The Integration of EMDR and

Expressive Arts Therapy

Rosa Richter

Integrating EMDR and Expressive Arts Therapy in the

treatment of complex PTSD
Table Of Contents

Vignette 7
Session 1 9
Session 2 12
Session 3 16
Session 4 18
Introduction 20
EMDR Standard Protocol 29
Complex PTSD 37
Main Features of Complex Trauma 39
The Expressive Therapies 46
De nitions 49
Bene ts of Integrating the Arts 60
Who can use the Expressive Art Therapy? 73
Conclusion 75
References 78
Integrating EMDR and Expressive Arts Therapy in the treatment of complex PTSD
by
Rosa Richter/ Ragnhildur G. Richter
BA, University of Iceland, 2006
Thesis Submitted in Partial Ful llment
of the Requirements for the Degree of
Master of Arts
Counseling Psychology with concentration in Expressive Arts Therapy
California Institute of Integral Studies
May 2015
This paper/ebook o ers a rationale for
integrating Eye Movement Desensitization and
Reprocessing therapy (EMDR) and Expressive
Arts Therapy. The main features of complex
PTSD, such as dissociation, alexithymia and low
a ect tolerance are suggested as the main
arguments for supplementing EMDR treatment
with EXA interventions. A general overview of
the two therapy forms is provided with a focus
on treatment of complex cases of trauma. The
paper outlines what the arts have to o er that
would signi cantly enrich EMDR treatment and
make it accessible to a larger percentage of the
population. It advocates increased trauma
awareness and an increased use of EMDR and
Expressive Arts Therapy in the practice of
psychotherapy and counseling.
01

Vignette
The following vignette illustrates the combined use of
expressive arts therapy (EXA) and eye movement
desensitization and reprocessing (EMDR) in the treatment
of a 15-year-old client of mine that I choose to call Andri. I
believe that although Andri had never been exposed to a life-
threatening event and would not meet posttraumatic stress
disorder (PTSD) diagnosis, he is one of the numerous cases
where trauma is at the source of the presenting symptoms
and needs to be addressed with specialized trauma
treatment. Through my literature-based research, I found
that there are a number of therapists integrating EMDR and
various forms of art therapy. They report similar results to
what I have observed, namely that the arts can unblock
blocked processing, help as soothing agents, and create a
magical experience that goes beyond what EMDR by itself
can o er.
02

Session 1
Integrating drawing and music therapy. Andri had been
referred to me by one of my colleagues, who was treating
his mother. The family, composed of his father, mother,
Andri and two younger siblings, had lived in Norway
for over 8 years and had returned to their native Iceland
3 years ago. They were all adjusting rather well, except
for Andri. In a phone conversation with his mother
prior the rst session, she told me that he was getting
more and more anxious, almost paranoid, that he hardly
went out to see friends and that sometimes he had too
much anxiety to attend school. She was very concerned.
Andri presented as a skinny, shy teenager, wearing jeans
and t-shirt. It was obvious that he was very
uncomfortable when he sat down in my o ce. When I
asked him how he was, he told me that he was very
nervous and that he did not know what to do with his
hands. I got up and handed him a sketch book and
crayons and asked him if he cared to doodle while we
talked. He accepted and started drawing. He told me
that he was constantly afraid of something bad
happening to him and to his younger siblings. He did
not enjoy school and spent most of his time playing
computer games. He was suspicious of strangers and
found it very di cult to leave the house with his
siblings. He felt he had to protect them as if they were in
danger. I asked him to rate his general anxiety level on a
scale from 0 to 10, with 0 being no anxiety and 10 being
unbearable. He said his anxiety oscillated between 7.5
and 9.5, always.
When I asked him when the anxiety had started he told me about an incident that had happened to him
when he was 12. He was walking in the street when a stranger stopped his car and asked Andri to get in.
Andri did not go with the stranger but had felt unsafe ever after.
This event seemed to have had a deep impact on the boy and I decided to suggest EMDR therapy to
process it. I explained the method to him and asked him if he was willing to try it in our next session.
He agreed. We then looked at his drawing. It represented a small box containing two stick gures
surrounded by a maze. He identi ed one of them as being himself and the maze as a possible way out of
the anxiety. He however had no idea who the other character was. Towards the end of the session I
asked him if he was willing to do some homework. I told him about binaural beats and suggested a
track on YouTube for him to listen to while relaxing and before he went to sleep. I told him it worked
best if he used headphones and if he listened every day. He agreed to do so.
The arts served multiple purposes in the rst session. Drawing helped sooth Andri and might therefore
have contributed in him feeling more comfortable to share his experience. His drawing also served to
tell a story and to convey hope. Hope of there being a way out of the su ering and hope of him not
having to go through it all alone. It gave both of us information of a di erent order than words could
have conveyed and it allowed to introduce the language of symbols.
03

Session 2
Andri told me that he was fully aware that his fear
was irrational, that he was safe here in Iceland and
that it was not likely that something terrible
would happen to his siblings when they went out.
He did not consider himself to be traumatized by
the event. He even considered it silly to be so
paranoid and yet, he couldn t help it. From a parts
´ apparently normal part) is going to sit down at
perspective his dilemma could be interpreted this
as a polarization between two parts: a part that
was aware that Andri was now safe, minimizing
the traumatic event and a frightened part that was
stuck in the moment of terror, not knowing that
the danger had passed and was thus causing
anxiety.
I decided to use Fraser’s Dissociative Table
Technique (DTT; Fraser, 1993) which
involves deep relaxation and guided imagery.
The client is asked to imagine a safe place with
a table and chairs. He is told that the part of
him that is as he sees himself today (the
the table to chair a meeting with di erent
parts of his psyche. I have found it surprising
to what extent this technique helps clients
identify various, previously unknown parts of
themselves. Andri immediately mentioned the
frightened 12-year-old, then a 15-year-old that
was rather tough and had no tolerance for the
12 year old. He also mentioned two
characters that I had not encountered before
during the DTT technique, namely the devil
and the angel. In parts work, the role of the
therapist is to help the client identify
opposing parts and facilitate cooperation
between the parts (Fraser, 1993). The
integration of the angel and devil parts went
quite smoothly using EMDR. Andri managed
to develop sympathy for both characters,
understanding how hard it was for each of
them to hold all the bad or all good. When it
came to the integration of the frightened 12
year old and the tough and angry 15 year old,
Andri s processing seemed completely
´
blocked. Even with the help of bilateral
stimulation, he could not develop sympathy
for the 12 year old.
Integrating drama therapy. I decided to follow
my instinct and suggested he embodied the two
characters. I asked him to stand up and show me
how the 12 year old would carry himself, how he
would move and if there was one sentence or
word that represented him, what that part would
say. Andri stood up, rounded his back and
lowered his head. He said: “be afraid, very afraid,
you are not safe”. I thanked the 12 year old part
for trusting us enough to show himself and
invited Andri to come over to me, a few steps
away. I told him that we are going to allow the 12
year old one to stay over there, and that we were
now going to invite the 15 year old to join us. I
asked him how the 15 year old would stand, how
he would carry himself, move and what he would
say. Andri went into character immediately. He
now looked like a cocky, self-assured teenager.
He did not have anything to say. I then asked the
15 year old to look at the 12 year old that was “Do you think you guys could help each
still standing there. Could he see him? “Yes, and other out?” I asked. “Yes, I am going to help
he looks pitiful, what a loser!” the 15 year old him, it is not his fault” Andri said.
replied. The shift had taken place. We sat down again
I then asked Andri to go back to the original and installed the newfound alliance with
position where the 12 year old had stood and bilateral stimulation, the EMDR installation
asked him to go back to embodying him. I placed phase.
myself in the place where the 15 year old had
stood. I imitated his body language and said to
the 12 year old part “you are pitiful, what a
loser!”.
I invited Andri to notice how the 12 year old felt
when hearing this and then asked him to step
back into the 15 year old role. “Do you see the
12 year old?” I asked him. “Yes.” “What do you
think of him now?” “He is just afraid, that s all. I
´

feel sorry for him now. It’s not his fault.”

04

Session 3
“This is not the same person” was my rst thought when I saw him in the waiting room. Something in
Andri had changed. He held himself straight and radiated a self-assurance I had not seen before. He was
wearing a fashionable cap and looked more grown up. He told me with great enthusiasm that he had
not had any anxiety during the whole week. He had almost forgotten that he had been so anxious
before. When I asked him if there had been any exceptions to this newfound freedom, he told me that
he had felt anxiety once, when he saw a TV news report on a pedophile. We decided to process the
event with EMDR and I recommended that he continue to listen to the binaural beats music, which he
told me soothed him.
05

Session 4
Integrating drawing. Andri’s remission from his anxiety had persisted. He rated his anxiety 0 to 2 on a
0 to 10 scale, and told me that he had not experienced any high anxiety states all week. He felt
absolutely ne, he told me. I asked him if he was willing to do some drawing and he agreed. I invited
him to draw a vertical line in the middle of the paper and draw how he had felt before starting therapy
on the left side of the sheet. He drew a few stick gures, all the same height except for one, which was
much smaller and trapped in a box. I then asked him to draw how he felt today on the right side of line.
He drew a few stick gures that were all the same height. One of them had a big smile on his face.
When I asked him to tell me about his drawing he told me that before he had felt like he was not an
equal, that he was so much weaker than all the others and trapped in his anxiety but that now he did
not see himself as inferior anymore. We used bilateral stimulation to install a future vision of him
feeling like an equal. He told me that he did not feel like he needed any more therapy at this point and
promised to get in touch if he needed me at a later point.
In my work with Andri, as with many other clients, I found the integration of the arts to be essential in
reaching the desired e ect. I sense that the moments where the arts are integrated stand out as being
more memorable and in some sense magical. This memorable and magical feeling is what makes the arts
in therapy so precious to me.
06

Introduction
Mental health has become an increasing concern
worldwide. An estimated 500 million individuals are
a ected and the number is rising fast. One in four
individuals are estimated to su er from a mental disorder at
one point in their lives. Mental disorders have become the
leading cause of disability and are a growing burden on our
societies. Governments are therefore increasingly interested
in providing mental health services that are both time and
cost e cient.
On an international level, action plans have been devised to
expand and improve the quality of mental health services. In
its “Mental Health Gap Action Program”, launched in
2008, the World Health Organization (WHO)
recommends an integrated approach that promotes mental
health care at all levels of care. It points out that there is a
considerable gap between the need and the provision of
adequate mental health care services. The action plan
addresses the signi cant lack of non-pharmacological
approaches and trained personnel to administer them. These
approaches should be evidence based, cost-e ective and
feasible.
The WHO action program also underlines that, because of
the high rate of co-morbidity of mental and physical health
problems, an integrated approach, addressing both
components is called for. It speci cally draws attention to
the fact that individuals, having been exposed to
psychological trauma require careful examination, especially
with regard to diagnosis. It de nes psychological trauma as
single traumatic incidents, repeated or continuing stressors
such as family violence, domestic violence or civil unrest.
The WHO s explicit recognition of the etiological link
´

