46 Vija B. Lusebrink and Lisa D.

Hinz
streams is important in understanding visual expressions in art therapy because
it separates information about form or “what is it?” from information about
spatial location or “where is it?” Both visual streams have direct reciprocal
connections with the prefrontal cortex (PFC) and both connect in the principal
sulcus of frontal lobe (Carlson, 2001).
The Affective (A) component of the P/A level is characterized by increasing
involvement with emotion, its expression, and the affective modification of
forms. The presence, differentiation, and transformation of affect are indicated
by increases and/or variations in the use of hues and their values. The A
component appears to primarily reflect the processing of emotions in the
amygdala, located in the subcortical limbic system, and its influence on the visual
stream (Christian, 2008; Lusebrink, 2004). Input from the amygdala is modified
by the hippocampus and two cortical structures: the cingulate cortex and the
orbitofrontal cortex. The amygdala connects directly to the PFC and indirectly
to the right orbitofrontal cortex (OFC) through the thalamus (Fuster, 2003; Hass-
Cohen & Loya, 2008). The interplay between the P and A components in visual
expression involves transition from feature-based information processing at the
P polarity on the left side of the ETC schema to the amygdala-based information
processing at the A polarity on the right side. The interchange between these
two ETC components is critical in trauma work as exposure to trauma elicits
affect and structured perceptual work contains it.

Cognitive/Symbolic Level (C/Sy)

The Cognitive (C) component of the C/Sy level emphasizes cognitive operations
and is characterized by concept formation, categorization, problem solving, and
differentiation of meaning of objective images and abstractions (Lusebrink,
2004, 2010). The cognitive component of the ETC presumably reflects the
activity of the PFC and the OFC. The PFC performs the integrative functions
of working memory. It generates a time-limited memory based on “the joint
activation of the neural components of a large cognitive network of perceptual
and executive memory” used in the processing of daily activities (Fuster, 2003,
p. 159). In addition, the PFC is responsible for maintaining attention and
inhibition, including integrating information from the posterior cortex (the
multimodal parietal cortex) and the different sensory information stored in the
temporal and occipital cortices (Dietrich, 2004). The C component of the ETC
also appears to reflect the regulatory “top-down” influences of the dorsolateral
prefrontal cortex and possibly the anterior part of the cingulate cortex (Christian,
2008; Lusebrink, 2010). The OFC is likely involved in emotional regulation,
whereas areas of the PFC have been conceptualized as dealing with affective
working memory and anticipating the consequences of positive and negative
emotions (Davidson, 2000; Davidson, Putnam, & Larson, 2000). Affective
working memory can be seen as a time-limited joint activation of the neural
components of a large network of perceptual and cognitive memory activated
by a particular set of emotions.
 The Expressive Therapies Continuum 47
The Symbolic (Sy) component of the C/Sy level emphasizes intuitive processing
of experiences and visual information through input from sensory and affective
sources, autobiographical processing, and symbolic expressions. It is character-
ized by symbolic affective images, symbolic use of color, symbolic abstractions,
and intuitive, integrative concept formation (Lusebrink, 2004, 2010). The Sy
component appears to predominantly reflect the processes of the OFC and
possibly the posterior part of the cingulate cortex and the ventromedial part of
the PFC. The integrative function of the OFC includes the retrieval of auto-
biographical consciousness (Carr, 2008). Both the Cognitive and Symbolic aspects
of the C/Sy level are necessary for memory work, and both aspects rely on
information stored in the multimodal cortex in the parietal lobe (Fuster, 2003).
C/Sy work in trauma aids in constructing a coherent trauma narrative (Gantt &
Tinnin, 2009; Hass-Cohen et al., 2014). In addition, C/Sy art therapy is important
for cognitive restructuring (Ford, Nader, & Fletcher, 2013), and for teaching
appropriate coping skills (Crenshaw, 2006; Ford, Nader, & Fletcher, 2013).

