Drawing is used as a form of exposure to assist children in constructing trauma nar-ratives while helping them to relive traumatic memories. Cognitive behavioral psy-chology has demonstrated “that memories determine the interpretation of the pres-ent even when they are not conscious” (Mihaescu & Baettig, 1996, p. 243). Children experience trauma at a sensorimotor level then shift to a “perceptual (iconic) repre-sentation at a symbolic level” (Mihaescu & Baettig, 1996, p. 246). “Later, in adult life, these memories are ordered linguistically. When a terrifying incident such as trauma is experienced and does not fit into a contextual memory, a new memory or dissociation is established” (van der Kolk, 1987, p. 289). When memory cannot be linked linguistically in a contextual framework, it remains at a symbolic level for which there are no words to describe it. To retrieve that memory so it can be en-coded, given a language, and then integrated into consciousness, it must be retrieved and externalized in its symbolic perceptual (iconic) form.
Drawing is one way to provide a link between dissociated memories and their re-trieval into consciousness after which the experience can be translated into narrative form and then reintegrated into the child’s past, present, and future life experiences.
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Malchiodi (1990, 1998, 2001) states that drawing provides children with an impetus to tell their stories and a way to translate their traumatic experiences into narratives.
Riley (1997) observed that the act of drawing is a form of externalization, visible projection of self, thoughts, and feelings.
Pynoos and Eth (1986) relied heavily on drawing as his primary intervention with children traumatized by violence. They indicate that drawing “invariably signi-fies the child’s unconscious preoccupation with the traumatic memory” (p. 316).
Drawing provides for an externalization of the experience and through the motor (drawing) and verbal (giving the narrative) actions helps the child move from a pas-sive (internal) powerless involvement with the trauma to an active (external) control of that experience. Once a traumatized child can form a trauma narrative and exter-nalize it in a symbolic fashion the child is able not only to find relief from the terror it created but to regain power over it to the point that energies are no longer spent avoiding and reacting to all the triggers and symptoms created by that trauma.
The use of drawing also has an additional advantage. For children as well as adults, trauma memories are encoded in images because trauma is a sensory experi-ence rather than a solely cognitive experiexperi-ence. For therapists to fully understand the impact of a traumatic incident on a child and to identify the critical trauma refer-ences for that child we need to become witnesses to the child’s experirefer-ences. We must be able to see what children now see related to themselves and to the world around them as a result of their exposure. Drawing provides this opportunity to view the ex-perience and see it as the child sees it. It also provides the stimulus for the child to tell his or her story and in essence make us a witness to the fear, terror, worry, hurt, anger, revenge, accountability, and overall victimization.
In trauma work it is essential to protect traumatized children from losing con-trol. The revisiting of trauma through drawing must be experienced in a controlled fashion so children experience that they, in fact, can gain control out of what has been until now an array of out of control internalized reactions. Not only must the drawing activities be structured, but the media used must also be “containing.” An 8″ × 11″ sheet of paper, for example, is far more controllable than is a 3 × 4-foot piece of paper. The larger the format, the greater the potential for losing control. A fine-point colored pencil, for example, is more containing than a jar of finger paints, which novices often discover can quickly move the child from painting the paper to painting the walls as well as the intervener.
KEY COMPONENTS OF INTERVENTION
• Trauma intervention should address the themes of fear, terror, worry, hurt (emotional and physical), anger, revenge, accountability, and victim versus survivor thinking. By focusing on these themes as opposed to the actual symptoms of trauma such as intrusive recollections, intervention defuses the symptoms and level of sever-ity of dysfunctional response triggered by the sensory and cognitive memories of the trauma experience.
• Reexposure, trauma narrative, and cognitive reframing are the theoretical Using Drawing in Short-Term Trauma Resolution 143
foundations supporting the intervention. With children and adolescents, exposure is accomplished through drawing. The trauma narrative (i.e., the telling of the story) is encouraged and facilitated by asking trauma-specific questions. Cognitive reframing addresses how children relate to the major theses of trauma.
• Trauma-specific questions must be related to the trauma experience, not nec-essarily to the incident itself. Trauma-specific questions include the following: What do you remember seeing, hearing, or touching? Do you sometimes think about what happened even when you don’t want to? Do certain sounds, sights, smells, etc., sud-denly remind you of what happened? What would you like to see happen to the per-son (or thing) that caused this to happen? Do you ever think it should have been you instead? Throughout the intervention process questions are specific to the theme being addressed. Their relevance keeps the child focused on the specific theme, en-courages the narrative (story) to be told for each theme, and enen-courages attention to details. Details of the sensory experience of the trauma are critical in helping to rees-tablish a sense of control, to provide the therapist with the opportunity to correct any incorrect information (fantasies) the child possesses, and to provide new infor-mation. Thus, the processing of details not only helps with control but can also facilitate cognitive reframing.
