BREAKING THE CODE:
IDENTIFICATION OF
MULTIPLICITY
THROUGH ART
PRODUCTIONS
Barry M. Cohen, M.A., ATR
Carol T. Cox, M.A., ATR
Barry M . Cohen, M .A., ATR, is Director of Expressive Thera-
pies, Mount Vernon Hospital, Alexandria, Virginia . Carol T.
Cox, M .A., ATR, is Adjunct Assistant Professor for the Gradu-
ate Art Therapy Program of George Washington University.
For reprints write : Barry M . Cohen, MA, ATR, Mount
Vernon Hospital, 2501 Parker's Lane, Alexandria, Virginia
22306.
ABSTRACT
The authors organized the art productions of clients diagnosed as
suffering multiple personality disorder into ten basic categories
reflecting thematic, structural, and process elements . These catego-
ries were derived from the study of nearly two thousand pictures
drawn over a period of nine years . Designed to aid therapists in the
identification of multiplicity, these categories can also be used as a
framework to help therapists understand the spontaneous artwork of .
multiples.
The majority of the literature on artwork and multiple
personality disorder (MPD) focuses on treatment issues
(Gerity, 1988 ; Jacobson, 1985, 1986, 1987, 1988, 1989 ; Luse-
brink & Dickstein, 1982 ; Shapiro, 1988 ; Spaletto, 1986;
Spring, 1986 ; Sweig, 1986) . The manifestation of conflict,
the abreaction of physical, sexual, and emotional abuse, and
the externalization of anger in the graphic expressions of
MPD clients have been observed and noted (Jacobson, 1985,
1986, 1987 ; Shapiro, 1988 ; Spaletto, 1986 ; Spring, 1986;
Sweig, 1986) . The therapeutic use of art to facilitate commu-
nication between alters (Jacobson, 1986, 1989 ; Spaletto,
1986 ; Spring, 1986) and to aid in the integration process
(Cohen, 1989b ; Lusebrink & Dickstein, 1982) has also been
discussed . Several authors have described the use of various
media with this population (Jacobson, 1986 ; Spaletto, 1986;
Sweig, 1986) . A variety of art therapy techniques may be
employed to great effect with MPD patients, including group
work (Jacobson, 1987), puppet making (Gerity, 1988), and
collage work (Sweig, 1986) . Techniques and treatments,
however, are beyond the scope of this article . Its focus is the
form and function of MPU artwork.
Little has been written about the formal qualities of
MPD art . One paper looked specifically at the symbolic
language of multiples and compared it with that of sexually
abused individuals who exhibited symptoms of post trau-
matic stress syndrome (Spring, 1986) . Another paper ana-
lyzed the differences between alters in the work of a single
client regarding media choice, expressive styles, color pref-
132
erences, symbolism, content, and formal indicators of psy-
chopathology (Lusebrink & Dickstein, 1982) . Differences in
levels of graphic development between alters have also been
studied (Fuhrman, 1988 ; Lusebrink & Dickstein, 1982).
The creations of an accused mass murderer were used in
court as evidence in a defense argument (Watkins, 1984).
This is the only instance in the literature, to the authors'
knowledge, of the use of art to support a diagnosis of MPD.
This paper represents an attempt to classify the artwork
of multiples into a format which may facilitate the identifica-
tion of clients with multiple personality disorder.
MPD AND ART
The etiology of the illness, usually based in the secrecy
of severe child abuse (Kluft, 1984 ; Putnam, 1989 ; Wilbur,
1984b) , can result in the need for expression at pre-verbal or
non-verbal levels . Art activity is a natural and nonthreaten-
ing way for children to communicate (Levick, 1986 ; Rubin,
1984) . For this reason it provides child alters, who have been
sworn to secrecy by, for example, the threat of death, with a
way of telling their stories without talking (Braun, 1989).
Visual art is inherently multileveled . Line, shape, color,
and movement form symbols and structures which can
simultaneously embody a multitude of meanings . Unlike
verbal communication, art expression is nonlinear ; vastly
divergent material can co-exist without any references to
time or context (Kreitler & Kreitler, 1972) . Thus, the trance
logic or magical thinking of multiples, which features para-
doxes, inconsistencies, and other cognitive errors (Fine,
1988 ; Ross & Gahan, 1988 ; Watkins, 1984), is easily trans-
lated from mental imagery into graphic imagery . In fact,
drawing and painting seem to be among the few vehicles that
can effectively externalize the idiosyncratic and highly sym-
bolic inner world of MPD, so that others may begin to
understand it.
