Expressive arts therapy

Expressive arts therapy can assist clients who struggle to express themselves verbally, especially if they have limited insight or experience with identifying and speaking about their thoughts and feelings. The use of expressive arts therapy allows individuals to find ways to process the inner turmoil they experience.

Expressive arts therapy also allows individuals to use whatever medium they are most comfortable with in order to work through mental health struggles.

Background of Expressive Arts Therapy

The expressive arts have been used for recreation with therapeutic benefit and as a form of human expression for much of recorded history. Dating back to prehistoric times, there is evidence of the use of art as communication.

Art, drama, and dance have been recognized as a form of communication, and because of this, therapists began to see that creative expression could be used as a way for individuals to gain better insight into topics that may be too difficult to discuss verbally.

Hospitals allowed patients to utilize drama and art recreationally, and professionals began to recognize that this method was effective therapeutically for some patients. In the mid-1900’s more therapists began to study the individual modalities, used in expressive arts and it gained more recognition as beneficial for clients.

Expressive arts therapy as a modality is relatively new in its official formation. This therapeutic modality is recognized as beginning around 1970 at the Leslie College Graduate School in Cambridge, Mass. Paolo Knill founded the International Network of Expressive Arts Therapy Training Centers and, then in 1984, began the ISIS European Training Institutes. Since that time, expressive arts therapies have grown in variety and acceptance as therapeutic techniques. In 1994, the International Expressive Arts Therapy Association (IEATA) was founded. The IETA is a professional organization whose mission is to “encourage the creative spirit.”

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Examples and techniques used in expressive arts

Expressive arts therapy encompasses a wide variety of art forms. In fact, all art therapy, drama therapy, and dance therapy would be considered as part of the overall umbrella of expressive art therapy as well as any other form of creative expression.

Techniques may include:

Playing or listening to music
Writing lyrics or compositions.
Improvisation or other forms of drama
Reading or writing poetry or journaling
Drawing
Painting or fingerpainting
Sculpting
Dancing

In a session, the therapist may describe what the project is, but will not suggest a specific topic or the colors to be used. They may provide general instructions such as “paint something important to you” or “act out a memory.” The therapist observes the content being produced and the behavior of the person in therapy.

Once the project is completed, the therapist may ask the client to tell a story about the painting or ask about emotions evoked when re-enacting the memory. The therapist may have the client describe general feelings while creating their project or play music designed to draw out an emotional reaction as the client creates. The specifics will be unique to each client and their story, there is no limit on the options available. It is up to each therapist and their client how to use the expressive arts in therapy.

What is the setting for expressive art therapy?

Typically this modality of therapy will be practiced inside a traditional office. The office may need to be a larger office to allow for effective use of materials and if drama is used often then a stage may be helpful for the process (but isn’t necessarily required).

However, the setting can really be up to the client and therapist. Mediums like chalk art may be done outside as long as privacy is maintained and the client is comfortable. The expressive arts are very much about outside-the-box thinking as long as the client is comfortable with the setting and the therapist can maintain privacy, the setting is flexible. Sometimes an outside setting can assist with comfort level and openness. Creative arts have been successfully adapted for teletherapy for rural vets as one example.

Effectiveness of expressive arts therapy

As expressive art therapies have grown in use, studies have been undertaken to establish the effectiveness of expressive art therapies.

Studies have shown the most efficacy with anxiety and mood disorders as well as with younger patients. However, studies involving a variety of disorders, genders, and ages have shown expressive therapies to be helpful in client’s progress when used in adjunct to traditional talk therapy models.

Studies have found limited benefit for expressive therapies in symptom reduction related to schizophrenia and similar disorders, however, even without symptom reduction mood improvement was shown.

Downsides of expressive arts therapy

While individuals do not need high levels of creative talent or ability to benefit from expressive art therapy, this belief often holds people back.

Individuals may be self-conscious about their skills or be so focused on perceived criticism that they are unable to focus on the therapeutic process. In these instances, it is important first to focus on developing a strong rapport and processing through this self-doubt and fear prior to undertaking any actual expressive projects in therapy.

If continued reluctance exists, then it is important for that client to be able to choose other modalities in therapy and if the therapist doesn’t offer other modalities, then a referral may be needed.

