The Arts in Psychotherapy 78 (2022) 101896

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The Arts in Psychotherapy

journal homepage: www.elsevier.com/locate/artspsycho

Clarifying the Creative level of the Expressive Therapies Continuum: A

different dimension
Lisa D. Hinz a, *, 1, Sung-ryun Rim b, Vija B. Lusebrink c
a
Art Therapy and Psychology, Dominican University of California, USA
b
College of Liberal Arts/The Graduate School of Art Therapy, PyeongTaek University, PyeongTaek, South Korea
c
Professor Emeritus, University of Louisville, USA

A R T I C L E I N F O A B S T R A C T

Keywords: The Expressive Therapies Continuum (ETC) originally incorporated creativity as the Creative “level.” This
Expressive therapies continuum denotation as a separate level is a misnomer because creativity can be present at any ETC level. Also, innate
Art therapy distinctive characteristics of the creative process differ from those of the other three levels. The objectives of this
Creativity
article are to help delineate the features of the Creative “level” within the ETC, designate its name as a Creative
Creative functioning
Flow
“dimension” to avoid confusion, and to provide case illustrations to help clarify these concepts. Creative func­
tioning within the ETC model has been described as the integrative and self-actualizing forces within the indi­
vidual occurring during expressive activities. Creative functioning has been described as comprising moments of
self-realization and unique self-expression associated with well-being. These moments share similarities with the
concepts of Flow, everyday creativity, small-c creativity, and mini-c creativity; concepts that can further describe
creative activity in art therapy.

This paper addresses creativity, creative functioning, and the crea­ hemisphere functions and are described as intuitive, visual-spatial,
tive process in the context of the Expressive Therapies Continuum (ETC), emotional, and spiritual. The hierarchical structure of the ETC schema
a foundational theory in the field of art therapy. First formulated by represents a developmental sequence of information processing and
Kagin and Lusebrink (1978) and further developed by Lusebrink (1990, image formation (Lusebrink, 1990). Processing develops from simple
1991) and Kagin (Graves-Alcorn & Kagin, 2017), the ETC offers a model kinesthetic and sensory activities at the bottom of the diagram, to so­
of the various ways in which people can interact with art materials to phisticated interactions involving complex thought processes at the top.
process information and form images. The ways in which clients interact The Kinesthetic/Sensory level reflects the ways that infants and toddlers
with media in art therapy are hypothesized to parallel the ways that they collect and process information through motion and sensation. Infor­
process information in other areas of their lives; to reflect how clients mation gathered through these channels does not require words because
think, feel, and behave. The ETC is a pantheoretical organizing system it is physical: active, rhythmic, tactile, and sensual. Progressing up the
that provides a language to facilitate communication across diverse developmental hierarchy, information processing and image formation
approaches to art therapy. Knowledge of the ETC can aid art therapists on the Perceptual/Affective level may or may not need words. It can be
in the selection of the most appropriate materials and processes to emotional and without form on the Affective side of the level, or be
effectively address their clients’ therapeutic needs. Through media characterized by precisely formed images on the Perceptual side. The
choices, task instructions, and questions, art therapists can focus atten­ functions represented on the Cognitive/Symbolic level of the ETC are
tion on specific levels of expression, enhancing the flow of information complex and sophisticated. They require higher-order cognitive func­
processing (Hinz, 2019). tioning and intricate, multilayered symbols. Finally, Creative func­
The ETC is represented schematically in Fig. 1. Components on the tioning is seen as an overarching dimension of the framework. It pertains
left side of the diagram are hypothesized to correspond to left- to the synthesizing or self-actualizing tendencies of the individual which
hemisphere brain functions which tend to be sequential, language- can be characterized by experience with one ETC component, or which
oriented, and logical. Functions on the right side correspond to right- can occur throughcombinations of ETC components or levels (Hinz,