During the course of psychotherapy, multiples may use
artwork as a method of bringing their circumstances to the
therapist's attention, or to share information which they are
unable to discuss . In the authors ' experience, they do this
more frequently than clients with other psychiatric diagno-
ses . Phenomena such as switching and internal threats be-
tween alters, as well as abreactive images, are often mani-
fested in the art . These pictures embody rich visual systems
that can be grasped or interpreted on many levels . Working
with the different levels of structure and content in the
artwork of multiples can be as complicated as working with
the hierarchical organization of their personality systems.
DISSOCIATION, Vol : September 1989
When MPD clients create art through their various alter
personalities, the layering of meaning often results in the
obscure coding of information . Because most therapists are
not trained in the formal analysis of nonverbal graphic
communication, many of the complex messages and poten-
tial diagnostic indicators in these works can be overlooked.
MPD clients typically attempt to disguise their symptoms
and deny their diagnosis (Kluft, 1985, 1987 ; Putnam, 1989) .
The authors believe that coding of drawings allows the
clients to maintain secrecy (both from their therapists and
themselves), white they paradoxically attempt to communi-
cate and achieve mastery over traumatic material . Careful
study of the art expressions of new or misdiagnosed clients
can provide the therapist with an additional method of
inquiry that may augment the traditional verbal interview.
Clients might inadvertently alert the therapist to their multi-
plicity through art productions, which are less easily cen-
sored than verbal expression (Kreitler & Kreider, 1972) . It is
therefore important for the clinician to become skilled in
apprehending this information . In this way the chances for
a timely and accurate diagnosis are increased.
PREREQUISITS FOR READING PICTURES
One need only peruse journals and conference pro-
ceedings to see that clinicians in a variety of mental health
disciplines other than art therapy use art in their work with
MPD clients (Coons, 1988 ; Frye, 1988 ; Fuhrman, 1988) . The
therapeutic use of art is often misperceived as safe and
simple . In fact, it is complex and can be potentially harmful.
Clinicians who choose to introduce art into their practice
should proceed with utmost caution, just as art therapists
must carefully monitor their own role when acting as adjunc-
tive therapists in the treatment of MPD.
Effective diagnosis and treatment through art is based
on a thorough knowledge of the elements that affect the art-
making experience . This includes, but is not limited to,
understanding the physical properties of art media and how
they interact with the structure and complexity of tasks at
each level of the creative process (Kagin & Lusebrink, 1978).
Lack of a working knowledge of these elements may result in
damaging effects to the client and the therapeutic relation-
ship .
To comprehend a picture at any of its many levels of
meaning, an understanding of media, structure, graphic
development, and process must be integrated with visual
literacy . Visual literacy requires the ability to "read" both the
"grammar "and "syntax "of visual communications (Dondis.
1978). This is best accomplished by studying the interaction
of pictorial elements and composition . For the reasons
stated earlier, this can be a formidable task when decipher-
ing MPD art.
Since art therapists are experienced in making art,
educated in psychopathology, and trained in visual literacy
and graphic development as well as theory of process, they
are especially prepared to comprehend the multileveled
messages in MPD art (Cohen, 1989a) . It is our intention to
aid clinicians who are unfamiliar with these practices, as
consultations with art therapists are not always available in
certain areas of the country.
TEN BASIC CATEGORIES
The authors offer a conceptual framework to aid in the
identification of multiplicity through art . It can also be used
to break the code in pictures of confirmed MPD clients . We
have organized the artwork of multiples into ten basic
categories that reflect thematic, structural, and process
elements . The authors believe that this ten category model
is specific for MPD art . It is intended to contribute to the
differential diagnosis of MPD, serving to augment a thor-
ough history, medical evaluation, and interview.
The development of these categories resulted from dis-
cussions with clients and the classification of nearly two thou-
sand pictures drawn over a nine-year period . Many of these
pictures predated the clients ' diagnoses of MPD . They were
created at home, in group, or in private art therapy sessions.
They include abstract, representational, and symbolic im-
ages . Each of the categories described below is illustrated by
a drawing selected from the portfolios of five MPD clients
and is reproduced here with their consent . These clients
contributed directly to the explanation of their pictures.
1. Systempictures depict an array of individual elements
forming and working as a unit, which represents the internal
organization of ego states, personality fragments, and alters.
Figrcr-e 1
 
Figure 2
 
Figure 3
133
DISSOCIATION, Vol : September 1989
i7 'IiW:li\1\`li'lIiiil VIIIIJI
There are three types of system pictures. Figure 1 is an
example of a full system picture, drawn by a client whose
internal system was composed of families, each containing
four alters. The system is organized around the core person-
ality, which is represented by the fetal image in the center of
the picture.