Creative Level (CR)

The Creative (CR) level of the ETC is conceptualized as a perpendicular
intersection of all three levels. The CR level can be present on each of the levels
at the intersection between the two polarities; at the same time, it can involve
information processing from all of the ETC levels. Artistically, creative visual
expression can encompass the characteristics along the whole continuum,
spanning any level of the ETC, whereby the preference for a particular level in
the expression is reflected in the artistic style (Feldman, 1972; Lusebrink, 1990).
Critical reviews of the cognitive neuroscience of creativity (Dietrich, 2004;
Sawyer, 2011; Zaidel, 2005) assert that the creative process consists of many
interactive cognitive processes and emotions, and that the right and left
hemispheres of the brain are equally active in most creative tasks. According to
Dietrich (2004), “creative insights can arise in two processing modes: spontaneous
or deliberate” (p. 1015). Creative insights based on deliberate searches are
initiated in the PFC; they encompass intentionally recruited long-term memory
retrieval from storage in the parietal, temporal, and occipital cortices and its
temporal representation in working memory. In contrast, creative insights in the
spontaneous processing mode happen effortlessly; they are based on intuition,
which can be “conceptualized as knowledge obtained while the frontal attention
system does not control the content of consciousness” (Dietrich, 2004: 1017).
Spontaneous creative insights can also emerge in working memory from the
parietal, temporal, and occipital cortices while the PFC is downregulated during
altered states such as dreaming or daydreaming (Dietrich, 2004).

The ETC and Two Functional Systems

The schematic representation of the ETC (Figure 3.1) visually illustrates two
different functional systems as they process their respective information
hierarchically on different levels of complexity. The left side of the schema
48 Vija B. Lusebrink and Lisa D. Hinz
incorporates the activity of visual pathways in the brain involved in the
perception and expression of visual forms on the Perceptual pole, which, in turn,
creates basic input for cognitive processing of this information in PFC on the
Cognitive pole. The right side represents the emotional experiences and values
based on input from the amygdala with the Affective pole. This information is
forwarded to the cingulate cortex in the limbic brain and then to the ventro-
medial prefrontal cortex (VMPFC), forming emotionally charged symbolic
images on the Symbolic pole.
This differentiation of the ETC into two different functional systems appears
similar to Dietrich’s (2004) conclusions based on his review of the literature on
brain functions involved in information processing. According to Dietrich, the
brain has developed two different types of neural systems for processing different
kinds of information from the environment; one system processes emotional
responses and attaches a value tag to the incoming information indicating its
subjective biological and emotional importance to the individual, whereas the
other “is designed to perform detailed feature analyses,” namely an objective
perceptual evaluation of the environment forming the basis for cognitive
processing (p. 1012). The first type of analysis provides information about, how
valuable is this stimulus for my survival? The second analysis answers the
question, what aspects of this item will benefit my survival? Initially, affective
content is processed in the amygdala, then in the higher limbic system structures,
namely, the cingulate cortex and the ventromedial PFC (VMPFC). The percept-
ual and conceptual content is processed in the three posterior cortices—occipital,
temporal, and parietal—and then forwarded to the dorsolateral prefrontal cortex
(DLPFC). Dietrich (2004) refers to Fuster (2003), stating that “although there
are multiple connections at various levels between the two information
processing systems, the full reintegration of emotional and cognitive information
does not appear to happen until both types of computations converge back to
the dorsolateral prefrontal cortex” (Dietrich, 2004: 1012).
The ETC schematically indicates the connections between the two informa-
tion processing systems on different levels of complexity. On the K/S level,
sensory-motor integration between the two components for routine and auto-
matic behaviors occurs in circular loops of neural connectivity at the basal
ganglia, hypothalamus, and other lower levels of the neural hierarchies involving
primary sensory and motor cortices. Corresponding cortical association areas
become engaged with novel and more complex expressions on the P/A level. On
the C/Sy level, activity in the PFC presumably involves the DLPFC, processing
cognitive information at the C polarity, with increasing input from the VMPFC
incorporating the limbic system-based affective input at the Sy polarity.

