Art Therapy Directives for Children who’ve Experienced Trauma

These art directives pertain to the specific population of children who have experienced trauma and are thusly dealing with its negative side effects. This is one of the most prominent populations that I have worked with as a clinician and as an educator thus far, and I am very passionate about promoting mental health awareness and healthy lives for children.

Definition of Trauma:

The American Psychological Association states that Trauma is “Any disturbing experience that results in significant fear, helplessness, dissociation, confusion, or other disruptive feelings intense enough to have a long-lasting negative effect on a person’s attitudes, behavior, and other aspects of functioning.

Traumatic events include those caused by human behavior (e.g., rape, war, industrial accidents) as well as by nature (e.g., earthquakes) and often challenge an individual’s view of the world as a just, safe, and predictable place. any serious physical injury, such as a widespread burn or a blow to the head.

Adapted from the APA Dictionary of Psychology

“Trauma- and stressor-related disorders are those disorders precipitated by events or circumstances that overwhelm the child or adolescent and that often threaten or cause serious injury, neglect, or death (American Psychiatric Association [APA], 2015)”.

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes trauma- and stressor-related disorders as a complete category, separate from anxiety disorders. The following diagnoses are included in the trauma- and stressor-related disorder category in the current version of the Diagnostic and Statistical Manual of Mental Disorders:

  • Post-traumatic stress disorder (PTSD)

  • Acute stress disorder (ASD)

  • Adjustment disorders

  • Reactive attachment disorder (RAD) (diagnosed only in children)

  • Disinhibited social engagement disorder (DSED) (diagnosed only in children)

  • Other specified trauma- and stressor-related disorder

  • Unspecified trauma- and stressor-related disorder

  • Anxiety disorders (Generalized Anxiety Disorder)

  • Adjustment disorders

Of these, the stress disorder PTSD and acute stress disorder may be some of the most commonly discussed, as both conditions were recently revised in the DSM-5 to reflect their wide range of symptoms. Specifically, the DSM-5 removed the required feelings of “fear, helplessness, or horror” in reaction to traumatic events. Both acute and longer-term responses to trauma can vary based on individual temperament, culture, age, and other factors and may not always be recognizable as fear, horror, or other visible expressions.

Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association [APA], 2013)


Effects of trauma and stressor-related disorders

Trauma and stressor-related disorders, such as acute stress disorder and post-traumatic stress disorder (PTSD), can have profound effects on an individual's mental health. These disorders often develop following exposure to a traumatic event or stressful event, significantly impacting daily functioning. Acute stress disorder manifests shortly after the trauma, while posttraumatic stress disorder persists for a longer duration. 

Anxiety disorders are common among those experiencing these stressor-related disorders. Additionally, conditions like social engagement disorder can arise, affecting an individual's ability to form and maintain healthy relationships.

Trauma- and stressor-related disorders stem from a traumatic experience(s). However, trauma can be complex, and an event that one person experiences as traumatic may have a lesser impact on someone else. Often, it’s a person’s perception of threat or danger that can lead to trauma. People who are diagnosed with a trauma- and stressor-related disorder may have experienced one or more traumatic and stressful events, including but not limited to the following types of situations: 

  • Physical and emotional violence or abuse

  • Sexual assault or abuse

  • Neglect or family/childhood abuse 

  • Family conflict 

  • A natural disaster

  • Combat or other military experiences

  • Being a first responder to an accident

  • Incarceration

  • Severe or terminal illness

  • Loss

These are all examples of “stressors,” which are any events that increase physical or psychological demands on a person. If the demands are too high, they can lead to one of the disorders mentioned previously. Note that an individual doesn’t have to personally experience a stressor to develop a disorder—acute or otherwise—either. After witnessing a loved one endure a distressing event, for example, they could still develop symptoms related to a trauma disorder. 


C-PTSD and PTSD are the most common reactions to trauma. The more complex and deep the traumatic experience or ACE (Adverse Childhood Experience) often times, the more complex the diagnoses.

Oftentimes people who have experienced trauma will have intrusive thoughts and can experience memories of traumatic experiences that they can still recall like yesterday. This can include experiencing the smells, sensations, and visuals of the traumatic memories, often called a “flashback”. This can span months, years, or someone’s entire life.

Individuals who have experienced trauma often experience a lack of control, as if they are involuntarily reliving their trauma, even when they are aware of the disproportionate nature of their own reactions. A main challenge for those who have experienced trauma is regulating these sensory imprints, and working towards reducing their intensity.