Another type of system picture is thepartial system pic-
ture, which usually portrays one or more alters within the
system. Partial system pictures are often the reflection of a
particular alter's frame of reference. Figure 2 shows an alter
sharing consciousness with other personalities.
The war zone picture is a third type of system picture. It
is characterized by chaotic structures representing opposing
forces within the system. Figure 3, a war zone picture, pre-
dated the diagnosis by several years.
System pictures are the most prevalent of the ten catego-
ries. They are equally common in the drawings of pre- and
post diagnosis multiples.
2. Fragmentation pictures are expressions of the severed and
detached experience of the client . They are visual meta-
phors for the effects of depersonalization and dissociation.
The use of linear elements and composition in-Figure 4
shows a variety of graphic techniques within a single picture
to express this phenomena.
3. Barrier pictures include a structure (usually drawn as a
fence, wall, or gate) which controls passage of people, alters,
thoughts, or feelings. These pictures represent a process of
separating objective from subjective realities, self from envi-
ronment, present from past, and ego states and alters from
one another . Barrier pictures have previously been noted to
appear in the art of MPD clients (Spring, 1986) . Figure 5
concretely depicts the wall separating one personality's
internal environment from the others' . At this point in the
patient's therapy, the break in the wall heralds the begin-
ning of fusion between personalities immediately prior to
the integration process.
inconsistent within the saute picture . Differing levels of
graphic development by various alters in separate pictures
have also been noted (Cohen . I989b ; Fuhrman, 1988).
Divergent handwriting can be another manifestation . De-
structive intentions may be evidenced by scribbling over, z-
ing out, or dest r . Recognizing a switching
picture is like meeting an alter personality . In our experi-
ence, it is the single strongest diagnostic indicator of MPD
within the context of this ten category model.
Figure 6 contains several elements which illustrate the
switching process
alter is scribbled over by another alter who poses the ques-
tion, "What is this supposed to be?" "Me" is the reply by the
alter who initiated the picture.
5. Threat pictures represent a warning by one or more alters
of impending punishment within the system or to the body.
This may be the result of a particular alter revealing informa-
tion or expressing a view not shared by a powerful alter
within the system (Beahrs, 1982 ; Putnam, 1989) . Threat
pictures are characterized by menacing imagery such as
pointed weapons, intimidating figures, staring eve(s), and
aggressive language. Figure 7was made by the client dipping
her hand in red paint and printing it onto the paper, thus
communicating a bloody threat from within. Certain seem-
ingly innocent images trigger abrupt changes in the clients
behavior because they contain symbols programmed by
abusers to induce fear or suicidalitv (Braun Sc Sachs, 1988).
This type of threat picture typically goes unnoticed by the
therapist, and is often destroyed by the client.
6. Alert pictures are the clients attempt to gain the therapist's
attention while simultaneously trying to conceal specifics
regarding abuse, dissociation, or the existence of the inter-
nal system before the diagnosis of MPD is made -
ated pathology may be depicted in order to ensure hospitali-
zation and/or continued treatment once the diagnosis has
4. Switching pictures concretize the shifting or changing
from one ego state or personality to another, which is the
central behavioral phenomenon of MPD (Putnam, 1989).
Graphic elements are often developmentally or stylistically
Figure 4
 
Figure 5
 
Figure 6
134
DISSOCIATION, Vol . II, No . 3:September 1989
been established . These pictures usually result in the inad-
vertent unveiling of significant clues to the client's multiplic-
ity or the etiology of the dissociation . The overt appeal for
the therapist's attention maybe perceived by the therapist as
a routine call for help by a manipulative and/or needy client.
What distinguishes the MPD alert picture from other crisis
pictures drawn by non-MYD clients is the concurrent pres-
ence of' symbolic or structural elements typical of multiple
personality art within the picture . Figure 8 was drawn several
years before the client was diagnosed properly . The alarm-
ing title of this picture, "Time Bomb," draws the attention
away from the coded images of fragmentation and multiplic-
ity in the center of the picture . The ticking time bomb was
the client's attempt to communicate to her therapist the
impending explosion in her inner world.
7. Deception pictures are coded benignly in order to throw
the therapist off the track . They often give the appearance of
pleasant imagery, which may range from the cute to the
aesthetically seductive . Figure 9 has a gentle appearance
until the vine is identified as a bird and the flower as its
genital area . The flower stem is an attempt to code a pene-
trating shape.