The Use of the ETC in the Treatment of Trauma

Structure of the ETC
The three-tiered structure of the ETC is based on the idea that several
component functions may be involved in visual expression, but that one
 The Expressive Therapies Continuum 49
component or level usually predominates. In using the ETC as a framework for
therapy, it is important to distinguish which of the components of client
expression reflect strengths in visual expression and which reflect respective
deficits. It is hypothesized that personal resources or shortcomings demon-
strated in ETC component processing mirror preferences in the reception,
processing, integration, and expression of information, emotion, and action in
other aspects of life (Hinz, 2009). For example, a person who is rational and
analytical in life will demonstrate an affinity for Cognitive processes; one who
is caught up in emotion will favor Affective processes. Art therapy in the context
of the ETC focuses on enhancing client strengths on different levels, while at
the same time improving areas of weakness (Hinz, 2009; Lusebrink, 2004, 2010;
Lusebrink, Mārtinsone, & Dzilna-Šilova, 2013). Clients enter therapy with
unique constellations of personal assets and deficits that are addressed in specific
ways, not through “cookbook” formulas (Hinz, 2009). Typically work begins with
the component process, where clients demonstrate strengths, and subsequently
moves in a stepwise fashion to enhance less well-developed areas of functioning
(Hinz, 2009; Lusebrink, 1990; Lusebrink, Mārtinsone, & Dzilna-Šilova, 2013).
Using the ETC allows therapists to customize interventions and goals in the
treatment of trauma; all clients are not treated similarly. The ETC encourages
individualized choices of media, art directives, and treatment goals. Effective
trauma treatment allows for the controlled exposure to trauma triggers and
associated affect, alternated with opportunities for conscious withdrawal and
containment (Hass-Cohen et al., 2014; Hinz & Ragsdell, 1991; Johnson, 2009;
Sarid & Huss, 2010). Thus, the two different functioning systems of information
processing represented on the left and right sides of the ETC can be differentially
and deliberately accessed and activated in treating trauma. Information
processing on the right side permits exposure through Affective and/or Symbolic
channels; processing on the left side provides containment and restructuring
through perceptual and cognitive functions. As compared to other clinical art
therapy approaches in the treatment of trauma (e.g., Chapman, 2014; Gantt &
Tinnin, 2009; Hass-Cohen et al., 2014; McNamee, 2005, 2006), the concept of
the ETC provides a flexible and comprehensive template marking horizontal and
vertical movement in therapy.
As mentioned above, vertical movement occurs between levels of the ETC.
Horizontal movement takes place within each level between the polarities of a
particular level. The three levels of the ETC also can be considered for their
vertical, “top-down” and “bottom-up” methods of action. The bottom-up
manner of information integration proceeds from the K/S level of sensory-
motor responses to the differentiation of forms and affective input in the
unimodal cortices and their multimodal integration in the parietal cortex on the
P/A level, and then to cognitive integration in the PFC on the C/Sy level. The
top-down sequence of information processing starts on the C/Sy level with
activity in the PFC and is followed by a gradual differentiation of form, affect,
and sensory-motor-based information in the parietal, temporal, and occipital
cortices on the P/A and K/S levels respectively.
50 Vija B. Lusebrink and Lisa D. Hinz
Media Choices and the ETC
Media choices can influence processing channels to promote or contain brain
functioning. Fluid media such as watercolors and chalk pastels are likely to evoke
and allow for emotional expression. Sensory engaging materials such as finger
paint and wet clay quickly will bring a client in touch with trauma memories (Sarid
& Huss, 2010). Therefore, materials such as paints and pastels channel informa-
tion processing through the right side of the ETC hierarchy and create the
careful emotional exposure associated with successful trauma work. The use of
fluid and sensory materials also can produce ambiguous forms, which can be
interpreted as personal or universal symbols, further promoting affectively laden
work on the right-hand side of the ETC. Resistive media such as hard clay or
crayon on rough paper are likely to require vigorous work to manipulate and thus
engage the Kinesthetic component. A focus on formal artistic elements required
for work with the Perceptual component is accomplished by media and processes
that emphasize clarity in the definition and differentiation of forms. Media such
as collage materials or sculpture, which have inherent structure and require
multiple steps to reach the end product, will elicit work with the Cognitive
component as clients work through the multiple steps to project completion (Naff,
2014). These left-hand functions support the detailed feature analyses necessary
for occasional emotional respite and promote cognitive restructuring.

