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The expressive therapies continuum:
an integrative systemic approach to visual expression
and its historical background

Kristine Mārtinsone, Ilze Dzilna-Šilova,
Vija Bergs Lusebrink, Liga Veide-Nedviga



Kristine Mārtinsone

Kristine Mārtinsone

–  Kristine Mārtinsone PhD, a certified art therapist and psychologist. She is an Associate Professor at the Faculty of Rehabilitation, Riga Stradiņš University, and head of the professional Master study programs “Health psychology” and “Arts therapies”. She is an expert of Latvian Council of Science in Psychology, chair of the board of the Latvian Association of Health psychology, a National delegate of the European Health Psychology Society, an Honorary Member of the Latvian Art Therapy Association, member of the Council at the Latvian Psychologist Association. She is the editor, author and co-author of a large number of articles and methodic materials, and monographies.

E-mail: kristine.martinsone@rsu.lv

Ilze Dzilna-Šilova

Ilze Dzilna-Šilova

–  Mag. healthcare, an art therapist, and an art and art history teacher. She is currently an art therapist at the social rehabilitation center “Valdardze”, and at the Riga Regional Hospital’s Rehabilitation Department. She is a guest lecturer at the Riga Stradins University on the professional Master study program “Arts therapies”, and is a member of the board of the Latvian Art Therapy Association.

E-mail: idzilna.silova@gmail.com

Vija Bergs Lusebrink

Vija Bergs Lusebrink

–  PhD, ATR, Professor Emerita, was born in Latvia. She has been an art therapist since 1969, and was a faculty member of the Expressive Therapies graduate program at the University of Louisville, Kentucky, USA, from 1974 to 1995 (as director from 1985 to 1995). She is an Honorary Life Member of the American Art Therapy Association, and has served on the Editorial Boards of art therapy journals. She is the author of Imagery and Visual Expression in Therapy (1990). New York: Plenum Press, as well as of many book chapters and articles on art therapy, imagery and sandtray therapy.

E-mail: vblusebrink@earthlink.net

Liga Veide-Nedviga

Liga Veide-Nedviga

–  Mag. healthcare, an art therapist, 3D designer and textile designer. She is currently an art therapist at the Montessori center for children “Marite ABC”. She is a guest lecturer at the Riga Stradins University on the professional Master study program “Arts therapies”, and is a member of Latvian Art Therapy Association.

E-mail: ligaveide@hotmail.com


Abstract. This paper provides a historical overview and practical applications of the Expressive Therapies Continuum (ETC). The theoretical concept of the ETC with its three hierarchical levels of expression has been developed over the last 30 years by Vija Bergs Lusebrink art therapist and Professor Emerita, formerly at the University of Louisville, Kentucky. This model could become a tool for professionals who use art expression in their professional practice.

Key words: Expressive Therapies Continuum, Kinesthetic/Sensory level, Perceptual/ Affective level, Cognitive/Symbolic level, Art therapy, Visual expression, Creative level, Art based assessment in professional practice, Expression and interaction with art materials, The theoretical concept of the ETC.




Representatives of various helping professions such as doctors, psychologists, art therapists, social workers and education specialists etc. use art based tools (such as projective tests, spontaneous (free) drawings, dance and music elements etc.) for assessment, intervention, and also for evaluation and research. Art helps to reveal the client’s unconscious and unnamed sensations, feelings, emotions, and to express them through symbols and images (Мартинсоне, Михайлов, 2010). Art provides inspiration for thoughts, associations, and can serve as a starting point of conversation, as it may contain broad and in-depth information (McNiff, 1998).

Art making process and the theoretical viewpoints of it in various professional contexts may vary. Results of a broader research have demonstrated that in Art Therapy, it is determined by work, environment and client groups (Karkou, Martinsone, Nazarova, 2011).  There are three fundamental parts that usually form the art making process in art therapy: the art expression of a client, the nonverbal perception of the creative expression, and the verbal description of its meaning (Бетенски, 2002, Копытин, 2008, Martinsone, 2011). Spontaneously generated work in art therapy sessions provides insight of the client’s unique situation, social and cultural reality, his/her feelings about him/herself and the others, whereas artwork generated by specific instructions allow to obtain comparative data of client’s mood and condition (Rubin, 1999). It is clear that serious difficulties may rise from spontaneously created works because of interpretation as the art work should be monitored from various points of view as a result of complex interactions such as individual, social and cultural factors (McNiff, 1998).

