Using Drawing as Intervention
with Traumatized Children
Cathy A. Malchiodi, ATR, LPAT, LPCC
This article is reprinted from TLC's Journal, TRAUMA AND LOSS: Research
and Interventions, Volume 1, Number 1, 2001
Cathy A. Malchiodi, ATR, LPAT, LPCC, is the Director,
Institute for the Arts & Health and advisory board member, The National
Institute for Trauma & Loss in Children, author of numerous books
including, Understanding Childrens Drawings (1998) and The
Art Therapy Sourcebook (1998), and published over 50 articles and
chapters on the use of art intervention with children. Cathy has given
more than 140 invited keynotes and presentations throughout the US and
the world and is the editor of Trauma & Loss: Research & Interventions.
Abstract: This article provides a basic overview of how
therapists and counselors can use drawing as intervention with children
who have experienced trauma or loss. Topics covered include: drawing as
a mode of communication for children; why drawings facilitate verbal reports;
how drawing helps the process of recovery from trauma; drawing tasks useful
in trauma debriefing and resolution, and overall considerations for professionals
using drawings in clinical work. An appendix on drawing materials is provided
for those therapists and counselors who do not have experience with art
as intervention with children.
Drawing is a natural mode of communication that children rarely resist
and that offers a way to express feelings and thoughts in a manner that
is less threatening than strictly verbal means. For the child who has
experienced trauma or loss, it helps to externalize emotions and events
too painful to speak out loud and is one of the only means of conveying
the complexities of painful experiences, repressed memories, or unspoken
fears, anxieties, or guilt. Drawings expediently bring issues relevant
to treatment to the surface, thus accelerating the helping professionals
ability to intervene and assist troubled children. A drawing can provide
information on developmental, emotional, and cognitive functioning, hasten
expression of hidden traumas, and convey ambiguous or contradictory feelings
and perceptions. With the advent of brief forms of intervention and the
increasing pressure to complete treatment in a limited number of sessions,
drawing helps children to quickly communicate concerns and problems, thus
enhancing the efficiency of therapist-child interaction.
Offering children the opportunity to communicate through drawing is a
strategy that can easily be a part of every therapists repertoire.
Although other modalities can help children express themselves, drawing
is certainly one of the most economical. Drawings are particularly useful
in trauma debriefing where sensory-based methods have been identified
as helpful in disclosure and crisis resolution (Malchiodi, 1997; Pynoos
& Eth, 1985; Steele, 1997).
This article proposes that therapists and counselors consider using drawing
with children who are recovering from traumatic events or loss. Topics
include a brief overview of drawings as intervention; why drawings facilitate
verbal reports; why drawing is helpful in recovery from trauma; drawing
tasks useful in trauma debriefing and resolution; and overall considerations
for professionals using drawings in clinical work. An appendix on drawing
materials is provided for those therapists and counselors who do not have
experience with art as intervention with children.
Drawings: A Picture is Worth a Thousand Words
For more than a century psychologists, educators, and others have tried
to determine whether or not childrens drawings reveal their thoughts,
feelings, and psychological well-being. To some extent, a drawing is worth
a thousand words and does reflect the child who created it. Drawings
are useful in understanding and evaluating a childs development
(Gardner, 1980; Golomb, 1990; Kellogg, 1969; Lowenfeld & Brittain,
1987) (Figures 1, 2, 3, & 4), and the universal stages of childrens
artistic expression are a basis for using drawing in intervention (Malchiodi,
2001a; 2001b). Childrens drawings have been used as projective measures
of personality (Buck, 1966; Hammer, 1967; Koppitz, 1968; Oster & Montgomery,
1996), but have proven to be less reliable in this regard than first thought.
Specific drawing tasks have also been developed and applied to the evaluation
of cognitive abilities in children (Silver, 1996; 2001).
Drawings as Intervention
While drawings may say a great deal about the child who creates them,
what is more important are the therapeutic benefits that the process of
drawing provides. In recent decades drawing has become a recognized modality
in therapy with children (Malchiodi, 1990; 1997; 1998; 1999; Rubin, 1984)
and has been used in the treatment of children who have been physically
or sexually abused or exposed to domestic violence (Malchiodi, 1990; 1997;
Riley & Malchiodi, 1994; Webb, 1991); have emotional disorders (Kramer,
1993); or have medical conditions (Malchiodi, 1999). Pediatrician Donald
Winnicott (1971) noted that childrens art could be used as means
of communication between therapist and child and believed that his young
patients wanted to be active participants in their treatment. Winnicott
recognized the value of drawing in helping children express their problems
and world-views. His work affirmed that drawings can be a catalyst for
increased interaction and interchange, thus expanding the effectiveness
and depth of the relationship between clinician and child.