In Talwar’s (2006) journal article titled Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP), it mentions that there are 2 ways that someone can deal with their trauma. One is the adaptive method, in which the individual processes the stressful event in a supportive environment by moving through the normal stages of grief and loss. The other is the non-adaptive method; here the event is pushed behind a wall in order to seek emotional and affective relief from the distress it causes.

Walled off memories from traumatic experiences can retain their power and freshness on an effective level, for weeks, or even years of someone’s life. Trauma can cause heightened physiological arousal, or thusly called hyper vigilance, initiated by a sensory experience related to the traumatic event (Rothschild, 2000; van der Kolk, 1994). This can also trigger or sustain the arousal response (Steel 7 Raider, 2001).

One of the major symptoms characterizing trauma is PTSD, which is “persistent increased arousal” in the autonomic nervous system. This is called “somatic memory” (Rothschild, 2000; van der Kolk, 1994).

References:

American Psychological Association. (n.d.). Trauma. American Psychological Association. https://www.apa.org/topics/trauma

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.

Materials to keep in mind

Considerations on safety

A Guide To Art Therapy Materials, Methods, and Applications - A practical step-by-step approach By Ellen G. Horowitz is a comprehensive manual on how to effectively and safely utilize materials with clients. I heavily recommend the use of this book for in depth guidelines about conducting Art Therapy. Here are some important things to keep in mind when choosing materials for clients.

  • Non-toxic art and craft supplies are readily available, but you should always read the labels before purchasing.

  • Keep in mind the tools and materials you use when working with children or those with physical, developmental, or have allergic reactions to specific chemicals.

  • Safety precautions need to be in place for those who are developmentally unaware or not able to comprehend the dangers/concerns of toxic materials. Making sure to remain focused on the client’s safety during the session is paramount to their therapeutic experience and building rapport. A client could ingest the material or hurt themselves, so making sure that age-appropriate and developmental-level appropriate materials are being utilized during the session.

Basic Guide to Materials Used in Art Therapy

Why Materials Matter

In Art Therapy, materials are not chosen randomly.

Different art materials can influence:

  • Emotional expression

  • Level of control or freedom

  • Sensory engagement

  • Cognitive processing

  • Comfort or challenge level

Some materials are highly structured and controlled, while others are fluid and expressive.

1. Drawing Materials

Examples

  • pencils

  • colored pencils

  • markers

  • charcoal

  • pastels

Characteristics

  • Structured and controlled

  • Easy to use and familiar

  • Low mess and predictable

Therapeutic Uses

  • Emotional check-ins

  • Journaling or sketching

  • Assessment drawings

  • Exploring identity or self-image

ETC Levels Activated

  • perceptual

  • cognitive

  • symbolic

These materials are often good for clients who feel anxious about art because they provide a sense of control.

2. Painting Materials

Examples

  • watercolor

  • tempera paint

  • acrylic paint

  • ink

Characteristics

  • Fluid and expressive

  • Less controlled than drawing

  • Encourages emotional release

Therapeutic Uses

  • Emotional expression

  • Exploring mood through color

  • Loosening perfectionism

  • Processing strong feelings

ETC Levels Activated

  • affective

  • sensory

  • creative

Painting can help clients express feelings that are difficult to verbalize.

3. Clay and Sculpture Materials

Examples

  • clay

  • air-dry clay

  • play dough

  • sculpting materials

  • wire

Characteristics

  • Highly tactile

  • Grounding and sensory

  • Involves the body and movement

Therapeutic Uses

  • Grounding exercises

  • Trauma stabilization

  • Releasing anger or tension

  • Building symbolic forms

ETC Levels Activated

  • kinesthetic

  • sensory

  • affective

These materials are often used in trauma-informed art therapy because they engage the body.

4. Collage Materials

Examples

  • magazines

  • photographs

  • printed images

  • colored paper

  • glue

  • scissors

Characteristics

  • Structured but creative

  • Less pressure to “draw well”

  • Combines imagery and symbolism

Therapeutic Uses

  • Identity exploration

  • Future visioning

  • Narrative therapy

  • Processing complex themes

ETC Levels Activated

  • perceptual

  • cognitive

  • symbolic

Collage can be helpful for clients who feel intimidated by drawing.

5. Mixed Media Materials

Examples

  • combining paint, paper, markers, fabric, or found objects

  • layered art processes

Characteristics

  • flexible and experimental

  • encourages creativity and exploration

  • allows multiple forms of expression

Therapeutic Uses

  • deeper emotional exploration

  • creative problem-solving

  • integrating multiple feelings

ETC Levels Activated

  • creative level (integration of ETC levels)

Mixed media allows clients to move between structure and expression.