* Corresponding author.
E-mail addresses: lisa.hinz@dominican.edu (L.D. Hinz), sungrim@ptu.ac.kr (S.-r. Rim).
1
ORCID ID: https://orcid.org/0000–0001-5924–565X

https://doi.org/10.1016/j.aip.2022.101896
Received 20 September 2021; Received in revised form 26 January 2022; Accepted 6 February 2022
Available online 9 February 2022
0197-4556/© 2022 Elsevier Ltd. All rights reserved.
L.D. Hinz et al. The Arts in Psychotherapy 78 (2022) 101896

small-c creativity, everyday creativity is derived from the interests and

hobbies of ordinary individuals. These pursuits allow people to develop
new skills, engage in self-reflection, and develop new views of the self
and the world. In turn, through the integration of increased competence,
new self-knowledge, and novel insights individual resilience is
strengthened. A virtuous cycle involving creative functioning is initiated
such that increased resiliency can inspire further engagement with
personal passions and therefore engender even greater resilience and
generalize to other areas of a person’s life. Art experiences can promote
seeing a problem in a new way; the art making process and achieving the
finished art product can allow for new connections or new combinations
of ideas which reveal new information about the self and thus promote
psychological growth (Graves-Alcorn & Kagin, 2017). This explanation
of artistic expression in art therapy recalls the standard definition of
creativity which states that creativity involves the combination of things
Fig. 1. The Expressive Therapies Continuum diagram. or ideas in ways that are new and useful (Runco & Jaeger, 2012). In the
case of art therapy, the use of art media for the depiction of client
2019; Kagin & Lusebrink, 1978; Lusebrink, 1990). concerns allows the possibility of countless combinations of ideas that
can result in art products providing new and meaningful information
Defining the Creative dimension of the ETC about the self that effectively stimulate psychological growth.
The creative process, which might be considered most aligned with
Although the Expressive Therapies Continuum incorporates crea­ the Creative dimension of the ETC, can be seen as similar to Wallas
tivity as one aspect of a theoretical model, the Creative “level” has not (1926) staged model of creative problem solving including: preparation,
been as fully elaborated as others leading to confusion as to its properties incubation, illumination, and verification. Csikszentmihalyi (2013)
and functions in art therapy. This article offers further expansion on expanded on Wallas’s creative process to include five steps. According to
several aspects of the Creative “level” of the ETC, including its desig­ Csikszentmihalyi, preparation is the stage in which problems are iden­
nation as a Creative “dimension” to avoid confusion of it as the highest tified and conceptualized; one is immersed, consciously or not, in the
level or goal in art therapy. Again, creative functioning is seen as a issue(s). The second stage is incubation where, through immersion in
pervasive and inclusionary dimension of the framework, related to the input from various sources, new combinations of ideas can come about.
synthesizing or self-actualizing tendencies of the individual. The Creative In the third stage, illumination, “aha moments” of discovery take place.
dimension refers to the structural organization of the abstract theoretical Evaluation is the fourth stage of the creative process in which the creator
ETC model; Creative functioning is the action that occurs within that must decide if the new discovery is valuable and worth further pursuit.
structural dimension. Other concepts that require definition include the Csikszentmihalyi added elaboration as a fifth and final stage of the cre­
various forms of creativity which later will be associated with different ative process in which the new idea is worked through to completion of
forms of creative functioning. The standard definition of creativity is the the creative product. According to Csikszentmihalyi (2013) the creative
combination of things or ideas in ways that are new and useful (e.g., process is not linear but rather the process can loop back to illumination
