The Arts in Psychotherapy 34 (2007) 114–123

Dissociation as depicted in the traumatic event drawings of child

sexual abuse survivors: A preliminary study
Galit Amir, M.A. a , Rachel Lev-Wiesel, Ph.D. b,∗
a CSA Survivors Center in Beer Sheva, Israel
b School of Social Work, University of Haifa, Haifa 31905, Hacarmel, Israel

Abstract
The proposed study aims to investigate whether dissociation-defined as a disturbance or alteration of the usually integrated
functions of identity, memory or conscious [American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental
Disorders (4th ed.).Washington, DC: American Psychiatric Association.] – can be depicted within drawings of the “traumatic event”
drawn by survivors of childhood sexual abuse.
Twenty-seven drawings, drawn by childhood sexual abuse survivors were collected from therapists after clients signed informed
consent forms. Following the completion of drawing the “traumatic event”, the Self Report version of the Peritraumatic Dissociative
Experiences Questionnaire (PDEQ; [Marmar, C. R., Weiss, D. S., & Metzler, T. J. (1997). The Peritraumatic Dissociative Experiences
Questionnaire. In J. P. Wilson, & T. M. Keane (Eds.), Assessing psychological trauma and PTS.D. (pp. 412–428). New York, NY:
The Guilford Press.]) was administered.
Drawings were analyzed by two practitioners according to the five dissociative symptom categories [Steinberg, M. (1997).
Assessing posttraumatic dissociation with the structured clinical interview For DSM-IV dissociative disorders. In J. P.Wilson, &
T. M. Keane (Eds.), Assessing Psychological Trauma and PTS.D. (pp. 429–448). New York, NY: The Guilford Press.]: amnesia,
depersonalization, derealization, identity confusion and identity alteration. Indicators were selected upon face validity and previous
studies, including a preliminary study conducted by the author.
Correlation analysis between indicators and PDEQ score was conducted. In addition analysis of variance to compare survivors
who were still minors and adult survivors was conducted.
Findings revealed that a significant correlation between indicators of derealization in drawings and PDEQ scores exists, in the
adult group only. In addition, minors scored significantly higher on the PDEQ than adults. However, comparison between drawings
of adults with drawings of minors indicated that adults scored significantly higher on the dissociative symptoms of identity confusion
and identity alteration than minors.
Findings may indicate that traumatic event drawings have a potential for being developed for diagnostic, therapeutic and forensic
purposes. Suggestions for further research are offered.
© 2006 Elsevier Inc. All rights reserved.

Keywords: Dissociation; Childhood sexual abuse; Traumatic event; Drawings

Clinical experience and studies indicate the usefulness of drawings for diagnostic and therapeutic purposes for
individuals who suffer from posttraumatic response or dissociative disorders (Silberg, 1998) associated with child
abuse (Lev-Wiesel, 2004; Malchiodi, 1990). According to Furth (1988), Gillespie (1994), and Lev-Wiesel (1999,

∗ Corresponding author. Tel.: +972 4 6732627; fax: +972 4 6734627.

E-mail address: rlev@univ.haifa.ac.il (R. Lev-Wiesel).

0197-4556/$ – see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2006.08.006
 G. Amir, R. Lev-Wiesel / The Arts in Psychotherapy 34 (2007) 114–123 115

2004), the drawn figure or symbol usually reflects the drawer’s inner knowledge and deep acquaintance with the
self.
One of the difficulties that legal professionals (e.g., police investigators, child investigators) and helping professionals
(therapists, medical staff, etc.) are faced with is the difficulty or sometimes apparent inability of survivors to verbally
describe their traumatic experiences. Milchman (2003) suggested that drawing might encourage verbalization relating
to the trauma and the traumatic event of victims.
Recently, a study conducted by Lev-Wiesel and Liraz (2006) examined the extent to which the use of drawing prior
to narrative description increases the richness of the narrative given by children who are exposed to a succession of
negative life events. Findings revealed that narratives of children who were asked to draw prior to verbally describing
events were more detailed and more emotionally revealing than those of children who were asked only to verbally
narrate. In contrast, expressions of resistance and splitting were more apparent in the children who were only requested
to narrate.
Since dissociation – defined as a disturbance or alteration of the usually integrated functions of identity, memory
or awareness (APA, 1994) – is difficult to diagnose (Duffy, 2002; Weber, 2001) and was found to have tremendous
impact on sexual abuse survivors’ lives and testimonies (Brand, 2001; Talbot, Talbot, & Tu, 2004), it is important
to develop tools through which dissociation activated during a traumatic event may be expressed. Therefore, the
current study is an attempt to identify dissociative indicators in sexual abuse survivors’ drawings of the traumatic
event.