6. Natural and Found Materials

Examples

  • leaves

  • stones

  • sticks

  • sand

  • shells

  • recycled objects

Characteristics

  • Sensory and grounding

  • Connected to nature

  • Symbolic meaning

Therapeutic Uses

  • Mindfulness and grounding

  • Environmental or eco-therapy

  • Symbolic storytelling

  • Grief and healing rituals

ETC Levels Activated

  • Sensory

  • Symbolic

  • Creative

Factors Therapists Consider When Choosing Materials

Art therapists often consider:

  • Client age and developmental level

  • Emotional regulation ability

  • Trauma history

  • Comfort with art

  • Therapeutic goals

For example:

  • Structured materials for anxious clients

  • Fluid materials for emotional expression

  • Tactile materials for grounding

| More Controlled | More Expressive |

| --------------- | --------------- |

| pencils | watercolor |

| markers | acrylic paint |

| collage | clay |

| colored pencils | finger paint |

Controlled materials support safety and structure, while expressive materials support emotional release and exploration.

Art Therapy Directives

In this section I offer Art Therapy directives that include DBT Skills, and specific levels of the Expressive Therapies Continuum (ETC).

The ETC is a hierarchical framework that describes different levels of creative expression, ranging from very basic sensory engagement with materials to complex, symbolic, and integrated meaning-making.

  1. It helps therapists understand how clients are using art materials and what cognitive/emotional processes are being activated.

  2. It guides interventions: different materials and tasks can support regulation, processing, or integration depending on client needs.

The levels of the ETC are as follows:

  1. Kinesthetic/Sensory Level (K/S)

    • Kinesthetic: Focus on movement, rhythm, energy release (e.g., scribbling, pounding clay, wide brushstrokes).

    • Sensory: Focus on tactile, visual, or sensory qualities of materials (e.g., finger painting, smudging chalk, exploring textures).

    • Purpose: Helps with grounding, emotional release, and regulation.

  2. Perceptual/Affective Level (P/A)

    • Perceptual: Emphasis on form, structure, and visual-spatial qualities (e.g., outlining, organizing, making realistic drawings).

    • Affective: Focus on emotional expression through color, movement, and intensity (e.g., bold colors, expressive brushwork).

    • Purpose: Supports emotional awareness and externalization, balancing structure with expression.

  3. Cognitive/Symbolic Level (C/S)

    • Cognitive: Logical, planned, problem-solving use of materials (e.g., designing, sequencing, structured drawing).

    • Symbolic: Use of metaphor, story, or imagery to represent deeper meaning (e.g., drawing dreams, symbols, or metaphors).

    • Purpose: Facilitates insight, meaning-making, and narrative construction.

  4. Creative Level (Integration)

    • Represents integration of all levels (kinesthetic, sensory, perceptual, affective, cognitive, symbolic).

    • Involves flow, flexibility, and the ability to move between modes.

    • Purpose: Promotes healing, growth, and a sense of wholeness.

TheWiley Handbook of Art Therapy states : “The expression and use of media and techniques in Art Therapy can be seen as taking place on different levels. These levels represent information processing ranging from spontaneous reaction to expression of thought and feelings through art media. Each level is a continuum between 2 opposite sides, or poles. The extreme pole of each level represents variations found in visual expressions on that particular level. It also reflects the mental and graphical development in progression from simple to more complex levels of information processing.”

it’s also worth mentioning that if a client is working on a specific level of the ETC, they will gravitate towards one side, or one pole, of the level. When a Client gravitates towards one pole of the ETC level, their focus remains high towards that pole, and the experience of the opposite pole is diminished.

By integrating DBT Skills and the ETC within the art directives, I can add efficacy to their designs.

Art Therapy’s effect’s on Treating Trauma

In the Journal Article Assessing traumatic memory through art making: An Art Therapy trauma protocol (ATTP) by Savneet Talwar, It’s stated that in recent years, advances in neurobiology and psychotherapy have informed the practice of Art Therapy, which has increasingly been utilized when verbal psychotherapy has failed to help clients (Talwar, 2006, p.22).