Flow and Post-traumatic Growth

Ultimately, integration of the two different functional systems of information
processing using all the levels of the ETC contributes to healing and post-
traumatic psychological growth. It is hypothesized that the fluid transition
between the two systems and the different levels of the ETC could reflect the
experience of “flow” (Chilton, 2013; Csikszentmihalyi, 2008; Lee, 2013). Flow is
an optimal state of functioning in which clients are challenged by a task, engage
in problem solving behavior to adjust skills and goals, and are able to achieve
mastery (Lee, 2013). While in flow, clients can experience highly focused behavior,
an altered sense of time, and moments of peak joy. The occurrence is intrinsically
rewarding and is followed by longer lasting periods of increased well-being
(Csikszentmihalyi, 2008). Increased well-being is exemplified by more satisfying
interpersonal relationships, an enhanced view of the self, and changes in life
philosophy: three cardinal features of post-traumatic growth (Joseph, Murphy,
& Regel, 2012). The following case studies demonstrate the processes by which
two brothers emerge from childhood trauma via flow experiences in art therapy.

Case Studies Demonstrating the Use of the ETC

Introduction to Two Brothers: Art Therapy Approaches to Trauma
Two brothers, aged seven (Steven, a pseudonym) and eight years (Ed, also a
pseudonym), were referred for art therapy by their social services caseworker.
 The Expressive Therapies Continuum 51
The boys had been removed from their mother’s custody following Ed’s dis-
closure that the mother’s live-in boyfriend was sexually abusing them. The chil-
dren first were placed with their biological father and his girlfriend, but Ed ran
away from that living situation because the girlfriend was physically and emo-
tionally abusive. The brothers were placed in separate foster homes and referred
for therapy. After introduction to the art materials and a description of art
therapy, the brothers completed their first free drawings (see Figures 3.2 and
3.3). Both boys drew houses, and, while the brothers experienced similar trauma,
their depictions of these houses and their preferred ways of processing
information were diametrically opposed.
Ed described his house (Figure 3.2) as being surrounded by a tornado.
Alternating energy and control can be seen in his precise coloring of the house
and his expansive creation of the swirling storm. Prominent features of the
drawing also include the use of many colors, the pointed black roof, and a
gutter drawn on the side of the house to allow “dirty water to escape.” Based on
this drawing, Ed was characterized as energetic, assertive, expansive, action-
oriented, and an externalizer of emotion and as experiencing unpleasantness
needing expression. Using the framework of the ETC, one could say that
although the house drawing was on the C/Sy level, kinesthetic action was Ed’s
predominant mode of processing emotionally threatening information. In con-
trast, 7-year-old Steven described his house as a castle that had many windows
and doors, including the key-shaped window in the center. Additionally, he
pointed out an intruder on a ladder trying to gain access to the house. Prominent

Figure 3.2 Ed’s first free drawing, “House”

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52 Vija B. Lusebrink and Lisa D. Hinz

Figure 3.3 Steven’s first free drawing, “House/Castle”

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features of this drawing include geometric shapes, two chimneys, and a dearth
of color. The drawing indicated that this boy was tentative, thought- or fantasy-
oriented, an internalizer of emotion, and possibly experiencing guilt, self-blame,
and depression. He preferred working on the C/Sy level of the ETC, and his
graphic representations were developmentally appropriate for his age.
These two different client presentations naturally required different thera-
peutic approaches but the same ultimate goals for weekly art therapy: the
expression of trauma-related thoughts and feelings, including expression and
integration of the nonverbal traumatic memories encoded as sensations, the
organization of a trauma narrative, and psychological growth allowing the free-
dom to choose appropriate coping skills based on a positive sense of self-esteem
(Crenshaw, 2006; Ford, Nader & Fletcher, 2103; Hass-Cohen et al., 2014). One
brother presented with tremendous energy and kinesthetic involvement. He had
to discharge a great deal of energy before he could express emotion appropriately
and, later, coherently relate his trauma narrative. The second brother was
comfortable using cognitive strategies to keep emotions under control. It was
important to meet him at the C/Sy level where his strategies could be respected
and reinforced before eliciting emotional and K/S learning.
 The Expressive Therapies Continuum 53
A Bottom-Up Approach to Trauma Therapy: Art Therapy with Ed
Ed began art therapy choosing to work with clay. In the first two sessions he did
not shape the clay; he pounded, pushed, pinched, rolled, and tossed it. Sarid and
Huss (2010) state that resistive media, those that require energetic manipulation,
can help manage the sensory excitation of traumatic memories and allow for a
sense of personal control. In addition, Ed achieved a release of energy evidenced
in his calm facial expression as he left the sessions. Although these meetings
were dominated by action, Ed drew pictures as well. Interestingly, Figure 3.4
demonstrates pent-up energy awaiting discharge in one of the early art therapy
sessions. As work continued and he was able to release energy in a controlled,
acceptable fashion, Ed’s drawings indicated decreased energy and increased
sensory involvement, as seen in the rhythmic horizontal strokes and yellow color
of Figure 3.5. In the next phase of art therapy, Ed was educated about the natural
presence and purposes of emotions. Psychoeducation combined with art
expression allowed Ed to understand that emotions are signals that require
appropriate expression. To learn about the range of personal emotions, Ed
created collages of facial expressions such as the one depicted in Figure 3.6. Each
emotion was examined individually with respect to the event(s) that might have
caused it and to what appropriate action might be taken in response to the
emotion. Ed, creating paintings of emotions that he personally experienced, also
began to separate and discriminate what he previously felt as the undiffer-
entiated, swirling storm. In addition, P/A work involved using art as a method
for responding to or soothing emotions.