But according to the artwork generated by instructions [for example, research on children’s drawings (Goodenough, 1928; Schmidt-Waehner, 1924) and other projective tests], when used for assessment, has not earned a high score for its reliability and validity (Betts, 2006), similar to the efforts to associate psychopathology in visual expressions with different diagnostic categories (Ahtik 1971; Volmat, 1956, Wiart, 1967).

Several studies show that there is no scientific evidence to draw conclusions from specific details of the drawing, as well as no justification to assign diagnosis from specific aspects of the drawing (Garb, Wood, Lilienfeld, Nezworski, 2002).

This indicates that the use of arts-based instruments in work with clients contain a contradiction — on the one hand, nowadays there is a requirement to use evidence-based practice in professional field, which promotes a specialist to focus on the science requirement for impartiality, and on the other hand — the subjectivity inherent in art (Gilroy, 2006).

As a consequence, the art-based methods do not meet the strict quantitative statistical benchmarks.

To find a solution to this contradiction, a number of specialists, for example, art therapists in the USA, believe that a specialist should have an understanding of formal elements of art or artistic “language” that would allow to understand the visual expression directly, in all its richness. Based on this view, there are art-based tools that contain formal elements of visual expression (for example, color fit, space used, integration, details of objects & environment, line quality) (Cohen, 1988; Gantt, Tabone, 1998).

Although these tools have been criticized for an inaccurate use of statistical methods (Betts, 2006), yet they are also used in normative studies (Bucciarelli, 2007, St. John, 2008).

The above implies that the instruments, which include artistic expression, are rated as methodologically debatable. At the same time, recognizing the importance of these tools in work with different clients, there is a need to look for a new perspective for understanding artistic expression, from a qualitative point of view.

One of these points of view highly rated in USA, as stable platform, in the use of art with clients (Hinz, 2009.17), is offered by art therapist Vija Bergs Lusebrink, Professor Emerita, formerly at the University of Louisville, Kentucky.

The conceptual model of Expressive Therapies Continuum (hereinafter — ETC) allows us to look at artistic expression as systemic, hierarchically organized concept. This model has been developed over thirty years, based on the latest research in neuroscience and psychology of imagery and visual information processing. It consists of three levels of artistic expression, including creative potential.

Expressive Therapies Continuum

Originally the ETC as formulated by Vija Bergs Lusebrink and Sandra Kagin (now Sandra Graves-Alcorn) synthesized existing ideas about artistic expression and their observations in work in art therapy with patients with acute psychosis and learning disabilities (Kagin & Lusebrink, 1978; Lusebrink, 1990, 1991). In further elaborations of this model Lusebrink highlighted that visual expression reflects the functioning of the human brains as well as the changes in its processes in the presence of feelings and mental illnesses, and connected visual expression with brain structures and functions (Lusebrink, 2004; 2010). Respectively, artistic expression can contribute to the changes in the pathways or create new pathways used in processing information due to the plasticity of the brain (Pascual-Leone, 2006). Lusebrink based her proposed theory about brain structures and functions involved in visual expression on her studies about imagery, information about the brain functioning in visual information processing, and her dissertation about psychophysiological components of imagery, under the guidance of professor F. J. Guigan (Lusebrink, 1986; Lusebrink & McGuigan, 1989). In her articles in 2004 and 2010 Lusebrink explains in detail the possible activation of the pathways in the brain during image formation and visual information processing, as well as elaborates on the characteristics of each level of visual expression in her 2010 article.

The ETC has been discussed in art therapy in the art therapy literature (Malchiodi, 2003, Мальчиоди, 2006) and adopted by a number of graduate art therapy programs in the USA as a foundational and unifying theory in the field of art therapy (Hinz, 2009, 17), and it is known and being developed also in Europe (Upmale, Martinsone, u.c. 2011).

The goal of this article is to characterize the ETC that can serve as a tool for professionals who use art media in counseling sessions, as well as to make comparison with other theories in a historical context.  