Chapman et al. (2001) published a study with pediatric trauma patients. They reported that although clinical trial did not indicate significant differences in the reduction of PTSD, there was evidence that children receiving art therapy did show reduction in acute stress symptoms. A recent study, however, conducted at Thomas Jefferson University, Philadelphia, provides data on improvement of the quality of life (Monti et al., 2005), and emphasizes the connection between the body-mind and creativity, illustrating the efficacy of art therapy (Talwar, 2006, p.23).

Art Therapy Directive: Jewelry Making

Mindful Beaded Necklace

The first Art Therapy directive offered pertains to the 1st ETC (Expressive Therapies Continuum) level: K/S, which pertains to the Kinesthetic level (with natural movement into Perceptual & Affective levels).

The kinesthetic level represents simple motor expressions with art media and corresponding visual manifestations or energy and sensory involvement.

Jewelry making primarily engages the Kinesthetic–Sensory level of the Expressive Therapies Continuum, supporting grounding and regulation. The activity can be intentionally paired with DBT skills such as mindfulness, distress tolerance, and emotion regulation by emphasizing repetitive movement, sensory awareness, and symbolic meaning-making.

Why jewelry making sits here:

  • Kinesthetic: repetitive hand movements (stringing, wrapping, knotting, clasping)

  • Sensory: tactile engagement with beads, wire, metal, stones, texture, weight, temperature

  • Encourages grounding, rhythm, and regulation

  • Excellent for nervous system settling, especially for trauma, anxiety, and dissociation

This makes jewelry making especially effective for:

  • Clients who are overwhelmed, dissociated, or emotionally flooded

  • Early-session grounding

  • Crisis stabilization

  • Somatic-based regulation

Secondary ETC Levels often emerge naturally as well.

The Perceptual Level involves Patterning beads, Symmetry vs. asymmetry, Color sequencing, Precision and organization.

The Affective Level involves Color choices tied to mood, Symbolic charms or stones, Emotional meaning embedded in the piece, Gift-giving or identity expression

Jewelry making often starts at K–S and moves upward through the ETC as regulation increases, which is ideal to the flow of art creation.

Incorporating DBT Skills into Jewelry Making

Jewelry making is exceptionally DBT-compatible because DBT values hands-on, present, in the moment skills. This reminds me of the BT skill Mindfulness, which was also utilized during the creation of this art piece.

DBT Skill #1: Mindfulness (Wise Mind)

ETC Level: Kinesthetic–Sensory → Perceptual

How to incorporate:

  • Invite the client to notice:

    • The feel of each bead

    • The sound of beads touching

    • The pressure of wire between fingers

  • Cue nonjudgmental awareness:

    “There’s no right or wrong way to do this directive.”

Therapeutic intention:

  • Strengthens present-moment awareness

  • Reduces rumination

  • Supports Wise Mind access

DBT Skill #2: Distress Tolerance (Self-Soothing & Grounding)

ETC Level: Kinesthetic–Sensory

How to incorporate:

  • Offer beads with cool stone, smooth glass, or weighted metal

  • Use repetitive stringing during distress

  • Frame the jewelry as a portable coping object

DBT framing:

  • “This bracelet can become a grounding tool when emotions spike.”

  • Teach TIP-adjacent grounding through temperature and pressure (without formal exposure)

DBT Skill #3: Emotion Regulation

ETC Level: Affective → Cognitive

How to incorporate:

  • Assign colors or stones to emotions:

    • Blue = calm

    • Red = anger

    • Green = balance

  • Invite clients to design a piece for:

    • “A feeling you want more of”

    • “A feeling you’re learning to tolerate”

Skill integration:

  • Naming emotions

  • Increasing positive emotional experiences

  • Building emotional literacy

DBT Skill #4: Interpersonal Effectiveness

ETC Level: Cognitive–Symbolic

How to incorporate:

  • You can create jewelry as:

    • A boundary symbol

    • A reminder of a value (e.g., self-respect)

    • A gift representing a healthy relationship

  • Pair with the DEAR MAN or GIVE DBT skill reflections afterward

Art Therapy Directive:

Sensory Grounding Medallion

The second Art Therapy directive offered pertains to the 1st ETC (Expressive Therapies Continuum) level: K/S, which pertains to the Sensory level.

(DBT Skill: Distress Tolerance – Self-Soothing & Mindfulness)

Clinical Intention

To support nervous system regulation and present-moment grounding through sensory engagement, while teaching a DBT distress tolerance skill that can be generalized outside the session.

This directive engaged the sensory level of the Expressive Therapies Continuum to support grounding and nervous system regulation, while teaching the DBT distress tolerance skill of self-soothing through sensory awareness.”