between non-life threatening events and health problems

mirrors a rising awareness of the importance of treating
trauma in a much larger population than previously
suspected.
One of the factors leading to this development were the
devastating events that shook the world´s nations in the
last two decades. Unprecedented terror attacks such as
9/11 and a number of catastrophic natural disasters
caused a new level of collective trauma and left a large
number of trauma survivors in need of help. In response
to this situation, governments multiplied their funding
for trauma research and treatment. Task forces were set
up to identify and develop the most e cacious
treatments for trauma survivors (van der Kolk, 2014).
The ensuing e cacy studies found two psychotherapies
to be most e cient: Trauma-Focused Cognitive
Behavioral Therapy (TF-CBT) and Eye Movement
Desensitization and Reprocessing (EMDR; Davidson &
Parker, 2001). Consequently, the World Health
Organization, the Department of Veteran A airs in the
US, National Institute for health and Care Excellence in
the UK, and other organizations in charge of public
health recommended these two therapies as a treatment
of choice for trauma related disorders.
Another, unintended outcome of the trauma research e orts was a new understanding and
conceptualization of the syndrome. It became increasingly evident that the symptoms of Post
Traumatic Stress Disorder (PTSD) could be found in a much larger population than the one exposed
to life-threatening events. Researchers started investigating the sequelae of a variety of general adverse
life experiences such as prolonged interpersonal trauma or repeated exposure to severe psychological
stressors, and concluded that symptoms observed in this population were considerably more complex
and severe than what was observed in single trauma survivors (van der Kolk, Roth, Pelcovitz, Sunday,
& Spinazzola, 2005).
Neuroimagery yielded conclusive results, the neurological e ects of prolonged interpersonal trauma,
especially with early onset, were devastating. Briere and Spinazzola (2005) explained that the
consequences of being exposed to overwhelming psychological stressors could be evaluated on a
complexity continuum. At the lower end of the spectrum were previously healthy and functional
individuals having su ered a single, isolated trauma, on the higher end were individuals with early-
onset, extended, repeated and invasive trauma exposure, involving shame and stigmatization.
The PTSD workgroup studying individuals exposed to repeated or prolonged trauma, identi ed 27
core symptoms manifested on a physical, psychological and social level. The symptom list can be
found under “associated features of PTSD” in the DSM V.
Complex trauma su erers were found to present dysregulations or alterations in the following seven
areas (Korn, 2009, p. 264):
(a) regulation of a ects and impulses
(b) attention or consciousness
(c) self-perception
(d) perception of the perpetrator
(e) relations with others
(f) systems of meaning
(g) somatization
Clinicians and researchers have referred to this conglomeration of symptoms as
Complex PTSD (C-PTSD), complex trauma, developmental trauma disorder (DTD) or Disorders of
Extreme Stress not otherwise speci ed (DESNOS). Even though the DSM-V o ers a broader construct
for PTSD than the DSM-IV, and has now placed PTSD under a new category, C-PTSD is not
included. The inclusion of the diagnosis was under consideration but was rejected for both the DSM-
V and the ICD-10.
C-PTSD or DESNOS not being formally recognized as a diagnosis, resources for research and
specialized treatment of the disorder are still sparse. According to Friedman (2013) however, the ICD-
11, due in 2017, will include complex PTSD as a diagnosis, which is expected to have considerable
clinical and political implications.

Page 19
Clients presenting the symptoms of complex
PTSD have signi cantly poorer PTSD treatment
outcomes than su erers of noncomplex PTSD
(Ford & Kidd, 1998; Zlotnick, 1999).
Dysregulation symptoms are more severe in this
population and functionality more impaired.
This evidence points to the fact that a much
larger population than previously suspected
require specialized trauma treatment. The C-
PTSD population typically seeks help for
depression, anxiety disorders, substance abuse
disorders or dissociative disorders and receives
treatment for these conditions. Trauma
specialists such as van der Kolk (2005) and Briere
and Scott (2014) are alerting the mental health
community that failure to detect and treat
underlying trauma makes treatment ine cient
and thus precludes their client´s recovery.
This underscores the necessity for clinicians not
only to be trauma informed, but also to have the The current C-PTSD literature advises a phase
training and skills necessary to detect underlying oriented, titrated, skill-focused, multimodal
trauma in clients that do not meet PTSD criteria treatment, stressing functional improvement
(van der Kolk, 2000). Although slowly, mental and symptom relief (Courtois, Ford, &
health services are reacting. The number of Cloitre, 2009; Ford, Courtois, Steele, van der
trauma informed practices (TIP´s) has multiplied Hart, & Nijenhuis, 2005).
in the last decade and the number of mental This paper intends to provide a rationale for
health care professionals trained in EMDR is integrating expressive arts therapy and EMDR
growing steadily. in the treatment of C-PTSD. It underscores
Even though C-PTSD has a lot in common with that because of more common and severe
noncomplex PTSD, the rationale presented in alexithymia, dissociation and compromised
this paper is to a large extent founded on what a ect regulation in C-PTSD, an alteration of
di erentiates them. Complex PTSD can be the standard EMDR protocol is required.
di cult to detect and often calls for EMDR
treatment to be supplemented with adjunct
interventions (Knipe, 2014).
The current literature in the elds of trauma,
complex trauma, dissociative disorders, EMDR
and art therapy was reviewed with regards to
theoretical, empirical and anecdotal data
supporting or opposing the integration of
EMDR and expressive arts therapy. A brief
overview of EMDR and expressive arts therapy is
provided and the neurobiological underpinnings
of complex trauma, presented as one of the
central arguments for the inclusion of the arts are
introduced.
The ndings on the nature of trauma supported
the use of both therapy forms and shed light on
their commonalities. These ndings provided
strong indications as to why the expressive arts are
a useful and e cient adjunct to the standard
EMDR protocol in the treatment of complex
trauma (van der Kolk, 2014).
Whereas EMDR has been extensively researched
and has full support as an evidence based mental
health practice in the treatment of trauma,
controlled empirical research on the expressive
therapies is very sparse. It is not recognized as an
evidence based practice and its use in mental
health settings, although steadily increasing, is
still marginal. This paper is intended to make an
argument for the increased integration of the arts
within EMDR treatment of complex trauma.
EMDR
“I was astounded” was van der Kolk´s reaction when he rst experienced EMDR (van der Kolk, 2014,
p. 251). Van der Kolk, like most of us who use EMDR, could not believe how e cient and fast this
treatment was. In fact, its e ciency has a tendency to leave clients and therapists alike ba ed at what
just happened. As mentioned above, the WHO recommends the following two therapies as treatments
of choice for PTSD: TF-CBT and EMDR. It has been shown repeatedly in randomized controlled
studies that although both are equally e cacious, EMDR works much faster and requires no
homework (Schubert & Lee, 2009), whereas TF-CBT requires numerous hours of homework every
week. Being more time and cost e cient than TF-CBT, EMDR is the treatment of choice for an
increasing number of mental health care providers. For licensed mental health care professionals, a one
weekend EMDR training, organized by a quali ed training institution, is su cient to be legally able to
administer EMDR treatment. The trainings are available many times a year in most countries of the
world. Considering the e ectiveness and ease of administration of EMDR, it is likely that the number
of trained practitioners o ering the treatment will continue to grow.
Eye Movement Desensitization and Reprocessing is an evidence-based psychotherapy initially designed
for the treatment of PTSD (Shapiro, 2001). However, its e ciency in the treatment of other mental
and physical disorders is being increasingly documented and researched (Boisset-Pioro, Esdaile, &
Fitzcharles, 1995; D'Argenio et al., 2009; Drossman, 2011; Kempke et al., 2013; Lackner et al.,
2004).
EMDR was created and developed by psychologist and researcher Dr. Francine Shapiro who in 1987,
made the chance discovery that eye movements can, under certain circumstances, reduce the intensity
of disturbing thoughts and emotions. Her consequent research and development of a psychotherapy
integrating bi-lateral eye movements led to her rst publication in 1989, reporting positive results with
PTSD su erers. In 2001, Shapiro introduced the Adaptive Information Processing Model (AIP)
o ering a theoretical framework and guidelines for the administration of EMDR. The main tenets of
the model were that adverse life experiences could have consequences comparable to what was
observed in individuals who had survived
life-threatening events. Those consequences manifested in the form of mental disorders, somatic
symptoms, behavioral disturbances or emotional distress. The second tenet was that we had an innate
ability to process adverse life experiences by categorizing them and integrating them into a memory
network of similar experiences. This integration process linked disturbing experiences with adaptive
information, thoughts and images, transforming them into a narrative.
However, when an individual was emotionally
overwhelmed by a traumatic event, this adaptive
information processing was thwarted. The individual
was unable to link the disturbing sensations and images
to prior events and they remained unprocessed. Shapiro
believed that the trauma related stimuli were stored in
isolated fragments, in a sensory and state-speci c form.
She saw this interrupted storage process as the origin of
trauma related disorders. The fragments were prevented
from being processed into a narrative and were stored in
a preverbal part of the brain, responsible for
ght/ ight/freeze reactions. Whenever the traumatized
individual encountered a situation, a thought, smell,
sound or any other stimulus in any way similar to the
traumatic event, the memory fragment was activated,
launching a physiological trauma response (Shapiro,
2001). This physiological stress response would take
place whether the individual was conscious of the
triggering stimulus or not, creating some of the most
characteristic symptoms of trauma related disorders,
hyper-arousal, hypo-arousal, ashbacks or dissociation
(Damasio, 2011).
07

EMDR Standard
Protocol
The EMDR standard protocol consists of 8 phases and 3 prongs (Shapiro, 2001). They are well
de ned and aim at accessing and reprocessing dysfunctionally stored memories. A central element of
EMDR treatment is bilateral stimulation (BLS). Shapiro posited that it helped access non-verbal
trauma memory fragments and reduce arousal while revisiting traumatic events.
In the early days of EMDR, eye movements were considered necessary, however, subsequent research
suggested that any bilateral stimulation, whether visual, tactile or auditory could be equally e cient
(Bergmann, 2000). Many EMDR therapists still use Shapiro´s original hand movement as a bilateral
stimulation, while others apply hand tapping, alternating sounds or hand-held, vibrating buzzers,
depending on client preference. Shapiro posited that the premise for trauma resolution was su cient
client stabilization before, during and after the processing of the traumatic event. Research has shown
that treatment delity to the eight phases produced the best results in most cases of PTSD (Shapiro,
2001).
However, ongoing research on complex PTSD and other trauma related disorders has encouraged a
modi cation of the standard protocol and recommends the integration of experiential methods and
EMDR (Adler-Tapia & Settle, 2012; Gomez, 2012; Lahad, Farhi, Leykin, & Kaplansky, 2010; Lovett,
1999).
Three prongs and eight phases. Three prongs in EMDR treatment refer to past, present and future. Past
memories are processed, present symptoms are alleviated, and functional beliefs leading to healthier
choices in the future are installed (Shapiro, 2001).
The eight phases of EMDR are as follows:
1. Client history phase. During the rst phase, the clinician takes a detailed client history with regard
to unmetabolized traumatic memories and current symptoms. She assesses the client's readiness for
EMDR, and establishes a treatment plan taking into account the duration of the symptom, its
manifestation, other relevant life circumstances and the desired treatment outcome. She identi es
targets for future processing. Ideally, she scans for dissociative identity disorder and investigates
possible secondary gains, which would complicate the treatment. In some cases, especially with
complex PTSD, a complete trauma history will have to be completed progressively. The clinician takes
time to build rapport with the client, which is paramount for safe trauma processing. Since C-PTSD
su erers tend to nd it di cult to establish trust and to express themselves verbally about trauma
related events, art modalities have been shown to be a helpful adjunct here (Badenoch, 2008; Gomez,
2012; Steele & Raider, 2001).
2. Preparation phase. In this phase, the clinician
continues to build a trusting relationship with
the client and introduces him to EMDR. She
describes the principles and procedures, explains
the theoretical framework and the administration
of the treatment. The clinician introduces the
client to the bilateral stimulation and they select a
form, speed and intensity that feels comfortable
to the client. She alerts the client that the
processing can evoke disturbing images and
emotions and encourages him, if possible, to
continue in spite of the discomfort and to look at
the images as if observing a scenery from a
moving train. She may o er the metaphor of
driving through a tunnel, if one slows down, one
will be in the tunnel longer.
Client and clinician agree on a hand gesture that
the client can use if he feels overwhelmed and
wishes to interrupt the processing. The clinician
explains that processing is likely to continue Clients with a complex trauma history often
between sessions and recommends keeping a log lack positive resources and adaptive memory
of disturbing emotions, memories, dreams or networks. The preparation phase therefore
situations. She then leads the client through the needs to provide supplementary tools for
“safe place” exercise, a relaxation technique stabilization and self-regulation skills.
designed to help the client experience calm and a A number of EMDR specialists have
feeling of safety before trauma processing. Part of recommended integrating the expressive arts
the EMDR treatment is to teach the client self- at this stage of the protocol. As will be
soothing and a ect regulation in order to be able outlined in more detailed at a later point, it
to remain stable in between sessions and in future has been shown that the arts can be a powerful
disturbing situations. Some clients may need tool for a ect regulation, mood alteration and
numerous sessions and lengthy training in self- soothing (Talwar, 2007).
soothing and resource building before starting
trauma processing.
 In the EMDR literature, the most common
adjuncts recommended when standard protocol
is insu cient, are “cognitive interweaves”.
Although the name implies that the
interventions are of a purely cognitive nature, it
can be argued that many of the cognitive
interweaves are in fact “expressive arts
interweaves”. They call upon the client´s
imagination, spirituality and creativity and
resemble methods commonly used in expressive
arts therapy, such as modifying the colors,
luminosity or distance of the mental image. If at
this stage, changing mental images is not
stabilizing enough, introducing an art material
could be seen as a natural and logical next step. A
number of art therapists using EMDR have
reported this to be e cient and have developed
EMDR protocols integrating the arts at this stage
(Adler-Tapia & Settle, 2012; Adúriz, Bluthgen,
& Knop er, 2009; Jarero & Artigas, 2010; Tripp,
2007). Being able to o er a variety of art
modalities to meet the client's preferred way of
expression o ers as a considerable advantage
(Knill, Levine, & Levine, 2005).
3. Assessment phase. This phase is aimed at
evaluating the client´s emotional disturbance level
and self-concept when thinking of the trauma. It
serves to evaluate the client's progress but,
simultaneously, by involving critical thinking, it
creates an initial link between emotion and
cognition.

