Expressive Therapies
This is a chapter excerpt from Guilford Publications.
Expressive Therapies, edited by Cathy A. Malchiodi
Copyright © 2005
EXPRESSIVE
History,
Theory,
THERAPIES
and Practice
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Expressive Therapies
History, Theory, and Practice
CATHY A. MALCHIODI
In his seminal work The Arts and Psychotherapy, McNiff (1981)
observes that expressive therapies are those that introduce action to psychotherapy and that “action within therapy and life is rarely limited to a specific mode of expression” (p. viii). While talk is still the traditional method of exchange in therapy and counseling, practitioners of expressive therapies know that people also have different expressive styles— one individual may be more visual, another more tactile, and so forth.
When …show more content…
therapists are able to include these various expressive capacities in their work with clients, they can more fully enhance each person’s abilities to communicate effectively and authentically.
This chapter introduces readers to the history and philosophy of expressive therapies and their applications in treatment. While there are approximately 30,000 individuals throughout the United States formally trained at the graduate level in one or more of the expressive therapies, these modalities have also been embraced by practitioners in the fields of psychology, psychiatry, social work, counseling, and medicine over the last decade. Activities such as drawing, drumming, creative movement, and play permit individuals of all ages to express their thoughts and feelings in a manner that is different than strictly verbal means and have unique properties as interventions. Indeed, with the advent of brief
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forms of treatment, many therapists find that the expressive therapies help individuals to quickly communicate relevant issues in ways that talk therapy cannot do. For this reason and others, psychologists, counselors, and other health care professionals are turning to expressive modalities in their work with individuals of all ages.
DEFINING EXPRESSIVE THERAPIES
The expressive therapies are defined in this text as the use of art, music, dance/movement, drama, poetry/creative writing, play, and sandtray within the context of psychotherapy, counseling, rehabilitation, or health care. Several of the expressive therapies are also considered “creative arts therapies”—specifically, art, music, dance/movement, drama, and poetry/creative writing according to the National Coalition of Creative Arts Therapies Associations (2004a; hereafter abbreviated as
NCCATA). Additionally, expressive therapies are sometimes referred to as “integrative approaches” when purposively used in combination in treatment. While expressive therapies can be considered a unique domain of psychotherapy and counseling, within this domain exists a set of individual approaches, defined as follows:
• Art therapy uses art media, images, and the creative process, and respects patient/client responses to the created products as reflections of development, abilities, personality, interests, concerns, and conflicts. It is a therapeutic means of reconciling emotional conflicts, fostering selfawareness, developing social skills, managing behavior, solving problems, reducing anxiety, aiding reality orientation, and increasing selfesteem (American Art Therapy Association, 2004).
• Music therapy uses music to effect positive changes in the psychological, physical, cognitive, or social functioning of individuals with health or educational problems (American Music Therapy Association,
2004).
• Drama therapy is the systematic and intentional use of drama/ theatre processes, products, and associations to achieve the therapeutic goals of symptom relief, emotional and physical integration, and personal growth. It is an active approach that helps the client tell his or her story to solve a problem, achieve a catharsis, extend the depth and breadth of inner experience, understand the meaning of images, and
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strengthen the ability to observe personal roles while increasing flexibility between roles (National Drama Therapy Association, 2004).
• Dance/movement therapy is based on the assumption that body and mind are interrelated and is defined as the psychotherapeutic use of movement as a process that furthers the emotional, cognitive, and physical integration of the individual. Dance/movement therapy effects changes in feelings, cognition, physical functioning, and behavior (NCCATA,
2004b).
• Poetry therapy and bibliotherapy are terms used synonymously to describe the intentional use of poetry and other forms of literature for healing and personal growth (NCCATA, 2004c).
• Play therapy is the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development (Boyd-Webb,
1999; Landreth, 1991).
• Sandplay therapy is a creative form of psychotherapy that uses a sandbox and a large collection of miniatures to enable a client to explore the deeper layers of the psyche in a totally new format. By constructing a series of “sand pictures,” a client is helped to illustrate and integrate his or her psychological condition.
• Integrated arts approach or intermodal (also known as multimodal) therapy involves two or more expressive therapies to foster awareness, encourage emotional growth, and enhance relationships with others.
Intermodal therapy distinguishes itself from its closely allied disciplines of art therapy, music therapy, dance/movement therapy, and drama therapy by being grounded in the interrelatedness of the arts. It is based on a variety of orientations, including arts as therapy, art psychotherapy, and the use of arts for traditional healing (Knill, Barba, & Fuchs, 1995).
Knill et al. (1995) observe that while all of the expressive therapies involve action, each also has inherent differences. For example, visual expression is conducive to more private, isolated work and may lend itself to enhancing the process of individuation; music often taps feeling and may lend itself to socialization when people collaborate in song or in simultaneously playing instruments; and dance/movement offer opportunities to interact and form relationships. In other words, each form of expressive therapy has its unique properties and roles in therapeutic work depending on its application, practitioner, client, setting, and objectives.
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EXPRESSIVE THERAPIES
Therapists who are unfamiliar with expressive therapies often wonder if these modalities have been used as a form of assessment. Some practitioners of expressive therapies believe that using art, music, movement, or other modalities for evaluation is not practical due to a lack of substantive research data, and, that in some circumstances, such use may even be counterproductive. Despite this stance, formal assessments have been developed in art therapy, music therapy, and other expressive therapies for the purpose of adding to other available psychiatric, behavioral, and developmental assessments. Feder and Feder (1998) identify several basic ways in which the expressive therapies have been used in assessment: (1) assessment of abilities and preferences including formal and informal inventories and observations of individuals’ skills and interests;
(2) assessment of life experiences and capacities; and (3) assessment of psychological, psychosocial, and/or cognitive aspects. Many of these assessments, described throughout subsequent chapters of this book, may be used in combination with other evaluation methods in the related fields of psychology and counseling.
Finally, expressive therapies, such as art, music, and dance/movement, have been sometimes incorrectly labeled as “nonverbal” therapies.
They are, in fact, both nonverbal and verbal because verbal communication of thoughts and feelings is a central part of therapy in most situations.
However, for a child who has limited language, an elderly person who has lost the ability to talk because of a stroke or dementia, or a trauma victim who may be unable to put ideas into speech, expression through art, music, movement, or play can be ways to convey oneself without words and may be the primary form of communication in therapy.