8. Therapy pictures directly or symbolically depict the client/
therapist relationship or a specific treatment session . These
are not exclusive to the artwork of multiples ; they are also
seen in the art of clients diagnosed with borderline person-
ality disorder . In the case of multiples, they reflect the
intense relationship which has been noted in the literature
to characterize the patient/therapist interaction in the treat-
ment of MPD (Kluft, 1984 ; Putnam, 1989 ; Wilbur, 1984a).
Figure 10 exemplifies the idealization of the therapist within
a special relationship which features sharing and exchange
of positive regard.
9. Trance pictures feature highly symbolic imagery created
in an autohypnotic state . Although MPD drawings are fre-
quently created in a trance state, this concept specifically
deals with those images drawn to communicate information
that cannot be put into words . Trance pictures are usually
the most difficult to decode . Their meaning may not become
fully apparent until after hypnotherapy and long-term psy-
chotherapv . Collaborative efforts between alters may result
in trance pictures and often include elements ofa variety of
the above-mentioned categories . Trance pictures may be
confused with the picture-salad compositions of psychotics.
Questioning the psychotic regarding the meaning of such
pictures will typically elicit an explanation of loosely-associ-
ated information . The multiple will simply "not know" the
meaning of a trance picture . Figure 11 illustrates trance
logic . By combining a variety of visual vantage points with
the manipulation of scale, a scenario is communicated
which defies objective reality . Pictures such as this offer the
therapist symbolic material which may take the length of the
entire treatment to fully decode . Figure 11 was drawn prior
to the client 's diagnosis.
10. Afrreaciion pictures may augment the abreactive process
in therapy (Putnam, 1989) by graphically recording (hence
externalizing) repressed or dissociated memories and expe-
riences . They frequently predate the verbal expression of
this material and often precede the memories and diagnosis
as well . These graphic depictions are often coded in idiosyn-
cratic ways by different alters, each of whom adds a personal
perspective to the memory of the trauma . Figure 12 is a
highly stylized depiction of a hymenectomy performed on
the client by her parents.
Some of the most startling examples of abreaction
pictures include scenarios of abuse stemming from ceremo-
nial, usually satanic, victimization . The overt contents of
these pictures contains a variety of cultic signs, symbols, and
structures (Braun & Sachs, 1988).
DISCUSSION
Clients often spend years in the mental health system
before an accurate diagnosis of MPD is made because the
diagnostic process is complicated by a variety of factors
(Putnam, Guroff, Silberman, Barban, & Post, 1986) . A high
percentage of multiples try to hide or dissimulate their
conditions, masking symptomatology (Klufi, 1985) . In cases
where symptomatology is evident, there are similarities and
parallels with other psychiatric syndromes (Coons, 1984).
Keeping secrets usually creates pressure to both reveal
and conceal (Putnam, 1989) . The adult MPD has pressing
Figure 8
 
Figure 9
135
DISSOCIATION, vol. II, No, 3 :September 1989
reasons to both reveal and conceal traumatic childhood
abuse and its sequelae . Even when childhood trauma stems
from an event which is not visual in origin, the lasting
memory is visual, not verbal or behavioral (Terr, 1988) . Art
activity provides the victim of childhood abuse an opportu-
nity for the simultaneous disclosure and disguise of re-
pressed or dissociated material in coded visual form . Once
concretized externally, these memories can be articulated
verbally and explored (Greenberg & van der Kolk, 1987).
The authors provide a conceptual framework for facili-
tating the identification of multiplicity through art produc-
tions . It is not intended as a substitute for consultation with
a trained and registered art therapist who is familiar with the
relevance of artistic productions to differential diagnosis.
The above-mentioned ten categories reflect thematic,
structural, and process elements of art by MPD clients . They
were derived from the study of thousands of drawings cre-
ated by a variety of clients over a period of years . Conversa-
tions with these clients resulted in the formation and clarifi-
cation of these categories . No statistical data is available
regarding their prevalence in the art expression of the MPD
population, the psychiatric population, or the general
population . A multi-center study would be beneficial in this
regard.
In our opinion, when three of these different categories
of pictures are seen in the art of a single client not diagnosed
MPD, the therapist 's index of suspicion for MPD should be
raised . The presence of five or more such categories appear-
ing in the work of a single client not diagnosed as MPD
merits a full diagnostic evaluation . These categories can also
help to frame the graphic communication of diagnosed
multiples so that their images can be interpreted in the
context of their ongoing therapy . Although all art produc-
tion is inherently personal and idiosyncratic, the authors
contend that these types of pictures will occur regularly in
the art of MPD clients and provide a valuable structure for
the identification and exploration of this complex disorder.
a73
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