Expressive Arts

Lesley College in the early 1970s

The CREATE Institute, a training body in the expressive arts tradition, states that expressive arts therapy was founded in the early 1970s at Lesley University in Cambridge, Massachusetts, by Shaun McNiff, Paolo Knill and others. This is an account from a training organization and not an independent history. The page does not say what the founders' first programs contained, so the sources used here do not describe the earliest teaching in detail.

Training institutes and associations

The CREATE Institute names ISIS Canada, founded in 1991 by Ellen Levine, Stephen Levine and Fran Harwood as an affiliate of the European Graduate School, as its predecessor. The International Expressive Arts Therapy Association (IEATA), a nonprofit professional association, gives its founding as 1994 in its About text and 1993 in its timeline, and names Nina (Anin) Utigaard, Jack Weller, Steve Levine and Phillip Speiser as founders. Its timeline lists a first conference in San Francisco in 1995 and later regional symposia in Guatemala, Hong Kong and Buenos Aires.

Person-centered and intermodal strands

IEATA's glossary says Natalie Rogers developed Person-Centered Expressive Arts Therapy, which joins intermodal creative work with the person-centered approach of her father, the psychologist Carl Rogers, and that she coined the phrase The Creative Connection for the insight that arises from interweaving arts modalities. The IEATA timeline lists a Person-Centered Expressive Arts Therapy Institute in 1994.

A second strand is associated with Paolo Knill. A 2004 book by Stephen Levine, Paolo Knill and Ellen Levine, as described by its publisher, argues that arts-based therapies often treat art as a tool for a psychological model and proposes instead that the act of making art, and the artwork, be central. The publisher says the book sets out intermodal therapy, crystallization theory and polyaesthetics. The book itself was not available for this draft, so these ideas are reported as described by the publisher.

Intermodal and multimodal

IEATA defines expressive arts therapy as a therapeutic model that combines several expressive arts modalities, such as visual arts, music, movement, drama and writing, in an intermodal way to create an integrated experience. It uses intermodal in preference to multimodal, because it holds that the term better captures how the arts relate to one another, and it describes the weaving and sequencing of modalities as leading to deeper insight and wider awareness. These are the association's own definitions.

How the term is used in research

In research the label is applied more loosely. A systematic review of expressive arts interventions for caregivers found that 59% of the interventions it included were music-based, 22% visual arts and 10% writing, so many studies filed under the term examine one art form and not a combination. A review of veterans with post-traumatic stress disorder searched for art, dance, drama, music and writing under the heading expressive therapies. Findings from such reviews should not be read as findings for the intermodal approach as IEATA defines it.

Process and emphasis

As described by its publisher, the Knill and Levine text places the making of art at the center of the work and not the use of art to illustrate a psychological theory, and it pairs theory with guidance on skills, case studies, supervision and training. IEATA describes its purpose as supporting therapists, artists, educators and consultants who use integrative, multimodal arts processes for personal and community growth. Sessions can therefore sit in clinical, educational or community settings, and the sources reviewed do not set out one standard session format.

Formats used in studies

Formats in published trials vary. A randomized trial in stroke survivors delivered eight weekly sessions of 90 minutes, and a trial of a storytelling program in older adults with mild cognitive impairment delivered weekly sessions for 24 weeks. The caregiver review reported durations from a single one-hour session to a program every two weeks for ten months, with eight programs lasting two weeks. These are research protocols, and the sources reviewed do not show what is typical in private practice.

What practitioners and associations describe

IEATA describes the purpose of the field in terms of encouraging the creative spirit and supporting personal and community growth and transformation. Practitioners in the person-centered and intermodal traditions describe emotional expression, insight and integration as aims of the process. These are descriptions of intent offered by the profession, and they are not outcomes that the studies below were designed to confirm.

Groups in which it has been studied

Published studies using the term or close variants have involved family caregivers, military veterans with post-traumatic stress disorder, young and pre-elderly stroke survivors, and older adults with mild cognitive impairment. The caregiver review reported that eleven of its 27 studies were with caregivers of people with dementia, and about 41% involved the caregiver and the care recipient together. Study in a population is not evidence of benefit for that population, and the next section sets out what was found.