Theoretical Framework

  • Expressive Therapies Continuum (ETC):Sensory level

  • DBT Skill:Distress Tolerance – Self-Soothing (5 Senses)

  • Population it addresses: Adolescents or adults experiencing emotional dysregulation, anxiety, trauma responses, or acute stress

Materials

  • Air-dry clay or model magic

  • Sand, rice, or textured gel

  • Fabric scraps, foil, textured paper

  • Glue, paint, or pastels

  • Small cardboard base or thick paper

Directive

Instruct the client: “Using the materials in front of you, create a small surface or object that focuses on how it feels, not how it looks. Let your hands explore textures, temperatures, and pressure. There is no right or wrong way to do this. This will be your Sensory Grounding Medallion.”

Mention to the Client: “As you work, notice one sensation at a time. Is it rough, smooth, cool, heavy, or soft. If your mind wanders, that’s okay. Practice Mindfulness by gently bringing your focus back to the sensations that your hands are feeling.”

DBT Skill Integration

Distress Tolerance – Self-Soothing (5 senses) & Mindfulness

  • Sight: noticing color and contrast

  • Touch: texture, temperature, pressure

  • Sound: materials contacting the surface

  • (Optional) Smell: scented clay or oils if appropriate

Mindfulness Prompt:

Ask the client to “name one sensation you are aware of right now.”

Time Frame

15–30 minutes (can be shortened during crisis stabilization to 10 minutes with prepared materials/set up studio space)

Processing & Reflection

One of the goals is to use minimal verbal processing during art creation to maintain sensory focus.

Questions to prompt the client are:

  • “Which texture felt most grounding to you?”

  • “What happened in your body as you worked on the artwork?”

  • “How could you use a similar sensation when you’re distressed outside of session?”

  • “Where can you keep this to easily utilize during times of cognitive overload?”

Why This Directive Works

  • The Sensory input that the client is experiencing bypasses their cognitive overload

  • This Medallions’s Hands-on engagement reduces their dissociative symptoms

  • DBT skill is practiced in tandem with the directive,

  • Product is secondary to regulation and process, maintaining a non-judgmental mindset.

Variations (Optional)

  • For Clients with high agitation: use heavier materials (clay, stones)

  • For Clients with dissociation: emphasize temperature contrast and texture differences

  • For group adaptations: create individual tiles that form a collective mosaic - building community and trust

Art Therapy Directive:

Intuitive Tarot Card

The third Art Therapy directive offered pertains to the 2nd ETC (Expressive Therapies Continuum) level: P/A, which pertains to the Perceptual level.

Creating a intuitive personal tarot card engages perceptual, cognitive, affective, and symbolic levels of the Expressive Therapies Continuum while integrating DBT skills such as mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness through intentional symbolism and meaning-making.

  • Perceptual – composition, borders, symbols, structure of the card

  • Cognitive – meaning-making, intention, archetypal themes, titles

Secondary / Integrated Levels

  • Affective – emotional symbolism, color choice, personal resonance

  • Symbolic – archetypes, metaphors, values, personal narrative

  • Kinesthetic–Sensory – cutting, drawing, gluing, brushing (grounding support)

Tarot creation often begins with perceptual containment and moves upward into symbolic integration, which is ideal for DBT-informed work.

DBT SKill - Mindfulness (Wise Mind)

ETC Level: Kinesthetic–Sensory → Perceptual

How to incorporate

  • Begin with a grounding check-in

    • “Notice your breath as you choose your materials.”

  • Invite the client’s mindful attention to:

    • The texture of paper

    • The weight of the tools

    • The color saturation

Tarot-specific prompt:

“Let your Wise Mind guide the image — not your inner critic.”

DBT Goals:
Present-moment awareness (Mindfulness), reduced judgment, increased self-trust

Distress Tolerance

ETC Level: Kinesthetic–Sensory

How to incorporate:

  • Frame the card as a coping anchor

  • Choose imagery that represents:

    • Safety

    • Survival

    • Endurance

  • Repetitive patterning (borders, backgrounds) during emotional activation

DBT Prompt:

“If this card were with you in a hard moment, what would it help you endure?”

Outcome:
Self-soothing, grounding, crisis-survival symbolism

Emotion Regulation

ETC Level: Affective → Cognitive

How to incorporate:

  • Have the client assign emotional meaning to:

    • Colors

    • Symbols

    • metaphors

    • Gestures or posture of figures

  • Have the client title the card

How is this related to DBT?