• The reexperiencing of the traumatic event must be structured so that reex-posure to the details and memories does not become an overwhelming flooding into consciousness. The therapist structures slow and progressive detailed reliving, ac-complished by presenting structured trauma-specific questions and drawing tasks that address one theme at a time (see “Case Example”). The trauma-specific ques-tions are designed to assist not only in the reexposure but also in the “slow and safe”
telling of the story.
Drawing activities should relate to the major themes of trauma. For example, children are asked to draw “what happened,” and “what the victim looked like at the time.” The purpose of drawing is not to analyze or evaluate but to trigger sensory memories of the trauma. When the child externalizes and “concretizes” experiences in a way that makes us a witness to the experience, it allows the child to regain power over these memories and reorder them in a way that is manageable. Drawings are initiated in a sequential order and in association with specific themes and activi-ties. The instruction is not, “Draw whatever you like.” It is specific; for example,
“Draw me a picture of what your hurt looks like.”
CASE EXAMPLE
Johnny was 10 years old when his older sister, Sally, was brutally murdered by a se-rial killer. Her body was discovered some 6 months following her murder. A boy-friend was a witness to the murder. He was tied up and unable to help Sally.
One year later Johnny was fighting all the time and preoccupied with such hor-ror characters as Freddie Krueger, and his grades had dropped. His mother reported that prior to the murder Johnny was the “best” youngster of the four children in the 144 CLINICAL APPLICATIONS WITH CHILDREN AND ADOLESCENTS
family. He was not a witness to the murder yet was understandably exposed to it through his relationship to the victim and through the media’s coverage of this high-profile killing.
Johnny was brought in for intervention 1 year following the murder. He had been working with a social worker and had had several visits with a psychiatrist.
These clinicians had not discussed the trauma directly, nor had Johnny been asked to draw.
Johnny was first asked to tell what happened. At times he had difficulty actually saying the words he wanted to use to tell his story. He also could not describe what images he was seeing in his mind as he was telling the story. For the first time in 5 months he broke down in tears.
Johnny’s physical and emotional reactions were still very intense as if the murder had only just happened. His responses caused many well-meaning adults to tell him it would be better not to think or talk about his feelings. Although this is an under-standable reaction, it also protects adults from the terror and powerlessness Johnny’s feelings could trigger in themselves. To become a witness to a child’s experience, we must be able to see how that child visually defines the experience as well as how he now views himself and the world around him.
Johnny was asked to draw a picture about his experience that he could tell a story about. His drawing (Figure 11.1) is primitive and yet he spent 20 minutes de-scribing the events of the last evening he spent with his sister. He was the last in his family to see her alive. (It does not matter what the trauma victim draws or how he or she draws, just that the victim draws. It is the psychomotor activity of drawing that will begin to trigger the sensory memories of the trauma experience).
Using Drawing in Short-Term Trauma Resolution 145
FIGURE 11.1.Drawing of living room where Johnny last saw his sister.
Johnny drew his living room where he, his sister, and her boyfriend were watch-ing television, eatwatch-ing pizza, and havwatch-ing fun the night she left and never returned. It is the starting point of his story, a safe place for him to begin.
In a later drawing (Figure 11.2) Johnny draws a picture that he identified as him-self before his sister was murdered. When asked about his mouth he replied, “I’m supposed to be smiling. I need to turn it to a smile.” He took a colored pencil and at-tempted to turn the corners of the mouth upward but was unable to do so.
Many professionals would begin to analyze this behavior and attempt to probe for insight into its meaning. However, analysis and interpretation stop the pro-cess and shift back to a cognitive level. Trauma is not a cognitive experience; it is a sensory one. It is important to intervene at a sensory level. Furthermore, only the child can tell us what the drawing means in this process.
Because this drawing (Figure 11.2) was a picture of himself before his sister was killed, Johnny was asked to draw a picture of himself (Figure 11.3) after his sister’s murder. In trauma we are always dealing with “then” and “now.” “What scared you the most then; what scares you the most now?” are examples of moving between then and now. Again, we avoid interpreting the drawing. It is Johnny who describes how he now feels: powerful yet driven by the terror of horror characters such as Freddie Krueger and Candyman.
Trauma-driven anger or fighting is a response to regaining the sense of power that trauma takes from us. It is a way of not having to experience the overwhelming sense of vulnerability and powerlessness that trauma can create.