A BRIEF HISTORY OF EXPRESSIVE THERAPIES
McNiff (1981, 1992) proposes that the arts have consistently been part of life as well as healing throughout the history of humankind. Today, expressive therapies have an increasingly recognized role in mental health, rehabilitation, and medicine. However, as McNiff observes, these therapies have been used since ancient times as preventative and reparative forms of treatment. There are numerous references within medicine, anthropology, and the arts to the earliest healing applications of expressive modalities. For example, the Egyptians are reported to have encouraged people with mental illness to engage in artistic activity (Fleshman
& Fryrear, 1981); the Greeks used drama and music for its reparative
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properties (Gladding, 1992); and the story of King Saul in the Bible describes music’s calming attributes. Later, in Europe during the Renaissance, English physician and writer Robert Burton theorized that imagination played a role in health and well-being, while Italian philosopher de Feltre proposed that dance and play were central to children’s healthy growth and development (Coughlin, 1990).
The idea of using the arts as an adjunct to medical treatment emerged in the period from the late 1800s to the 1900s alongside the advent of psychiatry. During this time the movement to provide more human treatment of people with mental illness began and “moral therapy” included patient involvement with the arts (Fleshman & Fryrear, 1981).
While late-19th-century programs were transitory, the ideas behind them resurfaced in the early 1900s. For example, documented uses of music as therapy can be found following World War I when “miracle cures” were reported, resulting from reaching patients through music when they responded to nothing else. Joseph Moreno (1923), the founder of psychodrama, proposed the use of enactment as a way to restore mental health.
He also described the use of positive creative imagery, role reversal, and
“monodrama” (in which a participant enacts all parts of the self). At the same time, Florence Goodenough (1926) studied children’s drawings as measures of cognitive development, and others, like Hans Prinzhorn, became interested in the art of patients with severe mental illnesses
(Vick, 2003). Finally, the fields of sandplay, sandtray therapy, and the foundations of play therapy were present in Margaret Lowenfeld’s
“World Technique” in the 1920s (Lowenfeld, 1969). Lowenfeld began her training as a pediatrician and subsequently began to make observations about children’s play, developing a method of using toys to understand psychosocial aspects of child clients.
The creative arts therapies became more widely known during the
1930s and 1940s when psychotherapists and artists began to realize that self-expression through nonverbal methods such as painting, music making, or movement might be helpful for people with severe mental illness.
Because there were many patients for whom the “talking cure” was impractical, the arts therapies gradually began to find a place in treatment.
Major psychiatric hospitals such as the Menninger Clinic in Kansas and
St. Elizabeths in Washington, DC, incorporated the arts within treatment, both as activity therapies and as modalities with psychotherapeutic benefits.
Professional associations for practitioners of art, music, and other expressive therapies were established and university programs training
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EXPRESSIVE THERAPIES
practitioners in these modalities rapidly developed. Over the last several decades, play therapy and sandplay therapy have also become part of expressive therapies practice and have developed specific theoretical foundations, methodologies, training, and professional associations. More recently, expressive therapies have been incorporated into a variety of mental health, rehabilitative, and medical settings as both primary and adjunctive forms of treatment. For example, music and imagery therapies are now used routinely with hospitalized patients for pain reduction, relaxation, and childbirth; art and play are proving to be essential in trauma debriefing, resolution, and recovery with children (Malchiodi,
2001); and writing is prescribed to ameliorate symptoms of illnesses such as asthma and arthritis as well as to decrease posttraumatic stress in individuals who have experienced crisis or loss (Pennebaker, 1997).
EDUCATION, COMPETENCY,
AND STANDARDS OF PRACTICE
Many practitioners who incorporate the expressive therapies into the practice of psychotherapy have studied these modalities through graduate-level training and may hold a credential in one or more of the media they use. These practitioners are distinguished by credentials in art therapy, music therapy, play therapy, and so forth, either in the form of a master’s or doctoral degree, or through registration, certification, or licensure in a specific creative art therapy or expressive therapy (see the
Appendix for a list of professional associations). Those therapists whose training has included multiple modalities are often referred to as “expressive arts therapists” or “expressive therapists.” Knill et al. (1995) propose that those who take an integrated approach (see Chapter 9) do not need to master all forms of expressive therapy. They observe that it is more important to have a focus on the artistic tradition that all expressive therapies have in common: human imagination. This is the same tradition that healers throughout history used who did not divide their work into specializations of drumming, art making, or ritual; rather, they used multimodal aspects in their work. Knill et al. conclude that using more than one modality in therapy is more efficacious and helps therapists to avoid the trap that Maslow is quoted as saying “If the only tool you have is a hammer, every problem starts to look like a nail.”
In terms of training, a discussion within expressive therapies continues about the importance and role of in-depth training in an art form through studio work in order to practice creative interventions. Some
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believe that in order for a therapist to be effective, he or she must have had significant experiences in art, music, dance, drama, poetry, play, or sandtray in order to competently and ethically use these modalities in therapy. With regard to art therapy, Agell (1982) notes that “a flirtation with materials is not enough. Only a love affair with materials can lead to a wedding of felt experience and formed expression” (p. 37). While many therapists are familiar with several expressive therapies, generally most tend to specialize in one or two that they are trained in and that meet the needs and situation of their clients. Others, such as Gladding
(1992) and Carson and Becker (2004), see expressive therapies as part of larger realm of “creativity in counseling.” They propose that creativity in counseling involves being able to flexibly respond to clients with a variety of techniques and to encourage creativity within therapy. Carson and Becker (2004) note that there is a need for “counselors to be continually cultivating and nurturing their own creativity” (p. 114), although they do not offer any specific ideas or recommendations on how counselors and other mental health professionals can achieve this depth of knowledge. Depending on the practitioner and the setting, expressive therapies may be used as a primary form of therapy, requiring the therapist to have a deeper understanding of how various modalities can be applied in response to a wide range of disorders. Often, expressive therapies are integrated within a psychotherapy or counseling framework. For example,
Gladding and Newsome (2003) highlight the integration of visual art activities into counseling treatment plans with adults and emphasize that a quick client drawing or collage can move a client forward when talk therapy is resisted or ineffective. Also, many expressive therapy techniques have been used to complement a wide range of psychotherapy and counseling theories, including psychoanalytic, object relations, cognitive-behavioral, humanistic, transpersonal, and others (Malchiodi,
1998, 2003).