  • It Identifies emotions

  • It Increases positive emotional experiences

  • and it builds emotional literacy

Interpersonal Effectiveness

ETC Level: Cognitive–Symbolic

How to incorporate into a client’s session:

  • Create a card that represents:

    • Boundaries & self-respect

  • Have the client Include symbolic elements that are meaningful to them. These could include ideas like: Gates, shields, bridges, hands, etc.,

  • Have the Client title their tarot card based on the clients assertive voice.

DBT Prompt for the client:

“What message does this card give about how you deserve to be treated?”

DBT Goals:
Gives the client clarification of their personal values, creates relational insight, bolsters empowerment

Distress Tolerance (Radical Acceptance & Meaning)

ETC Level: Symbolic → Cognitive

How to incorporate in a session:

  • Invite imagery that holds both:

    • Pain and strength

    • Reality and hope

  • Encourage acceptance without erasure the erasure of either experience.

Prompt:

“What truth can this card hold without trying to fix anything in it? What if we believed we were not broken?”

Integration & Reflection (Closing out the session)

Processing questions:

  • “Which DBT skill shows up most strongly in your card?”

  • “Where might you keep this card when you need it?”

  • “What does this card remind you to do when emotions rise?”

Encourage clients to:

  • Photograph the card

  • Journal about the card

  • Carry a copy

  • Use it as a visual Wise Mind cue

  • Get it laminated

Art Therapy Directive:

Coloring the Wave

The fourth Art Therapy directive offered pertains to the 2nd ETC (Expressive Therapies Continuum) level: P/A, which pertains to the Affective level.

This directive engaged the Affective level of the Expressive Therapies Continuum, supporting emotional expression and tolerance, while practicing the DBT emotion regulation skill of identifying and allowing emotions without judgment.”

(DBT Skill: Emotion Regulation – Identifying & Allowing Emotions)

Clinical Intention

To support emotional awareness, expression, and tolerance by engaging the ETC Affective level, while practicing the DBT emotion regulation skills of identifying, naming, and allowing emotions without judgment.

Theoretical Framework

  • Expressive Therapies Continuum (ETC):Affective level

  • DBT Skill:Emotion Regulation – Identifying & Allowing Emotions

  • Population: Clients experiencing emotional suppression, overwhelm, trauma-related affect, or difficulty naming emotions

Materials

  • Watercolors, tempera paint, or oil pastels

  • Large paper (encourages emotional movement)

  • Brushes, sponges, fingers (choice supports affective freedom)

  • Paper towels, water cups

Directive

Supply the client with a large piece of paper.

Before you allow the Client to begin on their artwork, Ask the client to “Think about an emotion that feels present for you right now — not one you should feel, just one that is.”

Now ask the client to “Choose colors, shapes, and movements that express this emotion. Focus less on making an image and more on letting the feeling move through the materials.”

“There is no need to explain or change the emotion. Your job is simply to let it exist on the page.”

Have the Client utilize various brushes, sponges, and even fingers allows for creative choice making and affective freedom.

Keep in mind the amount of colors you want to keep out for the client, what their developmental age is, and what materials are best suited for their cognitive & developmental levels, as well as keeping multicultural competencies in mind.

Emotion Regulation: Identifying & Allowing Emotions

  • Have the client Name the emotion internally or aloud

  • Have the client practice expressing their emotions without suppressing or escalating them

  • Practice a nonjudgmental mindset and radical acceptance

DBT Prompts for clients

“What does ___ feel like right now?”

Time Frame

20–35 minutes (Can be adjusted shorter for emotionally fragile clients to 15 minutes)

Processing & Reflection

Keep reflection affect-centered, not interpretive:

  • “What emotion showed up the strongest for you?”

  • “How did it feel to let this emotion exist without trying to fix it?”

  • “Did the emotion change, intensify, or soften as you worked through your art creation?”

  • “Where do you notice this feeling in your body now?”

Why This Directive Works

  • Affective (emotional) expression reduces emotional avoidance

  • Art externalizes emotion safely into a container

  • Emotion regulation is embodied within the directive, not only the ETC level

  • This also supports clients who intellectualize or suppress feelings

Variations/Considerations

  • For a client dealing with emotional flooding: limit their color palette to 2–3 colors, good for neurodivergent/hypersensitive kids

  • For clients dealing with emotional numbness: have them use bold colors and large movements, have them focus on the experience

  • For trauma-informed pacing: allow the client to stop at any time without explanation.

  • When working with groups: Have them process themes collectively without the pressure of personal disclosure.