Childhood sexual abuse (CSA) and dissociation

Childhood sexual abuse is defined as a sexual act between an adult and a child, in which the child is utilized for the
sexual satisfaction of the aggressor (Briere, 1992). Reviews of numerous studies examining the long-term sequelae of
CSA (e.g., Breslau, 2002; Kaysen, Resick & Wise, 2003; Neumann, Houskamp, Pollock, & Briere, 1996; Ruggiero et
al., 2004) list numerous psychological, behavioral, and social difficulties in adults that include depression, psychological
distress, poor self-esteem (Freshwater, Leach & Aldridge, 2001; Johnson, 2004), substance abuse, suicide attempts
(Dube et al., 2001; Plant, Miller, & Plant, 2004; Schumm, Hobfoll, & Keogh, 2004), severe posttraumatic stress
symptomatology (Petrak & Campbell, 1999), psychopathology disorders (MacMillan, Fleming, & Streiner, 2001;
Owens & Chard, 2003), self-destructive behavior (Merrill, Thomsen, & Sinclair, 2001), and dissociative disorders
(Fleming, Mullen, Sibthorpe, & Bammer, 1999; Simpson & Miller, 2002). Van Den Bosch, Verheul and Van Den
Brink (2003) found that the prevalence of dissociative experiences and posttraumatic stress disorder among those with
history of CSA were high compared to survivors of other forms of trauma.
According to Silberg (1998), in order to detach themselves during a traumatic event children tend to dissociate,
a phenomenon that allows the child to survive and retain a relatively normal, functioning self (Krystal et al., 2000;
Midgley, 2002). Dissociation refers to a mental process that produces a lack of connection in the person’s thoughts,
memories, feelings, actions, or sense of self. During the dissociation process, certain information is not associated with
other information as it would normally be (Lev-Wiesel, 2004; Zomer & Zomer, 1997). Dissociative mechanisms are
those that allow a person to temporary escape from pain and suffering (Silberg, 1998). Putnam (1993) lists the defensive
functions of the dissociative mechanisms, which include creating automatic behaviors, responding to overwhelmed
stimuli, escaping from life stressors and despair, compartmentalizing catastrophic events, cathartic relief from certain
feelings, avoiding and relieving pain, and, altering the sense of self so that the traumatic event is experienced as if “it
never happened to me.” As a defense mechanism, dissociation seems to protect against immediate experiences, yet it
results in a fragmentation of the self (Shengold, 1989).

Trauma organized system—avoidance of describing the event

Bentovim (2002) suggested that the relationship between a perpetrator-parent and a sexually abused child is a “trauma
organized system”– through minimalization, silencing and victim blaming, dissociative mechanisms are developed,
thereby decreasing the victimized child’s ability to verbally describe the experience. The pressure not to see, not to
hear and not to speak prevents the processing of the experiences, leading to unhealthy dissociative coping strategies
such as identification with the aggressor, identification with the other parent’s passivity or silent collaboration, or
identification with the victimized self. This might be strengthened by the victim’s attempt to avoid thinking about the
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abuse. The dynamics of helplessness, stigmatisation, and betrayal by family members serve as reinforcement to avoid
thought, feeling, or action, thus providing an additional catalyst for the development of dissociative disorders (Silberg,
1998). The dissociative process may take the form of temporary detachments, especially in stressful situations, and in
response to triggers associated with the abuse (Ellason, Ross, & Fuchs, 1996). Brown, Scheflin and Whitfield (1999)
who reviewed 68 retrospective and longitudinal studies of dissociation among sexual abuse survivors, showed that
amnesia is also a common and dominant phenomenon.
In general, dissociation consists of five major symptoms (Steinberg, 1997): amnesia – described as memory “holes”
or “lost time,” lasting from several minutes to several years (Steinberg, 1997); depersonalization – a sense of being
detached from oneself, a sense that the self is alien or unreal, a sense of being separated from different parts of the
body or the body as a whole, or a sense of being detached from feelings altogether (Steinberg, 1997); derealization – a
sense of detachment or estrangement from the environment, or a sense that the world and the surroundings are unreal
(Steinberg, 1997); identity confusion – a sense of fragmentation of the self that is unnoticed by the surrounding people
(Steinberg, 1997); and identity alteration – noticeable changes in identity or more than one ego state (Talbot et al.,
2004). The changes in identity or ego state may be accompanied by amnesia, so that the person is unable to remember
events that took place when the new identity emerged.
The severity of the dissociative symptoms may vary contingent on factors such as age of abuse onset, severity
of abuse, emotional closeness/dependence on the abuser, dysfunction of early social environment, and psychological
factors (Gold, 1999).