Description of Expressive Therapies Continuum

The expression and the use of media and techniques in art therapy can be seen as taking place on different levels. These levels contain information processing from spontaneous reaction to expression of thought. Each level of the ETC is described as a continuum between two opposite poles. The extreme pole of each level represents psychopathological variations found in visual expressions. The sequence of the first three levels (Kinesthetic/Sensory, Perceptual/Affective and Cognitive/Symbolic) reflects the mental and graphical development in progression from simple to more complex levels of information processing (Lusebrink, 2004; 2010).  The fourth creative level can occur at any single level of the ETC, or can represent the integration of functioning from all levels (see Figure 1).

The levels of the ETC and their polarities can be regarded as separate systems in relation to each other. These levels are organized in a hierarchical order, whereby the expression on a particular level of the ETC incorporates the characteristics of a system at a lower level (Lusebrink, 1990, p. 113).

ETC is not a psychometric test, but the visual criteria allow to follow intrapersonal changes in the visual expressions and their levels over a period of time.


Figure 1.


Figure 1. Schematic Representation of the Expressive Therapies Continuum. (Lusebrink, 1990).


Kinesthetic/Sensory level

Kinesthetic/Sensory level represents simple motor expression with art media and their corresponding visual manifestations of energy and sensory involvement.

An emphasis on kinesthetic activity decreases awareness of the sensory component of the expression, and emphasis on the sensory component decreases and slows down kinesthetic action, because the focus is directed to the experience of sensations. The psychopathological variations of the K component are characterized by agitated actions and disregard for boundaries and limits, such as frantic scribbling, throwing or destruction of materials, or marked lack of energy. Lusebrink (2010) hypothesizes that the K component appears to reflect the predominant involvement of the basal ganglia and the primary motor cortex (Carr, 2008) of the brain.

Regarding to sensory component (S) of the visual expression, attention is focused on sensory exploration of materials, surfaces, and textures. The psychopathological variations of the S component are manifested in an over-absorption in the sensory experience, extreme sensory sensitivity, and marked slowing down if movement involved in the expression. The S component appears to reflect an emphasis of involvement of primary somato-sensory cortex. The creative transition are of this ETC level encompasses kinesthetic expression integrated with sensory awareness of the movement involved in art making.

Perceptual/ Affective level

The perceptual component (P) of the Perceptual/Affective level focuses on forms and their differentiation. Perceptual processing of visual expression is characterized by figure/ground differentiation whereby forms are defined by lines as boundaries and/ or color to mark defined areas. The psychopathological variations of the P component manifests as disintegration of forms, incomplete forms, figure and ground reversal, geometrization of forms, and overemphasis of details or lack of details. Restricted affective involvement is characterized by, very small forms, minimal or no color to define forms, and constricted use of space.

The P component appears to reflect an emphasis on the processes of the ventral stream of the visual information processing (Carr, 2008; Fuster, 2003; Lusebrink, 2010) with its emphasis on differentiation and clarification of forms and shapes or "what is it?”, while the dorsal stream indicates where the form is located in space in relation to other forms, or "where is it?" (Carr, 2008, Fuster, 2003).

The affective component (A) is characterized by increased involvement with an expression of affect and affective modification of forms. The presence, differentiation, and change of affect are indicated by the increased use of hues and their values. The psychopathological variations of the A component is marked by disintegration of form, indiscriminate mixing of color, clashing colors or colors inappropriate to the subject matter, interpenetration of forms and/or merging of figure and ground, and especially, indiscriminate mixing of colors

The A component appears to primarily reflect the processing of emotions in the amygdala and its influence on the ventral visual stream (Carr, 2008; Lusebrink, 2010).

The creative transition area of this ETC level encompasses good and/or differentiated gestalts (Kreitler & Kreitler, 1972, 81-96), dynamic forms enlivened with color, and aesthetical ordering of forms.  

Cognitive/Symbolic level

The cognitive component (C) of the Cognitive/Symbolic level emphasizes cognitive operations. It is characterized by the cognitive integration of forms and lines leading to concept formation, categorization, problem solving, spatial differentiation and integration, word inclusion, differentiation of meaning of objective images, and abstractions. The psychopathological variations of the C component is characterized by disintegration of surface and spatial structure, illogical relations between forms, loss of conceptual meaning, and over-inclusion of words.