Finally, when using expressive therapies to complement verbal therapy, practitioners should be aware of the current standards of practice in the particular modality they are using. The American Art Therapy Association (AATA), the American Music Therapy Association (AMTA), the
American Dance Therapy Association (ADTA), the National Drama
Therapy Association (NADT), the National Poetry Therapy Association
(NAPT), and the Association of Play Therapy (APT) all provide helpful guidelines about the application and practice of expressive modalities with clients in mental health, rehabilitation, special education, and health care settings. The NCCATA also offers information on standards
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EXPRESSIVE THERAPIES
of practice, training opportunities, and other subjects useful for practitioners. Additionally, each association has ethical standards that therapists who plan to use expressive therapies as a form of treatment or assessment should consult before integrating art, music, movement, play, or other methods into their work.
EXPRESSIVE THERAPIES’ ROLE
IN TREATMENT AND INTERVENTION
In general, like counseling or psychotherapy, an expressive therapies session may open with a discussion of the individual’s, family’s, or group’s goals, concerns, or current problems. In contrast to therapists who explore these issues through talking, expressive therapists encourage individuals to use an expressive form of communication as a means for further exploration. For example, clients may be asked to draw an image of an idea, enact a situation or engage in a dramatic dialogue, manipulate a set of figures in a sandtray, write a short story or poem, play with toys or props, or use a musical instrument to express a feeling.
Depending on the client, the therapist may also begin a session with a warm-up activity or exercise such as a quick scribble, stretches, simple movements, or humming a familiar tune. The opening activity may be used simply for relaxation, to introduce a modality into the session, or to help the therapist evaluate the individual’s mood or current concerns. One or more expressive therapies may be used in a session—for example, while a drama therapy session may involve role play, it is also likely to involve movement or may start with some creative writing or a piece of poetry to stimulate or inspire the invention of a story. In subsequent chapters, applications and case examples of expressive therapies, including integrative approaches, are described in detail, illustrating their vast range of application as primary therapies and as complements to verbal therapy from a variety of theoretical models.
UNIQUE CHARACTERISTICS
OF EXPRESSIVE THERAPIES
Expressive therapies add a unique dimension to psychotherapy and counseling because they have several specific characteristics not …show more content…
always found in strictly verbal therapies, including, but not limited to, (1) self-
History, Theory, and Practice
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expression, (2) active participation, (3) imagination, and (4) mind–body connections. Self-Expression
All therapies, by their very nature and purpose, encourage individuals to engage in self-exploration. Expressive therapies encourage not only selfexploration, but also use self-expression through one or more modalities as a central part of the therapeutic process. Gladding (1992) notes that using the arts in counseling may actually speed up the process of selfexploration and that expressive modalities allow people to experience themselves differently. He adds that through these forms of self-expression, individuals are able to “exhibit and practice novel and adaptive behaviors” (p. 6).
Self-expression through a painting, movement, or poem can recapitulate past experiences and even be cathartic for some, but these are only two aspects of the role of self-expression in therapy. In fact, most therapists using expressive therapies in their work capitalize on the ability of art, music, play, and other forms to contain self-expression rather than to encourage cathartic communication of raw emotions or mere repetition of troubling memories. In essence, as therapist and client work together, self-expression is used as a container for feelings and perceptions that may deepen into greater self-understanding or may be transformed, resulting in emotional reparation, resolution of conflicts, and a sense of well-being. Expressive therapists generally do not seek to interpret individuals’ drawings, movement, poems, or play, but instead try to facilitate their clients’ discovery of personal meaning and understanding. For that reason, self-expression in an expressive therapies session also generally involves verbal reflection in order to help individuals to make sense of their experiences, feelings, and perceptions. While words are generally used to tell personal stories, expressive therapies are used to tap the senses as a source of stories and memories. Because thoughts and feelings are not strictly verbal and are not limited to storage as verbal language in the brain, expressive modalities are particularly useful in helping people communicate aspects of memories and stories that may not be readily available through conversation. Memories in particular have been reported to emerge through touch, imagery, or carefully guided body movements (Rothschild, 2000). For some individuals, telling a story through one or more expressive modality is more easily tolerated
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than verbalization. Individuals can “experience” their story, allowing the practitioner to capitalize on clients’ discoveries and use the activity to help them broaden their understanding.
Some therapists believe that the process of expressive therapy (the telling of a story through an expressive modality such as art, music, movement, etc.) offers as much therapeutic value as verbal reflection about the product or experience. Landreth (1991), a well-known play therapy pioneer, notes that this holds particularly true for young children who do not have the verbal capabilities necessary for reflection through language. Expression through a painting, play activity, imaginative role play, or movement may be a corrective experience, in and of itself, for some individuals.
In cases where self-expression is repetitive, rigid, or noncorrective, a therapist using expressive techniques will actively engage with clients in order to help therapy progress. Art and play therapist Eliana Gil (1998) notes that when a child who has been severely traumatized repeats a play or art activity without resolution or correction the therapist must introduce activities or directives to help the child transform the storyline into a more productive and satisfying experience. Other therapists encourage client dialogues that involve “talking to the painting” (McNiff,
1992) or use an expressive modality as a source of reflection and exploration. For example, a poem can be written about a drawing, a painting can be made about a movement, a short play can be enacted about a piece of music, and so forth. Throughout this book readers will find examples of how this is accomplished, using expressive therapies as the basis.
Active Participation
Expressive therapies are defined by psychology as “action therapies”
(Weiner, 1999) because they are action-oriented methods through which clients explore issues and communicate their thoughts and feelings. Art and music making, dance and drama, creative writing, and all forms of play are participatory and require individuals to invest energy in them.
For example, art making, even in its simplest sense, can involve arranging, touching, gluing, stapling, painting, forming, and many other tangible experiences. All expressive therapies focus on encouraging clients to become active participants in the therapeutic process. The experience of doing, making, and creating can actually energize individuals, redirect attention and focus, and alleviate emotional stress, allowing clients to fully concentrate on issues, goals, and behaviors. Finally, in addition to promoting active participation, expressive therapies are sensory in na-
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ture. Many or all of the senses are utilized in one way or another when a person engages in art making, music playing or listening, dancing or moving, enacting, or playing. These types of activities and experiences redirect awareness to visual, tactile, and auditory channels.