Runco & Jaeger, 2012). Big-C creativity is concerned with what has been in a recursive fashion several times, especially during the elaboration
called eminent creativity and attributed to artistic genius (Kaufman & stage. In Csikszentmihalyi’s view, the degree of immersion in the crea­
Beghetto, 2009; Puccio et al., 2020). Everyday creativity or small-c crea­ tive process depends, in part, on the length of time invested in it.
tivity occurs during the pursuit of everyday activities or hobbies and Creativity in art therapy can be seen as the integration of the sensory
allows people to discover new combinations of ideas, skills, or things and kinesthetic aspects of creative expression with the verbal, cognitive,
that enrich their daily lives (Richards, 1990, 2014). Finally, mini-c and symbolic aspects which open up new ways of understanding the self
creativity refers to new or personally meaningful insights into behaviors and the world. Further, the creative product can be viewed as a visible
or experiences (Kaufman & Beghetto, 2009). Thus, creativity might be reminder of the increased self-knowledge or enhanced resilience ach­
conceived of as occurring along a range of experiences from mini-c to ieved through engaging in the creative act. Occasionally reviewing the
Big-C, with only a select few able to attain artistic genius but the ma­ progression of artwork created in therapy can have an integrative effect
jority of people capable of benefitting from mini-c and small-c creativity. through the process of visually and verbally reintegrating images and
The original description of the Creative dimension of the ETC, their previously made connections and /or discovering new connections
expressing the synthesizing and self-actualizing tendencies of the indi­ (Lusebrink, 1990). Throughout her work on the ETC, (Lusebrink, 1991,
vidual (Kagin & Lusebrink, 1978), resembles the definition of “small-c 2004, 2010, 2016; Lusebrink, Mārtinsone, & Dzilna-Šilova, 2013)
creativity” which, as mentioned above, is concerned with creative re­ consistently emphasized the integrative nature of the Creative dimen­
alizations and approaches to everyday situations that can enrich and sion. Lusebrink (2010) elaborated on the Creative dimension by intro­
improve daily life (Kaufman & Beghetto, 2009; Puccio et al., 2020). The ducing it as a Creative Transition Area operating between the two
Creative dimension can be seen as being comprised of creative expres­ components on each level as can be seen in Fig. 1. The Creative Tran­
sion leading to a sense of closure and/or joy and resulting in feelings sition Area denotes and incorporates information from the respective
such as, pride, appreciation, and release. The feelings of satisfaction and polarities on each level, thus indicating the integrative nature of the
completion around the creative process should be acknowledged by the creative process and emphasizing that the Creative dimension is
therapist and client as an integral part of ongoing art therapy (Lusebrink, embedded in the model with the potential for creativity in every inter­
1990). The emphasis on closure though, can be mistakenly interpreted action. In art therapy, creative functioning and resulting and creative
as meaning that reaching the “Creative level” of the ETC represents the self-actualization can occur with one component of the ETC or through
end of therapy. Rather than being the endpoint of the therapeutic pro­ the interaction of multiple components or levels. The creative process
cess, the healing or therapeutic function of the Creative dimension was can be observed through the client’s involvement with the environment,
defined by Lusebrink (1990) as encompassing creative transactions with expression of positive feelings, and focused goal attainment.
the environment or creative self-actualization. The phrase “creative The Expressive Therapies Continuum was conceptualized and
transactions with the environment” calls to mind the concept of created in a Western society based on Western theories and values such
everyday creativity described by Richards (1990, 2014). Similar to as goal attainment (Lusebrink et al., 2013). The ETC has been described