Billing for Expressive Art Therapy

Expressive therapy doesn’t currently have a specific CPT code for use. However, because any expressive therapy projects could be considered similar to other ‘tools’ that therapists use, like games, then most therapists bill under regular coding 90837/34/32.

Code 90899 for Other Psychiatric Services or Procedures to report psychiatric services or procedures that do not have a specific code is also available for therapists to use. In the notes, therapists should indicate information referring to specific expressive therapy techniques used as well as the client's response to the treatment and any reasons for the therapy chosen.

Some specific insurance companies have their own billing codes to designate expressive therapies, including art therapy and dance therapy. Always consult information received upon credentialing with specific insurance boards for best billing practices as this is an important part of a clinician’s role.

If used in medical settings such as occupational therapy, G0176 is a valid 2022 HCPCS code for activity therapy, such as music, dance, art, or play therapies that are not recreational in nature but are related to the treatment of a patient’s mental health diagnosis. Sessions must be a minimum of 45 minutes to qualify for this.

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Expressive arts therapy training for the therapist

Psychotherapists, counselors, and teachers with standard qualifications can use different forms of creative arts therapy in their work.

With additional training, mental health professionals can be registered with various institutions as specialists in expressive arts therapy. Typically the minimum requirement is a master’s degree in expressive arts therapy, psychology, fine arts, education, or a related field, and depending on the individual’s educational background, additional supervised clinical work and training may be required.

What’s different about expressive arts therapy

It’s important to recognize that expressive arts therapy isn’t about a specific expressive form like art therapy or drama therapy. Expressive arts therapy focuses on the use of any form of art: music, drawing, painting, finger painting, writing, reading, acting, or anything else the therapist and client can think of in order to help the client express themselves effectively. Art therapy, drama therapy, and dance therapy are all branches of expressive art therapy that focus on a specific form of expression as opposed to utilizing all forms.

Other more specific therapies may focus on a specific style of art form and require the therapist to be proficient in that art form, teaching methods in the process of therapy. Therapists who use expressive arts therapy believe in the power of the arts, in general, to help individuals express themselves.

These therapists may or may not be artists in their own right, or they may also utilize art forms to help them during times of difficulty. Expressive arts therapy has nothing to do with creating amazing works of art to be hung in a gallery. It’s a private form of expression directed by a therapist, which leads to an increased ability to process emotions and memories.

Expressive arts are markedly different from more traditional talk therapy. Modalities such as Cognitive Behavioral Therapy or Dialectical Behavioral Therapy have specified steps and processes as well as didactic aspects. Expressive therapies are less prescribed and focus instead on the therapist and client working together and developing the individual's therapeutic process.

How are mediums chosen?

As anyone who has participated in therapy can attest, therapy is a team process. The therapist and the client work together to choose goals and sometimes methods. While an art therapist or drama therapist may be tied to a specific form of expression due to their area of expertise, a therapist who utilizes expressive arts, in general, is not tied to any method. This lack of specificity allows the client to have freedom of choice in the medium they choose.

Clients who are already comfortable with acting or verbalizing may choose to utilize forms of drama as their medium, and the clinician can then direct them in activities geared toward their specific therapeutic needs. Clients not comfortable with more verbal methods may choose hands-on art, like painting or working with clay, and the therapist would then direct their activities in an appropriate direction.

It’s important to note that this should always occur after an intake and identification of treatment goals. The arts are used as a tool in the process, not a substitute for the process. Often therapists use expressive arts in addition to another modality, such as psychodynamic or client-centered therapy.

Assessment of expressive arts in therapy

It’s important to note that the product itself isn’t ‘judged.’ Expressive arts are about the process of creation and expression. Clients are often concerned about this aspect of expressive therapies and may be hesitant to try them due to this misconception.

Many people are hesitant to express themselves creatively, so it is important to emphasize that the assessment of the product isn’t about what is created, it’s more of the process and the reasons behind what is included. The assessment is all about what the art is saying, not what it looks like.

Expressive arts therapy resources

The International Expressive Arts Therapy Association is a fantastic resource for practitioners and potential clients alike to find information about the process and what is available for training or other resources.

To find educational resources for providing expressive arts therapy IEATA has a dedicated page here.

For more information about expressive art therapy and trauma.

More information including an exercise to try out expressive art therapy.

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