Imagination
Levine (1999) observes that “imagination is the central concept which informs the understanding of the use of arts and play in therapy” (p.
259). McNiff (1981, 1992) believes that imagination is the healing agent inherent to all forms of self-expression. While some favor the use of the word “creativity” in describing expressive therapies, it is actually the use of imagination that informs theory and practice. In contrast to imagination, creativity occurs when self-expression is fully formed and achieves a novel and aesthetic value. In an expressive therapies session clients may not always make drawings, music, movements, or poems that would be considered creative or fully formed, but in most cases imaginative thinking is used to generate self-expression, experimentation, and subsequent verbal reflection.
The role of imagination in expressive therapies practice is illustrated throughout this book, but there are several specific qualities that are central to art, music, dance, drama, creative writing, and play in therapy.
These modalities are helpful in assisting individuals in moving beyond their preconceived beliefs through experimentation with new ways of communication and experiences that involve “pretend.” The imaginative thinking needed to make a drawing, create a movement, or manipulate figures in a sandtray also offers the possibility for trying out inventive solutions and transformation. Clients who may be otherwise restricted in their ability to use imagination in problem solving often find expressive therapies particularly helpful. For example, a person who has been severely traumatized may feel emotionally constricted or may have obsessive thoughts or memories. The therapeutic use of art, play, or sandtray can augment the productive use of imagination, helping the individual discover and develop corrective solutions leading to change, resolution, and reparation.
Mind–Body Connections
The National Center for Complementary and Alternative Medicine
(2004; hereafter abbreviated as NCCAM) has defined mind–body interventions as those that are designed to facilitate the mind’s capacity to in-
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fluence bodily functions and symptoms. Many of the expressive therapies are considered by NCCAM to be mind–body interventions because they are both forms of psychotherapy and therapies that capitalize on the use of the senses to effect change. The advances made in the field of neuroscience and neurodevelopment have also drawn attention to the potential of expressive therapies in regard to mind–body intervention, particularly in the areas of mood disorders, stress disorders, and physical illness. For example, art, drama, and play therapies show promise in the amelioration of posttraumatic stress and the expression of traumatic memories. Music, art, and dance/movement may be helpful in tapping the body’s relaxation response, a calm and confident state of being associated with perceptions of health, wellness, and happiness (Benson,
1996). Writing has proven to be effective in emotional reparation and in reducing symptoms in some chronic illnesses (Pennebaker, 1997). Overall, expressive activities may stimulate the placebo effect through mimicking self-soothing experiences of childhood and inducing self-relaxation (Malchiodi, 2003; Tinnin, 1994).
Finally, research on early attachment and brain development is beginning to inform psychotherapy of the value of expressive therapies.
Expressive therapies, particularly dance, art, and play therapies, may be useful in reestablishing and encouraging healthy attachments through sensory experiences, interactions, movement, and hands-on activities.
These modalities may be helpful in repairing and reshaping attachment through experiential and sensory means and may tap early relational states before words are dominant, possibly allowing the brain to establish new, more productive patterns (Malchiodi, 2003; Riley, 2002).
LIMITATIONS OF EXPRESSIVE THERAPIES
Like any therapy, there are limitations to expressive therapy in treatment and intervention. While expressive therapies have been applied to all age groups, to most psychiatric and medical disorders, and to a variety of settings, there are clients who may not benefit from these modalities for various reasons. First, some individuals, often adults, may be hesitant to engage in an expressive modality in therapy because they believe they are not “creative” or cannot produce something that is “artistic.” Therapists initiating expressive activities as interventions may encounter resistance to participation by clients who perceive themselves as unable to use imagination, who are anxious about self-expression, or who are resistant to active participation. Additionally, and ironically, those individu-
History, Theory, and Practice
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als with extensive experience in painting, music, or dance may not be able to let go of learned rules about self-expression and may be inhibited in their spontaneity in therapy when asked to express themselves in their particular medium.
For therapists who have not had extensive training in expressive therapies, there may be a tendency to want to interpret what their clients do in a given modality. This is particularly true of client-created drawings and other art expressions; practitioners may be tempted to project their own conclusions about content, sometimes missing their clients’ intended meanings. Additionally, therapists without experience may use expressive modalities in a mechanical fashion and use activities and techniques routinely rather than thinking about what would be best for clients given their histories, presenting problems and potentials, and goals. Because expressive therapies can include directed activities, it is easy for some therapists to fall into the habit of simply choosing an expressive activity or directive from a book or workshop. As with any form of therapy, it is important to listen to and respect what the client is communicating and then create an intervention that is best suited to the individual’s needs and objectives.
Finally, while research on the efficacy of expressive therapies is increasing dramatically, there is still much to be learned about how they work and how they should be applied in work with children, adults, families, and groups.
Music therapy is possibly the most widely researched modality, largely because physiological and behavioral reactions to music and music therapy interventions can be quantified. Within the field of art therapy, art-based assessments have been more extensively studied and efficacy studies in the areas of trauma and emotional disorders are receiving more attention (Malchiodi, 2003). In brief, while there have been some qualitative studies in the expressive therapies, most of the literature discusses clinical observations, case examples, and applications. Because of the recognition by mental health professionals of the inherent value of expressive modalities in treatment, interest in research is increasing, particularly in the areas of trauma, mood disorders,
Alzheimer’s disease and other forms of dementia, and childhood disorders such as attention-deficit/hyperactivity disorder and autism.
CONCLUSION
Johnson (1985) observes that expressive therapists “have a powerful vision, and we have emerged for a reason” (p. 238). In the same vein, the
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EXPRESSIVE THERAPIES
expressive therapies as a force with psychology and counseling have emerged for a reason. A growing number of mental health professionals are recognizing why expressive therapies enhance work with clients in ways that strictly verbal therapies cannot. Additionally, there is a growing movement in mental health to utilize “creative methods” in therapy and medicine.
Creativity in therapy has the potential to impact clients in memorable ways that traditional interventions do not. When therapists choose to use expressive therapies, they give their clients the opportunity to become active participants in their own treatment and empower them to use imagination in productive and corrective ways. Whether through art, play, music, movement, enactment, or creative writing, expressive therapies stimulate the senses, thereby “sensitizing” individuals to untapped aspects of themselves (Gladding, 1991) and thus facilitating self-discovery, change, and reparation.