Figure 3.4 Ed’s drawing showing pent up energy awaiting release

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54 Vija B. Lusebrink and Lisa D. Hinz

Figure 3.5 Ed’s drawing showing less energy needing an outlet

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Figure 3.6 Ed’s collage of emotions

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 The Expressive Therapies Continuum 55
In a subsequent stage of therapy, Ed created clay animal figures and told
stories about their lives, some of which he also illustrated with drawings
(see Figure 3.7.). These stories formed the basis of Ed’s trauma narrative; the
metaphoric telling allowed for enough reflective distance so that he could safely
tell his life story.
The stories also allowed for purposeful cognitive restructuring as the art
therapist witnessed the original stories, helped Ed to recognize themes and
emotions, and asked Ed to create new chapters or endings that emphasized his
strengths and inner resources (Steele & Kuban, 2012). For example, the story
that accompanied the drawing in Figure 3.7 was this: Two dogs are traveling and
they get lost. They end up on two sides of this big river. The little dog cries to the
big dog, I don’t know how to swim! The big dog tells him to shut up, and he (the
little dog) gets caught by the dogcatcher. The big dog tries to find his way home,
but there are too many signs pointing in too many directions. He doesn’t know
the way.
Clearly Ed was expressing guilt about leaving his brother, Steven, behind when
he ran away from their father’s abusive girlfriend. Steven suffered more abuse,
and eventually the boys were placed in separate foster homes. The art therapist
commented on how guilt often is manifested as anger at the victim and helped
Ed identify positive resources and skills that might be employed if the situation