Page 28
The client is asked to recall a traumatic memory and to observe what happens on an emotional,
physiological and cognitive level. This usually activates a dysfunctionally stored memory system and
triggers a physiological stress reaction or numbing. The clinician then helps the client to identify a
negative, irrational self-a rmation that is associated to the emotion, such as “I am worthless” or “I am
not safe”. When the negative cognition has been identi ed, the clinician asks the client to choose a
positive self-a rmation that he would like to believe instead. The client is asked to evaluate, on a scale
from 1 to 7, how true the positive a rmation feels to him in the present moment. The naming of the
positive belief serves as a primer for connecting traumatic memories with functional beliefs.
The problem with su erers of complex trauma is that they commonly report not being able to feel
anything when thinking of traumatic events. They often experience a strong disconnect between the
story and the emotions, a dissociation. The ability to dissociate emotions from disturbing events is a
survival mechanism that many of them had to develop early in life to make their life circumstance
bearable (van der Kolk, 1996).
Addressing dissociation within EMDR therapy can be challenging and requires skillful intervention.
In fact, addressing the obstacle of dissociation in EMDR has been one of the most researched subjects
within the EMDR community in the last decade (Forgash & Knipe, 2012; Fraser, 1993; Knipe,
2014).

Page 29
Fraser s (1993) “Dissociative Table Technique” and Schwartz s (1995) “Internal Family Systems
´ ´

Model” are two techniques that are commonly used within EMDR treatment to address dissociation.
Both methods work with mental imagery and thus lend themselves perfectly for the addition of the
arts. The vignette above illustrated an example of how integrating EMDR, parts work (Fraser s Table
´

Technique), drama therapy, drawing and music therapy (binaural beats) contributed to alleviating the
client s debilitating symptom of anxiety.
´

4. Desensitization phase. In this phase, the client is invited to bring up the traumatic memory while
bearing the negative self-a rmation in mind. The clinician tells him to “notice and let whatever
happens happen” and administers bilateral stimulation. The clinician observes the client’s nonverbal
cues closely during the administration and adapts speed and duration to the client s needs. After each
´

set of bilateral stimulation, the client gives a brief description of what he experienced during the set.
The clinician may sum up the essence of what the client said and then resumes the bilateral
stimulation. The clinician’s verbal interventions are to be kept to a minimum in this phase. Healing in
EMDR should be spontaneous, not driven by the clinician s interventions or interpretations. The
´

desensitization process is continued until the level of disturbance has reached zero or an ecologically
valid rating. For the processing to be successful, the therapist needs to help the client remain within the
window of a ect tolerance. For clients with a low level of a ect tolerance, the standard protocol can
be adapted to include expressive art therapy tools known to be soothing (Talwar, 2007).
5. Installation. Once the disturbance level associated
with the target memory has been su ciently reduced,
the clinician recalls the previously stated positive belief
and asks whether it still feels relevant. If not, she invites
the client to identify a new positive belief that has
emerged during processing. When the right a rmation
has been found, the therapist asks the client to hold that
in mind and, at the same time, think of the traumatic
memory. The client then rates to what extend he believes
this a rmation to be true about himself. The clinician
continues to administer bilateral stimulation until the
individual reports a seven on a 7-point scale. In this
phase, the standard protocol can be complemented with
expressive arts therapy techniques such as drawing,
imagery or movement that are likely to strengthen the
installation. Andri s drawing of the equal size stick
´

gures is an example of how the arts can be used to

anchor or deepen installation of a positive self-
a rmation.
6. Body scan.The clinician asks the client to scan his
body while holding both the positive cognition and
target memory in mind. If the client reports any
disturbing physical sensations during the scan, the
therapist administers bilateral stimulation until only
positive or neutral sensations are present.
7. Closure. The closure consists of bringing the client back to the present moment and to guarantee
that he does not leave the o ce without being su ciently stabilized. If the client is in a state of
disturbance or abreaction, Shapiro (2001) recommends applying guided imagery techniques or
hypnotherapy to facilitate stabilization. Shapiro urges therapists to learn these techniques before
administering EMDR. The therapist reminds the client that processing will continue in between
sessions and encourages him to keep a log or journal of the disturbances. Teaching the client how to
handle disturbances that occur in between sessions is an essential element of EMDR. It could be argued
that introducing an art modality to this e ect might be easy and e cient. The clinician could, for
example encourage the client to draw when he experiences distress or to listen to soothing music. As I
did with Andri, I often recommend the use of binaural beat music therapy, creative writing or
journaling to my clients.
8. Reevaluation. Each session after the intake session starts with a reevaluation. The therapist veri es
whether target memories that have been treated still elicit a disturbance. If this is the case, she explores
whether related material has been activated, new triggers emerged or challenges regarding the client s ´

future must be addressed. New targets, and residues of targets treated previously are addressed by re-
administering phases 3 to 8.
08

Complex PTSD
Shapiro (2001), the founder of EMDR, observed
that the standard EMDR protocol was
appropriate and su cient for only 40% of trauma
survivors. She described how the remaining 60%
“often enter into cognitive and emotional loops
that are not amenable to the simpler EMDR
interventions” (Shapiro, 2001, p. 249).
Most of these cases are considered to su er from
complex trauma or other trauma related
disorders. They are believed to originate in
repeated or chronic exposure to stressors such as
childhood abuse or neglect, domestic violence or
prolonged civil unrest. Mounting evidence
con rms that the potential consequences of this
kind of trauma have long been underestimated,
and that they might be at the source of a yet
unsuspected percentage of mental and physical
disorders (van der Kolk, 2000). A signi cant
association has been found between physical
and/or sexual trauma and neurologic,
musculoskeletal and gastrointestinal disorders
such as bromyalgia, chronic fatigue syndrome,
or irritable bowl syndrome (Boisset-Pioro et al.,
1995; Drossmann, 2011; Kempke et al., 2013;
Lackner et al., 2004;). Furthermore, a history of
trauma has been shown to signi cantly increase
the risks of developing obesity and coronary heart
disease (D'Argenio et al., 2009).
Randomized controlled studies on e cacious
treatments for C-PTSD are still few, but trauma
treatment experts have come to a general
consensus that such treatments should be titrated,
phase-oriented and multimodal (Korn, 2009).
09

Main Features of
Complex Trauma
As indicated previously, the complexity of PTSD
is considered to exist on a continuum (Briere &
Spinazzola, 2005). All the symptoms outlined
below can be found in simple PTSD but they are
more common and more severe in the population
su ering from complex PTSD.
Speechless terror. Psychotherapy has from its
inception had and unswaying faith in the healing
power of language. In 1893, Freud stated that
trauma could be relieved by recalling the
traumatic event, reliving the emotion related to
the event, and verbalizing what transpired.
Indeed, it remains undisputed that sharing one´s
trauma with another human being is necessary to
break the isolation of trauma. “Communicating
fully is the opposite of being traumatized” (van
der Kolk, 2014, p. 235). Naming a previously
concealed truth about oneself has been shown to
lead to self-discovery and can be experienced as
an epiphany, whereas suppressing our core In trauma, communication between emotion
feelings is believed to drain our energy and our and language is blocked in both directions.
motivation to pursue meaningful goals. Van der Clinicians working with trauma su erers have
Kolk (2014) explains how suppression leads to often been astounded at how little emotion
social isolation and can entail an array of physical their clients show when telling the most
and psychological symptoms. He stressed that horri c trauma stories. They tend to tell the
sharing the trauma is essential. story as if it happened to someone else (van
The di culty with PTSD, and especially C- der Kolk, 2014).
PTSD is that as soon as trauma survivors
experience physiological arousal or numbing
triggered by trauma related stimuli, they nd it
very di cult to express themselves verbally. This
phenomenon, called alexithymia, which is Greek
for “no words for emotions”, later described as
“speechless terror” by van der Kolk, was rst
documented in the 19th century.
In 1992, neuroscienti c imagery allowed for a
deeper understanding of this phenomenon. The
images revealed that self-awareness takes place in
two distinct parts of the brain. One, situated in
the prefrontal cortex containing Broca´s area, is
responsible for language and self-awareness across
time. It holds autobiographical information,
categorizes and classi es input and creates
context. It creates a narrative of our lives and
depends on language for the storage and retrieval
of information. It is the seat of episodic memory.
The other part, situated in the limbic brain, is in
charge of moment-to-moment self-awareness and
is the seat of emotions and physical sensations
(Farb et al., 2007; Niedenthal, 2007). Its
functioning is non-verbal, non-linear and non-
cognitive and it is activated by sensory or
emotional stimuli. It is considered to be a more
ancient and primitive part of our brains, closely
linked to our ght/freeze/ ight mechanism.
Another trauma study using neuroimagery
showed that when trauma su erers listened to a
script of their trauma, the language center of the
brain shut down (Taylor & Bagby, 2004). The
primitive brain however, especially the area close
to the amygdala, where our emotions are stored,
lit up. This illustrated that trauma su erers could
either experience trauma related arousal or talk
about the trauma, but not both at the same time.
However, in order for trauma to be processed,
both mechanisms, the emotional experiencing
and the verbal processing need to take place at the
same time.
These ndings, demonstrating why purely verbal
psychotherapy would be insu cient, had huge
implications for the development of new trauma
therapies. It provided a scienti c ground for what
many trauma therapists knew, namely, that body-
based therapies, including the expressive arts were
paramount in the healing of trauma.
Dissociation. The International Society for the Study of Trauma and Dissociation de nes dissociation
as “the failure to integrate information and self-attributions that should ordinarily be integrated; and as
alterations of consciousness characterized by a sense of detachment from the self and/or the
environment”.
Dissociation symptoms been observed in trauma survivors for over a century (Janet, 1889; van der
Hart, Nijenhuis, & Solomon, 2010). The symptoms observed are ashbacks, numbing,
depersonalization, derealization and amnesia. Clinicians and researchers have noted a characteristic
oscillation between hyper-arousal and numbing in trauma survivors (Steele, van der Hart, & Nijenhuis,
2005).
Recent neurobiological research underscores the role of dissociation in trauma related disorders. Van
der Hart, Nijenhuis, and Steele (2006) observed on fMRI images that, as opposed to healthy
individuals, whose brain activity was concentrated in one area, the brains of trauma survivors were
activated in at least two areas. When exposed to trauma related cues, the area responsible for daily
functioning shut down in trauma survivors. This, along with other similar observations, led to the
formulation of the currently most endorsed account of dissociation: the model of structural
dissociation of the personality (van der Hart et al., 2006).
According to this model, exposure to traumatic events can lead to a division of the personality. The
authors outlined how, when exposed to extreme stress, the personality could split into di erent parts:
the Apparently Normal Part (ANP), responsible for daily functioning, and the Emotional Parts (EP)
responsible for psychobiological ght, ight or freeze responses.
They posited that in order to guarantee daily functioning the Apparently Normal Part blocked
disturbing emotions from taking over. To this end it could cause a varying degree of amnesia and/or
sensory anesthesia (Nijenhuis, 2004; van der Hart et al., 2010).
The Emotional Part´s role is to react to threatening stimuli instantaneously. Emotional parts are created
during traumatic events that cause the ANP to shut o . In such situations, where the cognitive
processing part of the brain is disconnected, traumatic memories are stored as isolated, emotionally and
sensory based clusters of information.
The model posits that an EP is a complete psychological, biophysical and sensory motor system,
comparable to a personality structure. If the trauma survivor gets triggered, his brain shifts from the
Apparently Normal Part to the Emotional Part mode of functioning. This generally entails intense
emotions and/or irrational or self-destructive behavior. Once the ANP is in control again, the
individual often nds it di cult to explain his behavior and typically feels guilt and shame (Briere &
Spinazzola, 2005).
A common obstacle encountered when working with C-
PTSD clients having multiple EPs is that one or more of
them are reluctant to process the trauma. This resistance,
hindering EMDR processing, needs to be uncovered and
resolved. A number of methods such as Fraser s (1993)
´