The cognitive component appears to involve the regulatory „top-down” influences of the prefrontal cortex, especially the dorsolateral prefrontal cortex and possibly the anterior part of the cingulate cortex (Carr, 2008; Lusebrink, 2010).

The symbolic component (S) of this level emphasizes global processing involving input from sensory and affective sources, autobiographic processing, and symbolic expressions. It is characterized by affective images, the symbolic use of color, symbolic abstractions, and intuitive integrative concept formation. Large symbolic images may be associated with loss of reflective distance. The psychopathological variations of the symbolic component is characterized by obscure or idiosyncratic meaning of symbols, over-identification with symbols, symbolic manifestations of defenses, and figure/ground reversal.  

The symbolic component appears to primarily reflect the „top-down” processes of the orbitofrontal cortex and possibly the posterior part of the cingulate cortex (Carr, 2008; Lusebrink, 2010). The integrative function of the orbitofrontal cortex includes the retrieval of autobiographical consciousness (Christian, 2008).

The creative transition area between the cognitive and symbolic poles encompasses intuitive problem solving, images of self-discovery, and spiritual insight.

The efficacy of Expressive Therapies Continuum in the four arts therapy specializations.


Lusebrink provides an overview of the application of ETC model to variety of expressive modalities, describing it in regard to the four specializations of arts therapies and gives examples of directing the emphasis of expression on different levels (Lusebrink, 1991, 395-403).

For example, in Art Therapy kinesthetic activity may be expressed as beating of clay, but sensory experience and awareness can be gained by working with finger paints. Art materials such as pencils and markers, etc., contribute a relatively high structural quality and a clear representation of the internal form enhancing the perceptual aspect of the expression. The efficacy of the affective level may be emphasized by the use of “fluid” and liquid art materials such as watercolors, poster colors, etc., promoting emotional expression. Expression on the Cognitive level may be enhanced by art materials that cause resistance to the quick process of expression and requires planning (collage, wood sculpture) whereas art materials that create ambiguous forms, for example, sponge prints, contribute to symbolic perception of forms.

In Music Therapy expression of creating sounds by beating various objects and instruments, for example, drums, occurs in kinesthetic level. Auditory stimulation and sensory responses to sounds occurs at sensory level. The temporal sequence of music organization contributes the exposure of perceptive level, while expression of senses and mood with sounds emphasizes efficacy at affective level. Cognitive level draws attention to the structure of music, as well as to organized musical group activities whereas on the symbolic level attention is focused to the personal symbolic identification with music. Music is multi-dimensional and “touches the deepest strings of one's soul”, which cannot be expressed in words.

The kinesthetic level in Dance and Movement therapy occurs as spontaneous improvisation induced by internal drives; such movements may express also sensory feelings. The formal aspects of movement components are highlighted at perceptive level as opposite to the emphasis on emotional expression with dynamic nature of movement at the affective level. Movements involving group interaction and communication occur on the cognitive level, whereas movements that express symbolic images and opposites, as well as memories, describe expression at symbolic level.

In Drama therapy improvisation through nonverbal movements and sounds of voice without any prior planning occurs in kinesthetic/sensory level.

Role depictions that are planned indicate the action at perceptive level, while the affective level can be described with improvisation or role — play which is based on Stanislavsky method and emphasis on feelings. The social role-play and the portrayal of social activities occur at cognitive level. The symbolic level is characterized with symbolic identification with the material as well as with symbolic role — play.

A historical overview of the ETC and its comparison with other theoretical concepts.


ETC and its three levels are rooted in the concepts of art educator Victor Lowenfeld; pioneer of cognitive psychology Jerome Bruner; one of the first investigators of imagery psychiatry professor Mardi Horowit; neuroscientist and psychiatrist Joaquin Fuster; and several pioneers of the profession of art therapy (Hinz, 2009).

Art therapists’ approaches that influenced the concept of the ETC.


The first art therapists in USA came from different professional backgrounds, connecting their professional knowledge and experience with their interests in art and therapy. The fundamental ideas of the ETC are based on the first art therapists’ approaches to art therapy.

