Literature Review

This literature review examines the impact of trauma on childhood development and highlights the effectiveness of art therapy, the Expressive Therapies Continuum (ETC), and Dialectical Behavior Therapy (DBT). The purpose of this review was to provide an evidence-based foundation for the art therapy directives included in the toolkit.

During my internship at Behavioral Health Resources, common diagnoses among clients included posttraumatic stress disorder (PTSD), adjustment disorders, anxiety disorders, and depressive disorders. Several theoretical frameworks helped inform my understanding of these presentations, including the biopsychosocial model, Bowen’s family systems theory, attachment theory, and Maslow’s hierarchy of needs. These perspectives emphasize how developmental outcomes are shaped by biological, psychological, and environmental influences such as intergenerational trauma, socioeconomic status, family dynamics, and access to social support. Posttraumatic stress disorder (PTSD) is defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association [APA], 2013) as a trauma-related disorder characterized by intrusive memories, avoidance behaviors, negative alterations in cognition and mood, and changes in arousal and reactivity.

Research also demonstrates that exposure to adverse childhood experiences (ACEs) significantly increases the likelihood of negative long-term health outcomes, including heart disease, depression, substance misuse, and poor academic achievement (The Children’s Hospital of Philadelphia, 2017). As trauma exposure increases, both psychological and physiological symptoms may intensify. Trauma often leads individuals to develop adaptive coping strategies such as hypervigilance, emotional numbing, dissociation, avoidance, and control-seeking behaviors (Psychology Today, 2024). While these responses may initially serve protective functions, they can later interfere with emotional regulation and interpersonal functioning. An Adverse Childhood Experience’s (ACEs) study conducted by based at Kaiser Permanente’s San Diego Health Appraisal Clinic, (Felitti et al., 1998) stated that they found a “strong dose response relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults”, which demonstrates the direct correlation between ACEs and trauma’s effects on childhood development. 

Art therapy can be particularly effective for children who have experienced trauma because it provides a developmentally appropriate method for expressing emotions that may be difficult to verbalize. Waller (2006) highlights several foundational principles of art therapy, including the role of visual image-making in learning, the ability of artwork to contain intense emotions, and the use of art as a form of communication between client and therapist. Furthermore, art therapy’s impact on psychological well-being is closely related to its unique experiential characteristics, providing participants with a safe space for self-exploration and facilitating the integration of emotional expression and self-cognition (Stuckey and Nobel, 2010). 

Integrating DBT with art therapy can further support emotional regulation and coping skill development. DBT is an empirically supported behavioral treatment originally developed to treat borderline personality disorder and chronic suicidal behavior (Linehan, 1993). Dialectical behavior therapy (DBT), as a prominent branch of third-wave cognitive behavioral therapy, provides a systematic framework for understanding and improving emotion regulation (Nielsen et al., 2019; Rizvi et al., 2024).  Its structured skills training, particularly mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, can be useful for individuals experiencing trauma-related emotional dysregulation.

The Expressive Therapies Continuum (ETC) also informed the design of the art therapy directives included in this toolkit. The ETC describes how individuals process experiences through artmaking across multiple levels, including sensory, perceptual, affective, cognitive, symbolic, and creative functioning (Lusebrink, 1990; Lusebrink et al., 2013). Understanding these levels can help art therapists select materials and directives that align with clients’ therapeutic needs. Art therapy, as an emerging educational intervention method, demonstrates efficacy in emotion regulation through alternative expressive modalities (Oepen and Gruber, 2024). 

Overall, trauma can significantly affect childhood development and emotional functioning. This project seeks to provide clinicians with accessible, evidence-informed resources that integrate art therapy, DBT skills, the ETC framework, and art directives compiling both modalities.