“Dissociative Table”, Schwartz s (1995) “Internal Family

´

Systems”, and Watkins’s (1993) “Ego State Therapy” have

been developed to identify and work with EP s. They have
´

been successfully integrated with EMDR therapy (Lovett,

1999; Schmidt, 1999).
The model of structural dissociation of the personality
distinguishes three levels of dissociation: Primary
dissociation, with one ANP and one EP, observed in clients
with simple PTSD; secondary dissociation, presenting one
ANP and two or more EP s, seen in clients with C-PTSD;
´

and tertiary dissociation, where more than one ANP coexist

with at least two EPs, which is the mechanism believed to
underlie dissociative identity disorder.
C-PTSD treatment involves integrating multiple EPs.
Therapists working from this model are very alert to
switches between parts and commonly use one of the above
mentioned part therapies alongside EMDR. I nd the
integration of the expressive arts within parts work and
EMDR to be extremely powerful.
Compromised a ect tolerance and self-regulation.Van der
Kolk and Fisler (1994) found that unresponsive or abusive
caregivers could cause a state of chronic hyper-arousal in
their children, inhibiting their ability to develop the
capacity to modulate physiological arousal. Brain scans of
individuals having su ered such conditions showed clear
signs of underdevelopment in the areas responsible for a ect
regulation and self-soothing (van der Kolk, 2014).
This de ciency is believed to cause long-term a ective,
cognitive, somatic and interpersonal symptoms, such as
depression, anxiety, dissociative symptoms, substance
abuse, eating disorders, somatization or self-injury, to
name a few. It is also known to make EMDR treatment
more di cult (Korn, 2009).
To address the aforementioned obstacles encountered in
EMDR treatment, an increasing number of therapists
are integrating expressive modalities. They have been
found to o er an inexhaustible well of resources capable
of enriching EMDR treatment.
10

The Expressive
Therapies
Art has been used for healing purposes
throughout human history (Packard, 1980). We
seem to have a natural inclination, both as
individuals and as civilizations, to express our
deepest fears, pains and joys through art.
Anthropologists have documented that every
known civilization has reverted to some form of
ritual to heal from di cult life events (Packard,
1980). These rituals have been shown to be
surprisingly similar. They seem to follow a certain
formula composed of the following elements
(Perry, 2015): The rituals generally involve a
gathering of the whole community. Once
everyone is gathered, the traumatic event is
reenacted and the story told by means of artistic
expression such as dancing, singing, drumming,
storytelling or another symbolic language. This
usually involves attunement of the tribal members
and movement patterns which have been found
to downregulate the amygdala and facilitate a
discharging of the traumatic memory from the
body (Scaer, 2014). This reduces the disturbance
levels caused by trauma related images, making
them bearable and amenable to process. The
rituals are generally concluded with a meal,
beverage or substance shared by all present.
Perry (2015) hypothesized that these
ritualistic practices emerged instinctively and
they were kept alive because they yielded the
desired e ect. Interestingly, these traditions
closely resemble what neurobiology and
trauma research are now identifying as crucial
elements in the healing of trauma (van der
Kolk, 2014). The current evolution in health
care toward an integrative approach,
especially the integration of the arts, could
thus be seen as our modern society’s
uncovering of an ancient, universal formula.
Other ndings on the history of art therapy
showed how in ancient Greece drama and
music was used to relieve symptoms of mental
distress and Egyptian doctors prescribed
painting to the mentally unstable (Fleshman
& Fryrear, 1981).
In western, post-modern society, however, the
history of the expressive therapies is relatively
brief, dating back to the 1940s. In 1945,
British artist Adrian Hill coined the term “art
therapy”. He engaged in art making while
convalescing from tuberculosis and
recognized this as a potent healing agent. He
published his ndings in a book considered to
be the rst o cial book on the subject (Hill,
1945). Subsequently, an array of approaches
and techniques using art as an integral part of a
treatment or as a distinct form of treatment,
have been developed. Today there is an
estimate of 30 000 individuals with a graduate
degree in at least one of the expressive
therapies in the US.
11

Definitions
Malchiodi (2015, p. 2) de nes the expressive
therapies 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. The terms of “expressive therapies”
and “creative therapies” are often used
interchangeably, whereas “expressive arts
therapy” (EXA) refers to a multimodal or
intermodal approach described in more detail
below.
A brief, non-exhaustive list of the expressive
therapies follows:
Art therapy. The main criteria distinguishing art
therapy from other expressive therapies is the use
of art materials (Malchiodi, 2015). The materials
used can range from a simple piece of paper and a
pencil to complex computer-assisted material for
the creation of movies or images. For practical
reasons, art therapists most commonly restrict
themselves to the easy to use and transportable
materials. The selection of a particular material is
made in accordance to the need of the client.
There is a general consensus in the art therapy
literature that di erent materials evoke di erent
reactions in the client. Drawing with pencils or
markers, for example, tends to have a containing
e ect on the client, whereas materials such as clay
or watercolor are known to facilitate a deepening
of a ect and self-expression (Malchiodi, 2015).
As opposed to many of the expressive therapists,
an art therapist may use the client s art as a formal
´
assessment tool. Art therapy assessment tools
emerged in the early 20th century and have been
used in psychiatric and other therapeutic settings
ever since. The assessment is based on either
symbols detected in the art or an evaluation of the
client s use of color, shape, pressure and other
´
structural elements. Even though their validity
and reliability has been severely criticized, art-
based assessments are currently used in forensic
investigations involving children (Wadeson,
2002).
Art therapy has been recognized as a profession
since the 1940 s and is regulated by the various art
´
therapy associations around the world. Art
therapists generally hold a masters degree in art
therapy.
Music therapy. The American Music Therapy Association de nes music therapy as “the prescribed use
of music by a quali ed person to e ect positive change in psychological, physical, cognitive, or social
functioning of individuals with health or educational problems” (American Music Therapy
Association, n.d., as cited in Forinash, 2005, p. 46).
Music therapy is o ered in a variety of settings and within various approaches, such as behavioral,
humanistic, transpersonal and psychodynamic. Music therapy is used to treat an increasing number of
issues, such as dementia, brain trauma, palliative care and intellectual disabilities (Horne-Thompson &
Grocke, 2008). It is one of the most researched modalities among the creative therapies. Of all the
quantitative research undertaken in the eld, most studies are on music therapy (Dunphy, Mullane, &
Jacobsson, 2013). Some of the research reported inconclusive results, while others empirically
demonstrated the e cacy of music therapy in reducing self-reported anxiety in palliative care patients
(Horne-Thompson & Grocke, 2008) or improving functioning of clients with dementia indicating
that music therapy could be instrumental in improving the quality of life of those clients (Ledger &
Baker, 2007).
Quantitative studies have demonstrated the positive impact music can have on individuals su ering
from terminal illness, cancer, depression and in children with Autism Spectrum Disorder (Dunphy et
al., 2013). Music therapy has shown to be e ective in the treatment of pain, depression, Parkinson s
´