When Johnny was asked to draw (Figure 11.4) a picture of his sister dead, he could not quite do it. Instead he drew her in the process of being killed. The two lines going through her body are the arms of the serial killer. At this point he stopped and said he did not want to draw the serial killer. Later, when asked “What scares you the 146 CLINICAL APPLICATIONS WITH CHILDREN AND ADOLESCENTS
FIGURE 11.2.Self-image before his sister was murdered.
most now?,” he told of how he saw the killer in court during the trial and how he now fears the killer will reach out of jail and come kill the rest of his family. Is it any wonder Johnny needs to see and experience himself as powerful?
Because he had not drawn his sister dead, Johnny was again asked to do so. His drawing (Figure 11.5) is the memory he holds of his sister. Hurt is a critical theme to address in trauma intervention. Following this drawing, Johnny was asked, “When you first found out, where did you feel the hurt the most in your body?” His response Using Drawing in Short-Term Trauma Resolution 147
FIGURE 11.3.Self-image after his sister was murdered.
FIGURE 11.4.Drawing of sister being murdered.
was that he “got a really bad headache.” Johnny no longer has headaches, but when he thinks about his sister he “still aches all over.”
When participants view Johnny via the videotaped interview of this session, he is no longer choking on his words. He is animated, able to laugh, providing many de-tails without crying or intense reactions. There is a major change from the first 5 minutes of the interview to this part of the process 45 minutes later. The terror, the fear, the sensory struggle are no longer evident.
The intervener then asks Johnny to describe what that hurt was like. He really 148 CLINICAL APPLICATIONS WITH CHILDREN AND ADOLESCENTS
FIGURE 11.5.Drawing of the memory Johnny holds of his sister.
FIGURE 11.6.“This is what that hurt looks like.”
cannot describe it. Twenty minutes later when the intervener begins to close the inter-view, Johnny says, “Wait; you know that hurt we were talking about?” He then picks up a colored pencil and quietly completes another drawing (Figure 11.6). When he is finished he says, “This is what that hurt looks like.”
This process actively engages the child in his own healing. As the sensory memo-ries of Johnny’s experience are portrayed through drawing and he begins to develop the trauma narrative, he experiences a release of the terror-filled sensations of his ex-perience at the same time that he gains control over them.
Mother reported weeks later that Johnny was “almost like himself again.” It should be reported that we never talked about his fighting or other behavioral symp-toms, only about his feelings of fear, terror, worry, hurt, anger, revenge, and guilt.
When this process is taught at the Institute, it is difficult for seasoned clinicians to stop analyzing, an attempt at insight. They want to reflect, explore, and interpret feelings that take the child away from his story. Many assume that they cannot ask the child to draw a picture of the person who died, was killed, or was critically in-jured in the first session. Such an approach may feel safer for the clinician, but chil-dren who are living with trauma desperately want an opportunity to have others wit-ness their experience. Exposure through drawing and trauma-specific questions allow this to happen (Steele & Raider, 2001).
CONCLUSION
There are several key reasons why drawing is an important modality in trauma inter-vention:
• Drawing is a psychomotor activity. Because trauma is a sensory experience, not solely a cognitive experience, intervention must include ways to tap sen-sory memories of the trauma.
• Drawing provides a safe vehicle to communicate what children, even adults, often have no words to describe.
• Drawing engages children in the active involvement in their own healing. It en-ables them to move from passive, internal, and uncontrollable reactions to their traumas into an active, directed, controlled externalization of those trauma experiences.
• Drawing provides a symbolic representation of the trauma experience in a lan-guage and a format that is external and concrete and therefore manageable.
• The drawing format itself is effective: The paper acts as a container of that trauma. The contained trauma can now be managed at a sensory, tactile level by the child. The child can use it as he or she wants, thereby giving the child a sense of empowerment over the trauma.
• Drawing provides a visual focus on details that encourages children, via trauma-specific questions, to tell their story and to give it a “language” which can then be recorded in a way that is also manageable.
• Drawing provides for the diminishing of reactivity (anxiety) to these memories Using Drawing in Short-Term Trauma Resolution 149
through repeated visual reexposure in a medium that is perceived and felt to be safe by the child.
It is not possible to fully describe this trauma intervention model in one chapter.
The information here provides a framework and offers guidelines for treating trau-matized children. It stresses the importance of having a structured process to create a safe environment. In this safe environment children can reexperience the details of their traumas and tell their stories in order to find relief from the terrors of their experiences and regain a sense of mastery and power over themselves and their environment.
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