Drawings as a diagnostic tool for dissociation

Drawings have been widely used as an additional assessment tool for evaluation and diagnosis of cognitive abilities
(Abell, Heiberger, & Johnson, 1994), psychological symptoms of distress (Hjorth & Harway, 1981; Joiner, Schmidt, &
Barnett, 1996), personality characteristics (Lev-Wiesel & Shvero, 2003), and violent aggressive behavior (Lev-Wiesel
& Hershkovitz, 2000).
Diagnosing dissociative disorders is difficult, possibly due to the presence of numerous symptoms and the victim’s
resistance to disclose amnesia or multiple personalities (Coons, 1984). Several attempts to identify dissociation within
drawings were made by researchers and clinicians. Silberg (1998) for example, suggested that multiplicity of body
parts in self-figure drawings of young children might indicate a dissociative process. Cohen and Cox (1991) developed
the Ten Category Model to identify the multiplicity that is assumed to characterize dissociative identity disorder. In
analyzing nineteen drawings of children and adult survivors of childhood sexual abuse who were diagnosed with
dissociative identity disorder (DID), 84% of the self-figures drawn by either children or adults had some kind of
multiplicity: more than one facial profile, two or more human figures within a body, a figure split into two figures, or
additional figures drawn as shadows near or behind the main figure (Lev-Wiesel, 2004).
Based on the above review, assuming that drawing of the traumatic event is a sort of survivor narrative, the current
study examined the extent that dissociation is reflected within “the traumatic event” drawings of childhood sexual
abuse survivors.

Method

Participants

Twenty-seven CSA survivors, two males and twenty-five females, aged 7–59 years (M = 23.03, S.D. = 12.8), who
were clients in two treatment centers for sexual assault survivors in Israel were recruited for this study. Regarding the
identity of the perpetrator, 37% were abused by an acquaintance outside the family (e.g. teacher, neighbor, babysitter),
33.3% were abused by their biological fathers or stepfathers, 14.8% were abused by another relative (uncle, grandfather
or grandmother), 3.8% were abused by their brothers, and 11% were abused by a stranger. The average age of the
survivors at onset of the abuse was 9.25 (S.D. = 3.12), range 4–16. Twenty-six percent of the participants experienced
a single abusive event, while 74.1% experienced continuous abuse. Among those who were continuously abused,
duration ranged from one to nine years (M = 3.2, S.D. = 2.07) (see Table 1).
 G. Amir, R. Lev-Wiesel / The Arts in Psychotherapy 34 (2007) 114–123 117

Table 1
Participant characteristics
Range Mean S.D.

Age 7–59 23.03 12.08

Age of onset 4–16 9.25 3.12
Duration of abuse
Single event (n = 7, 25.9%) – – –
Continuous (n = 20, 74.1%) 1–9 years 3.2 2.07

N %

Perpetrator
Father/step father 9 33.3
Relative 4 14.8
Brother 1 3.8
Acquaintance 10 37.0
Stranger 3 11.1
Gender
Male 2 7.4
Female 25 92.6
Total 27 100

Procedure and instruments

The research assistant (a social worker) explained the study and its goals to participants and requested them to
sign an informed consent form in order to participate in the research. With regard to minors, informed consent and
explanations were provided to the participant’s parent or guardian together with the participant.
Participants were then asked to draw the “traumatic event” on a white, 210 mm × 297 mm size, sheet of paper, in
pencil, without access to an eraser. Subsequently, they were requested to describe the drawing and identify the figures
present in it. Indicators were assigned to dissociative symptom categories by face validity based on the literature review
(Lev-Wiesel, 2004; Silberg, 1998) (see Table 2). Two independent evaluators who were also art therapists assessed
the level of obviousness (from 1 to 4) of indicators that might signify the five categories of dissociative symptoms
(Steinberg, 1997): amnesia, depersonalization, derealization, identity confusion, and identity alteration. Correlation
analysis between evaluators was performed and items for which correlation was lower than r = 0.70 were dropped out.
Following the drawing phase, the self-report version of the Peritraumatic Dissociative Experiences Questionnaire
(PDEQ) (Marmar, Weiss, & Metzler, 1997) was administered. The two assignments (drawing and questionnaire) were
carried out within the therapy room for each participant in private with the research assistant presence only. Any
question asked about the meaning of the PDEQ items was answered by “as you understand it.”