disease and in the care of premature infants (Novotney, 2013). However, further research utilizing
larger samples and long-term trials are needed to determine the e cacy of music therapy.
The rst formal training program in music therapy was o ered in 1944. In 2002, the number of music
therapists worldwide was estimated at 15000 (Grocke, 1999).
Drama therapy. According to NYU Steinhard (2015),
“Drama therapy is the intentional use of theatre techniques
to facilitate personal growth and promote health, thus
treating individuals with a range of mental health, cognitive
and developmental disorders.” It is a relatively recent
professional treatment modality, developed by a number of
individuals in the early 20th century. It soon evolved into a
few di erent approaches (Jones, 2005). One of the most
in uential pioneers of drama therapy was Joseph Moreno
(1946), the founder of psychodrama. As a psychiatrist, he
observed the bene ts his patients harvested from acting out
di erent roles and life situations and consequently
developed his therapy model, psychodrama. Parallel
developments took place in the United Kingdom.
Beginning in psychiatric hospitals in the early 20th century,
where it consisted of setting up plays with patients, drama
therapy soon added an array of techniques such as role-play,
mime, puppetry, enactment or improvisation to its
therapeutic arsenal. The techniques allow the clients to
experience a safe distance from what is troubling them,
making it easier to express and thus process di cult
emotions or memories (Landy, Luck, Conner, &
McMullian, 2003). The techniques draw on and enhance
the individual´s capacity to play, which seems to be lost in
many trauma survivors (Tuber, Boesch, Gorking, & Terry,
2014). They provide a safe space to create or practice a
successful resolution of di cult situations and to gain
insight. Drama therapy is a potent tool to help
communicate, clarify and de ne emotions.
Randomized controlled trials on the e ectiveness of
Drama therapy are very sparse and many of them did not
yield conclusive ndings. However, a few empirical
studies have demonstrated the bene ts of drama therapy.
One of them found that group-based psychodrama
seemed to reduce anger, hostility, aggression and indirect
aggression in Turkish students with high aggression
levels (Karatas & Gökcakan, 2009a, 2009b). Another
study showed that school-based drama group therapy
contributed to reducing behavioral issues for school
students (McArdle et al., 2011). The e ect of drama
therapy on other populations has not been demonstrated
with controlled trials (Dunphy et al., 2013).
Although drama therapy is mostly used in group
settings, it has been found to be useful in individual,
family or couples therapy as well. Professional drama
therapy associations were founded in 1979 in the US,
and in 1977 in the UK. Formal drama therapy training is
now available in Britain, Germany, Canada, the
Netherlands, Israel, and the United States. Most
trainings are two year master´s degree programs which
include extensive practical experience.
Dance/movement therapy. The American Dance Therapy Association de nes dance/movement
therapy (DMT) as “the psychotherapeutic use of movement as a process which furthers the emotional,
cognitive, physical and social integration of the individual” (Sandel, 1975, p. 439). Its theoretical
underpinnings are the deep-rooted role dance has played in healing rituals and the interdependence of
movement and emotion (Ritter & Low, 1996). DMT therapists and theorists posit that by increasing
our body awareness we gain access to its universal language and are able to expand our movement
repertoire. Movement is seen as a vehicle to express emotions, spontaneity, authenticity and
community. Through the embodiment of her inner world, the client learns to identify emotions and
process them safely. Like most the other expressive therapies, DMT is action-oriented and facilitates
body-mind-spirit integration. One of the critical ingredients of successful dance/movement therapy is
the therapist's ability to mirror the client and thereby communicating a genuine and deep acceptance.
The level of attunement reached by physically mirroring a client is believed to have great healing
potential for trauma su erers, especially for those with early attachment wounding (Siegel, 2012).
Recent studies have provided evidence supporting the integration of dance and movement into trauma
therapy. Perry (2015) described how movement boosted brain plasticity, thereby promoting trauma
recovery. He underscored that the most in uential input to the lower parts of the brain was sensory-
motor information. Neuroimagery has shown that “the rhythmic loop of input and output between
the body and the brain is soothing, regulating and organizing” (Gray, 2015, p. 170). DMT is classi ed
as both a somatic therapy and a creative arts therapy. Neurological ndings increasingly support this
approach in the treatment of trauma because it has recourse to movement as a primary language,
facilitates expression, and stimulates creativity. DMT integrates the mind, body and the spirit (Levy,
2005).
As stated previously, in a state of trauma, the brain reverts to its most ancient system, the limbic brain,
in charge of primitive survival strategies while the brain centers responsible for verbal processing are
disabled. According to Porges (2011) and Levine (2010), the trauma memory is not only stored in the
limbic brain, but also in the body. According to them, movement is necessary to release the trapped
energy from the body and to activate the trauma memories.
Moreover, dance is believed to kindle our imagination, which in turn is associated with increased well-
being. Dance has been shown to help regulate a ect. When a traumatized individual can express his
experience through symbol and movement, it becomes more bearable. It contributes to meaning
making, an essential component of trauma recovery (Siegel, 2012).
From a physiological perspective, the endogenous rhythms most relevant to well-being are our
heartbeat, our respiration and vascular feedback. They are in uenced by social engagement,
mobilization and immobilization. By tapping into these physiological rhythms, DMT can be a potent
healing agent for trauma survivors.
Dance therapy was established as a profession in
the 1950 s. Dance/Movement therapy
´

associations regulating the profession were

founded in the US and the UK in the 1960 s. To
´

date, there are 6 universities o ering a master s

´

degree in DMT, all situated in the US.

Poetry therapy. John Fox (1997) de nes poetry
therapy as “the intentional application of the
written and the spoken word to growth and
healing”. Poetry therapists use poetic language in
its multiplicity of forms in the service of self-
discovery, creativity, communication and
healing. Its origins are considered to date back to
prehistoric shamanic incantations. In a poetry
therapy session, the therapist usually selects a
poem or another form of literature that is likely
to evoke feelings in the client. The clinician then
encourages the client to express these feelings in
written form and if possible share the text. Poetry
and creative writing can help the client access
disconnected memory fragments and regulate
a ect.
According to L Abate (2004), writing provides
´

additional levels of trauma processing. In a group

setting, it allows processing without having to
share with the therapist or other group members.
Although training in poetry therapy and creative
writing is o ered within expressive arts therapy
programs, formal training focusing solely on
poetry therapy or creative writing is not available
to date.
Multimodal/intermodal arts therapy (EXA). The
youngest of the expressive therapies is “expressive
arts therapy” (EXA). It is also referred to as
“integrative arts therapy”, “intermodal expressive
therapy” or “multimodal expressive therapy”
(Malchiodi, 2005). Its main tenet is that that
more than one art modality can be used within
the therapeutic framework and that the
combination of multiple modalities has the
potential to yield a deeper insight. Using various
techniques, applying multiple media forms and
grounded in many di erent theories, expressive
art therapists tend to focus on the creative
process, the aesthetic knowing or play. Johnson
and Quinlan (1985) de ne aesthetics as the study
of “beauty, harmony, rhythm, resonance,
brilliance, dynamic tension, and balance” (p.
236).
The EXA therapist mainly distinguishes herself
from other expressive therapists in her use of
intermodality, in “grasping the junctures as
which one mode of artistic expression needs to
give way to, or be supplemented by, another”
(Levine & Levine, 1998, p. 11). EXA´s
fundamental concepts of intermodality or
polyaesthetics re ect the idea that each art form
evokes all sensory modalities (Knill, Barba, &
Knill, 1995). We intuitively experience a
continuity between art modalities, as one single
“language of the imagination” (Knill, 1994, p.
322). McNi (1986) stresses that all
manifestations of creative expression, whether
words, gestures, sounds, imagery or movements
are inseparable and that they work together.
According to Knill (1994), the intermodal transfer, also called superimposition, which is the shifting
from one art modality to another, enables the client to clarify, amplify or accentuate his inner
experience. Having developed a sensitivity to the various art modalities and to what they might elicit in
a client, the EXA therapist is able to tailor an intervention that creates an ideal ground for the
crystallisation of the client s imagination. McNi (1992) considers expressive art therapy to be a
´

“therapy of imagination”.
EXA literature underscores the importance of using the arts to ignite a curative creative energy in the
client. As an integrated approach, EXA embraces spirituality and sees the use of multiple art modalities
as a way for the psyche to make itself known. The art product created during the session is often seen as
a valuable agent in the exploration process.
12