Art Therapy Directive:

Mapping the Choice Point

(DBT Skill: Emotion Regulation – Check the Facts & Wise Mind Decision-Making)

Clinical Intention

To strengthen cognitive organization, reflection, and problem-solving by engaging the ETC Cognitive level, while practicing the DBT emotion regulation skills of Check the Facts and Wise Mind choice-making.

This directive engaged the Cognitive level of the Expressive Therapies Continuum, supporting organization, reflection, and decision-making, while practicing the DBT emotion regulation skills of Check the Facts and Wise Mind integration.

Theoretical Framework

  • Expressive Therapies Continuum (ETC): Cognitive level

  • DBT Skill: Emotion Regulation – Check the Facts + Wise Mind

  • Population: Adolescents or adults who experience emotional reactivity, impulsive behavior, black-and-white thinking, or difficulty evaluating situations accurately

Materials

  • Paper (portrait or landscape)

  • Pencil, fine markers, rulers (structure supports cognitive processing)

  • Optional: pre-cut shapes, sticky notes, labels

Directive

Ask the client to “Think about a recent situation that brought up a strong emotion or reaction.”

Then ask the client, “On your paper, create a visual map of the situation. You might include sections such as: What happened, What I assumed or interpreted, What I felt, The facts I know for sure, and Possible responses”

Have the Client Focus on clarity, organization, and sequencing rather than artistic style.

DBT Skill Integration

Check the Facts

  • While the client is doing the directive, have them Separate

    • Observable facts

    • Thoughts or interpretations

    • Emotional reactions

  • Have the Clients utilize Use labels, arrows, boxes, or timelines to show these differences.

DBT Prompt for client:

Ask the client, “Which parts of this page are facts, and which are interpretations?”

Wise Mind

  • Add a section titled ‘Wise Mind Choice’

  • Have the client visually represent these items:

    • Emotional mind input

    • Rational mind input

    • Integrated response

Prompt:

“What action feels both effective and aligned with your values?”

Time Frame

25–40 minutes (Allow flexibility for processing speed and cognitive load)

Processing & Reflection

Keep processing grounded within cognition and effectiveness:

  • “What became clearer when you put this on paper?”

  • “Did any assumptions shift when you checked the facts?”

  • “How does your Wise Mind response differ from your first impulse?”

  • “How might you use this process next time?”

Why This Directive Works

  • It helps the client externalizes their thought patterns for examination

  • It slows impulsive reactions

  • It helps Strengthen executive functioning

  • It makes abstract DBT skills concrete and visual for the client to comprehend.

Variations

  • For clients who over-intellectualize: limit the sections to reduce rumination

  • For clients with ADHD or overwhelm: use pre-drawn templates

  • For groups: use neutral scenarios instead of personal ones

  • For trauma-informed pacing: allow opting out of specific details, they don’t have to share everything.

Art Therapy Directive:

The Wise Mind Guardian

(DBT Skill: Mindfulness – Wise Mind & Distress Tolerance – Meaning-Making)

Clinical Intention

To support integration, meaning-making, and internal guidance by engaging the ETC Symbolic level, while practicing the DBT skill of Wise Mind and distress tolerance through meaning and values.

This directive engaged the Symbolic level of the Expressive Therapies Continuum, supporting integration and meaning-making, while practicing the DBT mindfulness skill of Wise Mind and distress tolerance through symbolic representation.

Theoretical Framework

  • Expressive Therapies Continuum (ETC): Symbolic level

  • DBT Skill: Mindfulness – Wise Mind (with Distress Tolerance through meaning)

  • Population: Adolescents or adults navigating trauma recovery, identity development, values clarification, or emotional dysregulation

Materials

  • Mixed media (markers, watercolor, collage images, metallic pens)

  • Thick paper or cardstock (adds containment)

  • Optional: symbolic imagery (animals, mythic figures, nature, objects)

Directive

As the client to “Create an image of a symbolic figure, object, or presence that represents your Wise Mind — the part of you that can hold emotion and logic at the same time.”

Remind the client that “This does not need to be realistic. Let metaphor, fantasy, or archetype guide you. Focus on what it stands for, not how it looks.”

Finally, mention to the client that “As you work, imagine this symbol existing with you during difficult moments.”

Wise Mind (Mindfulness)

  • Emotional Mind → represented symbolically (color, shadow, movement)

  • Rational Mind → represented symbolically (structure, tools, light, geometry)

  • Wise Mind → the integrated symbol that holds both

DBT Prompt:

“If this image could speak during a hard moment, what would it say?”