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Expressive Therapies, edited by Cathy A. Malchiodi
Copyright © 2005
EXPRESSIVE
History,
Theory,
THERAPIES
and Practice
࣍1
Expressive Therapies
History, Theory, and Practice
CATHY A. MALCHIODI
In his seminal work The Arts and Psychotherapy, McNiff (1981)
observes that expressive therapies are those that introduce action to psychotherapy and that “action within therapy and life is rarely limited to a specific mode of expression” (p. viii). While talk is still the traditional method of exchange in therapy and counseling, practitioners of expressive therapies know that people also have different expressive styles— one individual may be more visual, another more tactile, and so forth.
When …show more content…
therapists are able to include these various expressive capacities in their work with clients, they can more fully enhance each person’s abilities to communicate effectively and authentically.
This chapter introduces readers to the history and philosophy of expressive therapies and their applications in treatment. While there are approximately 30,000 individuals throughout the United States formally trained at the graduate level in one or more of the expressive therapies, these modalities have also been embraced by practitioners in the fields of psychology, psychiatry, social work, counseling, and medicine over the last decade. Activities such as drawing, drumming, creative movement, and play permit individuals of all ages to express their thoughts and feelings in a manner that is different than strictly verbal means and have unique properties as interventions. Indeed, with the advent of brief
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forms of treatment, many therapists find that the expressive therapies help individuals to quickly communicate relevant issues in ways that talk therapy cannot do. For this reason and others, psychologists, counselors, and other health care professionals are turning to expressive modalities in their work with individuals of all ages.
DEFINING EXPRESSIVE THERAPIES
The expressive therapies are defined in this text as the use of art, music, dance/movement, drama, poetry/creative writing, play, and sandtray within the context of psychotherapy, counseling, rehabilitation, or health care. Several of the expressive therapies are also considered “creative arts therapies”—specifically, art, music, dance/movement, drama, and poetry/creative writing according to the National Coalition of Creative Arts Therapies Associations (2004a; hereafter abbreviated as
NCCATA). Additionally, expressive therapies are sometimes referred to as “integrative approaches” when purposively used in combination in treatment. While expressive therapies can be considered a unique domain of psychotherapy and counseling, within this domain exists a set of individual approaches, defined as follows:
• Art therapy uses art media, images, and the creative process, and respects patient/client responses to the created products as reflections of development, abilities, personality, interests, concerns, and conflicts. It is a therapeutic means of reconciling emotional conflicts, fostering selfawareness, developing social skills, managing behavior, solving problems, reducing anxiety, aiding reality orientation, and increasing selfesteem (American Art Therapy Association, 2004).
• Music therapy uses music to effect positive changes in the psychological, physical, cognitive, or social functioning of individuals with health or educational problems (American Music Therapy Association,
2004).
• Drama therapy is the systematic and intentional use of drama/ theatre processes, products, and associations to achieve the therapeutic goals of symptom relief, emotional and physical integration, and personal growth. It is an active approach that helps the client tell his or her story to solve a problem, achieve a catharsis, extend the depth and breadth of inner experience, understand the meaning of images, and
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strengthen the ability to observe personal roles while increasing flexibility between roles (National Drama Therapy Association, 2004).
• Dance/movement therapy is based on the assumption that body and mind are interrelated and is defined as the psychotherapeutic use of movement as a process that furthers the emotional, cognitive, and physical integration of the individual. Dance/movement therapy effects changes in feelings, cognition, physical functioning, and behavior (NCCATA,
2004b).
• Poetry therapy and bibliotherapy are terms used synonymously to describe the intentional use of poetry and other forms of literature for healing and personal growth (NCCATA, 2004c).
• Play therapy is the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development (Boyd-Webb,
1999; Landreth, 1991).
• Sandplay therapy is a creative form of psychotherapy that uses a sandbox and a large collection of miniatures to enable a client to explore the deeper layers of the psyche in a totally new format. By constructing a series of “sand pictures,” a client is helped to illustrate and integrate his or her psychological condition.
• Integrated arts approach or intermodal (also known as multimodal) therapy involves two or more expressive therapies to foster awareness, encourage emotional growth, and enhance relationships with others.
Intermodal therapy distinguishes itself from its closely allied disciplines of art therapy, music therapy, dance/movement therapy, and drama therapy by being grounded in the interrelatedness of the arts. It is based on a variety of orientations, including arts as therapy, art psychotherapy, and the use of arts for traditional healing (Knill, Barba, & Fuchs, 1995).
Knill et al. (1995) observe that while all of the expressive therapies involve action, each also has inherent differences. For example, visual expression is conducive to more private, isolated work and may lend itself to enhancing the process of individuation; music often taps feeling and may lend itself to socialization when people collaborate in song or in simultaneously playing instruments; and dance/movement offer opportunities to interact and form relationships. In other words, each form of expressive therapy has its unique properties and roles in therapeutic work depending on its application, practitioner, client, setting, and objectives.
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EXPRESSIVE THERAPIES
Therapists who are unfamiliar with expressive therapies often wonder if these modalities have been used as a form of assessment. Some practitioners of expressive therapies believe that using art, music, movement, or other modalities for evaluation is not practical due to a lack of substantive research data, and, that in some circumstances, such use may even be counterproductive. Despite this stance, formal assessments have been developed in art therapy, music therapy, and other expressive therapies for the purpose of adding to other available psychiatric, behavioral, and developmental assessments. Feder and Feder (1998) identify several basic ways in which the expressive therapies have been used in assessment: (1) assessment of abilities and preferences including formal and informal inventories and observations of individuals’ skills and interests;
(2) assessment of life experiences and capacities; and (3) assessment of psychological, psychosocial, and/or cognitive aspects. Many of these assessments, described throughout subsequent chapters of this book, may be used in combination with other evaluation methods in the related fields of psychology and counseling.
Finally, expressive therapies, such as art, music, and dance/movement, have been sometimes incorrectly labeled as “nonverbal” therapies.
They are, in fact, both nonverbal and verbal because verbal communication of thoughts and feelings is a central part of therapy in most situations.
However, for a child who has limited language, an elderly person who has lost the ability to talk because of a stroke or dementia, or a trauma victim who may be unable to put ideas into speech, expression through art, music, movement, or play can be ways to convey oneself without words and may be the primary form of communication in therapy.