Benefits of
Integrating the
Arts
Although there has been a signi cant increase in empirical
research on the clinical e ectiveness of the expressive
therapies, there is still a considerable lack of controlled
studies in the eld. The vast bene ts of integrating the arts
where verbal psychotherapy falls short are however are
corroborated by an increasing number of practitioners and
clients (Talwar, 2007). The following is a non-exhaustive
list of bene ts that have been ascribed to various art forms:
The arts are curative in themselves. The curative power of
artistic expression in itself is well known among expressive
art therapists and those who practice the arts. Some
expressive art therapists believe the art making to have as
much therapeutic value as the verbal processing of the art
product. Especially for clients with reduced verbal
capabilities, the process of artistic expression has been
observed to yield positive results.
A language without borders. Campbell (1999) underscored
the bene ts of using a universal and symbolic language such
as the arts to facilitate therapy with individuals with diverse
social backgrounds. She pointed out that art, because of its
universality, constituted an essential instrument in
providing equal services to members of all communities.
EMDR and the expressive therapies share the advantage of
requiring minimal verbal expression. In circumstances
where language is not available, combining the two has
shown to be tremendously e cient. In The Body Keeps the
Score, van der Kolk (2014) describes how, by using EMDR,
he was able to treat people whose language he did not speak.
He noticed how those clients, not being able to verbalize
how they felt or to describe their trauma, were fully focused
on their inner experience and achieved excellent results.
In the last decade, international humanitarian assistance
programs have been established to provide emergency
on-site EMDR treatment where natural or man-made
disasters have taken place. Volunteers trained in EMDR
travel to the disaster sites and apply speci c scripted
protocols designed to meet the need of groups in acute
distress. These interventions have proven to be highly
e cient in reducing distress and preventing PTSD in
a ected populations (Jarero, Artigas, & Luber, 2011).
The most commonly used modi ed EMDR protocol
used in this setting is Jarero and Artiga´s EMDR
Integrative Group Treatment Protocol (Jarero, Artigas
& Hartung, 2006; Jarero, Artigas, Montero, & Lena,
2008). Creating an EMDR protocol that could be
applied in groups implied considerable modi cations to
the standard protocol. With one-on-one processing not
being available in a group setting, the authors had to nd
a way to help the survivors express themselves non-
verbally and to self-evaluate their progress. The answer
was found in the literature on EMDR with children,
where drawing, acting, and sandplay were reported to
successfully activate trauma memories in children and
facilitate processing
The authors decided on integrating drawing into the protocol. They provided the participants with
paper and crayons and invited them to draw the most disturbing scene of the trauma. They also taught
the participants a self-administered bilateral stimulation method, called the butter y hug (Artigas,
Jarero, Mauer, López Cano, & Alcalá, 2000). After each set of the butter y hug they asked the group
to produce a new drawing and to evaluate their level of disturbance. Controlled empirical research has
proven these interventions to be highly e cient in reducing the sequelae of trauma and preventing
PTSD (Adúriz et al., 2009; Jarero & Artigas, 2009; Jarero et al., 2006; Jarero et al., 2008; Zaghrout-
Hodali, Alissa, & Dodgson, 2008).
Art makes EMDR applicable in groups. Jarero and Artigas (2010) demonstrated that integrating the
arts makes EMDR applicable in group settings. Marilyn Luber (2010), who has written numerous
books with EMDR scripted protocols, corroborates this nding and o ers EMDR group scripts
integrating drawing and writing. She suggests that group EMDR can be successfully applied with
homogenous groups such as addicts, people su ering from eating disorders or anxiety and professionals
exposed to high stress levels in their work environment, such as medical sta or casualty sta o cers.
Considering the essential role of social integration for trauma recovery, and considering the large
numbers of trauma su erers that do not receive any treatment at all, an increased o er of group EMDR
treatments could constitute an important step towards bridging the gap between need and provision of
mental health services for this population.
Resource building. Leeds (2009a, 2009b) has designed a number of adjunct EMDR interventions
intended to strengthen the client´s inner resources. One of his interventions involves remembering a
hero or other strong character from a movie or a book and borrowing that character´s qualities. At this
point, it would not be much of a stretch to have the client quickly draw the character or the quality she
stands for or nd a picture of the hero online. One can imagine that if one gives physical shape to an
inner reality, it becomes more tangible and more memorable. It could be seen as a rst physical
manifestation of a newly gained strength, a visible and tangible symbol, serving as an anchor (Blatner,
1991).
Inspirational. The use of visual images as an inspiration or a starting point for discussing di cult or
profound issues is well known in art therapy. This technique was explored in a recent study conducted
by Gelo and Manzo (2015) where 20 hospitalized individuals were invited to look at a selection of
paintings representing spiritual themes, select one, and discuss it with the interviewer. The aim of the
activity was to integrate spirituality into the treatment and thereby strengthen the patient's coping
skills and increase his well-being. Ninety percent of the participants evaluated the experience as being
positive. They noted that the images introduced a spiritual dimension that they found bene cial. The
authors concluded that applying imagery in therapy could facilitate conversations.
Stimulating imagination. Huss and Sarid (2013)
investigated the therapeutic value of visual images
in a study conducted with health professionals
exposed to stressful images in their work. The
authors devised an art therapy intervention in
which the participants created either a mental
image or a drawing of a stressful event they had
experienced. The participants were then
instructed to change the images, including
shapes, colors, textures and placement of objects,
without verbalization. Both groups, the group
with the mental images and the group producing
drawn images, reported signi cant reduction of
subjective levels of distress after having modi ed
their images.
The main di erence between the groups lay in
the fact that the group using drawings made a
signi cant higher use of additions or omissions.
They erased elements from their drawings or
added new ones. This created a greater repertoire Research on the use of color among
of changes for the group using drawings. This individuals su ering from depression,
nding supported the hypothesis that working life-threatening illnesses, and PTSD found
with a drawn image was potentially more e cient that the clients predominantly used grey,
than relying on mental images only. black and red in their paintings (Eaton,
The bene ts of color. Naumburg (1973), who is Doherty, & Widdrick, 2007). The client´s
considered the pioneer of art therapy in the choice of colors can thus serve as an informal
United States, believed that the use of color was assessment tool for therapists. Individuals
instrumental in eliciting emotions and in seem to have little di culty attributing a
promoting healing. She reported how the color to an emotion; colors can thus be seen as
therapist could aid the client access an indistinct a form of language, building a bridge from the
emotion, mood or feeling by asking him to unspeakable to the narrative.
associate it with a color. This made the emotion
or mood more tangible and facilitated verbal
expression.
Furthermore, color has been shown to have a
measurable impact on our body. In a study
carried out in 2008, muscular power and
handgrip of nineteen young men was measured
while exposed to blue, red or white light. The
men turned out to be signi cantly stronger when
exposed to red light than in the two other color
conditions (Elliot & Aarts, 2011).
Creates meaning. In a PTSD study led by Foe in
1997, trauma su erers interviewed about inner
perception reported “feeling dead inside” or “not
knowing themselves anymore”. Foe observed that
individuals who ignored their inner reality
seemed to lose their sense of self, their purpose in
life, and their identity. She found that
externalizing, expressing and sharing one´s trauma
was necessary in order to recreate meaning in the
trauma su erers´ lives.
Campbell (1999) demonstrated how the use of
art therapy was instrumental in creating meaning.
Art therapy helped the clients make sense of what
happened to them, which promoted recovery.
Numerous studies have found that images are
capable of initiating hermeneutic and semantic
meaning, necessary for the healing from trauma
(Huss & Sarid, 2012, Malchiodi, 2012, Sarid &
Huss, 2010)
The arts speed up target determination. In the
current environment of managed care, time is of
the essence. One of the therapist´s new
responsibilities is thus to provide as e cacious a
treatment in the shortest time period possible.
EMDR target determination can sometimes be
complicated and time consuming. Art therapy
has been shown to speed up this process.
Gladding (2011) described how art activities
facilitated externalization of the client's inner
world and allowed him to experience himself
di erently.
Art facilitates communication and attunement. It has been observed that applying art within therapy
facilitates rapport and promotes conversation (Gelo & Manzo, 2015). Clients often nd it easier to
express their concerns in a non-verbal manner, especially if they do not know their therapist well. “Art
allows us to go into our pain, rage, and grief. Using art sometimes is much more e ective than words
to deal with some of these very di cult emotions” (Sommers-Flanagan, 2007, p. 123).
Witnessing the client´s art, the therapist is given access to information that might have taken weeks to
uncover, allowing her to devise a treatment plan that best suits the client. This increased attunement
reinforces rapport building and speeds up the therapy.
Furthermore, art therapy directives such as “draw what happened” (Pynoos & Eth, 1985; Malchiodi,
2001) have proven to be instrumental in activating sensory memories and generate narratives, which in
turn can be modi ed through cognitive reframing techniques (Steele & Raider, 2001). Both elements
are considered crucial in the successful treatment of trauma.
In a study led by Gross and Hayne (1999), two groups of children were asked to talk about a past
experience that was unique to them. One of the groups was asked to draw while recounting the
experience. The drawing group provided signi cantly more information than the non-drawing group.
The ndings of this study suggest that drawing can facilitate communication about past events.
Art soothes and stabilizes. Van der Kolk (2005) documented the physiological dysregulation observed
in trauma su erers. They explained that trauma was a physiological, autonomic and neurological
response that entailed a secondary psychological response (Rothschild, 2000). Neuroimagery and
other physiological measures indicated that trauma survivors are in a constant state of arousal. They
have lost the ability to self-soothe. In order to reduce the level of arousal, EMDR o ers soothing
techniques such as “the safe place” and a mindfulness oriented approach. Furthermore, bilateral
stimulation is e ective in reducing this disturbance while revisiting trauma (Shapiro, 2001).
For some clients su ering from complex PTSD, however, these calming methods are insu cient.
They nd it hard to concentrate and to participate in guided imagery. In working with those clients,
adjunctive art therapy methods have been observed to be helpful. Huss and Sarid (2012) demonstrated
how the use of art therapy reduced physiological stress in trauma su erers.
It has been noted that C-PTSD su erers require a longer period of stabilization than PTSD su erers in
order to feel emotionally safe in the therapeutic setting (Briere & Scott, 2014). A fragmentation of
their personality, which is more common in these clients, needs to be assessed and addressed. The
personality fragmentation often entails phobic responses that are likely to get in the way of successful
EMDR processing.
Interestingly, Spring (2001) observed that C-PTSD su erers have in increased ability to generate
imagery. He refers to this proclivity as a “PTSD special language”, a language that might be useful
when methods such as guided imagery cannot be used.
Art re-ignites play and imagination. One of the sequelae
of trauma is loss of the ability to play or to be creative
(Tuber et al., 2014). Children having been exposed to
chronic stress nd it di cult to imagine or recall
positive attachment related images or sensations. They
are believed to have developed protective coping
mechanisms that preclude emotional ties and hamper
their imagination. Many of them have lost the capacity
to play and to use their imagination.
The expressive arts are known to kindle our imagination
and help recover the important capacity to play.
Art moves the body. Peter Levine (2010) explains
trauma as an un nished ght, ight or freeze reaction.
When exposed to danger, our physiology is programmed
to either ee, ght or freeze. The organism mobilizes a
large amount of energy for this task that, if not spent, is
blocked in the body and the nervous system. Levine
explains that in order heal trauma, this stored up energy
needs to be spent, which requires movement.
Within the eld of psychology, art therapies are de ned
as “action-oriented” or experiential. Contrary to talk
therapy, they involve movement and a targeted body
mind interaction. It is my experience that integrating
movement interventions within EMDR treatment can
be extremely powerful.
Art repairs attachment. Siegel (2012) de nes attachment as “an inborn system in the brain that evolves
in ways that in uence and organize motivational, emotional, and memory processes with respect to
signi cant caregiving gures” (p. 67). Clients with complex trauma resulting from childhood abuse or
neglect, have been found to have di culties forming and maintaining meaningful relationships.
Neuroscience demonstrated how lack of secure attachment precluded the neurological development
of mechanisms necessary for self-regulation, resulting in an oscillating between hyper- and hypo arousal
(Schore, 1994).
It has also been shown that the brain de ciencies caused by disorganized or insu cient attachment can,
with the help of appropriate interventions, be repaired at any age. Riley (2001) observed how simple
drawing exercises could strengthen therapist-client relationships and repair relational problems
between children and their caregivers. She hypothesized that the drawing activity tapped into early
preverbal relational states and allowed for new, attachment related neurological pathways.
Siegel (2012) and Schore (1994) posited that attachment formation to takes place in the right part of
the brain. They based this assumption on the fact that the right hemisphere developed more quickly
than the left during infancy. Siegel pointed out that in order to develop, the left brain hemisphere had
to be exposed to language. The right brain, where preverbal memories and attachment patterns are
stored, expresses itself in “non-word-based” ways. He argued that creative art therapy may o er an
invaluable tool in treating attachment related issues.
Allows for expression without words. Johnson (1987) underscored the critical role expressive therapies
play in the treatment of trauma related disorders. Long before the neurological con rmation of
blocked language in trauma survivors, he advised how art modalities could be used in circumventing
trauma related alexithymia. Badenoch (2008) established how art therapy interventions were
“brainwise” in the sense that they allowed for externalisation of the trauma, permitted sensory
processing, were mediated by the right hemisphere, helped reduce arousal and regulate a ect and were
potent agents in the repair of attachment related issues.
A sensory pathway to healing. There is general agreement that trauma takes a toll not only on the
nervous system, but on the body as well. In a landmark research, Damasio (2011) showed how
individuals can experience an emotion that triggers an array of physiological, hormonal and
neurological reactions without them being conscious of what triggered it. Many trauma researchers
(Rothschild, 2000) believe that the core of trauma resides in the body. Since traumatic memories are
stored in the limbic system, they can only be accessed through the body, through sensory experience or
other non-verbal pathways.
Art therapy draws upon a natural sensory mode of expression. Through touch, movement, smell,
hearing and other senses, art therapy has shown to be able to mobilize sensory memories (Steele &
Raider, 2001) making them available for cognitive processing.
Acts as an anchor and reminder. An art product
generated in an EMDR session can have multiple
bene ts:
It can be used as a focus point during processing
for those clients who nd it hard to stay present
or to concentrate. Lovett (1999), for example,
asks children she is treating with EMDR to draw
their trauma and to focus on the drawing while
she administers bilateral stimulation. She also has
them draw their inner resources or pleasant
images which she uses in the installation process.
The imagery that is produced can be used both to
elicit emotions and to stabilize the client. Most
EMDR therapists working with children
integrate the arts.
The second major bene t of having a tangible art
product within EMDR treatment is that it helps
both therapist and client keep track of the
progress made. The object can be looked at later
in therapy, symbolizing the progress that has been Fourthly, the art piece speaks its own
made. It can serve as a tangible reminder of how language. Expressive therapists often tell the
the client felt at a particular time. clients to take their art home and leave it
Thirdly, the art product can serve as an invitation somewhere where they see it regularly. The
or bridge for deeper communication within the invite the clients to pay attention to what the
client s family or close environment. The art that
´
art tells them, explaining that new meanings
the client brings home can be a starting point for or messages can transpire from the art as time
discussing issues that are di cult to discuss. In goes by. It is also common for art therapists to
this sense, the art is instrumental in the process of ask their client to turn their art work upside
sharing one s inner world or trauma in a less
´
down or in various directions and notice
threatening way. whether they see something new. Art as a
manifestation of the unconscious, the
symbolic or even the mystical can be seen as an
indispensable companion in recovery or
personal growth (Blatner, 1991).
Last but not least, is the argument that
materializing abstract concepts such as trauma,
pain, fear or hope can make those concepts feel
more real and more tangible to the client. For
clients that have been dealing with
depersonalization or dissociation it is particularly
di cult to connect to their inner world. Having
the opportunity to touch an object representing
an inner experience can therefore be particularly
healing for C-PTSD su erers. What has been
hidden and denied so long is now visible and
tangible, to the client and to others.
13

Who can use

Expressive Art
Therapy?
Opinions vary greatly on who should or may use the arts within therapy. There is those who argue that
if one is not an artist and does not have an extended and formal education in one of the art therapies,
integrating the arts would be unethical and unprofessional. Others, such as Gladding (1992) and
Carson and Becker (2004) see the integration of the arts as a vital part of creativity in counseling,
which mirrors exibility and creativity in the counselor himself and does not require him to be an artist
or to be trained as an expressive therapist. As a matter of fact, art interventions have been used within
numerous psychotherapies such as psychoanalysis, humanistic, transpersonal, object relations,
cognitive-behavioral or Gestalt therapy for over a century. It is recommended however, that those
clinicians, who are not trained in expressive art, look up guidelines, standards of practice and ethical
considerations before integrating the arts. This information can be found on the websites of various art
therapy associations such as www.aata.com for art therapy, www.amta.com for music therapy,
www.nadt.com for drama therapy, www.adta.com for dance therapy or www.apt.com for play
therapy.
As for group therapy integrating EMDR and the arts, the protocol scripts available provide detailed
guidance through every step of the treatment (Jarero et al., 2008; Jarero, Artigas & Hartung, 2006).
Moreover, trainings teaching the use of the arts within EMDR are organized regularly for therapists
interested in expanding their toolbox.
14