Florence Cane

Florence Cane, artist and art teacher in Walden School is considered as art therapy pioneer in USA.  Her approach to teaching art was based on her belief that human beings perceive the world and process the information from it through three main functions: movement, emotion and thought. She explained that life’s goal is to integrate all functions and become whole and balanced. Students’ experiences of academic, artistic and behavioral problems are likely the result from blocked basic functions. A blocked basic function either movement, emotion or thought, indicated that it was not fully integrated and that its use was limited or not available. She wrote that art might be a way of integrating all three functions, and that, if all three were used, „the child would be permitted to glimpse the fourth dimension, his spiritual awakening” (Cane, 1951, 35). Cane pointed out and discussed the fact that improvements in functioning were consistently demonstrated through parallel improvements in student’s artwork, namely, the artwork became more personally meaningful to the maker and more imbued with life and feeling (Cane, 1951).

Evidently Cane’s opinions about the function of movement, emotions, and thought are comparable to the Kinesthetic, Affective and Cognitive dimensions of the ETC. Kagin and Lusebrink broadened these concepts when used in the ETC, by their addition of the bipolar nature of each level (Lusebrink & Kagin, 1978).

Margaret Naumburg

Margaret Naumburg, teacher and psychoanalyst, after establishing Walden School worked in mental hospitals and in private practice. She based her approach to art therapy on the Freudian and Jungian ideas Working within the context of these theories, she concluded that art psychotherapy was equal or superior to verbal therapy in its ability to release repressed material. According to her, the process of art therapy was based on the belief that an individual’s most essential thoughts and feelings are derived from the unconscious. She hypothesized that unconscious content achieved its most complete expression in images rather than words. In addition, when the symbolic aspects of imagery as well as the verbal and cognitive aspects of experience were part of an art therapy session an integrative and healing opportunity occurred. Symbolic content was seen as central to Naumburg’s psychodynamic approach to art therapy. In practicing psychodynamically oriented art therapy Naumburg often used art not as the primary modality in therapy, but rather as a springboard into a verbal examination of the unconscious. According to her, the production of an image awakens its symbolic content and the discovery of its meaning was the most important aspect of therapy (Naumburg, 1950, 1953, 1966). This approach is also criticized in literature, indicating that any special contributions to the process deriving from the art materials used in creating the images themselves are minimized (Ulman, 1975a).

Despite the criticism Naumburg’s emphasis on mastering the meaning of symbolic content that emerged from the created images influenced the concept of the Symbolic dimension of the ETC.

Edith Kramer

Edith Kramer, artist and teacher, emphasized the importance of art as therapy in helping children achieve sublimation. She emphasized the importance of creativity and the different ways of using art media had an impact on the person and the art product, and discussed the use of „precursory materials”, to promote scribbling and smearing as a ways to explore the physical properties of the art media. Kramer added information about „chaotic discharge”, which she defined as spilling, splashing or destroying, as representing a loss of control in the therapeutic session (Kramer, 1971).

Kramer’s work contributed to the theoretical underpinnings of the ETC. Her use of „precursory materials”, and „chaotic discharge” helped formulate ideas about types of kinesthetic activities on Kinesthetic/Sensory level of the ETC.  Kramer’s elaborations on the use of form to contain emotion (Kramer, 1971), is similar to Kagin and Lusebrink’s definition of the bipolar nature of the P/A level of the ETC, in that as involvement with the perceptual aspect of image formation increases, affective involvement decreases (Kagin & Lusebrink, 1978). Kramer’s approach to the use of symbolic expression in more sophisticated artwork is comparable to descriptions of image formation with the Symbolic dimension of the ETC. Symbols contain many levels of meaning and can be used with or without words. Kramer’s overall emphasis on aesthetical qualities of the work and assisting clients to produce „formed” images dovetails with descriptions of the creative level of the ETC.

Elinor Ulman

Elinor Ulman, artist and art therapist, considered creative factor as dominant, and she wrote that often it is not necessary to translate it to symbolic interpretation spoken in words, in order to gain insight from the artistic endeavors (Ulman, 1975a). For Ulman, sublimation through the creative process was the key to art therapy (Ulman, 1975b, 32). As an artist she fully understood the power of creative experience to help the artist understand him/herself and his/her world, to bring order out of chaos, and to align one’s inner state and the outer representation of it.