Table 2
Indicators selected for analysis
The major dissociative symptoms (Steinberg, 1997) Indicators selected

Amnesia Omissions, attempts to erase, empty spaces, separations between victim and
perpetrator
Depersonalization Outside observer, multiple perspectives of the scene, compartmentalization of
victim/perpetrator, head detached from body, sexual area detached from rest of
body, excessive focus on details in surrounding
Derealization Unrealistic scene, empty surrounding
Identity confusion Fragmentation of self or other figure, diffused boundaries between victim &
perpetrator
Identity alteration Multiplicity of self, part of self or others
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Table 3
Correlation analysis of drawing dissociation scores and PDEQ scores
PDEQ score and dissociation symptom Amnesia Depersonalization Derealization Identity confusion Identity alteration

Whole sample
Pearson correlation coefficient −0.14 −0.04 0.21 −0.22 −0.28
p 0.48 0.84 0.29 0.27 0.16
Minors
Pearson correlation coefficient 0.19 −0.02 0.43 0.35 −0.09
p 0.58 0.94 0.18 0.29 0.79
Adults
Pearson correlation coefficient −0.01 0.13 0.53* −0.098 −0.10
p 0.97 0.63 0.03 0.72 0.71
* Correlation is significant at the 0.05 level (2-tailed).

The Peritraumatic Dissociative Experiences Questionnaire (PDEQ)

The PDEQ (Marmar, Weiss, & Metzler, 1997) consists of 10-items (five-category scale ranging from “not at all
true” to “extremely true”) that measure peritraumatic dissociation. The PDEQ was validated in a number of studies,
indicating that it was internally consistent and strongly associated with measures of traumatic stress response and with
a measure of general dissociative tendencies (e.g., Marmar et al., 1997). In the current study, the self-report version of
the PDEQ was adjusted for Hebrew-speaking populations (by translation and back-translation procedure).

Results

Correlation analysis was performed between the PDEQ and each of the indicators. No significant correlations were
found. However, when correlating the variables for adults (>18) and minors (<18) separately, a significant correlation
(r = 0.53) was found between PDEQ and derealization in the adult group’ drawings (see Table 3).
Analysis of variance comparing PDEQ scores of minors with adults showed that the level of dissociation among
minors was significantly higher [t(25) = 2.35, p < 0.05] than among adults (minors M = 4.03, S.D. = 0.42; adults M = 3.41,
S.D. = 0.80).
Analysis of variance was conducted comparing minors and adults with regard to each of the indicators. Signif-
icant differences were found in two categories: Identity alteration [t(25) = −1.88, p < 0.05] was less obvious in the
minors’ drawings (M = 1.91, S.D. = 1.37) than in the adults’ drawings (M = 2.87, S.D. = 1.20). Also, identity confusion
[t(25) = −2.39, p < 0.05] was found to be less obvious in the minors’ drawings (M = 1.90, S.D. = 1.37) compare to the
adult’s drawings (M = 3.06, S.D. = 1.12) (see Table 4).

Illustration 1

This picture was drawn by a 59-year-old woman who was sexually abused by her grandmother between the ages 5–9.
Describing her drawing she said: “I am lying in bed and my grandmother is sitting next to me on the bed touching me.”
The bed and the figures seem to be floating in space with no reference to the surroundings. Both evaluators assessed
derealization in this drawing to be very obvious (4.0) (Fig. 1).

Illustration 2

This picture was drawn by a 13-year-old boy who was continuously sexually abused by a trusted male teacher. The
boy seemed to be focused on the details in the environment yet neglected to draw the figures involved in the traumatic
event (Fig. 2).

