Adverse Childhood Experiences and Expressive Arts TherapyOn being alive and becoming whole (again)

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“The word ‘therapy’ has its roots in the word therapeia, which is the Greek word for ‘healing’- and healing simply means ‘making whole’. Therapy=healing=moving towards wholeness”-Jeff Foster

EXPRESSIVE ARTS THERAPY –MAKES IT VISUALArt is a language of its own. That which is difficult, or impossible to discuss, can become apparent when visualised through an image, a sculpture, or any form, allowing it to speak on its own accord.

Expressive Arts Therapy focuses on the experience in the present moment. A variety of materials can be used, for example pencils, paint, wood, clay, fabrics, and digital paraphernalia. The choices for the material, technique and task are carefully made together with the client according to their needs. Working through images creates the possibility to discover personal qualities and difficulties making them tangible and specific. It offers a way to experience and express feelings and emotions. This creates an opportunity to learn new skills. The client and the therapist explore creative ways to understand and make sense of daily life experiences. From: Dutch institute for Expressive Arts Therapy.

“Art is to console those who are broken by life” Vincent van Gogh- A life in letters

“Expressive Arts Therapy speaks to a world of experiences that are free from words and conceptions, and connects with the bodily and sensory awareness.” (Smeijsters 2003, in response to Smitskamp 1997)

Symptoms of early childhood trauma in expressive arts therapy.
Early childhood and chronic traumatization is classified as a sub-class of posttraumatic stress disorder (PTSD) according to the DSM-5. Adverse childhood events and early childhood and chronic traumatization interfere and hinder fundamental developmental tasks, such as developing a consistent sense of Self. When these tasks are placed under pressure during childhood, this can have life-long consequences. When clients with early childhood trauma are in expressive arts therapy, existential questions can arise as well as conflicting feelings in regard to belonging and being alive.

Destructive forces which have their origins in past violent experiences, clash with the vitality of actually being alive. In the expressive work this existential theme shows itself, for example, in difficulty taking up space and material, the difficulty of coming to (one’s own) form and the struggle of tolerating one’s own visual work. However, it is precisely the life force that is also present; the fact of living and the often-present intention to do so (Van Hemert & Kerkhof, 2012) that is addressed in the field of expressive art therapy. The expressive art therapy room, with all its belongings, can at best, together with the therapist, offer a Safe Holding Space, in which halted developmental tasks are given the freedom and space to unfold and continue to grow and blossom.

The formative and creating character of expressive art therapy is, in itself, already an antidote to the previously manifested violence and abuse, which was directed at destroying, repressing, putting down or being cornered. Experimenting, moving (outwards), claiming space, shaping, creating, playing, all these elements as part of universal basic needs, are being addressed as well as being put in motion by the expressive art therapist, within the safe confinement of the creating conditions that the expressive art therapy room offers in the present moment. Being offered something to have and hold, to give direction, intensity and form to, and having ownership to start, pause or stop an action, within the context of art therapy, allows clients to reclaim their own power.

Here I will discuss my experiences with clients with early childhood and chronic traumatization using several works from clients as well as a case presentation. All images are either my own work, or directly from clients, used with permission.


From a sense of disappearing, to a sense of being”The sensory feedback that accompanies expressive arts,  i.e.  the  sensation  of  scribbling,  of  pencil  on  paper, the temperature and density of clay, the sliding of oil pastel crayon on paper, all confirm on  a  fundamental  level  that  you  as  a  person  exist  and  are  present  in  the  here  and  now.  Furthermore,  sensorimotor work also offers an entrance or port-d‘entrée  for  working  with  early  childhood,  often,  nonverbal traumatic memories.

The tangible, visible, and remaining character of  the  created  works  during  art  therapy  acts  as  palpable  proof  of  the  presence  of  the  client  within  that  space,  at  that  place  and  time  (see  figures  2  and  3).  It  transforms  those  inner  experiences  to  something present, real and less fleeting, as well as more touchable/apprehendable, both physically and emotionally.  Experiences  rendered  as  an  image,  or sculpture, create a central thread, a process which can  be  reflected  up  on,  and  continued  with.  “I  can  see it, it is standing there, we can look at it together, it’s really true, it exists, I exist”. Where alienation of the Self often is part of the inheritance of the early childhood trauma, visual expression offers an opportunity to reclaim feelings, movements, experiences and thoughts. It is a first step towards integration, becoming whole.