Creative level of the ETC incorporates Ulman’s description of creative experience as one’s inner state and outer representation of it. Respectively, the creative level does not necessary require a translation into words, but is based on the creative expression itself (Kagin & Lusebrink, 1978).

Mala Betensky

Mala Betensky, a psychologist, founder of phenomenological approach in art therapy, emphasized the immediate experience of creating and perceiving art images. In her early work, she discussed the nature of art media and client’s varied responses to it and reported that individuals are drawn to certain media and repelled by others based on the media’s inherent structural qualities. In addition, Betensky discussed how the use of color helped facilitate the expression of emotion (Betensky, 1973, 1995).

This phenomenological approach to art therapy and the nature of art media influenced several aspects of the ETC, including varied responses to art materials Parallels to the ETC can be seen in the Betensky’s writings about the movement of fluid media and the emergence of images from the undifferentiated background, which can be used in art therapy (Betensky, 1973, 1995).

Similarities to the ETC can be seen in the way in which Betensky described the therapeutic process: art therapy session begins with a period of free play in which clients were encouraged to explore, experiment and get the „feel” of many different media (Betensky, 1995; Бетенски 2002). This portion of the session is similar to the Kinesthetic/ Sensory level of the ETC, which emphasizes the movement and sensory aspects of the art media. Secondly clients were asked to formulate images and when finished hang them up on a wall for visual exploration. In a process that M. Betensky called „phenomenological intuiting” clients were asked to intentionally look at their pictures and to perceive everything there (Betensky, 1995, 17).  The work was discussed in terms of its formal artistic properties, such as line, color and form. This phase, where clients look at their own artwork, parallels to Perceptual level of the ETC in which the formal elements of visual expression are paramount. Finally, in the third phase, clients were asked to concentrate on the question „What do you see?” (Betensky, 1995, 17), and thus derive meaning from the art product and discuss connections between art and life. This type of information processing is similar to that which has been described as occurring on the Cognitive/ Symbolic level of the ETC (Kagin & Lusebrink, 1978; Lusebrink, 1990).

Janie Rhyne

Janie Rhyne, anthropologist and gestalt therapist, influenced the perceptual dimension of the ETC with the Gestalt art therapy approach emphasizing perception and visual thinking (Rhyne, 1973, 1987). With this approach J. Rhyne provided a new and different way to view the created artwork. She asked the therapist and clients to examine client-created artwork in terms of the perceived structures and the dynamics of these structures by speaking in first person „I am”. Rhyne emphasized the „visual language” used to describe the artwork, which based on the perception of aspects of formal elements and structures as its content (1989). Rhyne stated that person’s awareness of immediate experience is gained through embodiment of forms with sounds, gestures and movements, thus concentrating on sensorimotor experience (Rhine 1987, 167-177). She stated that different types of sensory activities enhance the individual’s full appreciation of the present moment.

This method with its emphasis on the formal expressive elements was incorporated into the Perceptual dimension of the Expressive Therapies Continuum (Kagin & Lusebrink, 1978).

Authors’ Concepts that influenced the hierarchical sequence of the ETC.


The hierarchical sequence of the ETC levels is based on several concepts of different expressive styles in art, stages of graphical development, the sequence of perception and cognitive development, and sensory information processing in brain structures and functions.

Victor Lowenfeld

Victor Lowenfeld, an influential art educator, created a theory of developmental stages that underlay children’s artwork, based on Jean Piaget ideas about general principles of cognitive development. These stages of graphic development sequentially pass one into another parallel to child’ biopsychosocial development. Lowenfeld wrote that optimal learning takes place when there is integration of the information achieved through different modes: using kinesthetic, sensory, perceptual, emotional, and intellectual channels, thus providing optimal creative and learning experience. Lowenfeld contended that integrated education is highly individualized and that it occurs when child personally identifies with the experience about which he or she is learning (Lowenfeld & Brittain, 1970).

In formulating the ETC, Kagin and Lusebrink expanded Lowenfeld’s framework, pointing to the hierarchical progression of the increasingly complex three levels. The increasing complexity of visual expression at different levels of ETC reflects Lowenfeld’s proposed levels of graphical development. The fourth — Creative level incorporated Lowenfeld’s idea that the creative experience integrates information from many channels (Kagin & Lusebrink, 1978).