Art expression, particularly drawing, seems to be well suited as an intervention
with children who are traumatized or abused because it may be easier to
use visual communication than to talk about painful feelings and experiences
(Malchiodi, 1997; Steele, Ginns-Gruenberg, & Lemerand, 1995). Drawing
mobilizes the expression of sensory memories, and recent attention to
neurobiological factors in the treatment of trauma (Siegel, 1999; van
der Kolk, 1987) has enhanced understanding of why drawing can be particularly
helpful in debriefing, disclosure, and resolution of trauma. Because the
core of traumatic experiences is physiological, the expression and processing
of the sensory memories of trauma are essential to successful intervention
Drawing is an activity that taps a variety of senses--tactile, visual,
kinesthetic--in ways that verbal processing alone does not. It is possible
that drawing stimulates neurological processes that, in conjunction with
trauma-specific questions and debriefing techniques, may be specifically
helpful in resolution of stress reactions, intrusive thoughts, and other
posttraumatic effects. Drawing and art expression provide self-soothing
experiences, ones that are used by traumatized children to reduce stress
and ameliorate posttraumatic stress reactions (Malchiodi, 1990; 1997),
and the rhythmic actions involved in drawing and coloring are reminiscent
of the movements used in trauma interventions such as Eye Movement Desensitization
and Reprocessing (EMDR) (Schapiro & Forrest, 1997).
Facilitating Verbal Reports
Drawing is particularly useful in trauma intervention because it both
facilitates childrens ability to verbalize their experiences and
encourages the expression of emotionally-laden events more successfully
than talking alone. Gross and Haynes (1998) conducted a series of studies
to explore how and if drawing facilitated verbal reports in children,
supporting the premise that drawing does indeed appear to enhance childrens
communication of feelings and perceptions. In their initial investigation
they compared two groups of children: one group who talked about experiences
while they drew and a second who were simply asked to tell about their
experiences. Children who were given the opportunity to draw while talking
about their experiences did report more information than the children
who were merely asked to talk. A second experiment was conducted to examine
children who were interviewed with both procedures; it also revealed that
children do report more when asked to draw.
These researchers hypothesized that there may be several reasons why drawings
are helpful adjuncts to increasing childrens verbal reports:
- Drawing may reduce anxiety and help the child to feel more comfortable
with the interviewer or therapist;Drawing may increase memory retrieval;
- Drawing may help children organize their narratives;
- Drawing may help in prompting children to tell more than they would
during a solely verbal interview (Gross & Haynes, 1998).
In the field of art therapy, drawings have been traditionally used with
children in numerous ways to encourage verbal expression. For example,
Gabriels (1999) used a specific series of drawing directives to help children
with asthma relate their experiences with breathing difficulties and to
identify environmental triggers of symptoms. Barton (1999) developed a
drawing protocol using simple body outlines to assess pain severity with
children with arthritis. In legal contexts, Cohen-Liebman (1994; 2001)
has observed that drawings are useful in obtaining information on abuse
and neglect from children and in forensic interviews with child clients
for court cases involving maltreatment or child custody.
Specific Drawing Tasks for Trauma Debriefing and Intervention
There are several drawing tasks that seem to be particularly helpful in
situations where the helping professional encounters a child who has witnessed
a traumatic event such as an accident, domestic or neighborhood violence,
or has experienced traumatic loss such as the death of a family member,
friend, or classmate, or even the loss of a parent through divorce or
separation. In applying the drawing tasks described below, it is important
to accept that children who have been traumatized do need and want to
relate the terror of their experiences. For many years it was believed
that children should not be asked to talk about these traumatic memories
for fear of re-traumatization. However, it is now known that it is important
to the recovery process to provide children with ways to express their
apprehension and worries and to provide sensory experiences that mobilize
the expression of these feelings in a structured manner.
Several drawing tasks are particularly useful, including:
- Drawing What Happened. When an individual experiences
a trauma, drawing what happened is essential. Pynoos and
Eth (1985) found that in order to successfully resolve and master a
traumatic event, children must have the opportunity to recount the experience
in detail. They proposed a structured interview along with drawing to
facilitate this process. While it is a difficult task to recreate an
image on paper of the traumatic event, most children find a degree of
relief in finally being asked to describe what happened (Figure 5).
- Drawing of Self in Relation to Trauma Experience. It is helpful to
have the child draw a picture of yourself when the trauma happened,
especially if the child did not include him- or herself in the previous
drawing of what happened. A self-image gives additional
information about how children see themselves and how they see themselves
in relation to the traumatic event.