Distress Tolerance (Meaning & Values)

  • Invite symbols that reflect:

    • Survival

    • Endurance

    • Protection

    • Inner wisdom

  • Emphasize holding pain without erasing it

Prompt:

“What truth does this symbol help you tolerate?”

Time Frame

30–45 minutes
(Shorten for emotionally vulnerable clients)

Processing & Reflection

This directive is symbol-focused, not interpretive or diagnostic. Ask reflective questions such as

  • “What does this symbol represent for you?”

  • “How does it relate to Wise Mind?”

  • “When might you need to remember this image?”

  • “What emotions and thoughts can this symbol hold together?”

Encourage photographing or carrying a copy of the image as a visual DBT cue.

Why This Directive Works

  • Symbolism allows safe psychological distance from intense emotions.

  • Symbol archetypes bypass defensiveness and shame

  • Visual metaphors strengthen the recall of DBT skills

  • This directive supports identity, values, and trauma integration

Variations/Adaptations

  • For groups: invite shared archetypes (guardian, bridge, compass)

  • For trauma-informed pacing: allow abstract symbols instead of figures

  • For values work: title the image after a core value

  • For crisis use: create a simplified “symbol card” to carry

Art Therapy Directive:

Creating a New Way Through

(DBT Skill: Emotion Regulation – Building Positive Experiences & Opposite Action Through Creativity)

Clinical Intention

To support psychological flexibility, hope, and adaptive problem-solving by engaging the ETC Creative level, while practicing DBT emotion regulation skills that promote new emotional experiences and behavioral possibilities.

Theoretical Framework

  • Expressive Therapies Continuum (ETC): Creative level

  • DBT Skill: Emotion Regulation – Build Positive Experiences
    (Optional extension: Opposite Action)

  • Population: Adolescents or adults experiencing rigidity, hopelessness, trauma recovery, identity transition, or emotional stuckness

Materials

  • Mixed media (paint, collage, markers, pastels, found objects)

  • Paper or canvas (any size)

  • Optional unconventional tools (sponges, credit cards, fingers, sticks)

  • Glue, scissors

Creative-level work can benefit from choice and experimentation.

Directive

Have the client begin the directive by making marks, shapes, or forms without a plan.

Ask the client to "Allow yourself to experiment, combine materials, or change directions as you go.”

This is a good reminder: “If you notice yourself getting stuck or wanting to control the outcome, gently try something new — a different color, tool, or movement.”

Have the client explore the question:
‘What might a new emotional experience look like?’”

Build Positive Experiences

  • Encourage curiosity, play, and pleasure

  • Focus on process rather than outcome

  • Invite moments of enjoyment, surprise, or interest

DBT Prompt:

“What part of this process feels even slightly good, interesting, or freeing?”

Opposite Action

  • If the client feels:

    • Withdrawn → invite expansion or bold marks

    • Anxious → invite slow, flowing movement

    • Hopeless → invite unexpected or playful materials

Prompt:

“What would it look like to gently do something different than your usual response?”

Time Frame

30–45 minutes
(Shorten for clients with limited tolerance for ambiguity)

Processing & Reflection

Focus on integration and transformation:

  • “Where did something unexpected happen?”

  • “What helped you keep going when you didn’t know what to do next?”

  • “How does this process connect to building new emotional experiences?”

  • “Where else in your life might experimentation be helpful?”

Why This Directive Works

  • Creative-level work promotes resilience and adaptability

  • Novelty interrupts emotional rigidity

  • DBT skills are practiced experientially, not cognitively

  • Supports identity growth and post-traumatic integration

Variations/Adaptations

  • For trauma-informed pacing: allow collage-only experimentation

  • For groups: invite shared themes (growth, change, possibility)

  • For low motivation: set a timer for short creative “bursts”

  • For meaning-making: title the piece “A New Way Through”

References

Buchalter, S. I. (2009). Art therapy techniques and applications. Jessica Kingsley Publishers.

Gussak, D. E., & Rosal, M. L. (Eds.). (2016). The Wiley handbook of art therapy. John Wiley & Sons.

Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.

Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. Guilford Press.

Schouten, K. A., de Niet, G., Knipscheer, J., Kleber, R. J., & Hutschemaekers, G. (2015).
The effectiveness of art therapy in the treatment of traumatized adults: A systematic review. Frontiers in Psychology, 6, 1–8.
https://doi.org/10.3389/fpsyg.2015.00069