Psychiatric Annals

Psychiatric Focus 

The Unique Role of Art Making in the Treatment of Dissociative Identity Disorder

Carol Thayer Cox; Barry M. Cohen

Abstract

Like the complex inner world of people with DID, visual art is inherently multileveled. Line, shape, color, and movement form symbols and structures that can embody a multitude of meanings simultaneously. Unlike verbal communication, art expression is nonlinear; vastly divergent material can coexist in pictures without regard to time or context.

Trance logic or magical thinking in people with DID, which features paradoxes, inconsistencies, and other cognitive errors, translates easily from mental imagery into graphic imagery. Consequently, when they create art — often in altered states of consciousness — people with DID are able to layer meaning through symbolic and obscure coding of imagery. This phenomenon allows patients in treatment to maintain secrecy both from their therapists and themselves while they paradoxically attempt to communicate and achieve mastery over traumatic material. In fact, drawing and painting seem to be among the few vehicles that can effectively externalize the idiosyncratic and highly symbolic inner world of DID so that others may begin to understand it.

Because patients with DID may attempt to disguise their symptoms and deny their diagnosis, it is important for clinicians to become skilled in interpreting the valuable information within the artwork (Sidebar 1, see page 695), or to consult a specialist trained in this practice.

In our book Telling Without Talking: Art as a Window into the World of Multiple Personality, we created a 10-category model for recognizing and analyzing the artwork of people with severe dissociative disorders:

Only a true switching picture can be used on its own to identify multiplicity, and no single picture or stereotypical symbol should ever be used to diagnose a client. One needs to see at least five or more of the ten categories in a patient's artistic output during a period of at least several months, in conjunction with behavioral observations, to begin to make a responsible diagnostic assessment.

The intensity of affect associated with the emotional re-remembering and bodily re-experiencing of trauma during the abreactive experience is familiar to every patient with DID. In this painting (below left), the juxtaposition of the rigidly striped background and the expressionistic figure(s) in the foreground reflects the tension inherent in the patient's struggle to control the occurrence of spontaneous abreactions in everyday life. The ambiguously portrayed double figure may suggest a shift in consciousness.

(Artist: Navina Badura)

A classic photo collage by a person with DID, this work (below) is an eloquent evocation of “telling without talking,” usually the primary motivation behind art making by severely traumatized clients. Having grown up with the threat of harm from childhood abusers, the patient's communication through art provides a creative solution to the otherwise constant conflict of wanting to remember or communicate the past versus the patient's need to repress or dissociate it. Here, the use of sewn-up, blocked-out, and taped-over imagery alerts the informed viewer to the artist's dilemma.

(Artist: Annie McKenna)

This work of art (below) combines magazine photos with drawing media. The varied assortment of faces, most likely portraits of part-selves, is disorganized, suggesting the artist's internal system is not functioning optimally. When the system is in chaos, the patient is more apt to regress, switch more frequently and visibly, and even require hospitalization. The difference in graphic developmental levels and artistic styles used in representing the featured characters in this picture suggests that the patient was switching among various parts of self while making it.

(Artist: Victoria)

(Artist: Anonymous #1)

Rigid, repetitive forms enclose the depiction of a stylized single eyeball in this predominantly abstract drawing (above). A progression of dark blues and greens to light blue, then finally pink, pulls…

Like the complex inner world of people with DID, visual art is inherently multileveled. Line, shape, color, and movement form symbols and structures that can embody a multitude of meanings simultaneously. Unlike verbal communication, art expression is nonlinear; vastly divergent material can coexist in pictures without regard to time or context.

Trance logic or magical thinking in people with DID, which features paradoxes, inconsistencies, and other cognitive errors, translates easily from mental imagery into graphic imagery. Consequently, when they create art — often in altered states of consciousness — people with DID are able to layer meaning through symbolic and obscure coding of imagery. This phenomenon allows patients in treatment to maintain secrecy both from their therapists and themselves while they paradoxically attempt to communicate and achieve mastery over traumatic material. In fact, drawing and painting seem to be among the few vehicles that can effectively externalize the idiosyncratic and highly symbolic inner world of DID so that others may begin to understand it.