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L.D. Hinz et al. The Arts in Psychotherapy 78 (2022) 101896

as a culturally sensitive model (Hinz, 2019) and it has been applied in its Although the ETC represents a developmental hierarchy in which
present form to research and clinical settings in Asia (Nam, 2021; Nan & expression on a particular level incorporates the characteristics of lower
Ho, 2017; Nan, Hinz, & Lusebrink, 2021). Preliminary evidence of the levels, art expression can originate at any level. The manipulation of art
cultural adaptability of the ETC is its modification for use in other cul­ materials can begin with the client taking in movement and sensory
tures with emphasis placed on different aspects of creativity as appro­ information through the hands and eyes (Kinestheic/Sensory level
priate to each culture (e.g., Kim, Park, & Hwang, 2020; Muhammad, functioning). Subsequently, visual, tactile, and haptic information can
2017). For example, adaptation of the ETC to an Eastern culture is be organized within the safe structure of the Perceptual/Affective level
demonstrated by the model shown in Fig. 2. This view of the ETC model of the ETC to support different views and to promote emotional un­
created by Korean art therapists demonstrates the attributes of interre­ derstanding and expression. Integration of information from lower
lation and harmony characteristic of Asian concepts creativity (Kim levels continues on the Cognitive/Symbolic level as personally relevant
et al., 2020; Lee J.Y, 2015). The circular diagram emphasizes the central symbols are discovered and potentially enhanced through archetypal or
and integrative nature of the Creative dimension. Further, this version of universal associations to add depth and meaning. This “bottom-up” view
the ETC diagram indicates that various components can influence one of ETC information processing has been emphasized because the basic
another in diverse ways that a linear diagram cannot adequately depict. sensorimotor input that occurs is fundamental to and initiates the ma­
It emphasizes that information processing does not have to occur strictly jority of art making experiences. However, this description might have
in a bottom-up or top-down manner. contributed to the mistaken impression that starting at the bottom of the
ETC at the Kinesthetic/Sensory level and working up the continuum to
The Expressive Therapies Continuum as a system the Creative “level” is always the desired direction and goal of art
therapy. Although movement and sensory information are always
The Expressive Therapies Continuum presents a systems view of in­ available during art making, the Kinesthetic/Sensory level is not
formation processing and the application of the ETC in art therapy is considered the primary level of interest in art therapy unless it is
based on its characteristics as a system (Lusebrink, 1990, 1991). As such, determined through assessment to be the dominate level of information
a change in one level induces changes in other levels. Expression and processing for an individual. To the contrary, art therapy equally can be
interaction on the different levels of the ETC involve information conducted in a “top-down” fashion, initiated with a thoughtful choice or
intrinsic and unique to each level; at the same time, the levels are decision at the Cognitive/Symbolic level or with an image or feeling on
interrelated causing successive changes. For example, the successful the Perceptual/Affective level, and progress down the continuum. In this
completion of a safe place drawing (a Symbolic activity) may elicit case, the Cognitive/Symbolic and Perceptual/Affective feedback present
feelings of safety and calm as demonstrated through successive art ex­ would be incorporated during creative expression. Top-down func­
pressions with the Affective component. Moreover, the progressive tioning usually involves establishing or reinforcing conscious control
integration of visual and tactile expression occurs when information over emotion or behavior (Hinz, 2019; Lusebrink & Hinz, 2016; Luse­
processing progresses from the Kinesthetic/Sensory level to the hierar­ brink, 2010).
chically higher levels (Lusebrink, 1990, 2016). Therefore, a disconnec­ Rather than conceptualizing art therapy exclusively in terms of top-
tion between levels impacts functioning of the entire system. Creative down or bottom-up processing, art therapy conducted following the ETC
information processing includes many interactive cognitive processes model begins using the component with which clients are most
and emotional inputs with both the left and right hemispheres of the comfortable expressing themselves through the manipulation of art
brain equally involved in most creative tasks (Lusebrink & Hinz, 2016). materials and expressive methods (Graves-Alcorn & Kagin, 2017; Hinz,
The ability to stimulate interconnected functioning of the two brain 2019; Kagin & Lusebrink, 1978; Lusebrink, 1990, 2016). This individ­
hemispheres makes creative arts therapies uniquely therapeutic (Per­ ualized approach helps ensure that that clients feel a sufficient amount
ryman, Blisard, & Moss, 2019). of psychological safety to explore, experiment, and invest adequate
energy in the art making process to develop creative confidence and
receive therapeutic benefit from their endeavors (Hinz, 2019).
Furthermore, reaching the Creative “level” at the top of the ETC schema
is not considered the goal, and therefore the end, of art therapy. Art
therapy involves different exploratory and expressive elements that may
not be creative but that nonetheless contribute to the therapeutic
experience. It appears that the majority of art therapy sessions can occur
within the Creative dimension as defined by the ETC. These creative
experiences are variously characterized by feelings of satisfaction and
pride as materials and process are mastered and/or clients achieve
creative realizations accompanied by feelings of joy (S. Graves-Alcorn,
personal communication, July 22, 2021). However, they differ with
regard to the degree of the individual’s involvement in the process and
environment as elaborated below.