Figure 3.7 Animal illustration of Ed’s trauma narrative

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56 Vija B. Lusebrink and Lisa D. Hinz
were encountered in the future. Using cognitive restructuring (Rosal, 2001;
Steele & Kuban, 2012), Ed created a chapter that allowed the big dog to help the
small dog and a chapter in which the two dogs together found their way home.
The new images were reminders of positive and more rewarding approaches to
difficult situations.
Following the animal stories, Ed used clay to create human figures that he
arranged in teams to play basketball or soccer. He engaged the art therapist on
the opposing team, and the games provided opportunities for teaching
appropriate coping skills (e.g., cooperation alongside competition, compassion,
creation instead of destruction). In particular, these sessions offered experiences
of flow. Ed was occupied in decidedly focused behavior, problem solving, and
mastery. He demonstrated intense enjoyment at his abilities and, further, his
precise artistic behavior differed greatly from the unfocused, action-oriented
behavior characteristic of his first art therapy sessions. Integration of the two
different functional systems of information processing using all the levels of the
ETC occurred through the use of clay to create detailed human figures and the
use of these figures in fantasy and interactive play. The use of fine motor skill
and the planning and thought involved in the creation of the figures required a
combination of K/S and C processing. Using the human figures in an interactive,
fantasy scenario with the therapist added Sy and A activity. It is hypothesized
that the fluid transition between the two systems and the different levels of the
ETC could reflect the experience of “flow” which creates unique opportunities
for healing and post-traumatic psychological growth.
In terms of the ETC, Ed began art therapy on the left-hand side of the
hierarchy at the K/S level. In the first two sessions his work was utterly
Kinesthetic: he pounded, pushed, pinched, rolled, and tossed clay. The bipolar
nature of the K/S level necessitates that as participation with Kinesthetic activity
increases, Sensory involvement naturally will decrease. Therefore, if the sensory
nature of clay evoked trauma memories as has been hypothesized (e.g., Elbrecht,
2013; Sarid & Huss, 2010), action with the clay provided a necessary release
of tension. Pictures drawn during these early meetings demonstrated that after
the kinesthetic work and the additional release of energy, Ed could focus on
form. Consequently, work moved to the P/A level in order for Ed to identify,
discriminate, appropriately express, and soothe emotions.
At first the work stayed mainly on the P polarity of the P/A level, as Ed was
encouraged to identify and discriminate among other people’s emotions through
the use of collage images. The appropriate selection of both task and media
encouraged the reflective distance that allowed the experiences to remain more
Perceptual than Affective. When Ed demonstrated proficiency with the P
polarity, movement to the right side of the ETC was attempted. Again, the art
therapist’s choices of tasks and media moved the experience in the desired
direction. By encouraging Ed to express his personal emotions and to use paint
to do so, the therapist constructed experiences that became more affectively
charged.
 The Expressive Therapies Continuum 57
The final stages of this bottom-up approach to trauma mastery required
moving to the C/Sy level. Although Ed again chose to use clay, his work with
the material was more refined than previously in terms of the figures created
and the stories imagined. Previously his work was action-oriented and
haphazard; creating form was not integral to the experiences. As work moved
to the C/Sy level, Ed created figures of animals and detailed pictures and stories
to accompany them. The difference can be seen graphically by comparing
Figures 3.4 and 3.5 with Figure 3.7. The increasing complexity of these figures
and stories demonstrated Ed’s increasing ability to master the trauma experience
through Symbolic expression. In addition, through cognitive restructuring, the
art therapist encouraged PFC control over limbic system processing; thus, over
time, establishing increased conscious control over emotional responding.
The Creative level was accessed and flow experiences encouraged through Ed’s
creation of complex human figures and his actively and constructively engaging
the art therapist in team play. Ed showed problem solving skills and mastery of
challenges encountered with the art materials and processes. In dramatic
contrast to the trauma narrative related above in which the big dog tells the crying
little dog to “shut up,” Ed showed growth in his ability to incorporate and
demonstrate cooperation and compassion in his interactions with the art
therapist.

A Top-Down Approach to Trauma Therapy: Art Therapy with

Steven
Steven’s first images in art therapy mimicked the style seen in Figure 3.3: line
drawings with random color used mainly to outline forms. After a few sessions,
Steven began to experience nightmares. Therefore, he was asked to draw his
nightmares and create response drawings to them in an attempt to cognitively
restructure these highly emotional experiences. In the response drawings, Steven
was instructed to change negative images into ones that were more manageable
or ones in which he was in control of the outcome (Steele & Kuban, 2012). For
example, in one dream his father’s girlfriend was a giant who aggressively
pursued Steven.
pursued Steven. Steven
Steven drew
drew aa picture
pictureof
of the
the giant
giant (Figure
(Figure3.3.8); then he
8); then he “cut
“cut
her down to size” (Figure 3.9). In a subsequent series of drawings, the perpetrator
became smaller and smaller until she was merely a dot that disappeared into the
white expanse of paper.
Steven’s experience of nightmares is common among trauma survivors.
Nightmares are one way that the body re-experiences trauma (Ford, Nader, &
Fletcher, 2013), and the drawing technique helped Steven manage the anxiety
that he felt as he recounted his dreams in therapy. Consequently, he was coached
to use the technique at home so that his sleep gradually was less disrupted.
Because the nightmares included many trauma-related incidents, Steven
was encouraged to create a trauma narrative (Crenshaw, 2006; Gantt & Tinnin,
2009; Pifalo, 2009; Talwar, 2007) with the goals of organizing the story, increas-
ing understanding, expressing affect, and restructuring self-image from victim
58 Vija B. Lusebrink and Lisa D. Hinz

Figure 3.8 The original view of Steven’s nightmare

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Figure 3.9 Cognitive Restructuring of Steven’s nightmare

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