Systematic reviews

A 2023 systematic review of expressive arts interventions for caregivers searched four databases for 2001 to 2022 and included 27 studies with 1,359 participants from 14 countries, 12 of them randomized trials. Stress improved in 80% of the studies, anxiety in 69%, caregiver burden in 57% and depressive symptoms in 31%. The authors concluded the interventions hold potential and called for research on duration, intensity and other caregiver groups. Counting studies in which a measure improved does not give the size of an effect, and only the abstract was available for this draft.

A 2023 review of expressive therapies for military veterans with post-traumatic stress disorder screened 187 articles from five databases searched for 2014 to 2022 and included 16. Its authors reported that the therapies reduced symptoms and also recommended more research before the evidence could fully support their use in treatment. The abstract does not give study designs or effect sizes, so the strength of that conclusion could not be checked.

Randomized trials

A trial in Hong Kong randomized 157 stroke survivors aged 18 to 64 to an eight-week expressive arts-based program or a waitlist control. At two months the program group improved on perceived social support, hope and self-esteem (Cohen d 0.32 to 0.48). At eight months anxiety, self-esteem, physical quality of life and wake-up cortisol differed (d 0.34 to 0.46). The authors noted that effects varied by gender and stroke type. Participants cannot be unaware of an arts program, and the abstract reports no sham comparator.

A three-arm trial in China randomized 135 older adults with mild cognitive impairment to a creative expressive arts-based storytelling program, an active control or a waitlist, for weekly sessions over 24 weeks. At 24 weeks the program group scored higher than the active control on global cognitive function and quality of life and lower on depressive symptoms. At 48 weeks only one immediate-recall score still differed from the active control. The benefit was therefore modest and not sustained on most measures.

Related evidence for art therapy and what is missing

A UK health technology assessment of art therapy, a separate single-modality profession, for non-psychotic mental health disorders included 15 randomized trials with 777 participants. Ten reported significantly better symptoms than controls, four found improvement without a group difference, one favored the control, and trial quality was generally low. Because the review covers art therapy alone, its results should not be carried over to the intermodal approach.

PubMed searches run for this draft, one for expressive arts therapy with systematic review and one for expressive arts with randomized controlled trial, returned 25 and 17 records and surfaced the reviews and trials above. No review that was specific to the intermodal approach, and no independent replication of the two trials, was seen in the abstracts reviewed. Other databases were not searched.

Distress and harms reported

The UK assessment of art therapy found, in its qualitative review of 12 studies, that potential harms were related to the activation of emotions that were then left unresolved, a lack of skill in the therapist and sudden termination of therapy. A related qualitative systematic review of 183 service users and 16 providers found that most respondents considered art therapy acceptable but that small numbers described evoking feelings that could not be resolved. Both concern art therapy, not the intermodal approach, and they show the kind of risk that sources describe for arts-based work with emotion.

The authors of the qualitative review advised attention to the competence of the person delivering therapy, additional support such as other therapies where needed, and continuity of care. The abstracts of the trials reviewed here do not report adverse events, so the absence of such reports cannot be read as an absence of harm.

Suitability and care boundaries

Expressive arts work is not a diagnosis and does not replace medical or mental health care. Stroke rehabilitation, cognitive decline, post-traumatic stress and caregiver strain all call for assessment and treatment by qualified clinicians, and the studies above tested the programs alongside usual care or as an addition to it. A person who experiences worsening distress during or after sessions can raise it with the facilitator and with a health professional.

Training and professional registration

IEATA operates the Registered Expressive Arts Therapist credential, launched in 1998, and the Registered Expressive Arts Consultant/Educator credential, launched in 2007. Its REAT Code of Ethics page lists eight topic areas, including competence, confidentiality, welfare of the client and special considerations for nonordinary states of consciousness, and says registered members must keep their registration and association membership active and continue training in expressive arts. The eligibility requirements for the credentials were not available on the pages opened, and no statutory regulation or training standard was found in the sources reviewed.