Expressive Therapies Continuum: Three-Part Healing Harmony

Start with embodiment and work your way up.

Posted Dec 30, 2018

© 2018 Cathy Malchiodi, Ph.D.
"The Body's Wisdom" from the visual journals of Cathy Malchiodi, PhD
Source: © 2018 Cathy Malchiodi, Ph.D.

In psychotherapy and particularly trauma-focused work, we often talk about working from the “bottom-up.” That generally means a progression that begins with the body’s sensory and somatic experiences as the foundation for eventual exploration of emotions (affect) and personal narratives (cognition). While a “top-down” approach is still on the menu, most often reparative applications of expressive arts generally begin with somatic-sensory experiences — that is, the experience of embodiment. Simply put, embodiment is an implicit form of intelligence that is in direct contrast to the prevailing notion found in most forms of psychotherapy that focus on the mind as the main source of intelligence.

There actually already is a framework for this progression within the field of expressive arts therapy — the Expressive Therapies Continuum or ETC. And this may surprise you — it’s been around since 1978. The originators, Sandra Kagin (Graves) and Vija Lusebrink, based this continuum on the existing models of human development and information processing of the time. According to Lusebrink, the levels of the ETC reflect three established systems of human information processing: kinesthetic/sensory, perceptual/affective, and cognitive/symbolic. There is a fourth level of the ETC, called the creative level, which is a synthesis of the other three levels of the continuum. This last level is a little vague, explained as an intersection of the three previous levels or a transcendent experience beyond them. “Creative” is a loaded word that is often elusive by definition, but the prevailing ETC consensus maintains that it is an experience of wholeness, healing, and well-being found through self-expression either through the integration of the other three levels or fulfillment at any given level. Because of the way I apply this framework to trauma-informed practice, I refer to this level as “integration,” because the term more closely reflects actual reparation — the ultimate goal of any psychotherapeutic approach.

More recently, the ETC has been applied in various ways, but mostly within the field of art therapy. Because art therapy as a field tends to remain with in a well-circumscribed silo of specific visual methods, the ETC has not yet fully embraced what it truly is — a framework for “expressive therapies” (dance/movement, music/sound, dramatic enactment/theater/role play, creative writing, and play) rather than visual arts only. And this is where the “healing in three-part harmony” actually is found, in expanding the current thinking to include various embodied approaches. To accomplish this, art may not always be starting point for most traumatized individuals. “Getting into the body” through movement, musicality/sound, dramatic enactment, and play is more in sync with the sensory-kinesthetic level and support a “bottom-up” approach to trauma-focused intervention.

Here is a simple example of this progression in action. I normally start a session with some form of movement for a few minutes; this may involve some stretching, chair yoga, or just some bilateral movement where the person is simply moving both sides of the body. Sometimes I model movements that soothe and calm individuals, such as Peter Levine’s “hand over heart and hand over abdomen” approach, allowing the person to mirror my movements and to establish attunement at the beginning of the session. To capture any of these sensory/kinesthetic experiences, next I might invite the individual to use drawing materials to “show me through colors, shapes, and lines what that feeling in your body looks like. Don’t worry about making it into art, just put something on paper. You can even just make marks on the paper with colors.” For those individuals who do not relate to images, I may invite them to use a drum or other simple musical instrument to express the movement experience, or to stay with the movement and use props to express it in various ways.

To continue this process, and if the person is comfortable, I may suggest drawing the perception of that feeling (affect) in the body. I may provide a simple pre-printed body outline and give the following prompts: “Can you show me where that feeling is in the body? If it feels like it’s outside the body, that’s OK. Just show me through colors, shapes, and lines was that looks like.” Finally, I ask, “What kind of story (cognitive level) would that image tell me if it could talk? If it’s a worry, for example, what would that worry say?” This last part encourages storytelling, creative writing, or dramatic enactment through a third-person voice, as if the image is doing the talking. The use of a third-person narration is an option to support safety and establish some distance in talking about what may be difficult stories.

This is only one example of how to apply the ETC to work that begins with the sensory/kinesthetic, body-based experiences. Not every individual may move through all three levels of the ETC in a session or even several sessions. In fact, one or two levels may be optimal for some people, depending on what trauma reactions are present or need attention. For others, starting with a “top-down” sequence may be preferable, because talking may feel less threatening in the beginning than through more body-based or affect-laden experiences. Because I work with trauma, I generally start with a somatosensory activity, because most of my clients are holding energy in the form of tension in their bodies; it has to be released before the person can really engage in exploring emotion and narrative.

There are many more nuances to the ETC than I can describe in this short explanation. But what I repeatedly find essential is that the individual eventually is able to fully access all three expressive levels of the continuum through self-expression. This is the “three-part harmony” that I believe starts the flow of embodied intelligence and becomes the foundation of trauma reparation and integration via the expressive arts.


Kagin, S, and Lusebrink, V. (1978) The expressive therapies continuum. Art Psychotherapy, 5, 171-180.