Creative functioning and Flow

Creative functioning has been described as comprising moments of

self-realization and unique self-expression associated with well-being.
Csikszentmihalyi (2013) believed that creating something new is one
of the most pleasurable activities in which a person can engage, and can
result in an optimal experience that he called “Flow.” Flow is defined as
a state of focused attention in which a challenging task is undertaken
and mastered. In this concentrated state of mind, a person is so absorbed
in mastering a demanding task that the usual sense of time is altered
Fig. 2. The Expressive Therapies Continuum as a mandala (usually speeded up) and the experience is characterized by feelings of
Reprinted with permission from Kim et al. (2020). great satisfaction, punctuated with moments of peak joy. The Flow state

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L.D. Hinz et al. The Arts in Psychotherapy 78 (2022) 101896

is followed by enduring feelings of well-being (Csikszentmihalyi, 2008, reflects the individual’s level of functioning without the interference of
2013). Creative functioning within the ETC has been described as anxiety or boredom, both which hinder the occurrence of Flow (Csiks­
resulting in Flow and most likely occurring during sustained periods of zentmihalyi, 2013). The selection of art media (either by the client or by
creativity (Hinz, 2019). the therapist) is important in setting the stage for creative functioning
Creative functioning and creative self-actualization can be charac­ and Flow. While treating immigrant children in art therapy, Lee (2013)
terized, similarly to creativity, as occurring across a continuum of ex­ described client behaviors and comments indicative of the Flow state.
periences from brief self-revelatory moments through more prolonged Lee wrote that Flow in art therapy could be identified by an altered sense
involvement in the entire creative process. The differences between of time. She added that focused behavior and heightened motivation
these classifications would depend on the individual’s level of auton­ were indicative of the Flow state as well as the expression of positive
omy, depth of involvement, and length of time invested in the creative emotions such as pride and joy. Lee also described an optimal match
process. Brief art expressions prompted by the therapist’s directions between skills and challenges such that the clients were neither bored
and/or choice of media can be seen as Creative Incidents. Short periods of nor stressed by task demands but functioning optimally. Finally, when
self-initiated creative functioning or Creative Episodes, similar to functioning in a Flow state, children’s stories featured make-believe
everyday creativity, are likely to be associated with positive feelings. A characters that were capable and successful.
sequence of related creative episodes can follow the Creative Process Lee (2015) also identified self-assignment and self-correction as two
proposed by Csikszentmihalyi (2008, 2013). This type of prolonged behaviors that helped children seek and maintain a Flow experience in
creative functioning requires commitment over an extended time span, art therapy. Lee explained that self-assignment meant that her child
in-depth and thorough involvement, and is associated with a wide range clients set self-initiated goals in art therapy and sought out materials and
of emotions which result in Flow (Csikszentmihalyi, 2013). In art ther­ processes that allowed them to achieve those goals. In addition, they
apy, differences in creative functioning and creative self-actualization frequently assigned themselves increasingly challenging tasks in order
also can be observed in the individual’s involvement with the environ­ to achieve an appropriate balance between task demands and mastery
ment, the range of feelings experienced, and amount of attention thus enhancing the Flow experience. Self-correction was described as
focused on goal attainment. Creative functioning can be distinguished the ability and willingness to make adjustments in the artistic process
by absorption in a task that is adequately stimulating, a demonstrated rather than give up or start over. The ability to self-correct was seen as
desire to continue the creative project, satisfaction in the process, and essential to maintaining the Flow experience. Gaining a sense of safety
expressions of happiness or joy upon completion (S. Graves-Alcorn, (artistically) after revealing or confronting emotionally difficult themes
personal communication, July 22, 2021). These descriptions of crea­ in the art was another self-correcting behavior that allowed the young
tive functioning will be demonstrated in the case illustrations. Further clients to maintain a Flow state and experience resulting positive emo­