Because patients with DID may attempt to disguise their symptoms and deny their diagnosis, it is important for clinicians to become skilled in interpreting the valuable information within the artwork (Sidebar 1, see page 695), or to consult a specialist trained in this practice.

Sidebar 1.

Identifying DID Through Art

In our book Telling Without Talking: Art as a Window into the World of Multiple Personality, we created a 10-category model for recognizing and analyzing the artwork of people with severe dissociative disorders:

  • SYSTEM pictures depict an array of individual elements forming and working as a unit that represents the current internal organization of part-selves.
  • CHAOS pictures illustrate extreme emotional or physiological distress through compositional disorder or exploding or opposing elements.
  • FRAGMENTATION pictures reflect a sense of psychic disunity and physical disconnection by the depiction of fractured or shattered elements.
  • BARRIER pictures include a structure that separates objective from subjective realities, self from environment, present from past, and ego states or alters from one another.
  • THREAT pictures employ menacing imagery to represent a warning by one or more alters of impending punishment within the system or to the body.
  • INDUCTION pictures feature primitive markings characterized by dotting, spiraling, or meandering lines; they reflect the process of going into a trance state.
  • TRANCE pictures communicate information that cannot be put into words by combining a variety of visual strategies to create scenarios that defy objective reality.
  • SWITCHING pictures concretize shifting from one ego state or personality to another, as evidenced by changes in media, strategies, styles, and graphic development.
  • ABREACTION pictures graphically record aspects of repressed or dissociated memories and experiences prior to, during, or following their recall, release, and processing in psychotherapy.
  • ALERT pictures simultaneously reveal and conceal experiences of abuse, dissociation, and multiplicity by making use of the multi-leveledness of images.

Only a true switching picture can be used on its own to identify multiplicity, and no single picture or stereotypical symbol should ever be used to diagnose a client. One needs to see at least five or more of the ten categories in a patient's artistic output during a period of at least several months, in conjunction with behavioral observations, to begin to make a responsible diagnostic assessment.

Abreaction

The intensity of affect associated with the emotional re-remembering and bodily re-experiencing of trauma during the abreactive experience is familiar to every patient with DID. In this painting (below left), the juxtaposition of the rigidly striped background and the expressionistic figure(s) in the foreground reflects the tension inherent in the patient's struggle to control the occurrence of spontaneous abreactions in everyday life. The ambiguously portrayed double figure may suggest a shift in consciousness.

(Artist: Navina Badura)

(Artist: Navina Badura)

Threat and Alert

A classic photo collage by a person with DID, this work (below) is an eloquent evocation of “telling without talking,” usually the primary motivation behind art making by severely traumatized clients. Having grown up with the threat of harm from childhood abusers, the patient's communication through art provides a creative solution to the otherwise constant conflict of wanting to remember or communicate the past versus the patient's need to repress or dissociate it. Here, the use of sewn-up, blocked-out, and taped-over imagery alerts the informed viewer to the artist's dilemma.

(Artist: Annie McKenna)

(Artist: Annie McKenna)

Chaos and Switching

This work of art (below) combines magazine photos with drawing media. The varied assortment of faces, most likely portraits of part-selves, is disorganized, suggesting the artist's internal system is not functioning optimally. When the system is in chaos, the patient is more apt to regress, switch more frequently and visibly, and even require hospitalization. The difference in graphic developmental levels and artistic styles used in representing the featured characters in this picture suggests that the patient was switching among various parts of self while making it.