Jerome Bruner

One of the pioneers of cognitive psychology J. Bruner stressed that the course of cognitive growth during childhood occurs through the transition from a particular type of information processing (the particular way of thinking) to abstraction. Bruner formulated three types of representation: active, iconic and symbolic. Active type reflects events through response with movement; iconic type selectively organizes individual’s perception and images; and symbolic type names and transforms the experience through abstract and complex methods (Bruner, 1964).

These stepwise types reflecting the development of information processing are similar to ETC in its three levels: Kinesthetic/Sensory, Perceptual/Affective, and Cognitive/ Symbolic.

Mardi Horowitz

American psychoanalyst and psychiatrist Mardi Horowitz expanded Bruner’s model by proposing three modes of representation of thought: enactive, image and lexical (Horowitz, 1970, 1983). The first two modes represent thought based on perceptions, including inputs form all sensory channels, memories, and fantasies, whereas the lexical mode or mode based on words, serves abstraction and conceptualization.

Horowitz’s theory provided for the ETC the missing link that showed parallels among imagery formation, cognitive processes and art expressions on the different levels. His formulated enactive mode represents the type of information processing involving muscle activity and reflexive action. According to Horowitz’s theory, this type of information representation does not disappear with the development of more complex modes of thinking and it can be identified in adults through hand gestures during expression.  The second mode of thought is image representation. Horowitz wrote that images develop from the input of all sensory channels and thus allowing perceptual information to be cognitively processed. This type of cognition is more complex in that it allowed thoughts about images to continue in the absence of a concrete stimulus; thus cooks might have gustatory images, and dancers kinesthetic images. Horowitz described that the last type of cognitive representation, lexical mode, involves words, thus providing new levels of abstraction, reasoning and the conceptualization of information.

This theory of the three modes of information processing was incorporated in ETC as image formation on the Kinesthetic/Sensory level, Perceptual/ Affective and Cognitive/ Symbolic level in hierarchical succession.  Horowitz’s statement about the influence of one mode of information processing on others also was incorporated into the structure of the ETC (Kagin & Lusebrink, 1978).

Joaquin Fuster

Neuroscientist and psychiatrist Joaquin Fuster (2003) concluded that visual information processing in the brain moves from simpler to more complex processes. He considered that the hierarchy of sensory channels begins at the primary sensorial cortex and moves to unimodal association cortex and then to polymodal association cortex and then to prefrontal zones of the brain (p. 109). These pathways can be followed anatomically.

Fuster explained that neural pathways are accessible in both parallel processing and coordination of information and dissemination in both directions — upwards and downwards (p. 67). Fuster and other authors (Horowitz, 1970; Mark, 1983), indicate that images and sensory modalities of perception in their input and output processes use the same pathways and areas in the brain as in corresponding sensory modalities of perception

Thus Fuster’s approach to sensory information processing in a progressive sequence is similar to ETC levels in visual expression.

The use of Expressive Therapies Continuum in professional practice.


Considering the historical roots of ETC, the following elaborates on the use of visual expression or visual language and its application to therapy. Unlike verbal approaches to treatment, which deal mainly with the discussion of sensations, perceptions, feelings, concepts and symbols, visual expression portrays these through hand movements using art materials. Visual expression directly reflects thinking, feelings, emotions, and sensations or their absence, through lines, shapes and colors in various combinations and configurations and their spatial relation. It must be stressed that this expression is direct without description in words. Visual expression is multi-dimensional and includes several levels of information processing.

Thus, the organizing structure of ETC model is based on the understanding that several levels may be involved in artistic expression, but one level usually predominates.

Understanding the dominance of one or more levels in the client’s artistic expression helps to clarify his/her strengths and difficulties, namely, on which levels visual expression reflects normal functioning and which levels may display psychopathological symptoms. The characteristics of a level of the ETC model may represent psychopathology, but the levels are not differentiated on the basis of diagnoses, but on the basis of the levels of visual information present (Hinz, 2009, 205-207). The focus of ETC in art therapy is on the client’s strengths on different levels of the ETC, while at the same time strengthening the levels and solving problems at levels, which may display imperfections or psychopathology. When working with children these characteristics should be evaluated from the viewpoint of the levels of development. One of the main goals is to help children to be able to use expression and information processes in a developmentally logical order, additionally dealing with their behavioral, emotional, and cognitive disorders and difficulties.