- Drawing of the Body of the Victim. In cases of violent crime, accidents,
or death from natural causes such as cancer, heart attack, or illness,
at some point it is often helpful to ask the child to draw a body
of the victim. This task, when presented in a sensitive and supportive
manner, can be helpful in resolution of not only stress-related symptoms,
but also in identifying any intrusive or recurrent memories that the
child may have about the traumatic event. Often children have lingering
questions about the victims death that they may have been afraid
to ask; children also fear what happened to the victim will happen to
them or that they have in some way caused the death of the victim (Malchiodi,
1998) (Figure 6).
- Completing a Pre-structured Body Outline. The use of a
body outline as a therapeutic activity has been used for many years
in art and play therapy (Malchiodi, 1990, 1997, 1998; Webb, 1991). This
task basically involves the use of a pre-structured body outline which
the child may color in a variety of ways. The therapist may take several
approaches to this task with the child, depending on the childs
needs and experience of trauma. For example, a therapist might say:
We can have many different kinds of feelings when a bad experience
occurs. Sometimes when something bad happens, we feel it in our stomachs
like a tummy ache and other times we can get a headache. I want you
to color the body outline in the places where you felt the traumatic
event in your body when you first heard about it (or witnessed it, if
that is the case). The victim of a crime or accident may also
be addressed through this activity, and you might ask the child to consider
where did your friend (parent, brother, etc.) feel the trauma
(accident, crime) when it occurred. I want you to color the body outline
in the places that you think the person felt pain when it happened.
[Many of the tasks described above are used in structured sensory intervention
(SITCAP) described in the previous article in this issue of Trauma &
Loss: Research & Intervention and in Steele (2001).]
Working with Physically or Sexually Abused Children
The activities described in the previous section are generally helpful
in crisis work with children who have experienced acute traumas such as
exposure to a single violent crime or the loss of family member or friend.
However, children traumatized by physical or sexual abuse may require
adaptations of these drawing interventions, and the helping professional
must be sensitive to their unique treatment needs. For example, asking
a child to draw what happened in an initial session with a
child who has been chronically abused, either physically or sexually,
may not be appropriate or possible. Revision of the activities to support
the childs needs for secrecy and safety is essential. The following
case example illustrates one of many possible adaptations:
A six year old girl, Tessa, who was suspected of sexual abuse was referred
for an evaluation. The protective service worker who initially handled
her intake observed that Tessa was verbally communicative, but hesitant
to discuss who in her household may have abused her. Like many children
who have been sexually maltreated, Tessa was guarded about the details
of her abuse and found it difficult to talk about openly.
Instead of asking her to draw what happened, I first asked
Tessa to draw a picture of the inside of her house, the place where the
maltreatment was to have taken place. Tessa liked to draw and carefully
created a cut-away image of her home depicting two levels: the bottom
level included a kitchen with a large tea kettle and a dining area, while
the upper floor was a bedroom with numerous beds. I asked Tessa to tell
me about her drawing of her home and she proceeded to describe the
various rooms, noting that there were lots of beds in my house because
a lot of people live there.
Because I was primarily interested in finding out who the perpetrator
was, the people who lived in the house became an important topic to explore.
But because of Tessas hesitancy in talking openly about the perpetrator,
I took a different approach, one that capitalized on an unusual element
of her drawing-- the large tea kettle in the kitchen. I asked her about
the tea kettle and she told me that everyone in the house stopped at the
kettle to get hot water for instant coffee before going to work or school
in the morning. With this information, we were able to name, one by one,
each person in the house in order of their leaving in the morning after
having their coffee. There was only one person other than Tessa who remained
in the home alone with her, an uncle who turned out to be the perpetrator;
at this point, Tessa was able to draw herself and what happened.
In Tessas case, it was more beneficial to proceed at a slower pace
and to use a less direct approach in using drawing as an intervention.
Asking her to simply draw what happened would have been uncomfortable
for her and counter-therapeutic. Instead, I offered Tessa another way
to begin to reveal what happened through a series of questions
and drawing interventions, respecting her needs for safety and choice
in communicating her experiences and in identifying the perpetrator.
The case illustration presented above is one of many possible adaptations
to the drawing intervention, draw what happened, that supports
a childs need for safety in disclosure when abuse or other uncomfortable
experiences have taken place. It is important to remember that although
drawing is undoubtedly a beneficial form of expression in trauma debriefing
and resolution, drawing interventions cannot be applied randomly. Each
must have a rationale and a therapeutic purpose, but most importantly,
must respect the childs need to take things at his or her own pace.
When using drawings in treatment, a therapist must always consider the
childs circumstances and use art as an intervention with care and
sensitivity. Other considerations in using drawings as intervention include
- It is important to reinforce to the child that a simple drawing, even
one created with stick figures, is helpful in communicating feelings
and experiences and that putting these images on paper will assist the
child in overcoming painful emotions and memories.