Conclusion
Neurobiological research has in the last two decades
increasingly corroborated what many clinicians and
researchers have long hypothesized: trauma is at the source
of a high percentage of mental and physical disorders. There
is a general consensus within the trauma research and mental
health care community that trauma treatment should be
phase-oriented, titrated and multimodal. EMDR has been
recognized as one of two most e cient, evidence based
trauma treatments of trauma and is recommended by
numerous national and international public health
authorities.
This paper introduced the complex nature of trauma related
disorders as the main argument for supplementing EMDR
with the creative arts. It argued that because of low a ect
tolerance, alexithymia and dissociation, EMDR trauma
processing was often thwarted and required means capable
of soothing the clients and help them externalize what
words are unable to express. Di erent creative art therapies
and their curative e ect in the treatment of trauma were
presented. Art making was shown to be curative in itself and
to be instrumental in nonverbal expression, in building
inner resources and in kindling creativity. The creative arts
´

ability to facilitate attunement and repair attachment was

underlined as an essential argument for its integration. These
claims were supported with empirical, anecdotal and/or
theoretic arguments.
Very few controlled studies have been carried out to
empirically support the outcome of treatments combining
EMDR and the expressive arts. The ones available, however,
yielded exceptional results. One of its main advantages over
standard EMDR treatment is that it can be applied in
groups which makes it accessible to large numbers and more
diverse groups of trauma su erers such as children,
individuals with dementia, or other populations with
limited local language skills.
More research and an increased awareness of the
existence of this promising new treatment combination
could contribute to making trauma-speci c treatment
available to larger numbers of people su ering from
physical or mental trauma related disorders.
15

References
Adler-Tapia, R., & Settle, C. (2012). Specialty topics on using EMDR with children. Journal
of EMDR Practice and Research, 6, 145–153. https://doi.org/10.1891/1933-
3196.6.3.145
Adúriz, M. E., Bluthgen, C., & Knop er, C. (2009). Helping child ood victims using group
EMDR intervention in Argentina: Treatment outcome and gender di erences.
International Journal of Stress Management, 16, 138-153.
https:// doi.org/10.1037/a0014719
Artigas, L. A., Jarero, I., Mauer, M., Lopez Cano, T., & Alcala, N. (2000, September). EMDR
and traumatic stress after natural disasters: Integrative treatment protocol and the
butter y hug. Poster presented at the 5th EMDR International Association Conference,
Toronto, Canada.
Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal. New
York, NY: W. W. Norton & Company.
Bergmann, U. (2000). Further thoughts on the neurobiology of EMDR: The role of the
cerebellum in accelerated information processing. Traumatology, 6, 175-200.
https://doi.org/10.1177/153476560000600303
Blatner, A. (1991). Theoretical principles underlying creative arts therapies. The Arts in
Psychotherapy, 18, 405-409. https://doi.org/10.1016/0197-4556(91)90052-C
Boisset‐Pioro, M., Esdaile, J., & Fitzcharles, M. (1995). Sexual and physical abuse in women
with bromyalgia syndrome. Arthritis & Rheumatism, 38, 235-241.
https://doi.org/10.1002/art.1780380212
Briere, J., & Scott, C. (2014). Principles of trauma therapy: A guide to symptoms, evaluation,
and treatment (2nd ed.). Los Angeles, CA: SAGE Publications.
Briere, J., & Spinazzola, J. (2005). Phenomenology and psychological assessment of complex
posttraumatic states. Journal of Traumatic Stress, 18, 401–412.
https://doi.org/10.1002/jts.20048
Campbell, J. (1999). Art therapy, race and culture. London, UK: Jessica Kingsley.
Carson, D. K., & Becker, K. W. (2004). When lightning strikes: Reexamining creativity in
psychotherapy. Journal of Counseling & Development, 82, 111-115.
https://doi.org/10.1002/j.1556-6678.2004.tb00292.x
Courtois, C. A., Ford, J. D., & Cloitre, M. (2009). Best practices in psychotherapy for adults.
In C. A. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders
(pp. 82–103). New York, NY: Guilford Press.
Damasio, A. (2011). Thinking about brain and consciousness. In S. Dehaene & Y. Christen
(Eds.), Research and perspectives in neurosciences. Characterizing consciousness:
From cognition to clinic (pp. 47-54). Berlin, Germany: Springer-Verlag.