Illustration 3

The picture was drawn by an 18-year-old woman who was sexually abused by her father between the ages of 8 and
13. In the drawing, it is difficult to distinguish between the victim and the perpetrator’s figures indicating the possibility
of identity confusion (Fig. 3).
 G. Amir, R. Lev-Wiesel / The Arts in Psychotherapy 34 (2007) 114–123 119

Table 4
Means, standard deviations, and t-values of dissociation symptoms (as reflected in the drawings and in the PDEQ): minors vs. adults
Dissociative symptom Mean S.D. t p

PDEQ Minors 4.03 0.427 2.62 0.015*

Adults 3.41 0.800
Amnesia Minors 3.18 1.17 −0.145 0.886
Adults 3.25 1.24
Depersonalization Minors 2.90 1.30 −1.10 0.283
Adults 3.44 1.09
Derealization Minors 3.18 0.98 0.681 0.502
Adults 2.87 1.36
Identity confusion Minors 1.91 1.37 −2.3 0.033*
Adults 3.06 1.12
Identity alteration Minors 1.91 1.37 −1.88 0.044*
Adults 2.87 1.20
Total DD score Minors 3.05 0.38 1.33 0.328
Adults 2.91 0.50
* Correlation is significant at the 0.05 level (2-tailed).

Fig. 1. Derealization—the empty surrounding and major focus on the traumatic scene indicate derealization.

Illustration 4

The picture was drawn by a 13-year-old boy who was raped by two older adolescent boys when he was 8. When
asked to describe the drawing, he pointed to himself on the left (“this is me”) and the two perpetrators to his right,
one holding a plastic knife to threaten him and the other with a text bubble threatening to cause his family to leave the
kibbutz (agricultural cooperative) where they lived if he would dare tell. A fourth figure, smaller and almost lost in the
text bubbles which appear above the victim figure in the drawing was referred to as “this is also me . . .” (Fig. 4).

Discussion

The current study investigated whether dissociation can be depicted within pictures detailing the “traumatic event”
drawn by survivors of childhood sexual abuse. Findings demonstrate a significant correlation between indicators of
derealization in drawings and PDEQ scores in the adult group only. In addition, minors scored significantly higher
on the PDEQ than adults. However, comparison between drawings of adults and drawings of minors showed that the
120 G. Amir, R. Lev-Wiesel / The Arts in Psychotherapy 34 (2007) 114–123

Fig. 2. Depersonalization—the victim is detached from his/her body and watches the scene from above.

Fig. 3. Identity confusion—it is difficult to distinguish between the victim and the perpetrator, their bodies and organs.
 G. Amir, R. Lev-Wiesel / The Arts in Psychotherapy 34 (2007) 114–123 121

Fig. 4. Identity alteration—the additional self-figure.

adults’ drawings scored significantly higher on the dissociative symptoms of identity confusion and identity alteration
than those of the minors.
The fact that derealization, defined as a sense of detachment or estrangement from the environment or a sense that
the world and the surroundings are unreal (Steinberg, 1997), was found to significantly correlate with PDEQ score
among adults might point to the possible impact of time that had passed since the occurrence of the traumatic event.
The sexual abuse that had occurred during childhood was likely to shatter the victim’s world assumptions (Janoff-
Bulman & Frieze, 1983), the more time has passed the less the event seems possible, real, or likely to have happened
at all. Thus, the memory of the surrounding environment might be blurred and focus is on the traumatic event itself
(Milchman, 2003). Indeed, derealization was expressed in the drawings as an unrealistic surrounding environment,
excessive focus on the narrow traumatic situation, or lack of reference to the surrounding environment. However, the
fact that other indicators were not found to correlate with the PDEQ might be due to the fact that the drawings were
analyzed according to the five dissociative symptoms while the PDEQ is not.
The fact that the PDEQ scores of minors were higher than those of adults could also support the above supposition
that in the case of the minors, less time had passed between the events and the completion of the PDEQ. Indeed, the
PDEQ measures dissociation close to a specific event and is therefore entitled “peritraumatic.”
Findings also indicate that identity confusion, defined as a subjective sense of instability of the self, and identity
alteration, described as noticeable changes in identity or ego state, were also significantly higher in the adults’ drawings.
This finding may indicate that identity confusion and identity alteration are processes that continue to develop over
time. Longitudinal research from childhood to adulthood on the development of alters and ego states among CSA
survivors may shed light on these processes.
Despite the small sample size and its heterogeneity with regard to age, these preliminary study’s findings affirm
the potential for developing visual instruments that will enable the depiction of dissociation activated by survivors
of childhood sexual abuse. Based on the fact that traumatic memories are sensory in nature, stored and recalled by
visual images and cues (Van der Kolk et al., 1997), it seems worthwhile to use visual instruments when attempting
to revive dissociative experiences. Drawings might serve as a visual narrative for survivors, allowing them to disclose
their experiences and memories. Nevertheless, further research is needed to gather evidence for using traumatic event
drawings for diagnostic, therapeutic and forensic purposes.

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