When planning work, the gradual transitions may be marked in a step-by-step on each level. Lusebrink indicates that these transitions represent various cortical structures and functions of the brain involved in visual and affective information’s processing. Moving from lower to higher levels of ETC indicates the development or integration, whereas movement from higher to lower levels points to differentiation of the components or regression.

Selection of art materials, interaction with them, and questions asked by a professional may focus attention to specific levels of expression, enhancing the flow of information processing and thus overcoming difficulties or deficiencies in information processing. “The expression and interaction with art materials on different levels of the ETC model functions as a whole and changes in individual levels are interrelated” (Lusebrink, 1990, 113).

Difficulties with certain components of the ETC model may indicate a lack of linkage between systems or difficulties in transitions between different areas of information processing. Based on that, changes in imagery may represent internal movement, whereas repetitive or fixed and unchanging images may represent areas of conflict or emotional rigidity. Internal movement, which is reflected by changes in client’s imagery, may be increased by changes in visual expression at various levels of ETC model (Lusebrink, 2011, 17).

Possible steps and interventions towards integrated functioning of a client on the different levels, using various art materials, are based on impact of the internal structural qualities of art materials and the manner of their use on the art expression. In general, the activity of the left side components of ETC model, namely, kinesthetic, perceptive and cognitive, is increased, by using resistive materials, such as pencils, crayons, or markers. Whereas, the efficacy of components on the right side, namely, sensory, affective and symbolic, is increased, by using fluid materials, for example, tempera, watercolor, or finger-paints (Hinz, 2009; Lusebrink, 1990). Consequently, the choice of materials or changes in their use may strengthen the changes of the levels of ETC in visual expression and, related to brain plasticity, may contribute to changes neural pathways used in processing information. A. Pascual-Leone argues that “the brain undergoes continuous changes in response to modifications in its input afferents and output target” (Pascual-Leone, 2006, 315) and that “changes in activity across a distributed neural network may be able to establish new patterns of brain activation and sustain their function” (Pascual-Leone, 2006, 317).

The relationship between the visually art based therapy and verbal therapy approaches used depends on predominant level of ETC present in the visual expression and which particular verbal therapy approach could be most appropriate   for this level of expression.


This paper presents the model of ETC as a categorically organized schema to facilitate the understanding of visual expression in therapy. The main ideas of this model are based on a number of pioneering approaches in art therapy in the U.S.A. and on theories of cognitive psychology. It includes three levels of cognitive and graphic development (sensory-motor, perceptive-affective and cognitive-symbolic) and their complementary or integrative level of creativity. The ETC model provides a conceptual framework for the use of visual expression, including various concepts (processes of perception and information processing; psychodynamic concepts, for example, such as symbolic expression of unconscious material and sublimation through the creative process); developmental levels of graphic expression; the importance of the quality of art materials (the phenomenological approach); perception and immediate experience (gestalt approach); and developmental aspects of the imagery , but not insisting a certain theoretical direction. In addition, as mentioned before, the concept of the ETC may be applied to other modalities of artistic expression as well, namely, music, dance and movement, and drama.

An understanding of the Expressive Therapies Continuum makes it possible for professionals of different theoretical approaches to use it in their work. In other words, the theoretical approach and professional area of work of the specialist may be combined with this concept. For the time being this model has not been compared with the theoretical approaches developed in Russian psychology (for example, Березина, 2001, Василюк, 1993, Леонтьев, 1983, Смирнов 1985 etc.), but still, it is evident that there is a potential for such comparison and thus for a further development of this model.


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им. В.М. Бехтерева

Попов Ю.В., Пичиков А.А. Особенности суицидального поведения у подростков (обзор литературы)

Емелина Д.А., Макаров И.В. Задержки темпа психического развития у детей (обзор литературных данных)

Григорьева Е.А., Хохлов Л.К. К проблеме психосоматических, соматопсихических отношений

Деларю В.В., Горбунов А.А. Анкетирование населения, специалистов первичного звена здравоохранения и врачей-психотерапевтов: какой вывод можно сделать о перспективах психотерапии в России?

Серия 16



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