A BRIEF HISTORY OF EXPRESSIVE THERAPIES
McNiff (1981, 1992) proposes that the arts have consistently been part of life as well as healing throughout the history of humankind. Today, expressive therapies have an increasingly recognized role in mental health, rehabilitation, and medicine. However, as McNiff observes, these therapies have been used since ancient times as preventative and reparative forms of treatment. There are numerous references within medicine, anthropology, and the arts to the earliest healing applications of expressive modalities. For example, the Egyptians are reported to have encouraged people with mental illness to engage in artistic activity (Fleshman
& Fryrear, 1981); the Greeks used drama and music for its reparative
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properties (Gladding, 1992); and the story of King Saul in the Bible describes music’s calming attributes. Later, in Europe during the Renaissance, English physician and writer Robert Burton theorized that imagination played a role in health and well-being, while Italian philosopher de Feltre proposed that dance and play were central to children’s healthy growth and development (Coughlin, 1990).
The idea of using the arts as an adjunct to medical treatment emerged in the period from the late 1800s to the 1900s alongside the advent of psychiatry. During this time the movement to provide more human treatment of people with mental illness began and “moral therapy” included patient involvement with the arts (Fleshman & Fryrear, 1981).
While late-19th-century programs were transitory, the ideas behind them resurfaced in the early 1900s. For example, documented uses of music as therapy can be found following World War I when “miracle cures” were reported, resulting from reaching patients through music when they responded to nothing else. Joseph Moreno (1923), the founder of psychodrama, proposed the use of enactment as a way to restore mental health.
He also described the use of positive creative imagery, role reversal, and
“monodrama” (in which a participant enacts all parts of the self). At the same time, Florence Goodenough (1926) studied children’s drawings as measures of cognitive development, and others, like Hans Prinzhorn, became interested in the art of patients with severe mental illnesses
(Vick, 2003). Finally, the fields of sandplay, sandtray therapy, and the foundations of play therapy were present in Margaret Lowenfeld’s
“World Technique” in the 1920s (Lowenfeld, 1969). Lowenfeld began her training as a pediatrician and subsequently began to make observations about children’s play, developing a method of using toys to understand psychosocial aspects of child clients.
The creative arts therapies became more widely known during the
1930s and 1940s when psychotherapists and artists began to realize that self-expression through nonverbal methods such as painting, music making, or movement might be helpful for people with severe mental illness.
Because there were many patients for whom the “talking cure” was impractical, the arts therapies gradually began to find a place in treatment.
Major psychiatric hospitals such as the Menninger Clinic in Kansas and
St. Elizabeths in Washington, DC, incorporated the arts within treatment, both as activity therapies and as modalities with psychotherapeutic benefits.
Professional associations for practitioners of art, music, and other expressive therapies were established and university programs training
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practitioners in these modalities rapidly developed. Over the last several decades, play therapy and sandplay therapy have also become part of expressive therapies practice and have developed specific theoretical foundations, methodologies, training, and professional associations. More recently, expressive therapies have been incorporated into a variety of mental health, rehabilitative, and medical settings as both primary and adjunctive forms of treatment. For example, music and imagery therapies are now used routinely with hospitalized patients for pain reduction, relaxation, and childbirth; art and play are proving to be essential in trauma debriefing, resolution, and recovery with children (Malchiodi,
2001); and writing is prescribed to ameliorate symptoms of illnesses such as asthma and arthritis as well as to decrease posttraumatic stress in individuals who have experienced crisis or loss (Pennebaker, 1997).
EDUCATION, COMPETENCY,
AND STANDARDS OF PRACTICE
Many practitioners who incorporate the expressive therapies into the practice of psychotherapy have studied these modalities through graduate-level training and may hold a credential in one or more of the media they use. These practitioners are distinguished by credentials in art therapy, music therapy, play therapy, and so forth, either in the form of a master’s or doctoral degree, or through registration, certification, or licensure in a specific creative art therapy or expressive therapy (see the
Appendix for a list of professional associations). Those therapists whose training has included multiple modalities are often referred to as “expressive arts therapists” or “expressive therapists.” Knill et al. (1995) propose that those who take an integrated approach (see Chapter 9) do not need to master all forms of expressive therapy. They observe that it is more important to have a focus on the artistic tradition that all expressive therapies have in common: human imagination. This is the same tradition that healers throughout history used who did not divide their work into specializations of drumming, art making, or ritual; rather, they used multimodal aspects in their work. Knill et al. conclude that using more than one modality in therapy is more efficacious and helps therapists to avoid the trap that Maslow is quoted as saying “If the only tool you have is a hammer, every problem starts to look like a nail.”
In terms of training, a discussion within expressive therapies continues about the importance and role of in-depth training in an art form through studio work in order to practice creative interventions. Some
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believe that in order for a therapist to be effective, he or she must have had significant experiences in art, music, dance, drama, poetry, play, or sandtray in order to competently and ethically use these modalities in therapy. With regard to art therapy, Agell (1982) notes that “a flirtation with materials is not enough. Only a love affair with materials can lead to a wedding of felt experience and formed expression” (p. 37). While many therapists are familiar with several expressive therapies, generally most tend to specialize in one or two that they are trained in and that meet the needs and situation of their clients. Others, such as Gladding
(1992) and Carson and Becker (2004), see expressive therapies as part of larger realm of “creativity in counseling.” They propose that creativity in counseling involves being able to flexibly respond to clients with a variety of techniques and to encourage creativity within therapy. Carson and Becker (2004) note that there is a need for “counselors to be continually cultivating and nurturing their own creativity” (p. 114), although they do not offer any specific ideas or recommendations on how counselors and other mental health professionals can achieve this depth of knowledge. Depending on the practitioner and the setting, expressive therapies may be used as a primary form of therapy, requiring the therapist to have a deeper understanding of how various modalities can be applied in response to a wide range of disorders. Often, expressive therapies are integrated within a psychotherapy or counseling framework. For example,
Gladding and Newsome (2003) highlight the integration of visual art activities into counseling treatment plans with adults and emphasize that a quick client drawing or collage can move a client forward when talk therapy is resisted or ineffective. Also, many expressive therapy techniques have been used to complement a wide range of psychotherapy and counseling theories, including psychoanalytic, object relations, cognitive-behavioral, humanistic, transpersonal, and others (Malchiodi,
1998, 2003).