Page 72
 https://doi.org/10.1007/978-3-642-18015-6
D’Argenio, A., Mazzi, C., Pecchioli, L., Lorenzo, G. D., Siracusano, A., & Troisi, A. (2009).
Early trauma and adult obesity: Is psychological dysfunction the mediating mechanism? Physiology &
Behavior, 98, 543-546.
https://doi.org/10.1016/j.physbeh.2009.08.010
Davidson, P. R., & Parker, K. C. H. (2001). Eye movement desensitization and reprocessing
(EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69,
305–316. https://doi.org/10.1037/0022-006X.69.2.305
Drossman, D. A. (2011). Abuse, trauma, and GI illness: Is there a link? The American
Journal of Gastroenterology, 106, 14-25. https://doi.org/10.1038/ajg.2010.453
Dunphy, K., Mullane, S., & Jacobsson, M. (2013). The e ectiveness of expressive arts
Therapies: A review of the literature. Melbourne, Australia: PACFA.
Eaton, L. G. L., Doherty, K. K. L., & Widrick, R. R. M. (2007). A review of research and
methods used to establish art therapy as an e ective treatment method for traumatized
children. The Arts in Psychotherapy, 34, 256-262.
https://doi.org/10.1016/j.aip.2007.03.001
Farb, N. A. S., Segal, Z. V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z., & Anderson, A.
K. (2007). Attending to the present: Mindfulness meditation reveals distinct neural
modes of self-reference. Social Cognitive and A ective Neuroscience, 2, 313-322.
https://doi.org/10.1093/scan/nsm030
Fleshman, B., & Fryrear, J. (1981). The arts in therapy. Chicago, IL: Nelson-Hall.
Ford, J. D., Courtois, C. A., Steele, K., Van Der Hart, O., & Nijenhuis, E. R. S. (2005).
Treatment of complex posttraumatic self-dysregulation. Journal of Traumatic Stress,
18, 437–447. https://doi.org/10.1002/jts.20051
Ford, J. D., & Kidd, P. (1998). Early childhood trauma and disorders of extreme stress as
predictors of treatment outcome with chronic posttraumatic stress disorder. Journal of
Traumatic Stress, 11, 743–761. https://doi.org/10.1023/A:1024497400891
Forgash, C., & Knipe, J. (2012). Integrating EMDR and ego state treatment for clients with
trauma disorder. Journal of EMDR Practice and Research, 6, 120-128.
https://doi.org/10.1891/1933-3196.6.3.120
Forinash, M. (2005). Music therapy. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 46-
67). New York, NY: Guilford Press.
Fox, J. (1997). Poetic medicine: The healing art of poem-making. New York, NY:
TarcherPerigree.
Fraser, G. A. (1993). Special treatment techniques to access the inner personality system of
multiple personality disorder patients. Dissociation: Progress in the Dissociative
 Disorders, 6(2-3), 193–198.
Friedman, M. J. (2013). Finalizing PTSD in DSM-5: Getting there from here and where to go
next. Journal of Traumatic Stress, 26, 548-556. https://doi.org/10.1002/jts.21840
Gelo, O. C. G., & Manzo, S. (2015). Quantitative approaches to treatment process, change
process, and process-outcome research. O. Gelo, A. Pritz, & B. Rieken (Eds.),
Psychotherapy Research (pp. 247-277). https://doi.org/10.1007/978-3-7091-1382-0_13
Gladding, S. T. (1992). Counseling as an art: The creative arts in counseling. Alexandria,
VA: American Counseling Association.
Gladding, S. T. (2011). Groups: A counseling specialty (6th ed.). New York, NY: Pearson.
Gomez, A. (2012). EMDR therapy and adjunct approaches with children: Complex trauma,
attachment, and dissociation. New York, NY: Springer.
Grocke, D. E. (1999). A phenomenological study of pivotal moments in guided imagery and
music therapy. Melbourne, Australia: Faculty of Music, University of Melbourne.
Gross, J., & Hayne, H. (1999). Drawing facilitates children’s verbal reports after long delays.
Journal of Experimental Psychology: Applied, 5, 265-283.
https://doi.org/10.1037//1076-898X.5.3.265
Hill, A. (1945). Art versus illness: A story of art therapy. London, UK: Allen & Unwin.
Horne-Thompson, A., & Grocke, D. (2008). The e ect of music therapy on anxiety in
patients who are terminally ill. Journal of Palliative Medicine, 11, 582-590.
https://doi.org/10.1089/jpm.2007.0193
Huss, E., & Sarid, O. (2013). Using imagery to address physical and psychological trauma. In
C. A. Malchiodi (Ed.), Art therapy and health care (pp. 136-145). New York, NY:
Guilford Press.
Janet, P. (1889). L’automatisme psychologique: Essai de psychologie expérimentale sur les
formes inférieures de l'activité humaine. Paris, France: Félix Alcan.
Jarero, I., & Artigas, L. (2009). EMDR integrative group treatment protocol. Journal of
EMDR Practice and Research, 3, 287-288.
Jarero, I., & Artigas, L. (2010). The EMDR integrative group treatment protocol: Application
with adults during ongoing geopolitical crisis. Journal of EMDR Practice and
Research, 4, 148–155. https://doi.org/10.1891/1933-3196.4.4.148
Jarero, I., Artigas, L., & Hartung, J. (2006). EMDR integrative group treatment protocol: A
postdisaster trauma intervention for children and adults. Traumatology, 12, 121-129.
https://doi.org/10.1177/1534765606294561
Jarero, I., Artigas, L., & Luber, M. (2011). The EMDR protocol for recent critical incidents:
Application in a disaster mental health continuum of care context. Journal of EMDR
Practice and Research, 5, 82-94. https://doi.org/10.1891/1933-3196.5.3.82
Jarero, I., Artigas, L., Montero, M., & Lena, L. (2008). The EMDR integrative group
treatment protocol: Application with child victims of a mass disaster. Journal of
EMDR Practice and Research, 2, 97-105. https://doi.org/10.1891/1933-3196.2.2.97
Johnson, D. R. (1987). The role of the creative arts therapies in the diagnosis and treatment of
psychological trauma. The Arts in Psychotherapy, 14, 7-13.
https://doi.org/10.1016/0197-4556(87)90030-X
Johnson, D. R., & Quinlan, D. M. (1985). Representational boundaries in role portrayals
among paranoid and nonparanoid schizophrenic patients. Journal of Abnormal
Psychology, 94, 498-506. https://doi.org/10.1037/0021-843X.94.4.498
Jones, P. (2005). The arts therapies: A revolution in healthcare. New York, NY: Routledge.
Karatas, Z., & Gökcakan, Z. (2009a). A comparative investigation of the e ects of cognitive-
behavioral group practices and psychodrama on adolescent aggression. Educational
Science: Theory and Practice, 9, 1441-142.
Karatas, Z., & Gökcakan, Z. (2009b). The e ect of group-based psychodrama therapy on
decreasing the level of aggression in adolescents. Turkish Journal of Psychiatry, 20,
357-366.
Kempke, S., Luyten, P., Claes, S., Van Wambeke, P., Bekaert, P., Goossens, L., & Van
Houdenhove, B. (2013). The prevalence and impact of early childhood trauma in
chronic fatigue syndrome. Journal of Psychiatric Disorders, 47, 664-669.
https://doi.org/10.1016/j.jpsychires.2013.01.021
Knill, P. J. (1994). Multiplicity as a tradition: Theories for interdisciplinary arts therapies –
An overview. The Arts in Psychotherapy, 21, 319-328.
http://dx.doi.org/10.1016/0197-4556(94)90059-0
Knill, P. J., Barba, H. N., & Knill, M. N. F. (1995). Minstrels of soul: Intermodal expressive
therapy. Toronto, Canada: Palmerston Press.
Knill, P. J., Levine, E. G., & Levine, S. K. (2005). Principles and practice of expressive arts
therapy: Toward a therapeutic aesthetics. London, UK: Jessica Kingsley.
Knipe, J. (2014). EMDR toolbox: Theory and treatment of complex PTSD and dissociation.
New York, NY: Springer.
Korn, D. L. (2009). EMDR and the treatment of complex PTSD: A review. Journal of
EMDR Practice and Research, 3, 264-278.
https://doi.org/10.1891/1933-3196.3.4.264
Lackner, J. M., Gudleski, G., & Blanchard, E. (2004). Beyond abuse: The association among
parenting style, abdominal pain, and somatization in IBS patients. Behaviour
Research and Therapy, 42, 41-56. https://doi.org/10.1016/S0005-7967(03)00069-X
Lahad, M., Farhi, M., Leykin, D., & Kaplansky, N. (2010). Preliminary study of a new
 integrative approach in treating post-traumatic stress disorder: SEE FAR CBT. The
Arts in Psychotherapy, 37, 391–399. https://doi.org/10.1016/j.aip.2010.07.003
Landy, R., Luck, B., Conner, E., & McMullian. (2003). Role pro les: A drama therapy
assessment instrument. The Arts in Psychotherapy, 30, 151-161.
https://doi.org/10.1016/S0197-4556(03)00048-0
Ledger, A. J., & Baker, F. A. (2007). An investigation of long-term e ects of group music
therapy on agitation levels of people with Alzheimer’s disease. Aging and Mental
Health, 11, 330-338. https://doi.org/10.1080/13607860600963406
Leeds, A. M. (2009a). A guide to the standard EMDR protocols for clinicians, supervisors,
and consultants. New York, NY: Springer.
Leeds, A. M. (2009b). Resources in EMDR and other trauma-focused psychotherapy: A
review. Journal of EMDR Practice and Research, 3, 152-160.
https://doi.org/10.1891/1933-3196.3.3.152
Levine, E. G., & Levine, S. K. (1998). Foundations of expressive arts therapy: Theoretical
and clinical perspectives. London, UK: Jessica Kingsley.
Levine, P. (2010). In an unspoken voice: How the body releases trauma and restores
goodness. Berkeley, CA: North Atlantic Books.
Levy, G. (2005). 112 acting games: A comprehensive workbook of theatre games for
developing acting skills. Englewood, CO: Meriwether.
Lovett, J. (1999). Small wonders: Healing childhood trauma with EMDR. New York, NY:
Free Press.
Malchiodi, C. A. (2001). Using drawing as intervention with traumatized children. Trauma
and Loss: Research and Interventions, 1(1). Retrieved from
http://assets1.simpleclickcms.com/500051/tlcv1n1.pdf
Malchiodi, C. A. (2005). Art therapy. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 16-
45). New York, NY: Guilford Press.
Malchiodi, C. A. (2012). Art therapy with combat veterans and military personnel. In C. A.
Malchiodi (Ed.), Handbook of art therapy (2nd ed.). New York, NY: Guilford Press.
McArdle, P., Young, R., Quibell, T., Mosley, D., Johnson, R., & LeCouteur, A. (2011). Early
intervention for at risk children: 3 year follow-up. European Child & Adolescent Psychiatry, 20, 111-
120. https://doi.org/10.1007/s00787-010-0148-y
McNi , S. (1992). Art as medicine. Boston, MA: Shambhala.
Moreno, J. (1946). Psychodrama. Beacon, NY: Beacon House.
Naumberg, M. (1973). An introduction to art therapy: Studies of the “free” art expression of
behavior problem children and adolescents as a means of diagnosis and therapy.
New York, NY: Teachers College Press.
Niedenthal, P. (2007). Embodying emotion. Science, 316, 1002-1005.
https://doi.org/10.1126/science.1136930
Nijenhuis, E. R. S. (2004). Somatoform dissociation: Phenomena, measurement, and
theoretical issues. New York, NY: W. W. Norton & Company.
Novotney, A. (2013, November). Music as medicine. Monitor on Psychology, 44(10), 46.
Packard, S. (1980). The history of art therapy education. Art Education, 33(4), 10-13.
https://doi.org/10.1080/00043125.1980.11651992
Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions,
attachment, communication, self-regulation. New York, NY: W. W. Norton &
Company.
Pynoos, R. S., & Eth, S. (1985). Children traumatized by witnessing acts of personal
violence: Homicide, rape, or suicide behavior. In S. Eth & R. S. Pynoos (Eds.), Post-
traumatic stress disorder in children (pp. 17-43). Washington, DC: American
Psychiatric Press.
Riley, S. (2001). Art therapy with adolescents. Western Journal of Medicine, 175, 54-57.
Ritter, M., & Low, K. K. G. (1996). E ects of dance/movement therapy: A meta-analysis. The Arts in
Psychotherapy, 23, 249-260. https://doi.org/10.1016/0197-4556(96)00027-5
Rothschild, B. (2000). The body remembers: The psychophysiology of trauma and
trauma treatment. New York, NY: W. W. Norton & Company.
Sandel, S. L. (1975). Integrating dance therapy into treatment. Hospital Community
Psychiatry, 26, 439-441.
Sarid, O., & Huss, E. (2010). Trauma and acute stress disorder: A comparison between
cognitive behavioral intervention and art therapy. The Arts in Psychotherapy, 37, 8-
12. https://doi.org/10.1016/j.aip.2009.11.004
Scaer, R. (2014). The body bears the burden: Trauma, dissociation, and disease (3rd ed.).
New York, NY. Routledge.
Schmidt, S. J. (1999). Resource-focused EMDR: Integration of ego state therapy, alternating
bilateral stimulation, and art therapy. Retrieved
https://www.dnmsinstitute.com/doc/rf-emdr.pdf
Schore, A. N. (1994). A ect regulation and the origin of the self: The neurobiology of
emotional development. Hillsdale, NJ: Lawrence Erlbaum.
Schubert, S., & Lee, C. W. (2009). Adult PTSD and its treatment with EMDR: A review of
controversies, evidence, and theoretical knowledge. Journal of EMDR Practice and
Research, 3, 117-132. https://doi.org/10.1891/1933-3196.3.3.117
Schwartz, R. C. (1995). Internal family systems therapy. New York, NY:
Guilford Press.
Shapiro, F. (2001). Trauma and adaptive information-processing: EMDR’s dynamic and
behavioral interface. In M. F. Solomon, R. J. Neborsky, L. McCullough, M. Alpert, F.
Shapiro, & D. Malan (Eds.), Short-term therapy for long-term change (pp. 112-129).
New York, NY: W. W. Norton & Company.
Siegel, D. J. (2012). The developing mind: How relationships and the brain interact to shape
who we are (2nd ed.). New York, NY: Guilford Press.
Sommers-Flanagan, J. (2007). The development and evolution of person-centered expressive
art therapy: A conversation with Natalie Rogers. Journal of Counseling &
Development, 85, 120-125. https://doi.org/10.1002/j.1556-6678.2007.tb00454.x
Spring, D. (2001). Image and mirage: Art therapy with dissociative clients. Spring eld, IL:
Charles C. Thomas.
Steele, W., & Raider, M. (2001). Structured sensory intervention for traumatized children,
adolescents, and parents: Strategies to alleviate trauma. Lewiston, NY. Edwin
Mellen Press.
Steele, K., van der Hart, O., & Nijenhuis, E. R. (2005). Phase-oriented treatment of structural
dissociation in complex traumatization: Overcoming trauma-related phobias. Journal
of Trauma Dissociation, 6(3), 11-53. https://doi.org/10.1300/J229v06n03_02
Talwar, S. (2007). Accessing traumatic memory through art making: An art therapy trauma
protocol (ATTP). Arts in Psychotherapy, 34, 22–35.
https://doi.org/10.1016/j.aip.2006.09.001
Taylor, G., & Bagby, R. (2004). New trends in alexithymia research. Psychotherapy and
Psychosomatics, 73, 68-77. https://doi.org/10.1159/000075537
Tripp, T. (2007). A short term therapy approach to processing trauma: Art therapy and
bilateral stimulation. Art Therapy, 24, 178-183.
http://doi.org/10.1080/07421656.2007.10129476
Tuber, S., Boesch, K., Gorking, J., & Terry, M. (2014). Chronic early trauma as a childhood
syndrome and its relationship to play. In C. A. Malchiodi & D. A. Crenshaw (Eds.),
Creative arts and play therapy for attachment problems (pp. 215-226). New York,
NY: Guilford Press.
van der Hart, O., Nijenhuis, E. R. S., & Solomon, R. (2010). Dissociation of the personality
in complex trauma-related disorders and EMDR: Theoretical considerations. Journal
of EMDR Practice and Research, 4, 76-92.
https://doi.org/10.1891/1933-3196.4.2.76
van der Hart, O., Nijenhuis, E. R. S., Steele, K. (2006). The haunted self: Structural
dissociation and the treatment of chronic traumatization. New York, NY: W. W.
Norton & Company.
van der Kolk, B. A. (1996). The complexity of adaptation to trauma: Self-regulation, stimulus
discrimination, and characterological development. In B. A. van der Kolk, A. C.
McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The e ects of overwhelming
experience on mind, body, and society (182-213). New York, NY: Guilford Press.
van der Kolk, B. A. (2000). Trauma, neuroscience, and the etiology of hysteria: an
exploration of the relevance of Breuer and Freud’s 1893 article in light of modern
science. The Journal of the American Academy of Psychoanalysis, 28, 237–262.
https://doi.org/10.1521/jaap.1.2000.28.2.237
van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for
children with complex trauma. Psychiatric Annals, 35, 401-408.
https://doi.org/10.3928/00485713-20050501-06
van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in healing of
trauma. London, UK: Penguin Books.
van der Kolk, B. A., & Fisler, R. E. (1994). Childhood abuse and neglect and loss regulation.
Bulletin of the Menninger Clinic, 58, 145-168.
van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinnazola, J. (2005). Disorders of
extreme stress: The empirical foundation of a complex adaptation to trauma. Journal
of Traumatic Stress, 18, 389-399. https://doi.org/10.1002/jts.20047
Wadeson, H. (2002). The anti-assessment devil’s advocate. Art Therapy, 19, 168-170.
https://doi.org/10.1080/07421656.2002.10129684
Watkins, H. H. (1993). Ego-state therapy: An overview. American Journal of Clinical
Hypnosis, 35, 232-240. https://doi.org/10.1080/00029157.1993.10403014
Zaghrout-Hodali, M., Alissa, F., & Dodgson, P. W. (2008). Building resilience and
dismantling fear: EMDR group protocol with children in an area of ongoing trauma.
Journal of EMDR Practice and Research, 2, 106-113.
http://psycnet.apa.org/doi/10.1891/1933-3196.2.2.106
Zlotnik, C. (1999). Antisocial personality disorder, a ect dysregulation and childhood abuse
among incarcerated women. Journal of Personality Disorders, 13, 90-95.
https://doi.org/10.1521/pedi.1999.13.1.90
About the author

Rosa Richter M.A. is a licensed psychotherapist in

private practice in Reykjavik. She conducts
workshops and retreats and presents on material
related to topics covered in this book.