(Artist: Victoria)

(Artist: Victoria)

(Artist: Anonymous #1)

(Artist: Anonymous #1)

Barrier

Rigid, repetitive forms enclose the depiction of a stylized single eyeball in this predominantly abstract drawing (above). A progression of dark blues and greens to light blue, then finally pink, pulls the viewer's eye inward toward the center of the picture. These design strategies, reinforced by the thick black bands throughout, create strong barriers that protect and isolate inner from outer. As a result of a need for security and anonymity, the artist's “I,” a vulnerable internal witness to early abuse, becomes imprisoned from the outside world.

System

A drawing like this one (right) should alert the viewer to the artist's multiplicity because it is a straightforward illustration of the client's sense of an “internal family” of alternate personalities. In contrast with the “chaos and switching” image described previously, which depicts an internal system in chaos, here is a system of part-selves literally in repose. Each internal figure languishes separately from each other, but all under the “same roof” of the host or client. The clever bandit mask/eye composed of a reclining figure is an excellent example of the creativity that rarely is lacking in patients with dissociative disorders who enjoy making art.

(Artist: Anonymous #2)

(Artist: Anonymous #2)

Editor's Note: Cox and Cohen, registered art therapists and consultants in Fredericksburg and Alexandria, VA, respectively, were asked to comment on the artwork by adults with dissociative identity disorder (DID) included in this issue. They also have recommended selected publications on this topic.

Sidebar 1.

Identifying DID Through Art

In our book Telling Without Talking: Art as a Window into the World of Multiple Personality, we created a 10-category model for recognizing and analyzing the artwork of people with severe dissociative disorders:

  • SYSTEM pictures depict an array of individual elements forming and working as a unit that represents the current internal organization of part-selves.
  • CHAOS pictures illustrate extreme emotional or physiological distress through compositional disorder or exploding or opposing elements.
  • FRAGMENTATION pictures reflect a sense of psychic disunity and physical disconnection by the depiction of fractured or shattered elements.
  • BARRIER pictures include a structure that separates objective from subjective realities, self from environment, present from past, and ego states or alters from one another.
  • THREAT pictures employ menacing imagery to represent a warning by one or more alters of impending punishment within the system or to the body.
  • INDUCTION pictures feature primitive markings characterized by dotting, spiraling, or meandering lines; they reflect the process of going into a trance state.
  • TRANCE pictures communicate information that cannot be put into words by combining a variety of visual strategies to create scenarios that defy objective reality.
  • SWITCHING pictures concretize shifting from one ego state or personality to another, as evidenced by changes in media, strategies, styles, and graphic development.
  • ABREACTION pictures graphically record aspects of repressed or dissociated memories and experiences prior to, during, or following their recall, release, and processing in psychotherapy.
  • ALERT pictures simultaneously reveal and conceal experiences of abuse, dissociation, and multiplicity by making use of the multi-leveledness of images.

Only a true switching picture can be used on its own to identify multiplicity, and no single picture or stereotypical symbol should ever be used to diagnose a client. One needs to see at least five or more of the ten categories in a patient's artistic output during a period of at least several months, in conjunction with behavioral observations, to begin to make a responsible diagnostic assessment.

Sidebar 2.

Recommended Art Therapy References Related to DID

Cohen BM, Cox CT. Telling Without Talking: Art as a Window into the World of Multiple Personality. New York, NY: W.W. Norton; 1995.
Cohen BM, Barnes M, Rankin AB. Managing Traumatic Stress Through Art. Lutherville, MD: Sidran Press; 1995.
Kluft ES, ed. Expressive and Functional Therapies in the Treatment of Multiple Personality Disorder. Springfield, IL: Charles C. Thomas; 1993.
Gerity LA. Creativity and the Dissociative Patient: Puppets, Narrative, and Art in the Treatment of Survivors of Childhood Trauma. London, England: Jessica Kingsley; 1999.
Simonds SL. Bridging the Silence: Nonverbal Modalities in the Treatment of Adult Survivors of Childhood Sexual Abuse. New York, NY: W.W. Norton; 1994.

(Note: To locate art therapists around the country for consultation, contact the American Art Therapy Association, http://www.arttherapy.org.)

Authors

10.3928/00485713-20050801-11

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