research exploration is necessary to fully understand and describe the tions (Lee, 2015). Creative Flow experiences were not planned by the art
range of creative functioning in art therapy. therapist, they occurred spontaneously after a sense of psychological
Thus, understanding Flow may help art therapists notice when cre­ safety was established.
ative information processing is taking place. The occurrence of a Flow In summary, Flow indicators in art therapy can demonstrate func­
experience in art therapy can be demonstrated when the client is so tioning in the Creative dimension of the ETC. These signs include:
absorbed in a task that they do not talk or look at the clock; they might focused attention, time alteration, heightened motivation, the experi­
comment that the time passed more quickly than they imagined. Clients ence of positive emotions such as pride, satisfaction or joy, and artistic
can demonstrate self-initiation by choosing materials or processes that investment in challenging tasks characterized by self-assignment and
best fit their needs without the suggestion of the art therapist. Func­ self-correction. Finally, themes found in the descriptions of the art
tioning in the Creative dimension can be exhibited through the creation products or stories accompanying the images can be characterized by
of an art product that provides new and useful information about the feelings of pride, joy, competence, and success. Focus of attention,
self, resulting in an “ahhh” moment of satisfying self-expression or an involvement in the environment, and positive feelings associated with
“aha” moment of self-realization (Hinz, 2019). Clients can be described artistic expression are all part of the healing elements of creative func­
in these revelatory moments as discovering new levels of expression or a tioning in art therapy. Creative work is characterized by experiences of
novel experience of the self which may be viewed as a creative act cognitive or emotional contentment punctuated with peak experiences
(Lusebrink, 1990). The personal insights gained from creative expres­ of excitement and joy. The therapeutic function of the Creative dimen­
sion are similar to the original and unique interpretations of events, sion has been described as involving inventive and resourceful in­
behaviors, and personal incidents described by Kaufman and Beghetto teractions with the environment leading to a range of experiences from
(2009) as “mini-c creativity.” Gaining unique personal insight is a “ahhh” moments of satisfying self-expression to “aha” moments or cre­
demonstrated benefit of art therapy, creativity, and Flow (Csikszent­ ative self-actualizing experiences. Creative functioning seems to repre­
mihalyi, 2013; Kaimal et al., 2019). sent a range of experiences from brief creative incidents, to relatively
The experience of Flow can be enhanced by art therapy and short creative episodes, to prolonged and integrative periods of creative
conversely, art therapy can enhance Flow. Art therapy provides a safe expression characteristic of the full creative process. The following case
environment for the occurrence of Flow by ensuring psychological safety examples were specifically chosen to demonstrate this range of experi­
and gives immediate feedback to the creator about the experience. The ences as well as to clarify other aspects of creative functioning within the
therapeutic aspects of art expression are enhanced by the presence of structure of the ETC.
Flow and its harmonious and synchronized characteristics. Flow in­
volves the total demand of physical and psychological energy and Case illustrations of creative functioning
teaches concentration of attention, thus decreasing inner chaos. In
relation to the ETC, this reduction of inner chaos can be viewed as Creative incident
occurring when smooth and effective transitions take place between the
different levels of the ETC with no disruptions or disconnections be­ A creative incident can occur when a client uses one ETC component
tween levels. Feelings of satisfaction and joy resulting from Flow rein­ and does not necessarily involve a sophisticated artistic production. In
force the activity between different ETC levels and lead to the creative this example, John (all client names have been changed) was a 32-year-
formation of new connections and insights. One area in which these new old Caucasian male diagnosed with schizophrenia. At the start of art
connections can be seen is through the client’s self-initiated selection of therapy, John got lost in painting and his paintings became a “brown
effective art materials and tasks. blur” as various paint colors were excessively applied and mixed. The
In art therapy, self-selection of appropriate materials and tasks therapist believed that John’s difficulty controlling the fluid media