- In using any of these or other drawing tasks, it is important that
the clinician be as curious as possible about all elements of the drawing.
Asking about everything in a drawing demonstrates to the child that
you are interested in his or her creation. More importantly, your questions
will mobilize new information to surface and clarify for you what the
child intended to express in the drawing.
- It is important to ask the child about what is not included in the
drawing. For example, a child may draw an image of a traumatic event,
but may not necessarily include family members or friends who were present.
If someone significant to the traumatic event is not included, ask where
that person is; the child may have forgotten to include that person
or may wish to leave an individual out of the picture for some reason.
- Remember that drawing is not a panacea for trauma; drawing interventions
will only be helpful if the therapist understands how to sensitively
ask about the childs experiences. Trauma-specific questions are
key to the efficacy of drawings as intervention (Steele, 2001).
- Finally, before using any drawing intervention the therapist or counselor
should personally try the task and experience what it is like to use
the activity. The availability of supervision from another professional
who understands how drawing is used in trauma debriefing and resolution
Drawing is a natural language for children and especially for the child
who has been traumatized or experienced a significant loss. Self-expression
through the simple act of drawing is one of few means of conveying the
complexities of crisis, repressed memories, or unspoken feelings. Drawing
expediently brings relevant post-trauma issues to the surface, thus accelerating
the helping professionals ability to intervene and enhancing the
efficiency of therapist-child relationship. Most importantly, it is a
modality that addresses the sensory experiences inherent to trauma, and
for this reason, it is a potent tool in debriefing, resolution, and recovery.
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Appendix: Drawing Materials
This appendix is provided for therapists who may be unfamiliar with drawing
materials and resources for drawing supplies (adapted from Understanding
Childrens Drawings by Cathy A. Malchiodi, 1998).
Paper comes in various sizes and types, and it is important to have at
least a small assortment of papers on hand. This assortment should include
good quality white drawing paper in 8 x 10, 9 x 12, and 18 x 24 inch sheets.
Colored construction paper is important to have available for children
who may respond to drawing on colored backgrounds. Some therapists prefer
gray paper for some drawing tasks, the rationale being that a background
color other than white encourages children to use other colors, including
white. White or brown Kraft paper is appropriate for murals and large
individual drawing or painting projects; it generally comes in rolls 24
or 36 inches wide. This paper can be cut to any size, can withstand tempera
and poster paint, and comes on economical rolls so the therapist can cut
the sizes needed.
Most therapists use standard 8 1/2 x 11 inch paper (usually copier paper),
mainly because it is easy to obtain, but this is not always the best type
of paper for all drawing tasks. Although materials like oil or chalk pastels
(see below) can be used on simple white copier paper, these drawing materials
really require a heavier grade of paper. A white paper of 60 or 80 lb.
in 18 x 24 sheets is readily available in 100 sheet sketchbook
formats and the therapist can cut these down to make smaller sheets if
the additional cost of buying other sizes is a concern. Newsprint pads
are also available, but they are not recommended for use with children;
the thinness of the paper is frustrating and will not withstand any heavy
coloring, shading, or pressured lines. For chalk pastels, a paper with
a texture or tooth is best, in order to hold the pigment on
For those who are unfamiliar with art materials, there are a variety of
drawing tools available. Many therapists rely solely on one drawing medium,
such as pencils or crayons, especially if they regularly use standardized
drawing assessments and evaluations with children. However, it is important
to have a variety of media for drawing accessible because childrens
expressiveness benefits from the availability of a broad range of materials.
A basic assortment of drawing tools for use with children should include
- graphite pencils with good quality erasers
- pens: ballpoint and roller ball
- colored pencils: at least 8 colors and a pencil sharpener
- color sets of crayons: 24 color set
- felt markers (both thin and thick)
- colored chalks
- oil pastels (also called Cray-Pas): at least 8 colors
- handy-wipes for cleaning hands, especially if using chalks or oil
All of these drawing materials are easily transportable if the therapist
is itinerant. Some drawing media can also be used as paint (e.g. Payons
or water crayons) and are worth including because they offer children
a media that is more expressive than pencils or felt markers. These materials
are excellent for situations where messiness is a concern
or traditional tempera or poster paints are not available.
When using chalks or oil pastels, the therapist may want to use a fixative
(a spray preservative applied to artwork) after the drawing is completed
to keep the image from smudging. Although there are a great many fixatives
that artists use on their drawings to prevent smudging, a can of hairspray
will do the job fairly well and will be less toxic than the commercial
products. However, if you use hairspray or other fixative, it should be
used by the therapist in a well-ventilated area