativity as related to the ETC was a subject of discussion with each of the co-founders. Due to confusion about the Creative level, Hinz, Rim et al. (2022) proposed that it be renamed the “Creative dimension” hoping that this designation would separate the Creative level from the information processing aspects of the horizontal levels and amplify it as the interventive function of the ETC framework. Hopefully this change in name emphasizes that the Creative dimension does not describe a kind of information processing but instead that it facilitates intentional and therapeutic shifts in information processing.

Assessment and Treatment

Reaching the Creative dimension is not the goal of treatment; instead, enacting it is the journey to the treatment goal. Although the ETC diagram has a top and a bottom, the premise of ETC-based treatment is not about beginning at one end of the structure and finishing at the other; the ETC framework features three horizontal levels, but it is not a three-step treatment model. The premise of the ETC acknowledges that most people come to therapy with overused or underused information processing, and it proposes a method of assessment that helps illustrate individual uniqueness. Prior to the beginning of treatment, ETC-based assessment identifies a client’s preferred information processing component (Hinz, 2008). ETC-based assessment attunes to client-specific manifestations of symptoms that suggest how a client’s own nervous system responds to external and internal forces. These manifestations are indicated in the client’s overt behavioral presentation, image-related experiences, art products, and verbalizations.

The ETC offers a model not only for clarifying a client’s native information processing preferences, but also for intervening in a way that honors these preferences in conjunction with intentionally integrative treatment. ETC-based treatment begins with the component where the client demonstrates strengths, and the client’s response to deliberately chosen, component-specific interventions yield information to help the art therapist make clinical decisions about next steps. Other components are introduced as the client indicates readiness for them, again via indicators in their artwork, their art process, and their verbalizations (Hinz, 2020). This approach is consistent with outcome-informed treatment (VanMeter, 2021). There is no predetermined sequential order for introducing the components in ETC-based treatment, nor is there a mandate for moving the client through the continuum at a certain pace. Intervention is facilitated through the modification of MDV on a client-by-client basis to ensure responsive, individualized treatment. This approach gradually builds bridges to less frequently used, underused, and blocked components before ultimately shifting back to the client’s native component; in this way, integration is achieved, and the client emerges from treatment with the ability to utilize all components for information processing purposes. Over the course of therapy, ETC-based treatment ensures interventions are grounded in individual client needs, with both horizontal and vertical integration considered to integrate a client’s information processing capabilities and ensure psychological balance (Hinz, 2020).

The structure of the ETC is about information processing, and the function of the ETC is about modifying MDV to create therapeutic shifts in information processing on an individualized basis. Therefore, determining compatible materials and media experiences in art therapy would utilize ETC-based assessment to provide an understanding of the client’s starting point for treatment and their treatment goals (Haeyen & Hinz, 2020; Hinz, 2020). The way in which the art therapist asks a client to use a material (by varying the complexity of task instructions and the structure of the desired outcome) plays a role in determining what component is being targeted, and how the client engages with the material plays a role in determining what component is being embodied. To that effect, any art material can be used on any component of the ETC. Clients do not need to experience a change in materials to experience a change in information processing (Hinz, 2020).

Conclusion

Hopefully this article helped to clarify some nuances of the ETC theory that might not be obvious on first encountering the model. We made the point that the structure of the ETC describes various types of information processing, and the function of the ETC concerns modifying MDV to create therapeutic changes in information processing on an individualized basis. The Creative dimension is the interventive aspect of the ETC, where MDV are enlisted to initiate therapeutic movement within and among the horizonal levels. Reaching the Creative level is not the endpoint of therapy, but rather helping clients enact their creative potential can happen at any and all points on the therapeutic journey via modifications to task complexity, task structure, and media properties in all forms of creative expression. Treatment does not begin at one end of the continuum and continue to the other; in fact, there is no required way of conducting art therapy with the ETC because treatment is carried out in an individualized and outcome-informed fashion following ETC assessment.

No single article can cover all the information about the ETC, but perhaps this Viewpoint can serve as an invitation for the art therapy community to read critically about the ETC and to listen with discernment to talks at conferences. Please reach out to either of us with questions about this ahead-of-its-time framework that originated in the field of art therapy. We have recognized the need for formal training and are currently exploring options for what that could look like. In the meantime, we are offering support through consultation and supervision as well as conference presentations and a newsletter with a subscription list that spans five continents. Back in 1978 Lusebrink and Kagin could not have anticipated that their ideas would travel so far. It is an honor to carry on their legacy and encourage others to dive more deeply into the ETC.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Megan L. VanMeter

Megan L. VanMeter, MA, ATR-BC, LPC, LMHC, LPC-AT/S, is an art therapist in private practice at Megan VanMeter PLLC, Prescott, AZ. Lisa D. Hinz, PhD, ATR-BC, is Director, Art Therapy Psychology Doctoral Program, at Dominican University of California, San Rafael, CA.

Lisa D. Hinz

Megan L. VanMeter, MA, ATR-BC, LPC, LMHC, LPC-AT/S, is an art therapist in private practice at Megan VanMeter PLLC, Prescott, AZ. Lisa D. Hinz, PhD, ATR-BC, is Director, Art Therapy Psychology Doctoral Program, at Dominican University of California, San Rafael, CA.