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L.D. Hinz et al. The Arts in Psychotherapy 78 (2022) 101896

demonstrated an extreme expression of the Affective component and

that it was clearly unsatisfying for the client. The art therapist suggested
that the client work with templates and pre cut shapes which helped
John move to the Perceptual component to create form and structure. In
subsequent sessions, also at the therapist’s suggestion, John started
working with ballpoint pen or marker. With a greater ability to control
the medium John began taking turns with the therapist, creating forms
and lines, and he articulated satisfaction in the art expressions created.
For this client, alternating with the therapist and using structured as­
signments based on the formal artistic elements such as line and form
greatly supported his ability to express himself. John was able to
experience the relational and expressive aspects of the Perceptual
component without overwhelming affect. John’s creative expression
demonstrated that his use of ballpoint pen and marker to make a
conjoint drawing allowed him to organize and express emotion that
previously had been unmanageable with paint. He clearly enjoyed
himself and was satisfied with the product (a recreation of which is
shown in Fig. 3); it was a creative incident involving personal expression Fig. 4. A creative episode in the Creative Transition Area of the Perceptual/
with the Perceptual component that was uniquely satisfying. Affective level.

sense of time distortion, and expressed positive emotions. Through her

Creative episode
self-initiated change in medium to meet her therapeutic needs as well as
her happiness at the result, Lily demonstrated her involvement in a
Lily was a 28-year-old Latinx female who was seen in outpatient art
creative episode characterized by movement between two components
therapy. The young woman worked as a sous chef in an exclusive
on one ETC level or functioning in the Creative Transition Area.
restaurant and asked for help to augment her stress management skills.
In one of the first sessions, Lily created the painting shown in Fig. 4
which she described as her “mountain of stress.” Lily began the image by Creative functioning
using a pencil and ruler to very precisely draw a triangle in the center of
the paper. Her involvement with the structure and lines indicated use of It has been written that the Creative dimension of the Expressive
the Perceptual component. Rather than continue with pencil, Lily chose Therapies Continuum can represent integrative functioning of all levels
to use watercolor paint to fill in the mountain and the surrounding (Graves-Alcorn & Kagin, 2017; Lusebrink, 1990, 2016). The following
scenery. The client liked the way that the watercolor bloomed when wet case illustrates this type of integrative functioning which involves syn­
and thus demonstrated comfort with a more Affective expression. thesizing information from a series of creative episodes into a creative
However, Lily wanted to maintain some separateness between colors process. Kendra was a 45-year-old Caucasian female who sought art
and waited patiently for various areas of the painting to dry in order to therapy to work through a history of physical abuse by her adoptive
keep the colors distinct, thus moving back to the Perceptual component. mother after DNA testing helped her locate her biological mother and
Lily painted quietly and intently and was surprised when it was time to therefore brought childhood memories to consciousness. Kendra began
finish and clean up. When the image was completed, she expressed art therapy comfortably using acrylic paint with a paintbrush on paper
feelings of pride at her accomplishment and claimed that her stress to abstractly depict her emotions. She was clearly comfortable pro­
mountain was much more beautiful than she would ever have imagined. cessing information with the Affective component of the ETC and
Most importantly Lily stated that her level of stress, which she had rated involved with the preparation stage of the creative process (Csikszent­
8 out of 10 when she entered the room, was now a 2. She realized that mihalyi, 2013). After a few sessions, Kendra abandoned the brush and
she could use painting to achieve a focused state of attention which used finger paint to express herself. She stated that the subject matter
would allow her to express her stress and leave her in a relaxed and required that she “get dirty and really feel what she was dealing with.”
positive state. Flow indicators in the session were: focused attention, Fig. 5 was the first image created with finger paint and Kendra stated
that it looked like a rose which was her adoptive mother’s favorite

Fig. 3. A creative incident involving a single ETC component. Fig. 5. Kendra’s finger paint “rose”.