Finally, when using expressive therapies to complement verbal therapy, practitioners should be aware of the current standards of practice in the particular modality they are using. The American Art Therapy Association (AATA), the American Music Therapy Association (AMTA), the
American Dance Therapy Association (ADTA), the National Drama
Therapy Association (NADT), the National Poetry Therapy Association
(NAPT), and the Association of Play Therapy (APT) all provide helpful guidelines about the application and practice of expressive modalities with clients in mental health, rehabilitation, special education, and health care settings. The NCCATA also offers information on standards
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of practice, training opportunities, and other subjects useful for practitioners. Additionally, each association has ethical standards that therapists who plan to use expressive therapies as a form of treatment or assessment should consult before integrating art, music, movement, play, or other methods into their work.
EXPRESSIVE THERAPIES’ ROLE
IN TREATMENT AND INTERVENTION
In general, like counseling or psychotherapy, an expressive therapies session may open with a discussion of the individual’s, family’s, or group’s goals, concerns, or current problems. In contrast to therapists who explore these issues through talking, expressive therapists encourage individuals to use an expressive form of communication as a means for further exploration. For example, clients may be asked to draw an image of an idea, enact a situation or engage in a dramatic dialogue, manipulate a set of figures in a sandtray, write a short story or poem, play with toys or props, or use a musical instrument to express a feeling.
Depending on the client, the therapist may also begin a session with a warm-up activity or exercise such as a quick scribble, stretches, simple movements, or humming a familiar tune. The opening activity may be used simply for relaxation, to introduce a modality into the session, or to help the therapist evaluate the individual’s mood or current concerns. One or more expressive therapies may be used in a session—for example, while a drama therapy session may involve role play, it is also likely to involve movement or may start with some creative writing or a piece of poetry to stimulate or inspire the invention of a story. In subsequent chapters, applications and case examples of expressive therapies, including integrative approaches, are described in detail, illustrating their vast range of application as primary therapies and as complements to verbal therapy from a variety of theoretical models.
UNIQUE CHARACTERISTICS
OF EXPRESSIVE THERAPIES
Expressive therapies add a unique dimension to psychotherapy and counseling because they have several specific characteristics not …show more content…
always found in strictly verbal therapies, including, but not limited to, (1) self-
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expression, (2) active participation, (3) imagination, and (4) mind–body connections. Self-Expression
All therapies, by their very nature and purpose, encourage individuals to engage in self-exploration. Expressive therapies encourage not only selfexploration, but also use self-expression through one or more modalities as a central part of the therapeutic process. Gladding (1992) notes that using the arts in counseling may actually speed up the process of selfexploration and that expressive modalities allow people to experience themselves differently. He adds that through these forms of self-expression, individuals are able to “exhibit and practice novel and adaptive behaviors” (p. 6).
Self-expression through a painting, movement, or poem can recapitulate past experiences and even be cathartic for some, but these are only two aspects of the role of self-expression in therapy. In fact, most therapists using expressive therapies in their work capitalize on the ability of art, music, play, and other forms to contain self-expression rather than to encourage cathartic communication of raw emotions or mere repetition of troubling memories. In essence, as therapist and client work together, self-expression is used as a container for feelings and perceptions that may deepen into greater self-understanding or may be transformed, resulting in emotional reparation, resolution of conflicts, and a sense of well-being. Expressive therapists generally do not seek to interpret individuals’ drawings, movement, poems, or play, but instead try to facilitate their clients’ discovery of personal meaning and understanding. For that reason, self-expression in an expressive therapies session also generally involves verbal reflection in order to help individuals to make sense of their experiences, feelings, and perceptions. While words are generally used to tell personal stories, expressive therapies are used to tap the senses as a source of stories and memories. Because thoughts and feelings are not strictly verbal and are not limited to storage as verbal language in the brain, expressive modalities are particularly useful in helping people communicate aspects of memories and stories that may not be readily available through conversation. Memories in particular have been reported to emerge through touch, imagery, or carefully guided body movements (Rothschild, 2000). For some individuals, telling a story through one or more expressive modality is more easily tolerated
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than verbalization. Individuals can “experience” their story, allowing the practitioner to capitalize on clients’ discoveries and use the activity to help them broaden their understanding.
Some therapists believe that the process of expressive therapy (the telling of a story through an expressive modality such as art, music, movement, etc.) offers as much therapeutic value as verbal reflection about the product or experience. Landreth (1991), a well-known play therapy pioneer, notes that this holds particularly true for young children who do not have the verbal capabilities necessary for reflection through language. Expression through a painting, play activity, imaginative role play, or movement may be a corrective experience, in and of itself, for some individuals.
In cases where self-expression is repetitive, rigid, or noncorrective, a therapist using expressive techniques will actively engage with clients in order to help therapy progress. Art and play therapist Eliana Gil (1998) notes that when a child who has been severely traumatized repeats a play or art activity without resolution or correction the therapist must introduce activities or directives to help the child transform the storyline into a more productive and satisfying experience. Other therapists encourage client dialogues that involve “talking to the painting” (McNiff,
1992) or use an expressive modality as a source of reflection and exploration. For example, a poem can be written about a drawing, a painting can be made about a movement, a short play can be enacted about a piece of music, and so forth. Throughout this book readers will find examples of how this is accomplished, using expressive therapies as the basis.
Active Participation
Expressive therapies are defined by psychology as “action therapies”
(Weiner, 1999) because they are action-oriented methods through which clients explore issues and communicate their thoughts and feelings. Art and music making, dance and drama, creative writing, and all forms of play are participatory and require individuals to invest energy in them.
For example, art making, even in its simplest sense, can involve arranging, touching, gluing, stapling, painting, forming, and many other tangible experiences. All expressive therapies focus on encouraging clients to become active participants in the therapeutic process. The experience of doing, making, and creating can actually energize individuals, redirect attention and focus, and alleviate emotional stress, allowing clients to fully concentrate on issues, goals, and behaviors. Finally, in addition to promoting active participation, expressive therapies are sensory in na-
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ture. Many or all of the senses are utilized in one way or another when a person engages in art making, music playing or listening, dancing or moving, enacting, or playing. These types of activities and experiences redirect awareness to visual, tactile, and auditory channels.