Figures 2 and 3: Remnant traces of formative expression. Traces proving that you were here, visible


The  visual  works  produced  by  the  client,  create  an  opportunity to reflect together with the therapist, on  that  which  was  created  as  well  as  the  process  that was involved. In this way a movement is created (adaptation and change), from inside to outside, and back inside  again.  A  movement  that,  as  long  as  the  art  therapeutic process takes, can keep going and form  a  seed/bud  for  a  developmental  movement  which can reach far beyond the therapy room. This process,  however,  is  not  without  its  own  struggle.  Those who have endured suffering and were taught not to be, and to disregard all their intrinsic needs, require time and a sense of safety and trust,  or  perhaps  hope  and  a  sense  of  beckoning  potential before they desire and dare to start with visual  expression.  That  strange  curious  visual  art,  “Because what does it really say, and on top of that I am really bad at it…”. An exercise in co-regulation during a crisis is shown in figure 5 and 6.

As  with  every  form  of  therapy,  a  safe  therapeutic  relationship must first be established, in which any growth-limiting cognitions can be managed, or rather in which those cognitions have a safe space, free  of  judgement.  All  parts  of  the  client  should  experience a sense of being welcome, in that space, at that time together with the therapist. Without a doubt,  conflicts  will  arise  from  time  to  time,  but  what  a  gain  that  a  third  party  will  constantly  be  present  to  absorb  feelings  of  transference  or  for  instance an increased or decreased arousal.

The expressive arts therapeutic triangle offers capacity to see which re-enactment is occurring in the here and now, while the therapeutic relationship, with any luck, can remain free of any (counter)transference-violence. An example is offered in the following case-report.

The  client  can  hopefully  tolerate  the  therapist  as  their companion, after all the threat is the material, the  expressed  art,  created  by  the  client,  not  the therapist. (Grabau, & Visser, 1987) The shared experience offers the client the opportunity to use the  co-regulatory  nerve-system  of  the  therapist,  client and therapist exist side-by-side with a shared  perspective  of  something  that  appears  to  lie outside them.

Figure 5 and 6: Therapist and client R. together on one a single paper (50x65cm). tarting to move, getting in contact with your own acting power. The sensory feedback of scratching and rubbing on paper enhance the contact of the client with the here and

Figure 7. The therapeutic triangle


Today  is  the  first  time  that  Carla1  will  be  working  with clay during expressive art therapy.

It is natural clay, fine fireclay. Carla likes the feel of the  clay  on  her  hands,  she  kneads  and  pushes  the  piece  into  her  hands  enthusiastically.  There  is  play  and fun, an exploratory inner child part is addressed in this first session.

As the session progresses, Carla gets the idea that  the  piece  of  clay  in  her  hands  must  become  ‘something’. A well-defined idea emerges, with requirements for function and aesthetics. The space to play and experiment is now all of a sudden significantly reduced, by these self-imposed requirements. Carla’s arousal increases visibly when she undertakes attempt after attempt to give shape to the emerged idea.

In fact, at this point Carla is already caught in a trap: no matter what she will produce, it will never be good enough. This is the image that Carla  has  internalised  of  herself  with  a  history  of  early  childhood  trauma;  that  she  is  no  good  and  that everything that comes out of her hands is worthless. Every time the sculpture is finished and Carla judges it not quite good enough, she destroys the  piece  and  starts  over.  A  re-enactment  of  not  being  permitted,  or  not  being  able  to  be  a  child  in  the past, is being repeated in the here and now, with tremendous energy and tempo. After attempt four the  therapist  is  able  to  intervene  and  directs  the  client  to  allow  the  current  attempt  to  exist,  as  an  experiment, and to investigate what happens when one  deviates  from  the  beaten,  destructive  path.  The therapist moves the piece a little further away from Carla but still within sight, and she offers Carla a new piece of clay to accommodate the increased arousal.

The  destructive  force  is  directed  to  the  new  piece  of clay and space is opened to allow the (perceived) failure  and  all  that  it  represents  to  remain.  Carla  weeps, not for the failure of the sculpture, but due being  allowed  to  feel  the  grief  of  that  which  was  lost.  The  therapist  stays  close,  acknowledging  the  emotions  released  and  encouraging  Carla  with  a  sense of trust (I can witness it and you can bear it) to give the emotions space. A moment arises in which the pain and sorrow are allowed to exist.

1 Carla is a fictitious name. The case describes part of a session in  the  beginning  phase  of  the  visual  art  therapeutic  process.  After  these  experiences  nothing  is  ‘finished’  or  ‘solved’,  but  a  change has occurred in dealing with one’s own feelings of pain, sadness, failure and worthlessness. An impetus for further investigation and work.

As the previous example shows, the visual medium also  offers  a  very  welcome  safety  net,  in  the  case  of increased or decreased arousal. This space offers  to  work  with  physically  involved  methods  that  ventilate,  regulate,  or  activate  and  can  more  than once act as a lifeline during the session. It offers  the  client,  and  perhaps  even  the  therapist,  a  opportunity  to  co-  and  self-regulate  and,  in  that  way, return to a more comfortable level of arousal, which  allows  continuation  with  the  contact  in  the  here and now in all its forms, contact with the inner experience, contact with the visual work, contact  with  the  therapist,  and  contact  with  the  environment, see figures 8 and 9. In this way, clients can continue working through their emotions.