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L.D. Hinz et al. The Arts in Psychotherapy 78 (2022) 101896

flower. Kendra was participating in the incubation phase where, through

immersing herself in input from various sources, she set the stage for
new combinations of ideas to come about. Kendra changed the image to
the one shown in Fig. 6 by smoothing the red paint to eliminate the
yellow center and then adding blue paint to it. She was struck that it now
looked like a bruise and she cried as she talked about the physical abuse
that she underwent at the hands of her adoptive mother. Kendra next
created a monoprint of the bruise (Fig. 7) which demonstrated that,
“bruises fade over time.”
The use of finger paint in these images allowed Kendra to not only
depict her emotions but, through movement, tactile and visual sensory
stimulation, to feel her emotions. She was functioning on the Kines­
thetic/Sensory level with movement to the Perceptual/Affective level in
finding forms and experiencing emotion. The monoprint demonstrated
movement to the Cognitive/Symbolic level as Kendra explained meta­
phorically that bruises fade over time. The final image shown in Fig. 8
was a weaving together of the monoprint and original image. This
weaving demonstrates functioning on the Cognitive/Symbolic level as
well as the Creative dimension as Kendra explained that neither image Fig. 7. Kendra’s monoprint: "Bruises fade over time."
alone told the entire story but the combined image “wove the whole
story together.” The weaving was not easy as the pieces were damp and
uneven but Kendra demonstrated great concentration and persistence as
she carried out the task. She was proud of the final image which she
added was more sophisticated than either of the original finger paint
images alone. In an “aha” moment of self-realization, Kendra explained
that she was weaving together a more sophisticated understanding of
her past and releasing emotion related to it. This self-revelatory insight
was evidence of the illumination stage which is characterized by “aha
moments” of discovery (Csikszentmihalyi, 2013). In addition to signs of
the creative process in operation, other indications of creative func­
tioning and Flow in this case were self-assignment, self-correction,
focused attention, focused behavior, heightened motivation, and posi­
tive emotions. Kendra exhibited self-assignment when she initiated the
goal of experiencing greater emotion and she chose materials and pro­
cesses to help her achieve that goal. She was steadfast when the paper
was wet and difficult to work with, persisting with the weaving to
achieve the desired effect and thus demonstrating self-correction. Ken­
dra was deeply and directly engaged in the creative process, clearly
proud of the final product, and joyously fulfilled by the new
self-knowledge that she achieved during the integrative artistic experi­ Fig. 8. Kendra’s paper weaving.
ence. Hers was a full expression of creative functioning.
These case studies exhibit similarities and differences that emphasize They took in feedback about the processes in which they were engaged
aspects of the Creative dimension. All three clients demonstrated crea­ and, with more or less help from the art therapist, adjusted their goals to
tive interactions with the environment through their use of art materials. meet therapeutic needs. All three clients demonstrated intensely focused
attention and, to a greater or lesser extent, other Flow indicators. Each
felt positive emotions as a result of their creative engagment. Although
all three clients demonstrated positive emotions, they did not all expe­
rience the same type or degree of emotion. John demonstrated a creative
incident using one component of the ETC and Lily showed a creative
episode with her use of two complimentary components in the Creative
Transition Area. Kendra demonstrated full involvement with the entire
creative process, synthesizing experiences with each ETC level.
Depending on their level of engagement with the art making and amount
of therapist assistance, emotions ranged from satisfaction to pride to
joyous fulfillment. The final client achieved an “aha” moment of self-
realization through her commitment to the creative process and her
integrative use of all three ETC levels.

Conclusion

The Creative dimension of the Expressive Therapies Continuum is

integrative, synthesizing inner and outer experiences; it emphasizes
balance and harmony as well as feelings of satisfaction and joy that
occur as a result of engagement in the creative process. The Creative
dimension has been the least developed of the ETC levels and its
Fig. 6. Kendra’s finger paint “bruise”.

6
L.D. Hinz et al. The Arts in Psychotherapy 78 (2022) 101896

previous label as a “level” is a misnomer, possibly causing attainment of Acknowledgments

the Creative “level” to be seen as the ultimate goal in art therapy. It
therefore should be designated as a “Creative dimension” referring to The authors would like to acknowledge the contributions of Sandra
the structural organization of the ETC. Creative functioning, which oc­ Kagin Graves-Alcorn to the development of the Expressive Therapies
curs within the Creative dimension, refers to inventive and resourceful Continuum and to express our sadness at her passing.
interactions with the environment leading to Flow and self-actualizing
experiences. The aims of this paper were to help delineate the features References
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