Imagination
Levine (1999) observes that “imagination is the central concept which informs the understanding of the use of arts and play in therapy” (p.
259). McNiff (1981, 1992) believes that imagination is the healing agent inherent to all forms of self-expression. While some favor the use of the word “creativity” in describing expressive therapies, it is actually the use of imagination that informs theory and practice. In contrast to imagination, creativity occurs when self-expression is fully formed and achieves a novel and aesthetic value. In an expressive therapies session clients may not always make drawings, music, movements, or poems that would be considered creative or fully formed, but in most cases imaginative thinking is used to generate self-expression, experimentation, and subsequent verbal reflection.
The role of imagination in expressive therapies practice is illustrated throughout this book, but there are several specific qualities that are central to art, music, dance, drama, creative writing, and play in therapy.
These modalities are helpful in assisting individuals in moving beyond their preconceived beliefs through experimentation with new ways of communication and experiences that involve “pretend.” The imaginative thinking needed to make a drawing, create a movement, or manipulate figures in a sandtray also offers the possibility for trying out inventive solutions and transformation. Clients who may be otherwise restricted in their ability to use imagination in problem solving often find expressive therapies particularly helpful. For example, a person who has been severely traumatized may feel emotionally constricted or may have obsessive thoughts or memories. The therapeutic use of art, play, or sandtray can augment the productive use of imagination, helping the individual discover and develop corrective solutions leading to change, resolution, and reparation.
Mind–Body Connections
The National Center for Complementary and Alternative Medicine
(2004; hereafter abbreviated as NCCAM) has defined mind–body interventions as those that are designed to facilitate the mind’s capacity to in-
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fluence bodily functions and symptoms. Many of the expressive therapies are considered by NCCAM to be mind–body interventions because they are both forms of psychotherapy and therapies that capitalize on the use of the senses to effect change. The advances made in the field of neuroscience and neurodevelopment have also drawn attention to the potential of expressive therapies in regard to mind–body intervention, particularly in the areas of mood disorders, stress disorders, and physical illness. For example, art, drama, and play therapies show promise in the amelioration of posttraumatic stress and the expression of traumatic memories. Music, art, and dance/movement may be helpful in tapping the body’s relaxation response, a calm and confident state of being associated with perceptions of health, wellness, and happiness (Benson,
1996). Writing has proven to be effective in emotional reparation and in reducing symptoms in some chronic illnesses (Pennebaker, 1997). Overall, expressive activities may stimulate the placebo effect through mimicking self-soothing experiences of childhood and inducing self-relaxation (Malchiodi, 2003; Tinnin, 1994).
Finally, research on early attachment and brain development is beginning to inform psychotherapy of the value of expressive therapies.
Expressive therapies, particularly dance, art, and play therapies, may be useful in reestablishing and encouraging healthy attachments through sensory experiences, interactions, movement, and hands-on activities.
These modalities may be helpful in repairing and reshaping attachment through experiential and sensory means and may tap early relational states before words are dominant, possibly allowing the brain to establish new, more productive patterns (Malchiodi, 2003; Riley, 2002).
LIMITATIONS OF EXPRESSIVE THERAPIES
Like any therapy, there are limitations to expressive therapy in treatment and intervention. While expressive therapies have been applied to all age groups, to most psychiatric and medical disorders, and to a variety of settings, there are clients who may not benefit from these modalities for various reasons. First, some individuals, often adults, may be hesitant to engage in an expressive modality in therapy because they believe they are not “creative” or cannot produce something that is “artistic.” Therapists initiating expressive activities as interventions may encounter resistance to participation by clients who perceive themselves as unable to use imagination, who are anxious about self-expression, or who are resistant to active participation. Additionally, and ironically, those individu-
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als with extensive experience in painting, music, or dance may not be able to let go of learned rules about self-expression and may be inhibited in their spontaneity in therapy when asked to express themselves in their particular medium.
For therapists who have not had extensive training in expressive therapies, there may be a tendency to want to interpret what their clients do in a given modality. This is particularly true of client-created drawings and other art expressions; practitioners may be tempted to project their own conclusions about content, sometimes missing their clients’ intended meanings. Additionally, therapists without experience may use expressive modalities in a mechanical fashion and use activities and techniques routinely rather than thinking about what would be best for clients given their histories, presenting problems and potentials, and goals. Because expressive therapies can include directed activities, it is easy for some therapists to fall into the habit of simply choosing an expressive activity or directive from a book or workshop. As with any form of therapy, it is important to listen to and respect what the client is communicating and then create an intervention that is best suited to the individual’s needs and objectives.
Finally, while research on the efficacy of expressive therapies is increasing dramatically, there is still much to be learned about how they work and how they should be applied in work with children, adults, families, and groups.
Music therapy is possibly the most widely researched modality, largely because physiological and behavioral reactions to music and music therapy interventions can be quantified. Within the field of art therapy, art-based assessments have been more extensively studied and efficacy studies in the areas of trauma and emotional disorders are receiving more attention (Malchiodi, 2003). In brief, while there have been some qualitative studies in the expressive therapies, most of the literature discusses clinical observations, case examples, and applications. Because of the recognition by mental health professionals of the inherent value of expressive modalities in treatment, interest in research is increasing, particularly in the areas of trauma, mood disorders,
Alzheimer’s disease and other forms of dementia, and childhood disorders such as attention-deficit/hyperactivity disorder and autism.
CONCLUSION
Johnson (1985) observes that expressive therapists “have a powerful vision, and we have emerged for a reason” (p. 238). In the same vein, the
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EXPRESSIVE THERAPIES
expressive therapies as a force with psychology and counseling have emerged for a reason. A growing number of mental health professionals are recognizing why expressive therapies enhance work with clients in ways that strictly verbal therapies cannot. Additionally, there is a growing movement in mental health to utilize “creative methods” in therapy and medicine.
Creativity in therapy has the potential to impact clients in memorable ways that traditional interventions do not. When therapists choose to use expressive therapies, they give their clients the opportunity to become active participants in their own treatment and empower them to use imagination in productive and corrective ways. Whether through art, play, music, movement, enactment, or creative writing, expressive therapies stimulate the senses, thereby “sensitizing” individuals to untapped aspects of themselves (Gladding, 1991) and thus facilitating self-discovery, change, and reparation.
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