Figure 9. The involved body

Figure 8: Oil pastel and ink on paper, bilateral, both hands at once. Ventilate, regulate, integrate.

Besides the hard work when conflict arises, the driving force behind expressive arts therapy are the touching moments when a hurdle is overcome and the client can surrender to their own vitality and creative force and create without abandon. To freely and wholeheartedly experiment and create, shape and design. When one dares to take the space to see oneself reflected in the joint domain and when the developmental processes are given free rein, that is the power of expressive arts therapy.
A self-portrait created by client R is shown in figure 10, in this drawing an inner experience is expressed and created on paper.

Figure 10. Oil pastel on paper, by client R. Flooding. My head is filled. Both in movement as well as form, client R has successfully expressed that which she experiences on the inside. The creation process, as well as the final results are representa


“I had to fall apart only to have found myself whole again.”

Figuur 11: Ink and pen on paper, Falling a part, containment, gathering and becoming whole (again). From disintegration to integration.


After some experience has been gained in the fundamental work, space is created to jointly look  at  that  which  has  emerged  and  to  let  it  come  together as a whole. From implicit to more explicit, from unconscious to conscious, from hidden to seen, from loose-fixed to a whole, its own unity and image-story.

In  this  stage  of  the  process,  we  reflect  together  on  what  the  client  experiences  with  the  image,  the  images, and with the creative process that was behind  it.  Which  interpretation  suits  the  client  and  how  can,  will  and  shall  we  continue  to  work  on  it?  Which  themes  manifest  themselves?  How  can  we  make room for the difficult, the ugly, the dark? Learning to tolerate all aspects of oneself and what one’s own nature produces.

Expressive  work  offers  the  possibility  of  creating  a safe distance to the inner experience. By literally bringing  it  from  inside  to  outside  and  then  being  able  to  look  at  it  from  a  distance  (together).  The  image can be removed, put away, destroyed or just cherished and safely protected. The client gains access  to  a  new  ability  to  act,  a  new  expressive  language, with which an experience of grip and self-governance can be achieved. Essential experiences and abilities to let that which was so terrifying in the beginning, come closer and exist.

Figure 12; Neocolor on paper. From inside to outside. From a sense of being overwhelmed, towards some distance and compassion. From resistance to embracing.

Moreover, something special happens when the client can give form to extremely painful and/or destructive forces.  By  creating  from  that  which  was  essentially  destruction,  a  transformation  already  takes  place.  By  offering them a place in the shared external space, they often lose their destructive power and can develop  into  a  creative/creating  one.  This  takes  some  of the sting out of the inner conflict surrounding existence.

Figure 13: Various material on paper from client R. To bring out the unbearable. Ventilate. R. undertakes various brave efforts to externalize those destructive forces which she experiences on the inside. The high contrast of black and red, as well as the

TO  FEEL  IS  TO  HEAL  By  giving  space  to  various  internal tendencies using formative techniques, and  subsequently  enabling  them  to  exist,  space  is  created  for  recognition  and  acceptance  to  all  that  emanates from the client. The therapist is present here as a compassionate companion, acting as such and receiving all expressions of the client, bounding where necessary or putting them in a new perspective.

The  fact  that  it  is  possible  to  work  together  in  the  expressive art therapy room is of great added value. The therapist is an observer, a witness, sometimes even  a  participant  in  what  the  client  experiences,  shapes and experiences. Witnessing the client’s process and being able to look together at the proofs  of  it,  can  have  a  deeply  acknowledging  and  connecting effect.
The client experiences being permitted to be there and,  and  hopefully,  experiences  a  moment  of  right  to exist and connection.

The client is offered a Safe Holding Space in the here and now, in which the possibilities for exploring, experimenting, shaping and seeing oneself reflected are still included: in order to give stagnated developmental processes new space and  to  arrive  at  life  experiences  other  than  those  of early childhood and chronic trauma.

“There  is  something  more  and  different,  also  for  you.”

Grabau, E., & Visser, H. (1987), Creatieve therapie: spelen met mogelijkheden. Van Loghum Slaterus, Deventer.Smeijsters, H. (2003), Handboek Creatieve therapie. Coutinho, BussumVan Hemert, A. M., & Kerkhof, A. J. F. M.. (2012), Multidisciplinair richtlijn diagnostiek en behandeling van suïcidaal gedrag. De Tijdstroom, Utrecht.
Recommended reading
Trauma and Expressive Arts Therapy, Cathy Malchiodi. In Malchiodi, C. (2020), Trauma and Expressive Arts Therapy. Guilford Publications, New York City.

The images used in this ar ticle may not be copied or reproduced without the writ ten permission of the author. Kim Tukker, Registered Expressive Ar ts Therapist, based in the Netherlands. E-mail address: